Healthy Living November Issue
HEART DISEASE:Conquering the Number One Killer
A Worldwide Problem
Sue never worried much about heart disease. Sure, her dad had died
at 45 with a heart attack, but everyone knew that female hormones
would protect her from heart problems at least until she went
through menopause. Overnight, however, she was jolted back to
reality. At the age of 40 her younger sister died with her
first heart attack-before she went
through the "change of life." Suddenly,
Sue was confronted with what she feared deep inside all along:
she was at risk of a heart attack.
Almost every American knows someone who has died of heart disease.
Like Sue, you may have prematurely lost close relatives from this
dreaded killer. Perhaps you have had neighbors, friends, or
coworkers snatched away by heart disease. As a result of this
killer’s predominance, most of us have at least
occasionally wondered, "Will I be the
next one with a heart attack?" Such concerns
are warranted. Heart disease is the number one killer in
the industrialized countries, as outlined in Figure 1: Heart
Disease is Number One.1, 2
Contrary to popular misconceptions, heart disease is
not only a disease of men. In America, heart disease
is the leading killer of men and women alike. Despite
all that medical science knows about how to prevent
this disease, the latest statistics show that over
954,000 people died of diseases of the heart and blood
vessels (cardiovascular disease) in the United States
alone in 1994, up from 925,000 in 1992.3 Every 33
seconds an American dies of cardiovascular disease.
Since 1900 the number one killer in the United States has
been cardiovascular disease in every year but one (1918).
When an airline crashes in the U.S. and hundreds of people
die, the news is filled with this top story for days.
In-depth analysis is performed and broadcast regarding the
possible cause of the crash and how it might have been
prevented. Consider that approximately 2600 deaths, many
of them as sudden as in an airline crash, occur each day
in the U.S. from cardiovascular disease alone. This is
greater than 10 jumbo jet crashes per day. Yet, these
deaths do not even make the news broadcasts except when
a famous person dies from a heart attack, and then if
the disease is mentioned at all, it is only as an
afterthought, as if it was inevitable. The number one
cause of death deserves more thorough attention in America.
Sadly, deaths only tell part of the story of this
dreadful disease. Of the current U.S. population of
about 258 million, more than 57 million people have some
form of this disease.4 The annual cost to America for
diseases of the heart and blood vessels is an astounding
259.1 billion dollars, which includes not only the medical
and surgical treatment, but also lost productivity in the
work force.5 If you personally happen to survive a
stroke, the average lifetime cost in medical bills and
lost earnings will be $103,576.6 How much better to
prevent a stroke or a heart attack than to pay for one
and still suffer the diminished quality of life that is
almost certain to follow! No wonder Clyde Yancy, M.D.,
president of the American Heart Association’s Dallas
division and researching cardiologist at the University of
Texas Southwestern Medical Center in Dallas said recently,
"No matter where somebody is in their maturity
process, young, middle-aged, or old, incorporating
a heart-healthy lifestyle is the most cost effective
thing that can be done right now." Not only is it
cost effective, but even more important will likely be
life saving, and certainly will be life-enhancing!
How can the number of heart attacks be reduced? What
can a person do to reduce the risk of a heart attack?
Dr. Ivan Gyarfas, Chief of the World Health
Organization’s Cardiovascular Disease Prevention
Program, explains that prevention measures could
save a significant number of people from premature
death: "About twelve million people die [worldwide]
every year of heart problems, but up to half of them
could be saved if better prevention programs were
in effect."7
Although better prevention programs could cut deaths
due to heart disease (especially coronary heart
disease) by about 50 percent, evidence suggests that
optimal prevention programs could cut heart disease
deaths by as much as 90 percent. In short, although
heart disease is by far the number one cause of death
in America, it does not need to be. Nine out of ten
heart attacks may be preventable!
The Development of Heart and Blood Vessel Disease
Many people who have heart disease are not aware of it.
This is because heart disease usually develops silently.
Before any damage to the heart occurs, a process called
atherosclerosis (or "hardening of the arteries")
has been taking place in the arteries of the heart for
many years. The early phase of atherosclerosis is
called a "fatty streak."8 The process of atherosclerosis
is not confined to the heart arteries (known as
"coronary arteries"). The term "coronary artery
disease" refers specifically to the gradual narrowing
of atherosclerosis as it affects the heart arteries.
Large and medium sized arteries throughout the body
can become narrowed by this buildup of fatty material
as a plaque is formed, illustrated in Figure 2:
Atherosclerotic Fatty Streak Involvement of the Aorta.
Notice that there is more to the process of
atherosclerosis than the buildup of fat. When fat
accumulates on the inside of the coronary arteries
(or any other artery), the body reacts to prevent a
blood clot. It covers those fatty deposits with a
tough, fibrous cap, as shown in the figure. This is
an important response, because if fatty material is
allowed to come into direct contact with the blood it
can stimulate the blood to clot. The fibrous cap
protects against this deadly clotting. In fact, this
dual process gives atherosclerosis its name.
"Athero" refers to the "mushy" or "gruel-like" fatty
material that builds up inside the arteries.
"Sclerosis" describes the hard fibrous material
made by the body in response.
Unfortunately, an atherosclerotic plaque can
ulcerate, causing a break in the protective cap as
shown in the figure. When this happens, a
combination of fibrous and fatty material is released
into the blood stream. A now smaller, eroded fatty
deposit, called an ulcerated plaque (sometimes
called "lesion"), remains attached to the artery
wall. Both the liberated fatty material and the
ulcerated plaque itself can activate platelets,
the body’s clotting cells. This often sets in
motion a chain of events that can completely
obstruct any artery that is already significantly
narrowed by atherosclerosis.9 If this or another
process results in complete obstruction of a coronary
artery, the heart muscle that was dependent on the
blood flow in that artery will die. This death of
heart tissue is called a myocardial infarction (MI),
or heart attack.
Atherosclerosis progresses at different rates in
different people. The change over time in the
arteries of a person who at the age of 60 or 70
will suffer from heart disease is shown in Figure
3: Progression of Coronary Artery Disease.10
Note that early atherosclerosis is present at
age 20, as shown at the bottom of the figure. This
is common in Western nations. In fact, it may be
present at age 10 or 15. By the time a person
reaches 20, fatty streaks can be so prominent that
they are clearly visible when the coronary artery is
cut open. If the unhealthy lifestyle continues,
by age 30 the plaques progress to become even more
pronounced. By age 40, it is not unusual to have
significant coronary artery blockages that reduce
the diameter of the artery by more than half. Even
at this point, the effects of 30 years worth of
atherosclerosis will likely still be "silent." Most
individuals will have no symptoms at all, as noted
on the figure by the area labeled "asymptomatic."
If symptoms do arise, they may be vague or
"atypical," or they may be classic "angina pectoris,"
which is shown in the figure as the first symptom
in the progression toward a heart attack (shown as
MI in the figure). Angina pectoris refers to chest
pain on exertion or severe emotional stress that is
usually described as a heaviness, pressure, or
tightness centered in the middle or left side of the
chest. The pain can travel up to the neck or jaw
or down either arm. Occasionally there is also back
or stomach area pain. A large meal or cold weather
may also precipitate this pain.11 The symptom of
pain is caused by an insufficient blood supply to the
heart muscle, referred to as "coronary insufficiency"
in the figure.
Currently, approximately 6,750,000 people in the
United States suffer from angina pectoris.12
Unfortunately, many have no such symptoms until
they have their first heart attack. Even under
situations of significant exertion, a heart artery
must have at least 50 to 60 percent of its diameter
blocked before the heart muscle suffers from lack of
blood supply, which is the cause of the pain.13 Many
individuals with narrowing even in the 70 percent
range or greater have no recognizable symptoms.
As a result of the lack of symptoms, heart disease is
often not detected in its earlier stages. A person
may feel great, be working full time, and yet be on the
verge of a major heart attack and perhaps even sudden
death. Approximately 60 percent of heart attack deaths
occur suddenly or outside of a hospital before treatment
can be administered.14 Over half of all sudden
deaths (almost two-thirds of sudden death cases in
women) occur in individuals who were not previously
diagnosed with coronary artery disease. It is a
sobering reality for many that their first heart
attack is their only heart attack. Sudden death
offers no second chances.
Even when people survive a heart attack, over
two-thirds do not make a complete recovery, leaving
them with some form of disability and a permanently
decreased quality of life.15 Following a heart
attack, the heart is weaker because of lost muscle
tissue.
This weakness can be significant, particularly if the
heart attack was large. In such a case, the heart may
be unable to adequately perform even routine pumping
functions. This is an example of what is called
ischemic cardiomyopathy referred to in Figure 3:
Progression of Coronary Artery Disease. The term refers
to a heart muscle ("cardio-myo") disease or pathology
("pathy") that was caused by lack of blood supply
("ischemia"). When such a diseased heart is not able
to keep the body functions going, physicians use the
term "congestive heart failure." In this situation,
an affected individual may get short of breath easily,
experience feet or ankle swelling, or be generally
fatigued.
To prevent these progressive steps from leading to a
fatal or crippling heart attack, it is unwise to put
off heart evaluations until symptoms develop.
A variety of tests is available to diagnose heart
disease before a fatal event, such as an
electrocardiogram (EKG) with or without a stress
(treadmill) test. A resting EKG can reveal evidence
of previous heart attacks, but it is a poor tool for
detecting blockages that have not yet resulted in the loss
of heart muscle. One significant exception is the
occurrence of chest pain. In this situation, if a heart
problem is causing the discomfort, the EKG, when performed
while the pain is occurring, will often identify a potential
coronary blockage.
In a person without symptoms, an EKG stress test is far
superior for detecting coronary artery narrowing than the
plain EKG. Even a 50 percent blockage of a single
artery will sometimes show up on a good stress test.
Unfortunately, however, even a stress test can miss a
considerable number of diseased individuals. As many as
35 percent of those with significant heart vessel
blockages will have a normal stress EKG.16 The number of
falsely reassured individuals can be reduced significantly
by the use of a radioactive tracer called Thallium or by
doing the stress test in conjunction with echocardiography
(an ultrasound test of the heart performed immediately
before and after the stress test). Giving an injection of
Thallium at the maximum level of exertion on the stress
test will identify all but about eight percent of individuals
with heart artery blockages and all but about four percent
if the echocardiogram is utilized.17 Since coronary artery
disease and chest pain are so common, as a practicing
physician I perform one or more of these tests on a daily
basis.
The most conclusive test that can be performed is a dye study
of the heart and its blood vessels. It is very good for
identifying blockages that are likely to cause problems.
Such dye studies are sometimes referred to as "cardiac
catheterizations" or "coronary angiograms." Unlike
the previous
tests mentioned, a cardiac catheterization is an invasive
test (meaning we go inside the body with a catheter).
Once a blockage narrows the diameter of the blood vessel
by 40 to 50 percent or more, such a dye study usually
identifies the problem.
Keys to Preventing Heart Disease
There are some factors that influence our risk of heart
disease that we can do nothing about. For example, age
and sex cannot be changed, yet they have a significant
bearing on cardiovascular risk. The older we are, the
greater our risk. Similarly, men are at higher risk
than women of the same age-particularly in the years
before menopause. Fortunately, however, medical research
demonstrates that we can change a number of factors that
influence our risk of heart disease. The three most
important modifiable heart disease risk factors are cigarette
smoking, high blood pressure, and high cholesterol.
Addressing all three can make a considerable impact, as
was illustrated by a study of some 29,000 Finnish men and
women over a 20-year period (1972 to 1992). When these
individuals lowered the cholesterol in their diets,
lowered their blood pressure, and stopped their tobacco
use, they reduced their heart attack risk by more than
half, as shown in Figure 5: Lifestyle Changes Reduced
Heart Disease Deaths.18
Focusing on Cholesterol
Smoking and high blood pressure are each related to so
many different health issues that they warrant individual
chapters. We will examine them more closely later in the
book. Cholesterol, on the other hand, is of primary
interest because of its specific role in heart disease;
consequently, we will focus on it here. However, before
leaving the impression that cholesterol is only an issue
as it relates to increasing heart disease risk, I must
emphasize that cholesterol is an important and essential
natural compound. This white, waxy fat is manufactured
in our bodies and is used to build cell walls and make
certain hormones. However, too much cholesterol in the
blood stream (called "serum cholesterol") can contribute
to atherosclerosis. For this reason, high blood cholesterol
level as a single factor correlates well with coronary heart
disease death rate. It is recommended that all Americans
over the age of 20 know what their total blood cholesterol
and HDL are.19 The higher the cholesterol level the greater
the death rate, as demonstrated in Figure 6: Deaths for
Coronary Heart Disease vs. Cholesterol Level in Men.
This graph shows that the average serum cholesterol level
in 19 countries is a predictor of the risk of heart disease
among men in those nations.20 Note that Finland tops the
scale, with a very high average cholesterol and a very high
death rate. The United States is also relatively high on
both scales. Ireland and England are higher than Poland,
Yugoslavia, and Japan.
How to Achieve the Best Cholesterol Levels
How can we improve our cholesterol levels? Specifically,
how can we decrease total cholesterol and LDL and at the
same time raise HDL? The answer to this question is
extremely important. To fully appreciate the answers,
however, we must make sure we understand where cholesterol
comes from.
It is of primary importance that we recognize that our
livers manufacture more than enough cholesterol for all our
body functions. For this reason, we do not need to eat any
cholesterol whatsoever. In other words, cholesterol is
totally unnecessary in the human diet. However, many of us
get significant amounts of cholesterol from our foods.
In fact, the average American eats about 300mg of cholesterol
every day.35 Where does all this cholesterol come from?
Figure 13: Sources of Dietary Cholesterol gives us the
answer in simple terms.
Note that all the cholesterol we eat comes from animal
products. It is critical that we understand that fruits,
vegetables, grains, and even nuts contain no cholesterol.
If the food comes exclusively from plant products, then it
has no cholesterol in it. On the other hand, if the food
product comes from an animal, it almost always has
cholesterol in it. (A few exceptions exist where the
cholesterol-containing portion of the animal product has
been removed. Egg whites would be the main example of this.)
Further information regarding dietary sources of cholesterol
is tabulated in Figure 14: Cholesterol in Foods.36
All would be wise to pay careful attention to these examples
in the figure. Although most people may be aware that organ
meats such as liver and kidney are among the most intense
sources of cholesterol as the figure shows, many still do
not understand the basic prevalence of cholesterol in animal
foods. They think that if they eat chicken, turkey, or
fish they are not getting cholesterol. On the contrary, we
see that every animal product contains cholesterol. Also,
take note that chicken contains about the same amount as pork
and beef. This bad news about "white meat" has not received
much press. Furthermore, many kinds of fish have a high
cholesterol content.
To what extent does our intake of cholesterol affect our blood
cholesterol level? The more cholesterol we eat, the higher
our blood cholesterol tends to be, as shown in Figure 15:
Dietary Cholesterol Intake Raises Blood Cholesterol.37
Notice that as our intake of cholesterol increases, it is
reflected as an increase in serum cholesterol. An increase
of 75 points can occur if we consume 900 mg per day. If our
intake is greater than 900 mg, not much further increase in
serum cholesterol occurs. Fortunately, our bodies have
protective mechanisms to keep blood cholesterol from going
sky high after consuming extremely large amounts of cholesterol.
The curve in the figure also shows that we can dramatically
drop our cholesterol level by decreasing cholesterol intake
substantially below that 900 mg daily level. For example,
the figure shows that dropping the cholesterol in your diet
from 900 mg to 200 mg daily may lower your cholesterol 50 or
60 points. Notice that you get even more benefit when you
drop your cholesterol below 200. Going from an intake of 200
mg per day down to no cholesterol in your diet may drop your
blood levels another 20 points. The important message is that
you can dramatically lower your cholesterol by removing all
cholesterol (all animal products) from your diet.
Typical Sources of Dietary Cholesterol
Americans get most of their cholesterol from meat and eggs,
as shown in Figure 16: Food Sources of Cholesterol in the
American Diet.38
Note that 35 percent of the cholesterol consumed in America
each day comes from meat, fowl, and fish, and another 35
percent comes from eggs. The cooking fats and oils that
contain cholesterol are animal in origin, such as butter,
lard, and other fats. Commercial baked goods tend to use lard,
which accounts for eight percent of the cholesterol consumed
per day.
This figure shows that we can lower our cholesterol intake by
70 percent just by eliminating eggs, red meat, poultry, and
fish. Of course we can lower it even further just by
eliminating more of the animal products. If we really want to
eliminate all the cholesterol in our diet, essentially all
animal products must go.
Animal Fat’s Contribution to Cholesterol Levels
So far we have seen that elevated blood cholesterol levels
are closely associated with fatal heart disease. We have
also noted that cholesterol in the diet will raise blood
cholesterol levels. There are a number of other factors,
however, that contribute to elevated cholesterol levels.
Some of these factors were clarified by one of the great
cholesterol pioneers, Dr. Ancel Keys. In the 1960s, Dr. Keys
demonstrated his ability to predict with astounding accuracy
the average blood cholesterol levels of population groups.
All he used was a knowledge of their habitual diets in order
to make his startling predictions. Unfortunately, there was
too much genetic variability from person to person to do
this on an individual basis. However, when looking at large
groups of people, the average genetic tendencies tended to be
similar from one population to the next. Thus, Keys could
make his cholesterol predictions based on habitual food
choices alone-without dealing with genetics. He devised a
mathematical formula that fit the data. This equation is
often referred to as the "Keys Equation" and is illustrated
in Figure 17: Keys Equation.39 Those with a math background
will find the equation illuminating. Without going through
the calculations, Dr. Keys proves with this equation that,
apart from genetics, our blood cholesterol level is
determined by our diet, and essentially only three variables
in the diet: saturated fat (S), polyunsaturated fat (P), and
cholesterol (C).
Many people do not understand the difference between the two
fats. Imagine that you are sitting in front of two 10-gallon
glass fish tanks. Each tank is filled with fat. One is
filled entirely with saturated fat, and the other with
polyunsaturated. It would be easy to tell the difference
between the two. The saturated fat would be solid at room
temperature and the polyunsaturated fat would be liquid.
Generally, the more solid the fat, the more saturated it is.
Most fats from animal products are predominately saturated,
while most plant products are high in polyunsaturated fats.
We will look at specific examples shortly.
With a basic understanding of the three terms used in the
Keys equation, let me now explain what the equation tells
us. First, it asserts that both saturated fat and
cholesterol in the diet tend to raise blood cholesterol
levels. Second, it makes the point that saturated fat is
much more potent at raising your blood cholesterol than even
dietary cholesterol itself. Third, polyunsaturated fat
tends to lower cholesterol in the blood. However, saturated
fat has twice the power to raise your cholesterol as
polyunsaturated fat has to lower it. Expressed another way,
to cancel out the cholesterol-raising effects of a given
amount of saturated fat, you would have to eat twice as much
polyunsaturated fat. This fact can be used to judge whether
the fat content of a given food will raise or lower your
blood cholesterol level. Since all naturally occurring foods
have a combination of fats in them (both polyunsaturated and
saturated), you can divide the amount of polyunsaturated fat
in the food by the amount of saturated fat in it, and end up
with what is called a "P to S ratio" (abbreviated "P/S ratio").
If this P/S ratio is greater than 2.0, the fat in the food will
tend to lower one’s blood cholesterol level. Be aware that
this ratio tells us nothing about other factors in the food
(like cholesterol itself, for example) that may affect a
person’s cholesterol level.
Since a high P/S ratio in our diet will tend to lower the
blood cholesterol, we need to be aware of the P/S ratio of
common foods. This ratio is listed in Figure 18: P/S Ratio
of Foods for a variety of foods.40
Note that many of the animal products such as beef, venison
(deer), lamb, and bacon have extremely low P/S ratios.
These foods, based on their fat content, will tend to
dramatically raise an individual’s serum cholesterol. Thus,
red meats are undesirable not only because they contain
cholesterol, but their harmfulness is compounded because
they contain so much saturated fat, and so little
polyunsaturated fat. The same is true of milk, butter, and
cheese. Chicken and turkey have less saturated fat than red
meats, but their P/S ratios are still lower than two to one,
so they, too, will raise cholesterol levels. One of the
greatest myths is that chicken, turkey, and fish lower a
person’s cholesterol level. These foods actually raise a
person’s cholesterol, but they raise it less than red meat
does. As a result, a person’s cholesterol may go down when
leaving off red meat and substituting fish and fowl. But
the drop in cholesterol level occurs because chicken,
turkey, and fish raise one’s cholesterol level less than
red meat, not because they have a cholesterol-lowering effect.
I have had people come into my office and tell me, "I just
can’t understand what is happening. I have been eating
mostly chicken and turkey but my cholesterol still has not
come down that much!" When you understand the P/S ratio,
it tells where part of the problem lies. Furthermore, as I
mentioned earlier, chicken and turkey have as much
cholesterol in them as do the red meats. We will see later
that some of the cholesterol in fowl is undoubtedly oxidized.
Switching from one kind of meat to another is simply not the
ultimate solution for cholesterol control.
The story is similar with fish. Some fish have favorable P/S
ratios (greater than 2.0), but many others do not. Furthermore,
all fish contain cholesterol. In short, fish, like fowl, if
substituted for red meat, will tend to lower cholesterol levels,
possibly even more than fowl. However, your cholesterol
levels would be lower yet if you left chicken, turkey, and fish
completely out of your diet.
Vegetable Fat’s Effect on Cholesterol
In contrast to animal fats, vegetable fats have no cholesterol
at all. There are different kinds of vegetable fats, and all
but a few are highly polyunsaturated. In Figure 18: P/S Ratio
of Foods, notice that coconut has a P/S ratio of 0.01. This is
a highly saturated fat and will tend to raise cholesterol
levels. Although coconut has no cholesterol, its saturated
fat content dramatically increases blood cholesterol.
On the other end of the spectrum, walnuts can have a rather
dramatic effect in lowering an individual’s cholesterol.
Most nuts, in view of their fat content, are "heart
healthy" foods, as shown in the figure. Nuts in general
have been studied extensively and have been found not only
to lower blood cholesterol levels, but also to provide a
corresponding decrease in the risk of heart disease, as shown
in Figure 19: Nuts Reduce Heart Disease Risk.41, 42
This study on nut consumption was conducted at Loma Linda
University and has received international attention. The
initial study focused on the amount of nuts eaten by the
participants in the Adventist Health Study. They found that
those consuming nuts less than once per week had the highest
risk of heart attack. Those who consumed nuts one to four times
per week lowered their risk about 25 percent as shown in the
figure. Those who consumed nuts more than five times a week cut
their risk in half. The study was controlled for other
lifestyle variables so that the researchers could be more
certain that the nuts were the only factor involved. Many
health professionals were surprised by the findings of this
study. Previously, health professionals commonly encouraged
patients to avoid nuts because of their high fat content. Now
we know that nuts in small to moderate amounts are part of a
healthful diet because they supply some fat nutrients that are
beneficial for preventing heart disease.
Regarding peanuts, the fat in peanuts has a specific chemistry
and triglyceride structure (apart from the saturated and
polyunsaturated content) that makes them surprisingly harder
on your arteries than other vegetable fats.43 Thus, a person
who wants to protect his arteries would be wise to choose other
nuts such as almonds, walnuts, or pecans in place of peanuts.
Almonds have another advantage. They are unique among the nut
food group in that they contain far more vitamin E than other
nuts; in fact, they exceed just about all other foods in this
regard. We will see later that vitamin E reduces the risk of
heart disease. The realization of some of peanut fat’s
negative aspects leaves me impressed with a statement I read
about nuts that was written nearly 100 years ago in the
classic book on the principles of health, The Ministry of
Healing, written by Ellen White and quoted in Figure 20:
Almonds Preferable to Peanuts.44
Why did she warn against excessive nut consumption? One
likely reason is that a high fat diet (even if from "good
fats") tends to promote weight gain. For many people, a
large a proportion of nuts in their diet may contribute to
obesity. The overweight condition itself can raise
cholesterol levels and increase the risk of heart disease
and other health problems.
The Very Low Fat Theory
The research on nuts has helped to lay to rest a popular
but fictitious approach to heart disease prevention
sometimes called "the very low fat theory." For years,
many have advocated that to maximally reduce the heart
attack rate we must cut the fat in large amounts, to about
10 percent of calories. Some people have become famous by
advocating such a very low fat diet. Unfortunately, very
low fat diets are often not palatable and are not necessarily
the answer to reducing heart disease risk. If the fat is
coming from monounsaturated and polyunsaturated sources, a
higher fat diet can actually be as good for the heart as the
very low fat fare. The Committee on Diet and Health of the
National Research Council said this in so many words when they
posed the question, "Is the very low fat theory correct?"
From a review of the current literature, they concluded,
"No." They went on to state, "Intake of total fat per se,
independent of the relative content of the different types
of fatty acids, is not associated with high blood cholesterol
and coronary heart disease."45 We now know that we can
have a healthful diet that includes moderate levels of fat
if we are using the best types of fat.
After the 1992 study of nuts and cholesterol, Dr. Sabate took
the nut research a step further. Instead of using
Seventh-day Adventists again, who are already on a better
overall diet than most Americans, he now studied individuals
on an average American diet. One half of the total group
was placed on an average diet. The other half were fed an
identical-looking diet with one major difference. Walnuts
were blended up and added to various food items. Other
sources of fat were decreased to keep the calorie and total
fat levels the same in the two groups.
Eating walnuts daily had some amazing results. LDL
cholesterol, the "bad cholesterol," dropped by 18 points.
See Figure 21: Walnuts Reduce Cholesterol.46 This
represents a remarkable lowering of heart attack risk.
For each percentage point drop in the bad cholesterol,
there is a two to three percent drop in the heart attack
rate.47 An 18 point drop in LDL translates into a 36 to
54 percent drop in heart disease risk. The benefits of
walnuts may not simply be due to their excellent P/S ratio.
These nuts are also high in so-called omega-3 fatty acids,
which have some special benefits. Chapter 5, "The Truth
About Fish," has more information on this subject.
Fiber’s Cholesterol-Lowering Abilities
Fiber in our food will help lower cholesterol. Most
Americans eat far less than the recommended 25 to 30 grams
per day. Evidence now suggests that a low fat, high fiber,
high carbohydrate diet offers a number of advantages.
Eating at least 30 to 40 grams of fiber per day from a
variety of plant foods can lower your risk of heart disease,
cancer, intestinal disorders, and other diseases.53 A
list of diseases associated with a typical American low-fiber
diet appears in Figure 23: Diseases Associated with a
Low-Fiber Diet.54
Many are surprised to learn that there are different types
of fiber. Yet all fibers have one thing in common-they
cannot be digested by the normal human intestinal system.
One definition for fiber is "indigestible carbohydrate,"
meaning that fiber is not absorbed but is rather excreted.
Different categories of fibers include celluloses,
hemicelluloses, lignin, pectins, gums, mucilages, and algal
polysaccharides.
A simpler classification of fiber divides fiber types simply
into water soluble and insoluble fibers. It is the
water-soluble fibers that are particularly valuable for
lowering cholesterol. Fruits, vegetables, nuts, grains,
and legumes, all in their natural, unrefined state, are
the five main food groups that contain this
cholesterol-lowering fiber. Examples of such water--soluble
fibers are oat bran and fruit pectin. These compounds work
by binding to cholesterol and bile acids (excreted by the
liver) in the small intestine, thus preventing their
absorption. Fortunately, neither bile nor cholesterol is
absorbed high in the intestinal tract, but rather in the
distal ileum (the last part of the small bowel). This allows
the fiber plenty of time to bind up these compounds. If,
however, adequate fiber is lacking, both bile and cholesterol
are reabsorbed into the blood stream, raising blood
cholesterol levels. Bile acids are actually made from
cholesterol by the liver. As a result, the more bile you
lose in the stool, the more cholesterol the body must utilize
to make new bile acids that are necessary for fat digestion.
The medical literature is replete with examples of fiber’s
health-giving benefits. One study, published in 1992,
found that adding 15 grams of fiber per day to the diet
lowered serum cholesterol by 15 percent.55
The effect of fiber in lowering cholesterol correlates
with the decrease in heart disease risk in people who
consume high amounts of it. Those that consume a high fiber
diet have a 65 percent less risk of heart disease, as shown
in Figure 24: Dietary Fiber Reduces the Risk of Coronary
Heart Disease.56 In another study, seven groups were fed
differing amounts of either oatmeal, oat bran, or farina.
At the end of six weeks there were significant improvements
in total and LDL cholesterol for those daily consuming either
one ounce of farina, two ounces of oat bran, (2/3 of a cup
dry), or three ounces of oatmeal (one cup of dry rolled oats).
57 Because some skeptics were still not willing to believe
that oats can lower cholesterol, a computer assessment
(meta-analysis) of 20 carefully performed oat studies was
completed in 1992. The results demonstrated that oat
products in the diet significantly reduce cholesterol levels.
58 Another grain that has been found to have beneficial
effects on blood cholesterol levels is buckwheat.59 A
study from mainland China found buckwheat to lower both
total cholesterol and LDL cholesterol; at the same time it
lowered the ratio of total cholesterol to HDL.
Animal products (meat, milk, eggs, and cheese) have
absolutely no fiber. Many wonder why, since animals often
consume large quantities of fiber. For example, the cow, a
total vegetarian, eats fiber all day long. You would think
that eating the cow would furnish plenty of fiber, but it
does not. The reason is that when a cow eats, it extracts
and absorbs many nutrients, but the fiber in its food has a
different fate. Some of this fiber can actually be digested
by the cow (even though it is indigestible by humans). The
rest of the fiber passes through the cow’s intestinal tract
and is excreted onto the pasture. In either case, the
cow’s meat or milk incorporates none of the beneficial fiber.
In effect, when people eat cows or other animals, they are
eating nutrients second hand. Unfortunately, they get no
fiber, since the animal has "refined" the food through its
process of digestion. If we want an abundant supply of
fiber, we will choose to eat grains, fruits, vegetables, or
nuts directly. Foods that are good sources of fiber are
listed in Figure 25: Common Sources of Fiber.60
As we observed earlier, until very recently, most cholesterol
education programs never went beyond the Keys equation. They
told participants about the importance of cholesterol in the
diet as well as the dangers of saturated fat with most of the
emphasis being on saturated fat, but this is where discussions
ended. More recently, the topic of fiber has found its way
into lay educational efforts, but it often does not get the
full attention that it deserves. Other information that is
sadly lacking in most educational efforts is the topic of
protein and oxidized cholesterol.
Animal Protein Raises Cholesterol
The relationships between cholesterol and protein have been
published in the medical literature for some 20 years, but
for the most part have been sadly neglected. An extensive
body of research now has established that serum cholesterol
is extremely dependent on the type of protein consumed.61,
62, 63 Animal protein alone (even skim milk protein) will
increase blood cholesterol levels while plant proteins will
decrease cholesterol. In fact, many people who are on
otherwise heart-healthy diets will be unable to lower their
cholesterol sufficiently unless they completely eliminate
animal protein from their diets. Research has shown that
switching from a low saturated fat, low cholesterol diet
using skim milk protein to a low saturated fat, low
cholesterol diet using soy protein as a milk substitute
can drop cholesterol levels by as much as 60 to 80mg/dl
in as little as three weeks. I have seen this happen in
many of my patients who have tried a total vegetarian diet
(no animal protein). If a dramatic reduction does not
occur in such a diet, I thoroughly review what the patient
is actually eating, and often find that animal protein has
been unwittingly consumed in the form of casein in a milk
substitute or a cholesterol-free egg product such as Egg
Beaters. Once the animal protein is completely excluded,
the expected dramatic result usually occurs. More complete
information on the subject of protein sources and serum
cholesterol is found in Chapter 7, "The Great Meat and
Protein Myth."
The Problem with Oxidized Cholesterol
Cholesterol exposed to the atmosphere for a period of
time tends to combine with oxygen in the air, producing
what is called "oxidized cholesterol." Oxidized cholesterol
is another important dietary factor that the Keys equation did
not address. In fact, this compound may turn out to be the most
important dietary factor that influences heart disease risk.
As early as the 1940s it was discovered that not all cholesterol
was the same in its likelihood of causing atherosclerosis. Dr.
Chaikoff and associates found that chickens that were fed large
amounts of cholesterol developed high blood cholesterol levels
and a considerable amount of atherosclerosis. On the other hand,
chickens that were given hormones to raise their cholesterol to
similar levels had virtually no fatty buildup in their arteries.64
Drs. Peng and Taylor in Albany, New York carried on further
experiments looking for something in dietary cholesterol that
was particularly damaging to blood vessels. Their discoveries
are stated in Figure 26: Stored Foods Containing Cholesterol can
Become Lethal.65, 6
Some of the chemicals, called "oxidation products," were so toxic
that they destroyed cells that line the arteries in less than 24
hours. Furthermore, it took only a small amount of these toxic
chemicals to cause irreversible damage. In Peng and Taylor’s work,
the deadly effects on blood vessels occurred when as little as one
half of one percent of the blood cholesterol was oxidized.67 Their
research is particularly important because destruction of
artery-lining cells is one of the main factors that begins or
accelerates the buildup of cholesterol in atherosclerosis.
Peng and Taylor also made chemical measurements of specific foods
to see how much oxidized cholesterol they contained. The
researchers then tested the harmful compounds on blood vessel cells
of monkeys to determine how dangerous they were. Foods that
contained oxidized cholesterol products and produced damage to
blood vessel cells are listed in Figure 27: Stored Foods Containing
Harmful Cholesterol By-Products.68
The most harmful combination of cholesterol oxidation products was
found in custard mix where sugar, milk, and eggs were combined.
The dried mix was apparently exposed to air for a considerable
period of time due to its long shelf life.
Over 100 years ago the dangers of custards and puddings was
recognized by Ellen White. Her warning is quoted in Figure 28:
%Especially Harmful%69
Some have observed that ice cream is the most common form of
custard in America today. Pancake mixes containing eggs and
dried powdered milk were equally as harmful as custard. The
third most harmful item was Parmesan cheese; it turned out to
be as damaging as lard.
Furthermore, eating oxidized cholesterol may raise blood
cholesterol levels more than pure cholesterol alone.70 However,
even if your blood cholesterol level remains normal, animal
research demonstrates that eating oxidized cholesterol can have
adverse consequences, as summarized in Figure 29: Vascular
Damage from Oxidized Cholesterol.71
The rabbits were fed a moderate amount of pure, non-oxidized
cholesterol for 45 days. Their blood cholesterols stayed in the
normal range and they suffered no damage to their blood vessels.
Those rabbits that were given the same amount of oxidized
cholesterol also maintained normal blood cholesterol values.
However, they sustained significant damage to their blood
vessels. Research on humans also supports the fact that oxidized
cholesterol in the diet can increase your risk of heart disease
even if your blood cholesterol levels stay normal. For example,
we have known for years that-regardless of your blood cholesterol
level-the more cholesterol you eat, the greater your risk of heart
disease. Cholesterol in the diet is what is called an
"independent risk factor" for the development of heart
disease.72
Let me try to make this clearer with an example. Assume
that twin sisters are identical in every factor that relates
to heart disease. They have identical blood pressures, they
both have never smoked, they have identical genes, etc. Let
us also assume that they have identical blood cholesterol levels.
But suppose there is one difference: one of the sisters eats
much more cholesterol than the other. What the research tells
us is that the liberal cholesterol eater is much more likely to
suffer a heart attack. Simply put, we know that cholesterol in
your diet is harmful for more reasons than its tendency to raise
blood cholesterol. I believe that a large amount of this added
danger is explained by the presence of oxidized cholesterol.
Even though as of this date, detailed measurements of oxidized
cholesterol have not been made on every food, it is logical to
assume that every food that contains cholesterol has some
oxidation products in it. The important message is that even
individuals with normal blood cholesterols should be careful to
limit cholesterol in their diets. If you are not on such a low
cholesterol diet, then you are likely at increased risk of heart
attack or stroke, regardless of what your cholesterol numbers are.
Atherosclerosis often begins early in life. The oxidized
cholesterol studies may also help to explain why some individuals
develop atherosclerosis earlier than others. One important early
factor may be the type of milk that infants drink. When a baby
consumes human breast milk directly from the human nipple, it does
get cholesterol in that milk. However, the cholesterol that comes
from mom is pure, not oxidized like that present in cow’s
milk-based formulas that have been extensively processed in the
presence of air. Peng and Taylor identified toxic oxidized
cholesterol products in powdered infant milk formula.73 One theory
is that babies that are fed on cow’s milk formula are predisposed
to fatty streaks early in infancy. However, you should not
conclude from this that the best way for adults to get their milk
is to go down to the barn and get it straight from the cow to
minimize exposure to air! That method might decrease your
consumption of oxidized cholesterol, but it would also greatly
increase your exposure to a host of infectious diseases as listed
in Chapter 11, "Milk-Friend or Foe?"
Our growing understanding of oxidized cholesterol has lead me to
conclude that any program that does not address this subject is
neglecting one of the most important factors in decreasing heart
disease risk. I think that the increased research attention on
oxidation products of cholesterol will illuminate some other
relationships. For instance, it is very possible that foods
with high sugar content are more susceptible to oxidation.74
This would help further explain the abundant oxidation products
that are found in things like custard and pancakes-foods with a
source of cholesterol (milk and eggs) and sugar. It would also
explain why dietary sugar has repeatedly been linked to
atherosclerosis.
Vitamins Benefit Cholesterol Levels
We have seen that iron appears to increase the likelihood
that normal cholesterol will become oxidized in our bodies.
However, there are a number of substances in foods that appear
to prevent oxidation from taking place inside of us. These
substances are called antioxidants. Three of the most
well-researched compounds in this regard are the antioxidant
vitamins E, C, and beta-carotene.
Vitamin E intake has been found to reduce one’s risk of heart
disease. A total of 40,000 men were categorized as to the
amount of their daily vitamin E intake. Those who consumed 60
IU per day decreased their risk of heart disease by 34 to 50
percent, regardless of other food they consumed.77
How can we get enough vitamin E in our diet on a daily basis?
Since animal products are low in vitamin E, this leaves us with
a choice of taking supplements or making substantially more
vegetarian food choices. Although there are no known toxic effects,
there is also no medical justification for the use of large doses
of vitamin E supplements to prevent heart disease, particularly
since it is widely distributed in common foods.78 Good sources
of Vitamin E are wheat germ, vegetable oils, legumes, nuts
(particularly almonds), whole grains, and green, leafy vegetables.
79 As we have already noted, the protection against heart disease
provided by vitamin E is thought to be due to the prevention
of the oxidation of cholesterol within the body.
Beta-carotene Foods Benefit Cholesterol Levels
A Harvard University study found that the consumption of
beta-carotene foods reduced cardiac deaths. Over a period of
nearly five years, some 1300 individuals participated in this
research. The results showed that an increased consumption of
fruits and vegetables high in beta-carotene decreased subsequent
cardiovascular disease deaths.80 Interestingly, taking supplements
of beta-carotene does not lower the risk of heart disease.81
Thus, other antioxidant nutrients in the fruits and vegetables
may be adding a protective effect to the blood vessels.
Beta-carotene is plentiful in carrots, tomatoes, broccoli,
strawberries, and the leafy green vegetables such as kale,
collards, and mustard greens. It is also found in watermelon,
pineapples, and the yellow types of squash. In the study,
when these foods were consumed, no matter what the cholesterol
level was in the participants, there was an independent
relationship in lowering the heart attack risk.
Exercise Benefits HDL Cholesterol Levels
When the HDL cholesterol is high, it extracts the bad
cholesterol from the arteries and helps protect the arteries
from damage. High levels of HDL may even help reverse
coronary artery disease. How can we get our HDL levels up?
Exercise has been shown to raise HDL.95 The exercise that
raises HDL is not the weight-lifting type, but rather the more
active or aerobic sort that gets the heart rate up and
requires rhythmic body movements and deep breathing. The more
aerobic exercise obtained the greater the rise in HDL.96
Because of the role of exercise in raising HDL and thus lowering
the risk of atherosclerosis, low physical fitness should be
thought of as an independent risk factor for the development
of heart disease.97 A list of HDL-raising factors is shown in
Figure 33: Factors that Raise HDL Levels. The best news is that
if you are unfit now, and you get on a regular exercise program,
research indicates that you can decrease your risk of heart
disease by 50 percent.98
Other Factors That Raise HDL Cholesterol
Taking any of the drugs listed in Figure 33: Factors that Raise
HDL Levels, that raise HDL is not the preferred method due to
possible side effects.99, 100 High doses of the B vitamin,
niacin, can boost HDL levels; however, in these doses the
niacin is acting as a drug rather than a vitamin.101 Consequently,
if you are taking high doses of niacin you should be under a
doctor’s care. Careful medical monitoring for side effects is
strongly recommended. Particular attention should be paid to
the liver as high doses of niacin can be toxic to that organ on
occasion.
Estrogen in women raises HDL. This may be one of the primary
reasons why the average woman does not experience heart disease
until 10 years later than the average man. After menopause,
when estrogen production drops, women quickly catch up with men
with regard to heart disease risk. Thus, 52 percent of all
coronary heart disease deaths occur in women.102
Alcohol drinking has been associated with higher HDL levels.
However, I strongly discourage alcohol use because of the
significant hidden dangers that it carries. These dangers are
covered more completely in Chapter 17, entitled "Want a Drink?"
Furthermore, alcohol may not raise your HDL if you are already
on an excellent program. Hartung and colleagues found that
moderate alcohol consumption provided no HDL benefit for men that
were running regularly.103 In addition to alcohol, there are
other toxins that raise HDL levels, such as chlorinated pesticides.
Again, I would obviously not recommend such agents as HDL enhancers.
There are safer ways to raise HDL. When individuals stop smoking,
their HDL usually rises significantly as a result. Weight loss
can also help raise your HDL.104 Foods containing lecithin,
ginseng, garlic, onions, brewer’s yeast, the trace mineral chromium,
vitamin C, and vitamin E all can help raise HDL. An example of
a food with HDL-boosting effects is garlic. One garlic study had
individuals with coronary heart disease use up to four cloves of
garlic each day for eight months. The results are impressive and
are shown in Figure 34: Garlic's Effect on Cholesterol and
Tiglycerides.105
At the start of the study, HDL levels were dismally low, at
only 17 percent of the total cholesterol. They were solidly in
the danger zone. However, at the end of eight months their
absolute levels of HDLs were a full 65 percent higher, at 28
percent of the total. Moreover, garlic not only raised the
desirable HDL, it also lowered total and LDL cholesterol as well
as triglycerides. In other words, all cholesterol values moved
in the right direction. The only significant variable in this
study was the consumption of garlic. From many different
perspectives, garlic is not only a food enhancer, but is part
of a healthful diet.
Conclusion
The evidence is indeed clear. We can dramatically decrease
our risk of heart disease by following an optimal lifestyle.
We need to make these changes so that a known preventable
disease no longer leads the list of America’s killers. I am
aware that you probably will not change your lifestyle to
merely alter general statistics about the lethal impact of
heart disease in America. However, I am concerned about
individuals, hundreds of thousands of who will unnecessarily
go to their graves-this year alone-because they did not take
the proper lifestyle steps in time. And I know that you are
at least somewhat concerned about yourself.
At the risk of sounding trite or affected, I must honestly
say I feel a deep sense of responsibility for each one of you
who are reading this chapter. I want to do everything I can
to help prevent the tragedy of heart disease from touching
your life. I have seen too many that have been hurt,
killed, and crippled by this murderer to be unimpassioned on
the subject. From that perspective, let me make a closing
request: if this chapter has convinced you of areas that you
need to change in your life, do not delay. Now is the very
best time to improve your diet and other lifestyle habits.
Do not wait for warning signs or a first heart attack before
getting serious about lifestyle changes. By then you may
have already developed irreversible disease. Worse, yet,
heart disease may claim your life before you are ever aware
that you had a heart problem.
For your own sake and the sake of your loved ones, why not
embark on at least some elements of a new lifestyle today?
If you stick with such changes, I am convinced you will
regard them as among your life’s wisest investments. After
all, the investment will pay dividends in providing longer
life, disability prevention, and an enhanced quality of life.
Do not procrastinate-start to get more of the full benefits
of a heart disease preventive lifestyle today.
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