- I. Introduction
- II. The Well-Informed Patient
- III. The Nature of Medicine
- IV. The Personal Narrative of the Patient
- V. The Pharmaceutical Route
- VI. The Role of Herbs and Supplements
- VII. Food is Medicine for Heart Disease
- VIII. The Value of a Comprehensive Approach
- IX. The Patient-Doctor Relationship
- X. Conclusion
- Essential Resources
If you presently have heart disease or high cholesterol, or have been told by your doctor that you have some risk for heart disease then this article offers you some insight to help you become a more well-informed patient, and some basic structure for preventing heart disease. There is a significant amount of evidence that active, involved patients have better outcomes in their treatment of heart disease or it’s elevated ‘risk factors’ than those who are passive, seemingly uninterested patients. In fact, there are thousands of active, involved patients who have prevented development or reversed their heart disease by becoming a well-informed patient who, by definition employs a significantly healthier lifestyle.
A well-informed patient has the skills and knowledge to communicate with their doctor and form a mutually beneficial relationship where the patient’s health significantly improves and the physician becomes aware of the value in patients taking an active role in their healthcare with lifestyle modifications among other things. You do not have to presently be diagnosed with heart disease, or consider yourself to be ‘at risk’ for it in order to make great use of the information in this paper. After all the underlying condition of most heart disease, atherosclerosis, is found in 80-90% of Americans over the age of 30 (84). Knowledge of how to prevent heart disease can help almost anyone become a well-informed person and potentially live better.
If you know someone with heart disease or high cholesterol then they may find some use from the information presented, please forward it to them. For general background you can read the first post of this series entitled “Food is Medicine”, although it is not necessary. This is the second article in a series of papers covering the role of food in medicine. Cancer, auto-immune, gastrointestinal, diabetes and obesity will each be covered in this series, as will the conceptual-philosophical approach to healthcare/self-care.
First, I am not a medical professional, I am not offering medical advice whatsoever, and this article is not intended to give medical advice. Professionally, I am employed as a personal trainer in Pittsburgh, I also contract independently as a health/fitness/lifestyle consultations to people seeking to optimize their health and fitness locally and around the country via Skype, e-mail and over the phone. I am typically recruited by people who sincerely desire to improve their life and wellness by adopting a structured lifestyle which I formulate and customize for them to optimize their health and fitness.
Often times a client will come to me seeking information about a specific health issue in which they or a loved one is dealing with in the hope that there is something they can do about it themselves with diet and exercise. Heart disease is the most common disease I am asked about, high cholesterol is probably the most common health issue that clients and associates want to know more about, and other ‘risk factors’ for heart disease such as high blood pressure are very common as well.
As a result I have learned a considerable amount about lifestyle as it relates to the development and complementary treatment of heart disease and high cholesterol, as well as the specific lifestyle and dietary factors that contribute to improvement of overall health. My self-education is ongoing, largely consisting of reading the relevant literature which includes the latest medical research and a multitude of books written by those who have successfully treated heart disease and it’s ‘risk factors’ in the clinic. I am also in touch with the quickly evolving integrative health scene in order to become aware of and very familiar with how these clinicians view and treat high cholesterol, heart disease and it’s ‘risk factors’.
The integrative health scene generally employs a more holistic and comprehensive approach than that offered by practitioners of conventional medicine. The integrative health practitioners, including specially trained physicians, use lifestyle modifications which may include a specific therapeutic diet that has been formulated to address what these professionals typically believe is the underlying cause of most chronic disease, symptoms and ‘risk factors’. Integrative health practitioners also employ one or more of the following: herbs and supplements, exercise regimens, strategies for stress relief and various alternative therapeutic measures. These practitioners tend to focus on facilitating the inherent ability of the body to self-regulate and restore itself through addressing what they feel are the underlying condition behind the specific disease, symptom or ‘risk factor’ they are treating.
Occasionally an integrative practitioner will employ a pharmaceutical, but these physicians generally seek to avoid the risks associated with drugs unless they feel that it is relatively effective, poses little harm and is part of an overall course-of-action that encourages the body improve itself. As a result there are only a few pharmaceuticals these practitioners employ in treating their patients. In the conventional treatment of high cholesterol, heart disease and it’s ‘risk factors’ there is a prevailing focus on one bio-marker, cholesterol concentration, which often times leads to the prescription of statin drugs. It is up to the patient diagnosed with heart disease, evaluated as high cholesterol or elevated ‘risk factors’ to become well-informed in regards to their whole situation including the potential causes, the underlying condition, the various options for treatment and the risks and potential benefits associated with them.
II. The Well-Informed Patient
The purpose of the information shared in this paper is to add some perspective to how you view your diagnosis of heart disease, or high cholesterol or apparent risk for heart disease. More importantly this paper intends to help you shape a more holistic vision of your health, yourself and the beliefs you have about yourself, nature and medicine. The well-informed patient is curious about their health issue, health in general and various options for treatment. It is required that the well-informed patient become a skeptic.
Science is data-driven, assembled by scientists and presented in reports which can interpret and present the data in a multitude of manners. Naturally, it has to be questioned and even investigated by the well-informed patient; and they do not have to be a scientist to do such a thing. In this paper I will present a potentially different perspective on health, ‘risk factors’, the use of statin pharmaceutical in the treatment of heart disease and high cholesterol; and I will employ the medical research in doing such a thing.
First, the standard approach to ‘risk’ for, and treatment of heart disease always includes “eating a healthier diet”, therefore I will briefly introduce them now and analyze them later. There are a number of therapeutic diets that have been successfully used by people desiring to prevent or complement the various treatments, if any, employed by their physician. There is the Dean Ornish (M.D) lifestyle and diet which been clinically validated and has lead to hundreds of centers across the country directly employing it in treatment of heart disease. There is also the Caldwell Esselsytn (M.D) diet for preventing and reversing heart disease that has a considerable amount of positive anecdotal reports along with clinical studies that seem to support it. There is also a significant amount of anecdotal reports and clinical studies that support the use of the Paleo diet and the Mediterranean diet in the treatment of ‘risk factors’ for heart disease.
These diets have a common theme: they replace highly processed food and drink with minimal amounts of processed food and generous amounts of natural food. The client who comes to me seeking information about heart disease usually wants to know all about how their diet affects heart disease or high cholesterol. They may ask me about one of those diets. However, it is of the highest importance that the “health enthusiast’ with heart disease or ‘at risk’ for it becomes a well-informed patient for their physician and/or cardiologist prior to learning about the role of food as medicine.
The willingness of the client who comes to me seeking information is an encouraging sign because it shows that they do not feel like they have been sentenced to a life of suffering or permanently high cholesterol and/or other ‘risk factors’ such as high blood pressure. This also shows that this person may believe that he or she can change their present health situation. In my experience the degree of belief that someone has in the following two things largely dictates their success in dealing with heart disease:
1) belief that their situation can be improved, and
2) belief that they have what it takes mentally, physically and emotionally to improve their situation.
Belief is a powerful thing, there is no point to me feeding you the information as to why and how various lifestyle modifications can improve your life tremendously while diagnosed with heart disease or elevated ‘risk factors’, if you do not truly believe that you can improve your health situation. Belief in yourself and the ability to change your situation is what I call self-empowerment.
The Framingham Heart Study, a monumental epidemiological study (which may have originated “risk factors” of heart disease) of more than 5,000 people over the span of a few decades gave researchers enough data to make a lot of connections between heart disease and various lifestyle measures including one’s belief. There was even data on the role of belief in heart disease: researchers have observed that women, with similar ‘risk factors’ were four times (4x) more likely to die if they believed they were prone to heart disease (13), (31). This leads me to ask: Is the well-informed patient with self-empowerment four times (4x) more likely to live a high quality life if they believe that they can take control of their heart disease and ‘risk factors’ associated with it.
Prior to actually discussing with a client the extremely safe and highly efficacious lifestyle modifications that I am aware of, I make it clear to the client that they need to have a basic understanding of heart disease, and how it tends to be handled by conventional medicine.
Ask yourself: how risky is changing my eating patterns, employing a daily stress relief strategy, improving my sleep habits and exercising with structure?
Heart disease is complex and multi-factorial (111). The human body itself is complex and multi-variate, affected in many known and unknown ways by water, air, foods, thoughts, movement, posture, environment and so on. The development of risk factors for heart disease, which includes high cholesterol, high levels of inflammation and high blood pressure, is also very complex and each individual seems to respond differently to drugs, foods, stress, exercise, sleeping patterns and so on. You do not have to become an expert on heart disease, it’s risk factors or the human body, but it puts you in the best position to have a conversation with your doctor if have a basic understanding of heart disease, lifestyle factors and the human body.
Although each case of heart disease, high cholesterol and elevated ‘risk factors’ has a similar pathology and a similar pathogenesis (development), each patient is a unique case; it’s important that you remember this when learning about your health. You have your own story, and you can change it, and when you do you want to change your overall health, not necessarily some small signs of it.
It is also essential for many well-informed patients to prevent themselves from becoming hyper-critical of the conventional medical treatment of heart disease, high cholesterol and other ‘risk factors’. The physician uses medicine for treatment, that is what they have been trained for and are expected to do by almost every patient. Furthermore, a nice percentage of physicians prefer to use pharmaceuticals in treatment of chronic disease only after lifestyle modifications have been recommended and/or attempted. The problem is that these physicians are generally not well-equipped to give their patients the knowledge or skills needed to sincerely employ a better lifestyle and reduce their heart disease risk.
Physicians weigh the risks they are aware of, and the benefits they are aware of in regards to a prescribing a drug; prior to that they consider the health, mindset and outlook of the patient among other things. If a patient is sincerely interested in living significantly healthier, making lifestyle modifications, comes prepared to have a real conversation about treatment and desires to learn about their diagnosis and their ‘risk factors’ then the physician is likely to view the case in a different light than when a patient is not very involved.
In your role as well-informed patient you will have a candid conversation with your physician or cardiologist, offer useful perspective and give knowledgeable feedback when it comes time to determine your course of action for treating heart disease or it’s ‘risk factors’. It is the duty of the patient to be active in his or her health. The people who give up this duty may give up a lot more as you will see later….. But, it is up to you to not only make the choice to become active in your treatment, it also requires patience, persistence, sacrifice and discipline. It is my duty as a ‘lifestyle consultant’ to let you know that beforehand.
Finally, if you aren’t yet ready to take the role of well-informed patient because you are skeptical that heart disease is even controllable, and that you have the ability to significantly improve your overall health then I recommend that you apply that line-of-thought to everything else in life and see where that gets you. If you feel sorry for yourself and feel that there is nothing that can be done, then you’re probably right and I don’t feel for you.
The patient who believes that they have what it takes to improve their situation, maintains a healthy degree of skepticism in their accumulation of knowledge, and a positive view of their doctor in their role as patient will put themselves in position to improve their overall health, which is the ideal goal anyhow.
III. The Nature of Medicine
At present moment and in the recent past the standard physician tends to employ pharmaceuticals as the main line of treatment in heart disease, high cholesterol and ‘risk factors’ for heart disease. This is due to a number of reasons. Your doctor knows that lifestyle factors, specifically food choices play the primary role in the development of heart disease and it’s risk factors (19), (20), (21). Your doctor is well aware of the influence that food has on heart disease, but he or she is unlikely to be very knowledgeable of nutritional biochemistry, or be familiar with some established hypotheses regarding the pathogenesis of heart disease; it’s not what they do, conventional clinicians typically do not investigate and address the cause of heart disease.
The typical physician knows that high cholesterol is not the cause of heart disease, he or she is likely aware that low-grade systemic inflammation and oxidative stress seem to be at the root of heart disease (72). Atherosclerosis is the underlying condition of most heart disease, it is a term for thickening of the artery walls; it is the complications from atherosclerosis that are the most common causes of death in Western societies (75). Atherosclerosis is a form of inflammation that is driven by oxidative stress. Cholesterol can “clog” arteries, and cholesterol plays a role in the development of atherosclerosis; it may or may not be a symptom of the problem, think of it as such.
Oxidative stress drives atherogenesis by modifying the LDL carrier of cholesterol (LDL is just a carrier of cholesterol;it is not cholesterol) and making it potentially dangerous to blood vessels(61). Once the LDL carrier of cholesterol is oxidized it can collect inside the blood vessels where it forms atherosclerotic plaque; this process is inflammatory, and over time can be observed as the thickening of the walls of the artery (69). There is more than one type of LDL particle, for the purpose of this article there are large, buoyant particles that seem benign in terms of atherosclerosis (I feel that they may eventually found to be beneficial to atherosclerosis, as they have an overall beneficial impact on the human body) and there are small, dense LDL particles. It is rather well established that small, dense LDL particles are more atherogenic than other LDL particle types (133).
Small, dense LDL particles are the ones with the most potential to become oxidized, and once they are oxidized they more readily collect inside the blood vessel, furthermore they can collect in blood vessels even when not oxidized. Non-oxidized LDL carriers of cholesterol also have the ability to initiate and contribute to atherogenesis and atherosclerosis, but to a lesser degree than the oxidized version. Although it is not proven that inflammation or oxidative stress is the cause of heart disease, excessive inflammation is extremely common in heart disease patients; it is rare for one of these patients not to be inflamed (70).
The effects of atherosclerosis differ depending upon which arteries in the body narrow and become clogged with plaque (84). If the arteries that bring oxygen-rich blood to your heart are affected, you may have coronary artery disease, chest pain, or a heart attack (84). If the arteries to your brain are affected, you may have a transient ischemic attack (TIA) or a stroke (84). If the arteries in your arms or legs are affected, you may develop peripheral artery disease (84) . As a result, inflammation and oxidative stress are linked with the evolution of cardiovascular disease and acute coronary syndromes. When you think of heart disease you should think of inflammation and oxidative stress.
Excessive inflammation and oxidative stress are not idiopathic; there is an underlying cause. It is very reasonable to believe that dietary factors directly cause damage to the artery and oxidation to the LDL particle which sets the stage for atherosclerosis to develop and in many cases persist to the point of heart attack and death. There is enough evidence to believe that hyperglycemia damages and inflames the arteries, which is the result of eating food and drinks that have excess sugar and/or starch (104). There is also a lot of evidence that excessive levels of omega-6 fats, especially linoleic acid directly lead to oxidation of the LDL carrier of cholesterol (105), (106).
Inflammation and oxidative stress only become detrimental when they overwhelm the body. The human body needs some inflammation and some oxidative stress to operate properly,as they initiate a number of chemical reactions and metabolic actions that benefit the human body in dealing with stressors among other things. They also tend to occur together and activate the endogenous antioxidant system (the Antioxidant Response Element or ARE) which is an internal system that responds with internally derived antioxidants such as glutathione or superoxide dismutase to neutralize the situation. But when the inflammation and oxidative stress overwhelm the capabilities of the ARE these once normal activities can become excessive and potentially become persistent as well. And, if an LDL cholesterol carrying particle has a weak protective membrane or hangs around in the blood for “too long” it will be readily oxidized and perhaps cause excessive inflammation, lead to atherosclerosis and the development of heart disease.
The conventional diagnosis for atherosclerosis and the determination of ‘risk’ typically results from a blood test and possibly a more advanced test like an ultrasound, ecg, stress test or angiogram. It seems that the total cholesterol and especially the LDL carrier of cholesterol carry more weight than the results from other tests; even moderately high cholesterol or high LDL often result in the suggestion for treatment with a cholesterol-lowering pharmaceutical, typically one from the statin classification.
Statins may also be prescribed for patients ‘at risk’ for or with signs of atherosclerosis but with safe levels of cholesterol. Pharmaceuticals are the leading treatment for atherosclerosis and heart disease, but they do not fully address the conditions or the causes of atherogenesis and heart disease.
An individual who has not had a heart attack or diagnosed with heart disease (especially coronary artery disease), but with high cholesterol or another elevated ‘risk factor’ is considered a primary prevention patient; an individual with the more serious condition is considered to be a secondary prevention patient. Both of these patients have atherosclerosis to varying degrees, both likely have excessive inflammation and oxidative stress to varying degrees as well, and both are not likely at present moment to seriously address the underlying causes or condition of their health issue.
In the conventional medical arena the primary prevention and secondary prevention of heart disease do not address the underlying causes of atherosclerosis and poor health because that is not the present nature of medicine. Medicine is presently focusing on reducing the body and the pathology of disease to small components in order to address them with increasingly complex chemical compounds that are designed to improve one small picture of health. As you will soon find out, this has resulted in many people improving their cholesterol numbers with statin drugs yet experiencing detrimental side-effects, detrimental changes to their physiology and no improvement to their overall health.
Statin drugs do not affect the underlying causes of atherosclerosis and heart disease, but diet can: therapeutic diets (presented in this paper) have the ability to significantly reduce levels of inflammation and levels of oxidative stress, build up their ARE, construct more resilient membranes for the LDL particles and prevent them (LDL particles) from hanging around in the blood for “too long”. All of the therapeutic diets for heart disease discussed in this paper are constructed with real food and complemented with minimally processed food which encourages the body to restore and regulate itself.
But no patient should expect their doctor to present one of the various therapeutic diets that have been reportedly used by thousands of heart disease patients in the clinical setting and on their own accord to significantly minimize their ‘risk factors’, reverse their heart disease in many cases and generally improve their overall health to significant degree. The typical physician and cardiologist have taken one course on nutrition; if they are somewhat knowledgeable it is generally from reading a few books and possibly taking a continuing medical education (CME) course on integrative medicine or lifestyle as it relates to health.
There is also a general misconception in the medical community, potentially stemming from the lack of diversity and open-mindedness when it comes to investigating the research on nutrition, that reducing saturated fat is the key for preventing and complementary treatment of heart disease with dietary measures. In fact, the Ornish and Esselstyn diets both focus on reducing and eliminating saturated fat despite the fact that there is no significant evidence for concluding that dietary saturated fat is associated with an increased risk of coronary heart disease or cardiovascular disease (22).
That conclusion is based upon a comprehensive review paper which features many, many other studies which may or may not include these prospective studies which also found no association between saturated fat and heart attack risk (32), (33), (34), (35), (36). There is also a study from Japan which shows that diets lower in saturated fat are associated with higher rates of mortality from stroke (56). There are also two infamous studies that attempted to reduce patients cholesterol levels by advising them to eat less dietary cholesterol and less saturated fat over a 5-year period only to watch those people have the same heart attack rate and heart attack death rate as those who did not (50), (51), (52).
This is not to say that the Ornish and the Esselstyn diets do not work at improving bio-markers associated with heart disease such lowering LDL-concentration of cholesterol, because they do, very much so in fact (46), (47). . This is also not to criticize the physician who has invested considerable time and effort into researching lifestyle as it relates to health and recommends that their patients reduce saturated fat as a means of addressing heart disease, high cholesterol and elevated ‘risk factors’ with dietary measures. There are a multitude of other general health diets that are likely effective in helping heart disease, high cholesterol and elevated ‘risk’ because they offer structure to one’s eating pattern and prominently feature natural food and discourage highly processed food.
This generally reduces chronic low-grade inflammation, oxidative stress, encourage the ARE to build itself, and potentially also reduce the number of LDL particles and their circulation time as well which direclty encourages the body to return itself to more normal operation. Real food has known and unknown affects on the human body that encourage it to restore and regulate itself; which is likely enough for primary prevention (without disease) and can be a centerpiece for secondary prevention complemented by whatever route the physician chooses to take.
For now the point is that the physician and/or cardiologist are unlikely to have deep, practical knowledgeable of how to use dietary measures in their treatment of heart disease and reduction of ‘risk factors’. He or she may give diet a mention, recommend that the patient consult a nutritionist, suggest they read a book or two and very likely will make the broad suggestion to “eat healthier”. The typical physician and cardiologist do not give lifestyle modifications the appropriate respect because that is not the nature of their practice or of medicine as a whole.
If a doctor also has advanced training in nutrition as it relates to disease and offers sincere, structured guidance to their patients for employing lifestyle modifications then they are already labelled an ‘integrative physician’. In which case the patient would already be aware that their doc does these things and they would no longer be classified as typical. But these medical professionals are hard to find and many of them are so busy that new patient have to schedule appointments from months beforehand. This puts the onus on the patient to become well-informed about their condition and the potential of lifestyle modifications.
Another prominent reason that pharmaceuticals are employed by conventional medicine as the chief treatment in heart disease and high cholesterol, and by many clinicians in the reduction of ‘risk factors’ is due to the relentless influence of the pharmaceutical industry. Drug companies advertise directly to the patients and they bombard the physician and cardiologist with propaganda, which or may not be misleading.
An older research paper found that only 6% of the brochures from drug companies that are routinely sent to, directly given to, and found in doctor’s offices contained statements that were scientifically supported by identifiable literature (29). The physician is highly unlikely to give legitimate consideration to these brochures when evaluating the risk/benefit of prescription drugs for their patients, but it is a sign that the drug company is in the doctor’s office.
IV. The Personal Narrative of the Patient
This article is not anti-pharmaceutical propaganda. The point of this article is to help the heart disease patient or patient with high cholesterol or elevated ‘risk factors’ improve their overall health and become a well-informed patient; awareness of the profound influence of pharmaceuticals is necessary information for the patient. Pharmaceuticals are useful in one respect; they offer physicians the chance to manage the symptoms of the problem, such as high cholesterol. Therein lies the problem though; pharmaceuticals generally do not offer the patient a solution for their chronic heart health issue, generally this is atherosclerosis. The search for a solution will become the chief concern of an enthusiastic, well-informed, self-empowered patient when they are confronted with options for treatment of their issue.
At this point you may find it easier to see why the typical patient employs a flawed view and employs a powerless personal narrative of their own health and healthcare. The typical patient asks their doctor some questions and has a general idea about what their diagnosis or ‘risk factors’ mean, but probably hasn’t performed diverse research and is unaware that employing a therapeutic diet is a legitimate, safe and effective option for primary prevention or as complementary treatment in secondary prevention.
As a result we have millions of patients who overlook the fact that their development of heart disease and increase of it’s ‘risk factors’ is just one sign of an overall lack of health, which is a systemic issue that is the result of a lifestyle that is incompatible with their own optimal health. The flawed personal narrative often times leads to surrendering hope for serious improvement, instead these people tend to hope for “management” of symptoms and ‘risk factors’ with a pill.
But you have read this far, you are similar to my inquisitive client, you seek to empower yourself by learning more about heart disease and the therapeutic diets that offer you the ability to address the underlying cause of atherosclerosis and improve your overall health. You have what it takes to become a well-informed patient. You are ready to develop your skills, increase your knowledge base and work towards improving your self-awareness.
V. The Pharmaceutical Route
Once again, pharmaceuticals typically offer patients the chance to reduce their symptoms to some degree (this may be accomplished by simply delaying the progression), or reduce their high cholesterol or ‘risk factors’ to a potentially significant degree, with side effects, of course. In addition to the risk associated with introducing complex chemical compounds into the body the main problem is that pharmaceuticals are not designed to improve the overall health of the patient.
Pharmaceuticals are designed to improve one sign of one aspect of health. The treatment and prevention of heart disease, high cholesterol and it’s ‘risk factors’ with statin drugs may be a shining example of how some treatments are very good at taking care of one small picture of someone’s health, by lowering someone’s high LDL cholesterol, while doing nothing to improve their overall health.
Is your overall health going to be considerably better by having a lower concentration of cholesterol in your blood? Maybe. It does appears that a person is more likely to have a heart attack or stroke if they have higher concentration of cholesterol (30). The standard cholesterol test evaluates the concentration of cholesterol carried in lipoprotein molecules; LDL, HDL and so on.
However, based on the previously described process of thickening of the artery (atherosclerosis) and development of heart disease it seems that the quality of the lipoprotein carrier (the degree of oxidized LDL particles) and the number of them (if you have less then they are less likely to get oxidized) may be more influential in terms of heart disease and overall health than the concentration of cholesterol found within them. But testing for LDL-concentration is standard and that is what cholesteol-lowering drugs like statins are designed and effective at reducing.
Would you take a pill that is highly effective at improving one small picture of your health (cholesterol concentration is obviously a very small picture of health)? Can improving one small picture of health lead to improvement in overall health? Does that pill came with side effects? Does everyone feel the side-effects, or are they just rare adverse events? This is a sample line of thinking that takes place in the process of becoming a well-informed patient. The answers to these questions will become more clear as you become a well-informed patient.
It is routine for a patient with heart disease to be prescribed a statin drug,this is secondary prevention. But the majority of statin users are not this type of patient; they are primary prevention patients without heart disease but with high cholesterol and/or other elevated ‘risk factors’. For your information there are more than 30 million statin drug users; the majority are primary prevention patients.
There are physicians and cardiologists who prescribe statins to primary prevention patients based largely the on strength of the conclusion from from this well-known study which shows that a statins can reduce major cardiovascular events when used in prevention, even in people with low risk (53).
Statin drugs appear to reduce cardiac events, but do they improve overall health? In a meta-analysis of 11 studies involving 65,000 participants it was found that statins offered no benefit to all-cause mortality in low to high-risk preventive patients (54). The conclusion from that study of other studies implies that statins do not offer an overall health benefit to people with elevated ‘risk factors’ (considered medium to high risk) but without a history of heart disease. Therefore, patients with low to high risk for heart disease appear to have less heart attacks when taking a statin, but their overall health appears no better and they die at the same rate as those who do not. It appears that primary prevention patients who take statins trade their heart attack risk for other illnesses, including cancer.
In women statin drugs actually show no overall mortality benefit to those with or without diagnosed heart disease; in those women diagnosed with CHD they lower death from CHD but increase death from other causes which neutralizes the benefits from lowered LDL concentration (8). It is on the way to becoming established in medicine that women do not derive much benefit from statins; when the mainstream starts to agree on something you know that there is an overwhelming amount of evidence.
A previously popular heart disease drug called Vitorin, which is not a pure statin but instead a combination of two chemical compounds, one being a statin, that lower cholesterol by different mechanisms, worked incredibly well at lowering cholesterol but nearly doubled the risk of heart disease (7). This leads to questioning just how important the role of cholesterol is in the development of heart disease, and encourages me to view LDL-concentration of cholesterol as relatively small picture of one’s heart health, and a miniscule picture of one’s overall health.
The physician has to be confident that the benefits of statin use outweighs the risks associated with them when prescribing them to patients. It may be up to the well-informed patient to ask their physician to consider their overall health, and not just the likelihood for cardiac events when considering treatment options. It is also up to the well-informed patient to be aware of negative information in regards to stain drugs and present it to the physician when they are “working together”in determining the risk/benefit of various treatments for elevated ‘risk factors’ or heart disease itself.
At this point the overall health benefits of statins for prevention of heart disease do not appear significant. How about for people with heart disease?
Statin therapy for people with established coronary heart disease (CHD) prevents complications related to atherosclerosis and there is literature supporting the contention that statins reduce all-cause mortality in only these types of patients (2), (3). This is considered to be the case where statins undeniably “work”, but upon closer inspection of data from the well-known PROSPER study there is some serious doubt as to whether the benefit from statin use in people with established CHD is actually “clinically significant” (16).
The PROSPER study is routinely cited as evidence that statins reduce the risk of coronary disease in elderly individuals, the data does show that there is “statistical significance” to their benefit with use in people with established CHD. However, we have to “look inside” the data to find the reality of the situation. In this study there were 2913 placebo and 2891 in the treatment group. In the first 3 years there were 306 deaths in the placebo-group and 298 deaths in those taking the statins; a very small difference which is enough to be considered “statistically significant” (16) .
The patients in the PROSPER study were selected because they were the type of patient considered to be undeniably helped by statins. Coronary heart death was significantly reduced in the treatment group, but the overall number of death in the placebo group from other causes, especially cancer means that 10.3% of those in the statin group died as opposed to 10.3% of those in the placebo group; a virtually undetectable difference which potentially makes it “clinically insignificant” (16). In the clinic, would this be enough to convince a physician of the efficacy of statin drugs when treating similar patients? Or, would it make sense to look for better options since the difference was so small?
First, there are different types and levels of side-effects. Everything other than the intended effect is a side-effect; regardless of whether it is beneficial, potentially detrimental or clearly harmful. At this point we can see that statins do not appear all that effective at improving the overall health of it’s users despite being very good at lowering cholesterol levels and decreasing risk for heart events. The presently popular statin drugs are relatively more complex than the older ones, but they all come with a multitude of effects in addition to their intended effect to inhibit cholesterol sythesis in the liver in order to decrease free cholesterol.
Statins also appear to increase the expression of the LDL receptor which allows the liver to take in more cholesterol from the blood (this is a new hypothesis generated from studying statins) (39), (38). This qualifies as a side-effect, although it is very, very helpful in lowering cholesterol levels which is the overall intention of the drug. There are also a multitude of unknown and not yet well understood beneficial effects of statins which are known as it’s ‘pleiotropic effects’ (12).
The presently known ‘pleiotropic’ effects of statins include, but are likely not limited to their ability to lower blood pressure and display an anti-inflammatory effect (10), (11). Some statins may also increase HDL cholesterol concentration levels in ways that are yet unknown (80). Higher HDL levels are associated with better health, as is less inflammation. I hypothesize that the ant-inflammatory effect is the chief reason is why statins “work” in reducing likelihood for heart attack.
Cholesterol is not the cause of heart disease although it undoubtedly plays an important role in the pathogenesis of atherosclerosis and the development of heart disease and heart events. It doesn’t appear that simply lowering the concentration of cholesterol in the blood helps people improve their overall health as reflected in a study a multitude of trials where patients had their cholesterol levels lowered in a variety of ways yet never improved their overall health as represented by no improvement to length of life (113).
Oxidative stress and inflammation are much more influential to overall health, atherosclerosis and heart disease. As a result I feel that the anti-inflammatory effect of statins, although relatively small, my legitimately be the reason why it can save some lives from heart attacks and help some very ill people. However, I strongly feel that the small level of anti-inflammatory effect is nowhere near enough to help anyone qualifying as primary prevention, and many, possibly the majority of those considered secondary prevention patients.
The increase of HDL cholesterol recently found from some statin drugs is probably less important than the anti-inflammatory effect. There is reason to believe that HDL does not “protect” people from heart disease and atherosclerosis in the way that scientists previously speculated that it did. The standard narrative is that “the body makes HDL to remove excessive cholesterol from the blood (and tissues), known as “reverse cholesterol transport” where the HDL takes cholesterol back to the liver in order for it to metabolized and removed from your body“.
However, the body is much more complex than that and it appears that HDL promotes good health because of other reasons (HDL delivers cholesterol to adrenals and reproductive organs, HDL also has the ability to minimize oxidative stress and inflammation), not because it clears cholesterol, although it does. There was a highly funded study called ILLUMINATE where researchers combined a drug that increases HDL with a statin (atorvastatin) in order to attempt to make it’s user “bulletproof” from heart disease by optimizing one’s “good” and “bad” cholesterol at the same time (107).
However, the results were disastrous as it had to be stopped unexpectedly after a little more than a year of treatment due to an excess of deaths in the torcetrapib/atorvastatin versus the statin only groups (atorvastatin) (82 versus 51, respectively) (107). . Increases in heart failure, angina, and revascularization procedures were also observed. This is another piece of evidence that points to the danger and ineffectiveness from “optimizing” one’s health with pharmaceuticals. Even the simplest statin, losuvastating which is derived from fungus and the closest to the natural world has detrimental effects.
Improvement of overall health is a holistic practice, the body is a system of systems in which good health can be signified with biological markers and not created by the biological markers themselves. Changing biological markers with pharmaceuticals is not the same as improving body function by eating real food, which is likely to improve biological markers. Many pharmaceuticals are derived from a natural substance, as the most basic, least complex statin called lovastatin has been, which means that it may be the safest of all the statin drugs, yet it still has detrimental effects in the body.
Lovastatin is able to reduce LDL concentration by up to 40% and also appears to have less severe, and less overall reports of side-effects than other statins. However, lovastatin has been shown to disruptsinsulin signaling which may promote insulin resistance and metabolic syndrome (90). Lovastatin, which is the statin closest to the natural environment, and likely the safest, still has a detrimental effect that compromises overall health.
Statins tend to have a multitude of known detrimental effects (there are more unknown that I am confident will be uncovered in the future) on body functions that are seemingly unrelated to cholesterol and not immediately noticeable. It appears that all statins have the potential to cause unfavorable metabolic effects such as reduction of insulin secretion and exacerbation of insulin resistance which may cause glucose intolerance and exacerbate or potentially form metabolic syndrome (97). Statins may affect the insulin signaling and glucose intolerance by way of the liver, but scientists just cannot say that without further investigation (98).
Statins pharmaceuticals have become increasingly more complex over the last few decades, progressing well beyond the lovastatin form derived from fungus. In fact, the type II statins are fully synthetic, whereas lovastatin is the base for type I statins which are chemical modifications of a naturally derived substance, which also includes provastatin and simvastatin. Type II statins appear to have more drastic, yet still somewhat modest, impact on the physiology not related to cholesterol. The following information as it applies to side effects from statins is predominantly related to the type II statins: atorvastatin, rosuvastatin, cerivastatin and fluvastatin.
In a review of statins not published in a mainstream journal the author showed that 96% of non high-risk users saw no benefit at all, 1.2% (1 in 83) had their lifespan extended (were saved from a fatal heart attack), 2.6% (1 in 39) were helped by preventing a repeat heart attack, 0.8% (1 in 125) were helped by preventing a stroke, 0.6% (1 in 167) were harmed by developing diabetes yet 10% (1 in 10) were harmed by muscle damage (6).
In a thorough review of clinical trials and epidemiological studies on statins by a researcher from Harvard upon reviewing the data he was lead to question the risk/benefit of statin use in patients without a history of CHD, stating that “in some subgroups statins cause serious unrecognized harm, which negates the beneficial effects if the benefit is small—ie, most primary prevention settings.”(4), (5).
A recently published study in the Annals of Internal Medicine found that 17 percent of patients taking statins reported side effects, including muscle pain, nausea, and problems with their liver or nervous system (17). That is a recent update to the widely assumed statistic that only 10% of statin users reported side effects.
Also, if you are not able to hold a conversation with your physician in regards to the risk/benefit analysis, and if you meet the basic example that I previously gave for the ‘typical’ patient then you may be more likely to take a drug without basic knowledge of it’s dangers. I hypothesize that the ‘typical’ patient is responsible for the under-reporting of side-effects from statin drugs since it seems very likely that the number of patients typically assumed to experience side effects while taking a statin drug is significantly underestimated (18).
The ‘typical’ patient may never report side-effects, and the typical physician may not mention them to uninvolved patients. There is a research study showing that physicians when talking with patients are more likely to deny than affirm the possibility of statin side-effects, even for symptoms with strong evidence in the scientific literature (18). The ‘typical’ patient may be less likely to report an adverse reaction in these circumstances. The typical patient may not be aware of the danger posed by the complex, not fully understood class of statin drugs.
At this point we can say that statins are really good at lowering the concentration of LDL cholesterol, they have an anti-inflammatory effect, they may raise HDL some, they may damage someone to a notable degree, and they will change the physiology of the body to some degree, all of which leads to no improvement to overall health for almost every type of patient taking them (all primary prevention and most secondary prevention).
Despite this, statin drugs continue to be one of the most popular class of pharmaceuticals in the history of medicine in the United States. Statins are the drug of choice for treating high cholesterol, other ‘risk factors’ of heart disease and management of the diagnosis of heart disease. Statins are highly effective at reducing a single bio-marker of heart disease (concentration of LDL cholesterol) but come with a variation in cholesterol responses and a multitude of known side effects (1), and appear to offer little to no overall health benefits.
I have not and can not be critical of the effectiveness of statins in their ability to lower LDL concentration, I am contending that statins and other complex cholesterol-lowering drugs do not improve the overall health of it’s user. Additionally, the detrimental unintended effects of statin drugs, generally known as side effects, far outweigh the small-picture benefits of lower LDL concentration, potentially higher HDL, anti-inflammatory effects and less mortality from heart complications (although overall mortality is about the same).
Pharmaceuticals cannot offer solutions for atherosclerosis or heart disease because they cannot address the cause or make significant, continuous change to the underlying conditions associated. Statins may be able to reduce the concentration of LDL cholesterol, but they do not appear to reduce the likelihood that the system will have low-grade inflammation, that LDL particles will be small and dense and/or become oxidized and collect in the artery walls leading to atherosclerosis.
If an outstanding scientist comes along and invents a chemical compound that somehow prevents the formation of small, dense LDL particles and/or prevents the oxidation of LDL particles I am confident that it will come with a tradeoff that compromises overall health. This is because the underlying condition of the body that relate to atherosclerosis, heart disease and overall health (inflammation and oxidative stress) are largely determined by how the person (or patient) interacts with the physical world; how they eat, drink, sleep, handle stress and move. Therefore, a pharmaceutical can improve one small sign of health, like LDL concentration, and have little influence to improve one’s overall health.
However, self-empowerment (belief and persistence among other things) and knowledge of how to eat “healthier” offers a solution to all primary prevention and secondary prevention patients, although each case is unique which means that drugs and/or supplements are often times necessary for a patient to facilitate restoration and regulation of their body (talk to your physician please).
VI. The Role of Herbs and Supplements
There are a multitude of supplements and herbs that have been shown to prevent atherosclerosis, decrease LDL, decrease inflammation and improve overall health as it relates to heart disease. Nutritional supplements and herbs are decidedly safer than statin drugs, although their danger generally lies in their ability to interact with the prescription drugs that someone also takes, so be sure to discuss with your physician the herbs and supplements that you want to take.
There are too many supplements and herbs with claims to help with heart disease for this discussion to include them all, but I have included all of the non-prescription drugs with scientific research that I am presently aware of, and demonstrate some effectiveness or initiate a useful discussion. This is not a comprehensive list. These are:
- red yeast rice
- fish oil
- the amino acids taurine and arginine
- Ligusticum chuanxiong hort (a chinese herb)
- vitamin D, fiber, various antioxidants
- there are many more commonly used, but not covered here
Aspirin is available over the counter, it is a relatively simple compound in relation to statins, and may be just as effective at half a dose as it is in a full dose (41), (42). Although aspirin does not seem to affect LDL cholesterol, the British Medical Journal published a paper showing that aspirin may be almost as effective as statin drugs in the overall treatment for people that have risk of heart disease but are not yet symptomatic (9). Although aspirin is not considered a prescription drug, it may be just as effective as statins are and appear to be safer than statins, although they also come with risk (44) (43).
Niacin, a natural compound essential to the human body is remarkably safe and effective at improving overall health in the context of primary and secondary prevention of heart disease and high cholesterol. Niacin, or nicotinic acid, raises HDL levels by as much as 20% and lowers LDL slightly which leads to a reduction of heart events and regression of atherosclerosis (88). Niacin is appropriately classified as a supplement, but it has been used by physicians for more than 50 years, and newer formulations typically offered through the pharmacy are decidedly safer than the isolated version available in supplement stores (89).
Lovastatin the pharmaceutical is derived from fungus, but it is also a naturally occurring substance found in red yeast rice. Red yeast rice, available as a dietary supplement, lowers LDL-concentration very signficantly, comparable to that of statins and offers an alternative to patients with ‘statin intolerance (91), (93), (94). Red yeast rice shares another trait with statin drugs: potential for serious side effects (95). Red yeast rice may be a useful alternative for people with high cholesterol and low to medium risk;it can especially useful for someone in the midst of making lifestyle and dietary changes that address the condition and cause of atherosclerosis and heart disease.
A review of prospective, randomized, placebo-controlled clinical trials that evaluated clinical cardiovascular end points which all lasted more than one year found that dietary supplementation with omega-3 fatty acids should be considered in the secondary prevention of cardiovascular events (it is already widely used and believed helpful in primary prevention) with no adverse events or side effects reported (26). Fish oil, a dense source of omega-3 fatty acids has been combined with garlic to lower LDL by about 10% and triglycerides by about 33% in just one month (111).
Short-term supplementation with garlic has shown increased resistance of LDL particles to oxidation (109). There are a multitude of mechanisms by which garlic can display a cardioprotective affect which makes it a useful component for those managing their risk factors and those with CVD in the highest risk group with virtually no chance risk or side effect potential (27), (28). Garlic has been shown to help overall health in numerous ways which makes it useful for virtually everyone for helping almost anything related to health. Chocolate has also been shown to help overall health in many ways.
Chocolate, real and dark, not the industrialized version with sugar has been shown to modestly reduce LDL oxidation susceptibility, increase serum total antioxidant capacity and HDL-cholesterol concentrations (116). Dark chocolate lowered blood pressure, improved insulin sensitivity and lowered LDL in this relatively short-term study (117). Dark chocolate, at least 70% cocoa appears to be very helpful to overall health.
Chocolate is also very good for endothelium function, which is the inner lining of the artery which is responsible for producing nitric oxide that widens the blood vessels. Obviously, it is very important to optimize endothelial function in anyone with any degree of atherosclerosis. Therefore, supplementing with as much as 100 g of dark chocolate (70% and more) may be helpful as it has been shown to increase nitric oxide availability, and thus improve arterial function (140), (141).
Arginine, an amino acid is actually a precursor for the synthesis of nitric oxide, and supplementing with it will increase nitric oxide synthesis in the endothelium (142). Arginine is naturally made in the body, but supplementing with it has been shown to be of great benefit to arterial function by way of improving insulin sensitivity, decreasing oxidative stress in addition to the nitric oxide generation (143), (144). It may be advantageous to take it with a mixture of citrulline, the substance it is synthesized from in the body, in order to maximize the benefit. Another amino acid, taurine, is also beneficial to endothelial function as it reduces inflammation and oxidative stress while increasing NO generation (145).
The typical physician may not be aware of just how effective and safe these herbs and supplements are in helping someone improve their health and treat atherosclerosis and heart disease. It is not the nature of their work, but when a well-informed patient presents them a well thought out approach that employs pharmaceuticals they will likely become more informed about them and potentially be open to using them as part of a safe and effective course of action for primary prevention, and even many secondary prevention patients. Herbs have been around for thousands of years before pharmaceuticals, and there may be some real potential there for some help.
There are many herbal protocols that have been used by Traditional Chinese Medicine (TCM) in the treatment of cardiovascular disease. Ligusticum chuanxiong hort which has been shown to decrease the levels of serum cholesterol, lower density lipoprotein, relieve the extent of atherosclerosis and reduces the red cell deformability in vivo, thus making it likely to help prevent atherosclerosis (23), (24).
Antioxidants, fiber and vitamin D have also been used recently in the treatment and prevention of heart disease and atherosclerosis, but the results are not yet very encouraging. Neutralizing oxidative stress with supplemental antioxidants, such as Vitamin E and C sounds good in theory because it is known that dietary antioxidants are extremely beneficial to overall health, but has not worked out yet in clinical trials (118), (119).
One antioxidant has become an integral part of primary and secondary prevention protocols by integrative physicians is Coenzyme Q10, but this is not because of it’s ability to neutralize the free radicals that cause high levels of oxidative stress. Coenzyme Q10 is regularly recommended by these practitioners because it is depleted by statin drugs (120), of which many, if not most of their patients are either presently using or have used in the past. Coenzye Q10 plays a role in supplying energy to the cells, and defending the mitochondria from oxidative stress; it is possible that the depletion of Coenzyme Q10 is a reason why statin drugs seem to compromise metabolic function in many people.
Fiber is another example where the supplemental form may not be as powerful as the form from real foods. Relatively long-term treatment with supplemental fiber can lower LDL concentration and sustain it (92), supplemental fiber in the form of a processed bar derived from fruits has alsonbeen shown to lower cholesterol as well (121). But only dietary fiber from real food is associated with better cardiovascular health for the long-term (120).
Observational studies strongly associate lower Vitamin D levels with a higher likelihood for heart disease, but studies evaluating supplementation with it have not shown any benefit (122). This is not to say that Vitamin D is not a relatively important marker of overall health, because it appears to be. However, improving one’s vitamin D levels is about more than supplementation, and is once again simply just one biological marker of health. Also, there is some evidence that vitamin D from sun exposure is far superior to that from supplementation, and that the ability to metabolize Vitamin D can be greatly diminished if someone has excess inflammation or excess oxidative stress.
Once again, an individual would be wise to address the causes and conditions of atheroscelerosis and heart disease before, or at the same time they take supplements and pharmaceuticals If they don’t they are likely to derive minimal benefit from them and make little improvement to their overall health, which should be the key to any course-of-action from a well-informed patient.
Also, using herb and supplements whilst using pharmaceuticals may present some serious potential for adverse events so it is your duty as a primary or secondary prevention patient to discuss this with your physician. Other than that the supplements and herbs discussed here appear to be very safe, with red yeast rice and aspirin presenting the most danger, therefore consult your physician prior to use.
Additionally, I would like to add that health is not created by herbs and supplements, health is created by our interactions with the natural world (how we eat, move, sleep, handle stress, etc.). Herbs and supplements are extracted, isolated, standardized and in most cases abstracted from the physical world, although to a lesser degree than pharmaceuticals, thus safer than pharmaceuticals, they are all considerably less effective than real food at addressing the underlying causes and conditions of atherosclerosis and heart disease. Herbs, supplements and pharmaceuticals can be a powerful part of one’s ability to improve their overall health, but it is the consumption of a better diet and more compatible lifestyle that actually improves one’s overall health to any significant degree.
VII. Food is Medicine for Heart Disease
Patients and physicians do not understand how much of an effect that “bad” food and an overall “bad” diet has on the human body. “Bad” foods tends to be those with concentrated doses of nutrients that are only made possible by extracting them from natural foods and using them as ingredients in processed foods. Sugar, starch and linoleic acid, a type of Omega-6 fatty acid are not inherently “bad” when they are found in the package of a whole food, but when they are extracted from real food, or delivered within the package of a highly processed food they become problematic. Starch from wheat is highly processed and inherently different than starch in a sweet potato or starch in white rice because it is rapidly digested and raises blood sugar faster than most commonly consumed starches (123), (124.)
Food may have the most profound influence on overall health. It is my hypothesis, and one that is shared, in part, by a multitude of other scientists, clinicians and M.D’s that excess sugar, starch and linoleic acid along with deficiencies in a multitude of micronutrients are the primary dietary causative factors of chronic disease. It is my opinion, and most of those who share my hypothesis that saturated fat has been wrongly incriminated in heart disease and atherosclerosis.
The conventional misconception that eating foods with saturated fat and dietary cholesterol will increase cholesterol and directly increase their risk for heart disease and a heart attack has lead to low-fat, vegetarian diets becoming the “gold standard” for preventing and complementary treating heart disease. And they work! But not because of the lack of saturated fat.
The Dean Ornish diet and the Caldwell Esselstyn diet are undoubtedly effective as evidenced by the clinical data and anecdotal reports turned in by thousands of people who feel better, look better, experienced virtually no side-effects and perhaps even prevented or reversed heart disease with their plans (80), (81), (82). These two therapeutic diets are highly effective and incredibly safe (in general and in relation to drugs) because of three main reasons
1) they are significantly better than the baseline diet of those implementing them
2) they encourage the body to regulate and restore itself
3) they encourage the participant to avoid highly processed foods in general, and those with excessive sugar and excessive linoleic acid
Ornish recommends 10% fat in his diet, Esselstyn recommends no oils and almost no fat at all. They both recommend that the large majority of calories are derived from complex carbohydrates with some protein as well. Ornish accepts egg white, lowfat/nonfat milk and lowfat/nonfat yogurt in his diet. Esselstyn and Ornish both promote vegetables and legumes, both are dismissive of refined grains although Esselstyn to a more significant degree. Both of these diets allow the ‘whole-grain’ food, but seek to only have the type without added sugar or added fats which makes the motivated participant think twice before buying the highly processed bread, cereals and pastas that are prevalent in the Standard American Diet. These diets very, very likely lead many of their participants to consume less refined starch.
It is my opinion that these diets work because they are very significant improvements to the Standard American Diet (high in refined carbs and vegetable oils and overall high in calories devoid of nutrition), they supply the body with a multitude of nutrients that may have been lacking, they somewhat address the underlying causes and conditions of atherosclerosis and they discourage excess sugar, excess starch and excess linoleic acid consumption. All of these factors work together in putting the body in position to restore and regulate itself at a heightened rate which in this case (with these specific diets) is very likely to result in lower LDL cholesterol concentration and improved overall health.
It is pretty clear that the avoidance of saturated fat is not why the Ornish and Esselstyn protocols work. In fact, upon examination of the literature it appears that saturated fat is benign at worst, but more likely beneficial to overall health of the human body. As Stephan Guyenet has noted, the studies which have shown saturated fat to increase LDL cholesterol were short-term (115). Saturated fat may increase total cholesterol by increasing LDL and HDL, but a multitude of studies have shown that saturated fat is not associated with an increased risk of coronary heart disease or cardiovascular disease (22), (32), (33), (34), (35), (36).
If the singular goal of one’s diet is to decrease their concentration of LDL cholesterol it seems like they would be better off restricting their overall calories then they would be from decreasing their saturated fat intake (99). Saturated fat also seems to offer protection. One review of The Nurses Health Study found that risk of coronary heart disease went down steadily as dietary carbohydrates were reduced and replaced by fat, some of which had to be saturated. Those eating a 59% carb diet were 42% more likely to have heart attacks than those eating a 37% carb diet. This only an association, but it does show that people can actually increase their relative fat intake, including saturated fat and experience better overall heart health (83).
There is also long-term study which asked one group to replace saturated fat with an oil largely composed of linoleic acid over a 5+ year span and left one group to their own devices which had previously been diets high in saturated fat.
The linoleic acid group suffered tremendously in relation to the other group who tended to eat saturated fat at levels near to, or potentially slightly lower than previous. The linoleic acid group had an increased risk of death from all causes, an increase in death from cardiovascular disease, and an increase in deaths from heart disease. The researchers calculated that an increase of 5% of calories from linoleic acid predicted a 35% increase in deaths from cardiovascular disease and a 29% increase in deaths from all causes. All of this despite the fact that they had lower cholesterol (100).
The misconception that replacing saturated fat with vegetable oils will improve one’s health is not based on data that specifically evaluated dietary linoleic acid (101). Making that switch may lower cholesterol, but linoleic acid will harm your body in excess amounts. In fact, when considering the data from 4 randomized controlled trials where researchers replaced saturated fat and trans fat (which may be the worst, although we already know that) it has showed no benefit, and a relatively consistent signal toward harm from selectively increasing linoleic acid (101).
Excess sugar and excess starch seem to only harm the body when consumed from highly processed foods like soda, bread, cereal, fruit juices, sports drinks, coffee-type drinks and pasta to name some of the most common American sources of sugar and starch. Starch and sugar is not inherently bad or threatening, as evidenced by the Kitavans, a traditional culture who get about 70% of their calories as carbohydrate. That is a higher proportion of calories from carbohydrate than Americans, which sounds excessive at first.
But when you get into their food quality their diet is composed of real food ( yam, sweet potato, taro, cassava, coconut, fruit, fish and vegetables) which leads them to having significantly lower insulin levels (insulin reflects carbohydrate metabolism to some degree, and is a risk factor for cardiovascular disease), much lower prevalence of heart disease, obesity and experience much better overall health than Americans (125), (126). Kitavans are a shining example that people can eat real food in a variety of manners, high carbohydrate or high fat, and experience very good overall health and less heart issues than Americans regardless of their cholesterol levels; oh yeah, Kitavans do not have great cholesterol numbers either.
Excess sugar and excess starch in the context of highly processed foods harm the body in a multitude of ways, fructose may do the most harm out of all foods, drinks and nutrients that raise blood glucose levels (126). It seems as though the Ornish diet and the Esselstyn diet basically reduce the level of fructose down low enough to allow the liver, the metabolism and the whole body to begin returning back to normal function as opposed to someone following a very Americanized diet. Excess fructose is terrible, that is undeniable, but in the development and treatment of atherosclerosis and heart disease we are equally concerned with preventing hyperglycemia.
As previously mentioned in the brief description of atherogenesis there is more than enough evidence to believe that hyperglycemia damages and inflames the arteries, which is the result of eating food and drinks that have excess sugar and/or starch (104). However, the standard definition and evaluation of hyerglycemia does not apply here, what applies here is the level of blood glucose following a meal, called the postprandial blood glucose. I hypothesize that keeping one’s postprandial blood glucose below 140 will put the body, the blood vessels specifically, in a position to restore itself by way of removing a stressor to the arteries in addition to allowing the metabolic system to self-regulate.
There is medical literature that support my contention. This study suggests that 2-hour postprandial blood glucose above 140 either represents, signifies or has potential to form a variety of health issues and higher mortality (128). This study found a link between glucose tolerance tests where someone’s blood glucose rose above 140 at the 2-hour mark it gave them significantly higher risk for stroke, which is an expression of heart disease (129). There is simply not a lot of studies on postprandial glucose as it relates to atherosclerosis, heart disease and health compromises related to them.
But, there is enough medical science literature regarding the composition of a diet to make the recommendation to eliminate highly refined foods with excess sugar and excess starch. This study implies that eating a diet high in carbohydrates (possibly around the American average of 50-60%) promotes atherosclerosis significantly more than a diet high in fat, low in carbohydrate (130). In fact, the researchers mention that the evaluation method used here, the Respiratory Quotient (RQ), a parameter measuring the fuel utilization is a solid, yet underutilized form of predicting atherosclerosis (130).
If you recall, atherosclerosis is caused by foods which lead to excessive inflammation and oxidative stress that then modify the LDL carriers of cholesterol while also harming the blood vessel. My contention is that excess sugar and excess starch harm the blood vessel with their resulting hyperglycemia, but it also appears that excess sugar and starch also have the ability to modify the LDL particle with oxidative stress, something I had previously presented as being due to excess linoleic acid.
This study compared low fat/carb dieting to high fat/low carb dieting and found that when the subjects consumed the higher carboohydrate eating a multitude of negative shifts occurred in various bio-markers related to atherosclerosis, including the shifting of LDL particles towards a smaller, denser structure (131). Another study compared 26% carbohydrate diet with 54% carbohydrate diet and found that the lower carbohydrate diet improved many bio-markers of heart disease including reduction in small LDL and increase in larger LDL (the benign kind) (132).
There is plenty of evidence to hypothesize that any diet which directly encourages the participant to directly cut out foods, drinks and meals that have excess sugar, excess starch and excess linoleic acid without focusing on reducing saturated fat can be considered therapeutic for heart disease, high cholesterol and elevated ‘risk factors’. Primary and secondary prevention patients can progressively create higher levels of control over their health, create higher levels of self-empowerment and create better overall health with a diet built from that framework.
That is a great framework for us to start with, from here the science shows that eating real food has a multitude of benefits including but not limited to:
- There is a considerable amount of evidence showing that eating more natural plant and animal foods is associated with less risk for heart disease (71), (73), (74). Individuals with a high intake of fruit and vegetables have a clear reduction in heart disease(66), (67), (68).
- A very high fiber vegetable, fruit and nut diet can notably decrease LDL-concentration levels in as little as 1 week (148)
- Eating nuts frequently is associated with a decreased risk of coronary heart disease of the order of 30-50%. Nuts may include reduction in LDL cholesterol, the antioxidant actions of vitamin E, and the effects on the endothelium and platelet function of higher levels of nitric oxide. (102).
- Nut consumption improves blood lipids in a dose-related manner, particularly among people with higher LDL concentration (103).
- Increasing consumption of omega 3 fatty acids from fish or fish oil reduces the rates of all-cause mortality, cardiac and sudden death, and possibly stroke in secondary-prevention settings (25).
In addition to the Dean Ornish diet and the Esselstyn diet the Mediterranean diet and the Paleo diet have been returning considerable positive anecdotal data in regards to helping primary and secondary prevention patients improve their health. The Mediterranean diet like the aforementioned vegetarian diets does not specifically restrict foods with excess sugar and excess starch, but it also does not encourage them. The Mediterranean diet is still centered around real food (plants and animals) with some minimally processed, “healthy” foods like olive oil.
People with high risk for cardiovascular events have eaten a Mediterranean diet and experienced less major cardiac events (136). Another study suggests that a Mediterranean diet promotes less oxidative stress which makes it ideal for anyone with any disease associated with age (137). There is little argument against the assertion that the Mediterranean diet, the Ornish diet and the Esselstyn diet are far superior to the baseline diet of most people with high cholesterol, established heart disease or elevated ‘risk factors’.
But what is the ideal diet for using food as medicine for heart disease?
First, the ideal diet has to be centered around real food. Real food supplies levels of micronutrients and essential nutrients that have been lacking in the baseline diet. Real food encourages the body to self-regulate and restore itself by manners that are known and unknown; real foods, plants and animals, have an inherent ability to nourish the body in a way above and beyond our present understanding.
Second, the ideal diet has to focus on keeping linoleic acid, sugar and starch to levels well below excess. The ideal diet focuses on food quality, so linoleic acid from nuts will only become excessive if the participant goes nuts with nuts. Also, there should not be an extreme restriction on any one nutrient, including carbohydrates, as it is the source of those carbohydrates that seem to lead to excess consumption and resulting disease.
The ideal diet can include saturated fat and it can include all kinds of animal food since they are quite nutritious and generally not found to be detrimental to the body as it self-regulates and restores itself following consumption of a diet incompatible with human health. Additionally, what is the causative mechanism or mechanisms that make animal foods potentially health compromising? It is becoming increasingly more widely accepted as the standard narrative in regards to health that animal foods are not healthy, but the scientific literature does not support this, at least without heavy bias or confounding variables. Heavily processed versions of animal foods are likely detrimental, but animal foods are not inherently harmful, same as fructose and starch.
Finally, the ideal has to somewhat practical with a community of other people who have used that diet to greatly improve their overall health. The diet labelled as “Paleo” or “Primal” meets each of those criteria; there are thousands upon thousands who have used a version of this diet to improve their overall health tremendously, or to directly help them in primary prevention and secondary prevention of heart disease. The basic Paleo-Primal diet specifically restricts vegetable oils, wheat products, corn, soy and highly processed foods in general. Therefore, you are left with vegetables, fruits, nuts, seeds, meat, seafood and the Primal version of this diet also recommends high quality dairy.
The Paleo diet has many different versions, it was introduced to the public by Loren Cordain, explained to the public by Robb Wolf, refined into the Primal diet by Mark Sisson and thoroughly researched and synthesized by Paul Jaminet. There are many other notables in the Paleo field, too many to name in this article, that is representative of just how powerful this dietary approach has become. There is low carb Paleo, high carb Paleo, even a vegetarian Paleo, there is Paleo with a grain (Paul Jaminet), there is Primal which includes dairy (Mark Sisson); and they are all an incredible improvement from the baseline diet.
In one study of the Paleo diet it was shown to improve glucose tolerance in relation to a diet similar to the Mediterranean diet (140). Another study showed that the Paleo diet improved HbA1c and HDL levels in diabetics (141). There have not been randomized controlled trials involving the Paleo diet, and there have been no studies on the implementation of the Paleo diet in primary or secondary prevention patients of heart disease.
The Paleo diet may not lower LDL-c levels to a notable degree (although it might), but it is very likely to improve a lot of other more relevant bio-markers and is very likely to improve overall health because it can be the most nutrient dense diet (based on essential nutrients and nutrients known to be beneficial), it is relatively anti-inflammatory and unlikely to contribute in a significant degree to high levels of oxidative stress. As a result of the influx of real foods along with the extreme reduction in harmful foods the body will self-regulate and restore itself.
The beauty of the Paleo diet is that it is just a framework for someone to start with. From here the participant can “tweak” everything ranging from macronutrient ratio (carb:protien:fat) to food type inclusion. There is a vegan and a vegetarian form of Paleo. There is ketogenic Paleo (low carb/high fat) and there is high carb paleo; but it is always based on real food and can be tailored to each individuals metabolic needs. The information about diet as it relates to heart disease, high cholesterol and elevated ‘risk factors’ is designed to help you become a well-informed patient; let this be a framework for you to consider other information and have a knowledgeable conversation with your physician.
VIII. The Value of a Comprehensive Approach
Restorative sleep on a regulated cycle. Transcendental meditation. Proactively managing stress. Structured resistance strength and conditioning exercise. Yoga. Going for a walk or run Getting sun. Finding joy and satisfaction with the world. Strengthening present relationships or forming new relationships. Learning about anything interesting.
All of those will help anyone improve their life and possibly even their overall health whether they are seeking to prevent heart disease or high cholesterol, or already deal with those things. Covering these is beyond the scope of this article, but they may be the missing link for someone already eating real food and avoiding the highly processed foodstuffs that appear to be the underlying cause of atherosclerosis and heart disease.
Many times it is stress that puts someone “over the edge” and into a heart attack. Paying close, loving attention to yourself and situations that you consider stressful may be more than a supplement to a clean diet, it may be the difference between you experiencing life for the long run. A comprehensive approach is what Dean Ornish recommends, and virtually all of the diet books covered here recommend. When you speak with your physician about heart disease, high cholesterol, ‘risk factors’ and the treatment plans for it, he or she will almost undoubtedly discuss various measures considered ‘comprehensive’ in this article
IX. The Patient-Doctor Relationship
As a well-informed patient you will be prepared to:
- investigate resources, first directly from this article, and then from your own searches in order to form your own perspective on heart disease.
- communicate to your doctor the perspective with which you view heart disease, high cholesterol and elevated ‘risk factors’. of note, the perspective in this paper is very holistic-oriented and thus focusing on overall health.
- ask for additional testing of more relevant bio-markers than those provided by the standard lipid panel. TG:HDL is the most relevant offered from the standard, and is ideal around 1.
- these are: LDL-p, CRP, NMR Lipid Profile, Postprandial Glucose Tolerance, HbA1c, Lipoprotein (a) (under 15), Homocystein
- discuss the real risk of having a high LDL concentration, or any elevated ‘risk factor’.
- discuss the cause and conditions behind high cholesterol, heart disase or elevated ‘risk factors’.
- discuss the risk in addressing LDL-c with statin drugs
- discuss the safety in addressing overall health with a therapeutic diet
- discuss the risk of employing a therapeutic diet and
- discuss the risk in certain supplements and herbs
- ask whether the treatment will address the underlying condition
If you presently have heart disease, high cholesterol or elevated ‘risk factors’ it is your duty as a patient to become well-informed of your situation and the options ahead of you. Although it is not your duty to optimize your health and prevent or reverse heart disease, you can . However, with your internally derived courage and some dedication you can employ the information presented here to become a well-informed patient, communicate thoroughly with your physician,chose the most appropriate treatment plan and put yourself in position to experience the benefits of improved overall health and feelings of self-empowerment.
Taking a pharmaceutical such as a statin may be a helpful, sound decision in many cases, but it cannot create health; only the way you live, think and believe can create health. If you eat a diet largely composed of real food in a structured manner which keeps the levels of linoleic acid, sugar and starch well below that of ‘excess’. Additionally, employing a comprehensive approach that directly seeks to improve how you sleep, handle stress, exercise, view and interact with the world will go a long way to helping you become a healthier individual.
The point of becoming a well-informed patient is to take responsibility for the health that you create with your choices, actions and deeds. It doesn’t matter how far along your atherosclerosis is at present moment, the most powerful thing you can do for yourself is to live in a way that is more compatible with the human body than previous; and if you have heart disease, high cholesterol or other elevated ‘risk factors’ then you have not been living in a way that is compatible with health and vitality. That can begin changing right now.
There is no evidence that pharmaceutical intervention designed to modify cholesterol levels will lead to people becoming healthier and living longer. Statins do not offer improvement to overall health for primary prevention patients (without disease but with risk) and offer very little improvement to overall health for many secondary prevention patients. Statin drugs do not improve overall health because they cannot address the cause of poor health. Statin drugs are flawed by default: they are designed to effect one small sign of health, and they seem to work due to their ‘unintended’ effects, many of which also change the physiology of the body in subtle ways that lead to a diverse array of side-effects and adverse events.
There is no singular most important ‘risk factor’ or bio-marker of heart disease, as there is no singular bio-marker for overall health. But, the concentration of LDL cholesterol itself is not a very relevant marker of ‘risk’, and improved health may or may not be signified by improvement to this figure because the synergy of other things going on in your body are making you healthier. By eating a carefully structured therapeutic diet constructed by the most relevant science one can put their body in position to self-regulate and restore itself which will ultimately lead one to improved overall health.
In this paper I presented a compelling argument that food can be used as medicine, primary and preventive, for heart disease, high cholesterol and elevated ‘risk factors’. The therapeutic diets for heart disease address the underlying causes of, and alter the underlying condition of atherosclerosis; these are the problems which need a solution. The risk/benefit ratio and effect size of dietary modifications are likely to be superior to any of the current statin drugs for those interested in primary prevention, and deserves strong consideration for secondary prevention as well, in a complementary fashion or as directly guided and approved by the physician. Food as medicine for heart disease is effective, poses no threat and can be part of a treatment plan for secondary prevention, or the treatment plan for primary prevention.
Once again, please consult with your physician and/or cardiologist when considering the information provided in this article. It is meant to be educational only.
- Stephan Guyenet http://wholehealthsource.blogspot.com/search/label/cholesterol
- Chris Kresser http://chriskresser.com/specialreports/heartdisease
- Robb Wolf http://robbwolf.com/
- Paul Jaminet http://perfecthealthdiet.com/category/disease/cvd/
- Peter Attia http://eatingacademy.com/category/cholesterol-2
- Chris Masterjohn http://blog.cholesterol-and-health.com
- Petro Dobromyslkyj http://high-fat-nutrition.blogspot.com/
- Pubmed http://www.ncbi.nlm.nih.gov/pubmed