Changes in Diet and Exercise Better Than Prescription Drugs for Preventing Heart Attack Recurrence

Heart disease is an ailment of modern civilization and behavior – and it’s one, therefore, that can be treated effectively and with dramatic results by making fairly simple lifestyle changes. People in African villages don’t need bypass operations. Studies have consistently shown that rates of heart disease are higher in Western cultures, that heart disease rates go up in countries that adopt Western diet and lifestyles, and that modifications of diet reduce heart disease. Some of the differences may not be attributable to the diet per se, but rather to how food is raised and the industrialization of American agriculture (e.g. the effects of corn fed versus pasture fed animals). However it is clear that the majority of heart disease is caused by factors associated with Western Civilization, such as poor diet and a lack of exercise.

There are also “non-medical” factors not directly related to lifestyle that increase the risk for heart disease, like low income, lack of social support, depression, marginalization in society, and stress in childhood. I can’t fix all of these social ills with this book, but I just want you to understand that it is not as simple as a “one disease, one pill” kind of thing.

Exercising for just 30 minutes a day reduces your risk of developing heart disease by 30%. This can include anything from running, playing tennis, or just vigorous walking. And there is no need to obtain a minimal heart rate. If you are older and don’t run or play a sport you should incorporate a daily 30 minute walk into your routine. That is better for you than statins by any measure. And there are no hidden side effects of exercise that we don’t know about yet, other than spraining your ankle.

If you have risk factors and don’t yet have heart disease, you should address them. Improving your diet will help you lower cholesterol and prevent heart disease. In fact, following the low fat diet advocated by the National Cholesterol Education Program lowers LDL cholesterol equally well as treatment with a statin, with no side effects (Jenkins et al 2005).

The so-called Mediterranean Diet (vegetables, legumes, fruit, cereals, and fish) reduces heart disease risk and prolongs life (Trichopoulou et al 2005). Patients with heart disease who followed the Mediterranean diet had a 50-70% reduction on recurrent heart attacks (de Lorgeril et al 1999). These results are twice as good as any medication.

It’s a pretty simple diet to follow over the long term. Eat at least one serving of fruit every day, which I define as one apple, one banana, one peach, one cup of blueberries, and so on. Have three or four servings of vegetables every day – a cup of broccoli, two or three cups of leafy greens, a cup of tomatoes, etc. Five to seven one cup or 2 ounce servings of whole grains, beans, and starch such as cracked wheat, whole-wheat pasta, lentils, and sweet potatoes should also be consumed on a daily basis. Meat and other animal proteins, like eggs and dairy, should be limited to once or twice a week. People who followed this diet had mortality cut in half over a four year time period. This diet substitutes unsaturated fats (olive and nut oils) for saturated fats (butter, animal fat), and also includes wine and nuts. In fact, olive oil has been shown in laboratory studies to improve endothelial function (Translation: increases the flexibility of your coronary arteries, which can be beneficial for reducing your risk of heart attacks).

You may have heard about the recent Women’s Health Initiative (WHI) study which showed that a low fat diet did not reduce heart disease (Howard et al 2006). The problem with that study is that it lumped all fats together. We now know that some fats are better than others. For example there are fats in things like olive oil and fish that actually promote good health. As an example of that, the generic low fat diet of WHI reduced LDL cholesterol by only 10 points, whereas a diet high in fruits and vegetables, soy, and nuts, and low in animal fat, dropped cholesterol by 30%, which was equivalent to the effects found with a statin (33%) (Jenkins et al 2005).

The low carb diet does not prevent heart disease. Look at the doctor who developed it-he died of a heart attack. Women from the Nurse’s Health Study (82,802) filled out questionnaires about diet and then were followed for 20 years. Low carbohydrate intake was not associated with reduced heart disease. Eating a high sugar diet increased the risk of heart disease by 90%. High vegetable intake was associated with a 30% reduction in heart disease (Halton et al 2006).

Eating fish is good for your heart; beware of eating a lot of fish high in mercury (a pollutant that gets into fish), like swordfish and tuna, during pregnancy, as it can cause birth defects. Foods that are a part of the Mediterranean diet like fish, olive oil, and nuts, increase “good” HDL cholesterol and reduce the “bad” LDL cholesterol. These foods are high in omega-3 fatty acids (like docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) and low in omega-6 fatty acids). It is often pointed out that ancient diets had a ratio of omega-3 to omega-6 of 1:1 whereas current diets have much higher amounts of omega-6, largely through the substitution of calories in the forms of leafy plants with grains and seeds.

When I was a medical student at Duke in 1985, I distinctly remember sitting on the front porch of my house in Durham, North Carolina, and reading The New England Journal of Medicine, where an article described how the Inuit people of the Arctic, who had a diet high in fish and low in meat, had much lower rates of heart disease. That observation led to the idea that the omega-3 fatty acids in fish prevented heart disease, which naturally led aggressive marketers to try and put it in a pill or a bottle and sell it. However there is a lot of stuff in fish and it is not clear what it is exactly you get out of it in terms of health benefit (or what you avoid by eating fish instead of other stuff).

de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N (1999): Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: Final report of the Lyon Diet Heart Study. Circulation 99:779-785.

Halton TL, Willett WC, Liu S, et al (2006): Low-carbohydrate-diet score and the risk of coronary heart disease in women. New England Journal of Medicine 355:1991-2002.

Howard BV, Van Horn L, Hsia J, al. e (2006): Low-fat dietary pattern and risk of cardiovascular disease: The Women’s Health Initiative randomized controlled dietary modification trial. Journal of the American Medical Association 295:655-666.

Jenkins DJ, Kendall CW, Marchie A, et al (2005): Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants. American Journal of Clinical Nutrition 81:380-387.

Trichopoulou A, Orfanos P, Norat T, et al (2005): Modified Mediterranean diet and survival: EPIC-elderly prospective cohort study. British Medical Journal 330:991-998.

Retiring in France: Need To Know Before Living In The Land Of Love

If you are retiring with your spouse or partner, there is no better country to do so than in the land of love itself. France will probably continue to be one of the top destinations of travellers, lovers and adventurers. While the focus is clearly in Paris, there are other notable places to live in like Marseille, Bordeaux, Nantes and Lyon.

Nicknamed as “Hexagon” because of the country’s shape, France is made up of mountainous regions, plains, rolling hills and of course, beaches. The French Riviera is dotted with various upscale resorts and golf courses. The French Alps is also a sight to behold and it certainly has its share of nature thrill seekers. The country is also known for their extensive system of rivers that are cutting across the lands of both countryside and cities.

This country is home to an estimate of 65 million people. This number bloats especially during the tourist season.

If you are wondering about the climate, it is quite varied and will depend on where you are in the country. The mountainous regions will obviously be cold – sometimes having snow for six months. Continental climate rules inland where the weather can turn stormy and hot during the summer and cold during the winter. The coastal areas have a high amount of rainfall and very warm summers. They also experience the mildest of the winter season.

Living in France can be a dream for seniors because their health care is one of the best in the world. In fact, the locals enjoy a high expectancy rate compared to others. The government is bent on becoming one of the greenest countries so this will bode well for any ailing health.

The thing about the country being a top destination is that living in it can be quite expensive. Because of tourism, it has become one of the richest nations in Europe. This allows the government to impose high standards for local living and also a well funded public education.

The French have a lot of rich historical places and cultural treasures – distributed among renowned museums and countryside castles and estates. While the Eiffel Tower and the Louvre may be a great pull in the cities, a lot of tourists visit the countryside for the beauty, tranquility and unforgettable trip in the past eras. The very architecture of some of the estates along the rural areas exhibit the glamorous eras of the French.

The thing about this country, though, is the fact that it is difficult to speak to the locals because they prefer to speak French. Though a lot of them speak English, they have a strong preference for their native tongue. So if you wish to retire here, brushing up on the language may be necessary.

In terms of food, the country is known for its fine dining but you can also find really good food here – but you need to know where to look. Some of the local restaurants only offer ordinary food and a lot of the tourist oriented establishments can be quite expensive. It will probably best if you cook your meals at home.

Inflammation and Disease

There is a process in the body that is now believed by medical experts to be involved in all known disease processes from heart disease to cancer to Alzheimer’s disease – inflammation. Most of you will have experienced inflammation before. Have you ever got a splinter in your finger? It got red and swollen, it may have bled a little and it was certainly hot and painful – all the classic signs of inflammation. Now, inflammation is actually a normal response to an injury like this and it serves us well. It helps to kill bacteria, parasites and viruses that try to invade us and this inflammation keeps us healthy. This type of inflammation usually demonstrates a 100 fold increase in immune system markers, such as white blood cells and cytokines like IL-6, TNF alpha, or C reactive protein (CRP).

However there is another, darker inflammatory response that happens in the body – what Dr Barry Sears calls “Silent Inflammation”. This type of inflammation doesn’t elicit the pain, swelling, redness and heat associated with classic inflammation and may only demonstrate a 4-5 fold increase in immune system markers – so can often be hard to detect. It can take years or even decades to develop and slowly but surely damages DNA and leads to disease. Unfortunately modern medicine is not very good at treating this type of silent inflammation. It is the result of poor lifestyle choices and changing lifestyle and nutrition is a much better tactic than using anti-inflammatory drugs.

The causes of silent inflammation are multi factorial:

  • Over nutrition
  • Excess alcohol
  • Poor diet
  • Inactivity
  • Pollution
  • Poor sleep
  • Stress / depression
  • Drug use

One of the primary sources of silent inflammation in the body is excess body fat. Fat is not just an unsightly inert substance that sits on your love handles or muffin top. It does not just serve as a reservoir of energy to be called upon when needed for energy. Fat is metabolic tissue that can cause all manner of things to happen in your body. Fat cells become infiltrated with high levels of immune cells that release inflammatory chemicals disrupting the uptake of sugar and burning of fat in liver cells contributing to insulin resistance, the onset of type 2 diabetes and narrowing arteries. Fat cells release chemicals that clot your blood, increase your blood pressure and convert inactive stress hormones into active stress hormones and contribute to conditions such as hypertension, stroke, cardiovascular disease and PCOS.

(Take home point – lose body fat)

Here is a short inflammation questionnaire developed by Dr Barry Sears

1. Are you overweight?
2. Are you taking cholesterol medication?
3. Are you taking blood pressure medications?
4. Do you wake feeling groggy each day?
5. Do you get carbohydrate cravings?
6. Do you suffer from fatigue?
7. Dou you have brittle nails?

If you answered YES to 3 or more questions you are likely suffering from Silent Inflammation. In the following blog posts this weak I’m going to discus inflammation as the course for heart attacks (not cholesterol), inflammation and blood pressure, inflammation and cancer and inflammation and diabetes. I’ll also discuss how to reduce inflammation through good nutrition, Stay posted.

Inflammation and heart disease

Now, this might be a little out there for some of you, especially as we have been brain washed in to thinking that saturated fat and cholesterol blocks arteries and causes heart attacks. But what researchers are now finding out is that inflammation is perhaps the major player here, not cholesterol.

As I mentioned the inflammatory response gets mobilised anytime there is damage to the body. Unfortunately the body is under constant low level oxidative damage all the time from free radicals. These free radicals are nasty little unstable molecules that fly around stealing electrons from cells and generally causing havoc. The body’s defence to these free radicals are antioxidants; antioxidants are able to safely donate their electrons to the free radicals rendering them safe. The main source of antioxidants in our body are formed from the food we eat, foods that contain amino acids and nutrients such as vitamin A, vitamin C, vitamin E, zinc, selenium and many other compounds such as alpha lipoic acid, green tea extract and carotenes.

The classic heart disease theory looks a little like this:

  • Too much cholesterol in the diet causes cholesterol to be deposited in the arteries, such as the coronary arteries.
  • Cholesterol deposited in the coronary arteries causes narrowing or blocked arteries and hey presto a heart attack.

A novel approach to heart disease involving inflammation looks like this:

  • A poor diet lacking in antioxidants leads to poor protection from free radicals and oxidative damage.
  • As cholesterol travels though the arteries it moves in and out of the vascular epithelial cells.
  • Cholesterol is attacked by free radicals and becomes damaged “oxidised cholesterol”.
  • Oxidised cholesterol is not recognised by the by the immune system which mounts an inflammatory reaction whereby immune cells called macrophages come along and eat the oxidised cholesterol.
  • The macrophage that has eaten the damaged cholesterol becomes a foam cell that is now trapped inside the epithelial cells that line the walls of the arteries.
  • As these foam cells build up they cause narrowing of the artery and can lead to reduced blood flow to the heart muscle.
  • Hey presto a heart attack.

So cholesterol just seems to be the innocent bystander of the oxidative damage caused by a diet lacking antioxidants.

Consider these couple of studies to highlight the point:

The JUPITER study in 2008 investigated 17,000 people considered not to be at risk for heart disease. This trial assessed whether the statin drug Crestor could prevent heart disease in healthy individuals with low LDL-cholesterol levels but elevated CRP (a marker for inflammation).

The study found “unequivocal evidence of a reduction in cardiovascular morbidity and mortality (about 40%) among those treated with the statin compared with placebo”. However what mechanism was at work? We know that the study group had low cholesterol so was lowering it even more what helped, or do statins lower CRP and prevent heart disease by reducing inflammation.

Another study called The Lyon Diet Heart Study investigated 600 people who had survived a first heart attack and were at high risk of another. The authors divided the people in to one of two groups:

  • Group 1 received no dietary intervention.
  • Group 2 received advice to follow a Mediterranean diet (More on this later).

What were the results? Well, as with the JUPITER trial, The Lyon Diet Heart Study was also stopped early because those following the Mediterranean diet had such a significant reduction in recurrent heart attacks that the authors were ethically compelled to put everyone on a Mediterranean diet. After 4 years, those still following a Mediterranean diet had a 50-70% lower risk of recurrent heart attacks! Compare this to the JUPITER study where those taking a drug only had a 40% reduction in cardiovascular morbidity and it’s quite plain to see that making significant changes in your diet and lifestyle are far more effective for preventing heart disease than taking drugs.

TheMediterranean diet

TheMediterranean diet is generally considered to be the native diet of the inhabitants of Crete from between 1945 to 1970. It consists of the following foods:

  • Abundant in plant food (fruits, vegetables, pulses, beans and lentils, whole grains, nuts and seeds)
  • Fresh fruit as the typical daily dessert
  • Olive oil as the principle source of fat
  • Saturated fat less than 8% of total calories
  • Moderate dairy products mainly cheese and yoghurt
  • Moderate fish, lamb and poultry
  • Low red meat
  • Less than 4 eggs a week
  • Moderate wine consumption 1-2 glasses a day
  • Less than 2000 calories a day

This diet may be moderate to low in saturated fat, but it is high in omega 3 fats, fibre and antioxidants that help prevent inflammation.

Inflammation and high blood pressure

Dr Barry Sears’ “silent inflammation” not only contributes to heart disease but also to high blood pressure or what is sometimes referred to as hypertension. Now, hypertension is somewhat of a unique disease as there aren’t any noticeable symptoms in the early stages, so it’s a good idea to get your blood pressure checked and do all you can to keep it in the “normal” zone.

Many of you will have gone to the GP and had your blood pressure measured. You may have been told that you blood pressure is 120 over 80 or 135 over 90, but what do these number actually mean?

When your heart beats it forces blood out in to the arteries, which produces the first number in a BP reading. This number should be 120mmHg, which is considered normal, any higher than 140mmHg would be considered bad, conversely if that number is too low it can also be bad. However if the arteries were not strong or did not produce some resistance against the pressure of the blood being pumped out by the heart, the arteries would rip open. This resistance produced by the arteries is the second number in a BP reading. This number should be 80mmHg, which is considered normal, any higher that 90mmHg would be considered bad, conversely if that number is too low it can also be bad.

From scientific research we can make estimations about your life expectancy based on your blood pressure, as you can see the higher your blood pressure the shorter your life expectancy.

  • BP of 130/90 = 67 ½ years
  • BP of 140/95 = 62 ½ years
  • BP of 150/100 = 55 years

The arteries are not just static tubes thorough which the blood flows, they are able to constrict and dilate depending on different factors such as stress, smoking and nutritional status. If a tube through which a fluid is moving narrows, the pressure in that tube increases, conversely if it widens, the pressure in the tube decreases much like what happens in arteries.

Many of you will have heard that if you are overweight or eat too much salt you will have higher blood pressure, and that to reduce blood pressure you need to reduce salt in the diet – true, but this is not the only mechanism at work here. Inflammation also plays a big role in high blood pressure.

To understand this we need to learn a little bit about vascular biology (I can see your eyes glazing over but bear with me). The arteries are lined with cells called endothelial cells that produce a host of chemicals that can constrict or dilate your arteries. One of the major vasodilators produced by endothelial cells is nitric oxide, Nitric oxide basically tells the arteries to relax and widen, which will reduce blood pressure. What we know is that C-reactive protein (CRP) that inflammatory cytokine that I mentioned earlier can decrease the production of endothelial nitric oxide and increase inflammatory nitric oxide, leading to vasoconstriction and increased blood pressure. Inflammation basically devours nitric oxide. We also know that oxidative damage and free radicals reduces nitric oxide, and that hypertensive patients have reduced antioxidants such as glutathione, superoxide dismutase, vitamin E, vitamin C, vitamin A, copper, and polyunsaturated fats.

So there you have it – inflammation causes increased blood pressure.

One thing that has been shown to reduce blood pressure is something called the DASH (Dietary Approaches to Stop Hypertension) diet. The DASH diet is essentially a low salt, low carb diet that is higher in protein and essential fats.

  • Meat poultry and oily fish 2-4 servings a day
  • Vegetables 6-8 servings a day
  • Fruits 4 servings a day
  • Dried beans, seeds and nuts 1-2 servings a day
  • Low fat dairy products 1-2 servings a day
  • Cereals, grains and pasta 1-2 servings a day
  • Fats and oils 4-5 servings a day (mainly unsaturated fats like olive oil, fish oil, however some saturated fat is allowable)
  • Fibre – 50g a day (mix of soluble and insoluble fibre – may need to use a fibre supplement)

Again this diet is lower in inflammatory foods and higher in antioxidants much like the Mediterranean diet I mentioned earlier (in fact there are many similarities).

Inflammation and cancer

A growing number of cancer researchers are coming to the conclusion that cancer is basically an inflammatory disease and that the longer there is inflammation present in a tissue or an organ, the higher the risk of associated carcinogenesis.

Epidemiological studies estimate that nearly 15 percent of worldwide cancers are associated with microbial infection; this may include cervical cancer and the HPV1 virus, bowel cancer and inflammatory bowel disease due to bacterial dysbiosis and stomach cancer secondary to H. Pylori infection. All of these infectious agents are associated with an inflammatory response in the body.

One way the immune system deals with these invaders is to release free radicals that kill the invading viruses and bacteria. However, these free radicals can also damage the DNA of healthy cells. These cells either repair themselves or die. If a large number of cells in an area dies secondary to infection there is an inflammatory mediated response that may lead to tumour growth.

Many other cancers may be the result of long term chronic irritation and inflammation such as in smoking and lung cancer or chemical toxicity (xenoestrogens) and breast cancer. Once again there is DNA damage, inflammation cell death and tumour growth.

Eventually these tumours are capable of releasing inflammatory chemicals that can maintain their growth, such as by initiating the growth of new blood vessels that feed tumour growth.

I’m not going to present an “anti cancer” diet, but I am going to suggest that sugar could be a contributing cause to cancers. Cancer loves sugar is a statement that seems to get banded around. Cancer cells appear to use a combination of lots of sugar and specific proteins to ignore cellular instructions to die off and keep growing. Plus we know that people who consume more omega 3 fats, antioxidants and fibre suffer less from cancer. So by eating a diet that is anti-inflammatory such a diet rich in oily fish, fruits and vegetables may protect you from cancer.

Inflammation and diabetes

Inflammation might also be a cause for type 2 diabetes. This type of diabetes is generally considered to be the results of being overweight and from eating too much sugar which makes the cells resistant to the effects of insulin.

But what might actually be the cause is… inflammation!

I’ve already discussed how being overweight causes the release of a whole load of inflammatory chemicals that contribute to what Dr Barry Sears calls “silent inflammation”. Well, research on mice shows that inflammation provoked by immune cells called macrophages (the same cells that become foam cells and lead to blocked arteries – and that are also concentrated in fat cells) leads to insulin resistance and type 2 diabetes.

This research was done in mice that were genetically engineered to lack a specific gene present in the insulin-producing cells of the pancreas. These genes are sensitive to the inflammatory response caused by macrophages and when these mice lacked the gene they did not develop diabetes, even when fed an extremely high-fat diet.

Now this research was done in mice and applying it to humans needs to be taken cautiously, however there is a good argument to reduce inflammation to protect the pancreas.

Other anti-inflammatory foods that can be very useful in protecting yourself from “silent inflammation” include:

  • Oily fish rich in omega 3 fats
  • Ginger
  • Garlic
  • Turmeric
  • Quercitin found in onions, broccoli, tea, wine and grapes.