The Nuts that May Clobber Cholesterol
Stress Now, Cholesterol Later?
High Cholesterol Q & A
Do You Know Your Numbers?
Beyond Cholesterol: Emerging Risk Factors for Heart Disease
Want to Dodge Heart Disease With Diet? Eat Like an Ape
A Drink to Your Health?
Treating and Controlling Hypertension
The Nuts That May Clobber Cholesterol By Karen Barrow
If you are looking for a way to keep your heart healthy and still satisfy your snacking mood, pistachios, and sunflower seeds may be the powerful cholesterol-fighting tool your body needs.
A new study, published in the Journal of Agricultural and Food Chemistry, shows that these nuts and seeds rank at the top of the list for containing cholesterol-lowering compounds, phytosterols. While many nuts contain this helpful compound, the study is the first to determine which of these little treats have the largest amount of this cholesterol-clobbering ingredient.
"We tried to establish values for all these foods, so others can determine their value in the diet," said Dr. Katherine Phillips, study author from the department of biochemistry and food chemistry at Virginia Polytechnic Institute.
Phytosterols are found only in plant-based foods and very closely resemble the molecular structure of cholesterol. But unlike cholesterol, phytosterols are not easily absorbed by the body. Scientists believe that the compound can partially block cholesterol from being absorbed, thereby lowering overall cholesterol levels naturally.
Philips and her colleagues recognized that nuts and seeds tend to be high in phytosterols, but no study had adequately compared the amounts of the compound found in all of the varieties, which range in size from poppy seeds to walnuts.
While wheat germ and sesame seeds were found to contain the highest amount of phytosterols, according to the tests, most people do not eat these foods by themselves, let alone in high enough amounts for it to matter. So, the third and fourth place finishers, sunflower seeds, and pistachios, were considered by Philips to be the most practical nutty snack for people looking to lower their cholesterol.
Even if you don't consider sunflower seeds or pistachios a desirable treat, any of the nuts and seeds tested were found to contain at least a small amount of phytosterols. So, if walnuts are more tempting than pistachios, munch away. But Philips also advises you to consider other options, such as diet and exercise, that are proven to substantially help lower your cholesterol.
"This isn't the only food product to prevent high cholesterol," she said. "There are many other factors at play."
Stress Now, Cholesterol Later? By Eric Sabo
People who respond poorly to stress may see their cholesterol levels shoot up years later, a new study suggests. The ultimate effect is relatively small, but researchers say that this it is yet another reason to get a handle on runaway anxiety.
"I would be surprised if the effects of stress were as big as the impact of lifestyle on cholesterol," said the lead author of the study, Dr. Andrew Steptoe of the University College London. "What this study does is help us understand exactly how stress is linked with heart disease."
Chronic stress is associated with a range of problems, including heart attacks, the common cold, and even a shorter life expectancy. Steptoe's study, published in Health Psychology, looked at nearly 200 middle-aged men and women to see if stressful events triggered higher cholesterol three years later.
After having their cholesterol levels measured, the participants were put through a series of mild, nerve-rattling tests, such as picking the correct names of various colors that were rapidly flashing on a computer screen. They were tracked for changes in their heart rate and other signs to see how they handled the pressure.
Three years later, the researchers measured cholesterol levels again. As to be expected, all showed higher levels than before, a common occurrence with growing older. But those who had the highest stress response to the test also had the highest cholesterol levels. Compared to participants who seemed to take the tests in stride, the most stressed-out group was three times more likely to have dangerously high LDL, or bad cholesterol, down the road.
No one can avoid stress completely, but Steptoe said the key is how you handle it. "It is the combination of exposure to stressful conditions and the way in which we respond to those conditions that are crucial," he said.
This spike in cholesterol was independent of the usual culprits, like being overweight or smoking. Steptoe suggests that stress may produce more nervous energy in the form of harmful fatty acids and sugar, or it may even interfere with the body's ability to get rid of cholesterol. The rise in cholesterol was relatively modest, Steptoe added, at least in comparison to a poor diet or other causes.
Still, with stress linked to heart problems already, higher cholesterol is the last thing anyone would need.
"The best way of maintaining heart health is still regular physical activity, a prudent diet, controlling body weight and not smoking," he said.
High Cholesterol Q & A By: Jaya M. Raj, MD
Recently, I saw a new patient in my office who asked me questions very similar to the questions above. She was a 46-year-old woman in fairly good health. She came to see me because her father had suffered a heart attack a few weeks before; at that time, he had also been diagnosed with high cholesterol (hypercholesterolemia). My patient wanted to know if her father's high cholesterol and penchant for junk food had caused his heart attack. She was also very anxious about whether this meant that she, too, was likely to have hypercholesterolemia and she wanted to be tested right away. However, she wasn't really sure what cholesterol was or how it related to heart disease, so I started with the basics.
What is Hypercholesterolemia?
Hypercholesterolemia is an excess of cholesterol, a fat-related substance, in the blood. It may also be referred to as hyperlipidemia or dyslipidemia (lipids are a group of fat-like substances that include cholesterol and triglycerides).
Why is Hypercholesterolemia Important?
Approximately 60 million Americans have hypercholesterolemia. While this fact in itself may not be frightening, it is important to realize that high cholesterol is a major risk factor for atherosclerotic heart disease (narrowed arteries due to cholesterol plaque buildup), which is the leading cause of death and disability in the Western hemisphere. More than 13 million people in this country alone have coronary artery disease; about 500,000 people die from heart disease each year. For these reasons, we focus a great deal of attention on diagnosing and treating high cholesterol; it is an effective way to prevent people from developing and dying from atherosclerotic heart disease. People of any age can have hypercholesterolemia, but it is most commonly diagnosed in the fifth through seventh decade of life.
Causes of Hypercholesterolemia?
Most cases of hypercholesterolemia are caused by a combination of genetics and diet. A diet which contains foods that are rich in fat and cholesterol can contribute to the development of hypercholesterolemia. These foods include red meat, fried chicken, whole milk, egg yolks, butter, ice cream, and pastry. The genes involved in hypercholesterolemia are usually multiple; however, a small percentage of people (less than five percent) with hyperlipidemia have a defect in a single gene that results in a hereditary disorder of lipid metabolism. The two most common types of these disorders are familial hypercholesterolemia, in which the cholesterol is elevated, and familial combined hyperlipidemia, in which both the cholesterol and triglycerides are elevated. Both these conditions are related to the onset of heart attacks and other symptoms of atherosclerotic heart disease at an early age. Hyperlipidemia can also occur as a result of other medical conditions, such as diabetes mellitus, hypothyroidism, liver disease, alcoholism, and certain types of kidney disease. Various medications, including estrogen, steroids, and certain blood pressure drugs can cause hyperlipidemia as well
What are "Good" and "Bad" Cholesterol?
Dietary fat is naturally absorbed from the small intestine into the bloodstream, where it is broken down and packaged for transport by binding to special proteins, called lipoproteins. There are different types of lipoproteins that carry cholesterol in the blood; the two most famous types are a low-density lipoprotein (LDL) and high-density lipoprotein (HDL). LDL cholesterol is nicknamed "bad cholesterol" because it delivers cholesterol to the walls of blood vessels and is associated with atherosclerosis. HDL cholesterol is called "good cholesterol" because it is targeted to other organs, like the liver, where it is used in making substances that the body needs. This is really an oversimplification; actually, there are different phenotypes (or subtypes) within each class of lipoprotein that make it more or less likely to cause atherosclerosis. However, thinking of good and bad cholesterol in this way can be useful.
How is Cholesterol Related to Heart Disease?
Coronary artery disease (CAD), which is the cause of heart attacks and angina (chest pain associated with blocked coronary arteries), develops partly as a result of cholesterol deposition in the coronary arteries (the blood vessels that supply blood to the heart). This process leads to the formation of atherosclerotic plaques, which can reduce blood flow to the heart and cause angina. If one of these plaques ruptures, the blood supply to a portion of the heart may be blocked entirely, and a heart attack ensues.
Numerous studies have demonstrated a strong link between coronary artery disease and hypercholesterolemia. Specifically, high levels of LDL-cholesterol and low levels of HDL-cholesterol are associated with a significantly increased risk of CAD. Put another way, people with high LDL levels have a much higher risk of having a coronary event than do people with normal levels. In contrast, a high HDL level is protective against CAD.
What are the Desirable Levels of Cholesterol?
The cholesterol levels that are considered desirable vary, depending on whether or not you have coronary artery disease or risk factors for CAD. These risk factors include your age, older than 45 for men and older than 55 for women, postmenopausal status (without hormone replacement therapy), significant family history of CAD, cigarette smoking, hypertension, and diabetes.
In healthy adults without CAD or diabetes, a total cholesterol level less than 200 mg/dl, an LDL level less than 130 mg/dl, and an HDL level greater than or equal to 60 mg/dl are desirable. Borderline levels are a total cholesterol of 200 to 239 mg/dl, an LDL level of 130 to 139, and an HDL level of 35 to 59 mg/dl. A total cholesterol level greater than or equal to 240 mg/dl, an LDL level greater than or equal to 160, and an HDL level less than 35mg/dl is considered undesirable. These are levels that you can use to direct your efforts in lowering your cardiac risk.
Although we tend to focus on LDL- and HDL-cholesterol, other lipid components are also important. These include triglycerides (a building molecule of fats) and the triglyceride-rich lipoproteins: very low-density lipoprotein (VLDL) and intermediate density lipoprotein (IDL). As with cholesterol, a high triglyceride level is usually the result of a person's diet and genetic makeup, but it can also be caused by other conditions, such as diabetes and hypothyroidism, and by some medications. The relationship between triglycerides and atherosclerosis is not as well established as it is for cholesterol. What we do know is that hypertriglyceridemia is linked to other CAD risk factors, such as low HDL level and central (apple-shaped) obesity. The desirable level of triglycerides in healthy adults is less than 200 mg/dl.
Who Should Have Their Cholesterol Checked?
Virtually everyone should be screened for high cholesterol. Many physicians, including myself, follow the guidelines put forth by the National Cholesterol Education Program, which recommends that all individuals begin screening with total- and HDL-cholesterol levels at age 20 and continue to check their cholesterol levels at five-year intervals if they are normal. Other physicians favor a more targeted approach and screen only those individuals who have other risk factors for CAD. Patients with established coronary artery disease, diabetes, familial hyperlipidemia, or other CAD risk factors should be tested more frequently, using a fasting lipid profile (this includes total, LDL and HDL cholesterol, and triglycerides).
What if My Cholesterol is High?
If your cholesterol is high, you should talk to your physician about your overall risk for CAD; this assessment will guide the intensity of treatment. Healthy people with hyperlipidemia can often reduce their cholesterol and triglycerides to desirable levels by diet and exercise alone. Others may require medication to lower their lipids. However, it is important to remember that lowering your cholesterol is part of a larger plan to reduce your risk of developing coronary artery disease and to foster a healthy lifestyle.
Let's return to the example of my new patient. She was interested in learning not just her cholesterol level but her overall risk for coronary artery disease. As I mentioned, she was in fairly good health. She had no history of hypertension, diabetes, or other chronic conditions. She never had chest pain or shortness of breath. She ate a well-balanced diet for the most part but had frequent cravings for chocolate cake and ice cream which she could not resist. She also smoked about a half-pack of cigarettes per day since the age of 18.
I checked my patient's lipid levels that afternoon. She had a total cholesterol of 248, with an LDL of 162, an HDL of 36, and a triglyceride level more than 250. Because she was post-menopausal and a smoker, she had, at least, two other risk factors for CAD. We talked about several ways she could not only lower her cholesterol but reduce her overall cardiac risk and feel healthier too. She was actually quite relieved to know that there were many things she could do to achieve these goals. For example, reducing the fat in her diet, exercising, and enrolling in a smoking cessation program. I also told her that medication would be a future option.
Hypercholesterolemia is an excess of cholesterol in the blood. High levels of LDL cholesterol are associated with a significantly higher risk of coronary artery disease (CAD). Low HDL cholesterol is also associated with an increased risk of CAD. The desirable cholesterol levels for healthy, asymptomatic adults are a total cholesterol less than 200 mg/dl, LDL less than 130 mg/dl, and HDL greater than or equal to 60 mg/dl. For those with coronary artery disease or diabetes, the guidelines are more stringent. I recommend that all healthy adults have their cholesterol checked every five years, starting at age 20. If you have diabetes, coronary artery disease, or a family history of premature CAD or hyperlipidemia, you should check your cholesterol more often. If your cholesterol is high, talk to your doctor about the various treatment options that would be appropriate for you.
Do You Know Your Numbers? By Christine Haran
Cholesterol, blood sugar, body mass index, blood pressure—there are a lot of risk factors to keep track of if you want to avoid many of the diseases associated with aging, such as heart disease, stroke and diabetes. And if it seems like the cut-off for what cholesterol or blood sugar or blood pressure level is considered healthy keeps dropping, that's because guidelines for managing many of these risk factors have been revised.
Most recently, the National Cholesterol Education Program (NCEP) guidelines for cholesterol management were changed. The update, published in the July 13 issue of Circulation recommended that people at very high risk of cardiovascular disease lower their level of LDL, the "bad" cholesterol, to less than 70 mg/dL, down 30 points from the prior guidelines' suggested goal of less than 100 mg/dL. The NCEP defines very high-risk patients as those who have had coronary heart disease and have multiple or poorly controlled risk factors.
For high-risk patients, including those with coronary heart disease, a disease of the blood vessels to the brain or extremities, or diabetes, or multiple risk factors such as smoking and hypertension, the goal is still an LDL level of less than 100 mg/dL. If your LDL level is between 100 and 129 mg/dL, the guidelines advise you and your doctor to consider adding a cholesterol-lowering medication or increasing the dose you are currently taking. People at moderately high risk may now opt for a lower LDL goal as well: They can aim for under 100 mg/dL, rather than 130 mg/dL.
"The studies demanded this change in the guidelines," says Adolph M. Hutter, Jr., MD, a cardiologist at Massachusetts General Hospital in Boston. "There's probably no LDL level that's too low for people with coronary heart disease." Dr. Hutter said that reaching the new LDL goals would require the use of cholesterol-lowering statin medications in many cases. The NCEP report also stressed the importance of a healthy lifestyle that includes a nutritious diet and exercise and maintaining a healthy weight.
Below is a compilation of some of the measurements important to your health that you and your physician should track. These numbers are estimates: Keep in mind that you and your physician should set your own personal targets based on your individual needs.
Cholesterol Levels for People with Low to Moderate Risk of Heart Disease:
Having a lot of cholesterol in the blood leads to a build-up in the walls of the arteries and can cause arteries to narrow and harden, blocking blood flow to the heart. While LDL cholesterol is the primary source of cholesterol build-up, HDL cholesterol, or the "good" cholesterol, helps to prevent LDL build-up.
LDL Cholesterol in mg/dL: Less than 100 Optimal
100–129 Near optimal
130–159 Borderline high
Greater than or equal to 190 Very high
Total Blood Cholesterol in mg/dL: Less than 200 Desirable
200–239 Borderline high
Greater than or equal to 240 High
HDL Cholesterol in mg/dL: Less than 40 Low (undesirable)
Greater than or equal to 60 High (desirable)
Body Mass Index (BMI):
The BMI is a measure of body fat based on height and weight that applies to adult men and women. To calculate your BMI use the formula below or use the BMI calculator on the Web site of the National Heart, Lung, and Blood Institute. It is a more reliable indicator of a person's body fat than their weight alone.
Weight in Pounds
(Height in inches) x (Height in inches)
Underweight Less than 18.5
Normal weight 18.5–24.9
Obese 30 or greater
In diabetes, blood sugar, or glucose, levels are above normal. There are a number of tests used to measure blood sugar levels though the fasting plasma glucose (FPG) test is generally considered the most reliable.
Plasma Glucose in mg/dL 99 and below Normal
100 to 125 Prediabetes
126 and above Diabetes
Blood pressure is defined as the pressure exerted by blood on the walls of blood vessels. When blood pressure is taken, the top number (systolic pressure) is the pressure when the heart beats and the lower number (diastolic pressure) refers to the pressure when the heart is at rest. High blood pressure increases the risk for a heart disease and stroke.
BP in mm/Hg Less than 120/80 Normal
140–159/90–99 Stage 1 high blood pressure
160 or higher/100 or higher Stage 2 high blood pressure
Beyond Cholesterol: Emerging Risk Factors for Heart Disease By Christine Haran
Just when we've mastered the difference between good and bad cholesterol, researchers have introduced a host of new risk factors for heart disease. While the major risk factors such as family history and elevated LDL cholesterol are still the strongest predictors of risk, emerging factors such as high levels of homocysteine and C-reactive protein may also play a role in the development of heart disease. Doctors can now use these extra clues to better determine if patients need treatment and how aggressive the treatment should be.
Below, MacRae F. Linton, MD, a professor of medicine and pharmacology in the division of cardiovascular medicine at Vanderbilt University Medical Center, discusses how heart disease is assessed and when the emerging risk factors should be considered.
What are the major risk factors for coronary artery disease?
The major cardiovascular risk factors can be divided into modifiable and non-modifiable risk factors. The non-modifiable ones include age; for a man, age 45 and for a woman, age 55 or older. Family history, having a parent or sibling who has had a premature coronary disease, is another non-modifiable risk factor.
The modifiable risk factors include elevated LDL cholesterol, or the bad cholesterol, and low HDL cholesterol, which is the good cholesterol. Other major risk factors are hypertension, diabetes, and cigarette smoking.
How is risk assessed?
According to the National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III), you first count the traditional risk factors, and if somebody has fewer than two risk factors, they're at low risk. And if they have two or more risk factors, they're potentially at high risk or intermediate risk. If they already have evidence of coronary disease, they're in the highest risk category. In addition, you are also put in the highest risk category if you have diabetes mellitus, atherosclerosis (plaque build-up) in non-heart blood vessels, or a 10-year risk of coronary heart disease (CHD) events that are greater than 20 percent.
The treatment of hypercholesterolemia is based on the level of LDL cholesterol and risk, so the goal for your LDL cholesterol is determined by your level of risk. For people who are in the highest risk categories, the goal for their LDL cholesterol is less than 100 mg/dL, whereas if you're in the intermediate category, the goal is less than 130 mg/dL, and if you're in the low-risk category, it's less than 160 mg/dL.
What are some lifestyle risk factors?
The lifestyle cardiovascular risk factors are obesity, physical inactivity and a diet that promotes plaque buildup in the arteries; this is basically a high-fat, high cholesterol typical American diet.
What are the emerging risk factors for heart disease?
All the emerging risk factors appear to contribute to heart disease risk and are mentioned in the formal guidelines as things to consider in situations where doctors feel like they need more information to stratify the patient's risk.
Elevated levels of triglycerides, high LDL, and low HDL cholesterol are often referred to as the lipid triad. This lipid triad is clearly associated with plaque buildup. The role of triglycerides as a risk factor for CHD has been somewhat controversial because they have not been found to be independent risk factors in all studies. A major reason for this is the inverse relationship between triglyceride levels and HDL cholesterol levels (when triglycerides are high HDL cholesterol is usually low).
Another independent risk factor that's particularly important for people who have a high LDL cholesterol is lipoprotein a, Lp(a).
Another risk factor is the metabolic syndrome, which is a clustering of a lot of these risk factors; it's also been called the insulin resistance syndrome, or syndrome X. It includes high triglycerides, low HDL, high LDL, hypertension and abdominal obesity. When we're in our 20s, about 5 percent of the population has it. By the time we're in our 60s, about 40 percent of the population has it. Metabolic syndrome clearly confers an increased risk, both for cardiovascular events and diabetes.
The other non-lipid risk factors include homocysteine, fibrinogen and inflammatory markers such as C-reactive protein (CRP).
What is homocysteine?
Homocysteine is an amino acid, and interest in it came from observations of a rare genetic disorder called homocystinuria; children who had it developed premature atherosclerosis and vascular events and recurrent thrombosis. You can lower homocysteine levels by taking folic acid and B vitamins. Outcomes studies to evaluate the benefits of lowering homocysteine in terms of reducing CHD events are in progress, so there's really not definitive proof of that yet.
What is C-reactive protein?
C-reactive protein (CRP) is a nonspecific marker for inflammation. It's an acute phase protein, which means that in situations of stress, trauma, injury or infection, it can go up enormously, 1,000-fold. It's produced by the liver but may also be relevant when it's produced elsewhere. It's been looked at in a number of large studies, and it's been shown that it's an independent risk factor for cardiovascular events.
In order to accurately measure CRP, you have to use a high-sensitivity assay, and individuals need to be free of infection or other kinds of acute traumas that may cause it to go up. Right now, we're still figuring out how to use it.
What they've recommended now is to use CRP in that intermediate risk category to stratify people further in terms of how aggressively they should be treated to lower their cholesterol.
What is fibrinogen?
When you think about myocardial infarctions or heart attacks, the underlying process is atherosclerosis, which is plaque buildup in the artery. But what causes the heart attack is when the plaque ruptures and you form a clot. Fibrinogen plays a role in clot forming, so it's a risk factor for heart attacks.
When is the use of the emerging risk factors appropriate?
You use these emerging risk factors in situations where you're concerned that there may be more risk than is apparent. So doctors might consider them in individuals who have a strong family history, yet their risk comes out to be low when the traditional risk calculation is done.
A lot of people who have either very high risk because they have very high cholesterol or a very strong family history are now being referred to preventive cardiology clinics and lipid clinics or cholesterol clinics. In those settings, there's probably more use of the emerging risk factors.
How would the presence of emerging risk factors affect treatment recommendations?
You'd be more likely to upgrade people into a category where they might be treated. If you had somebody who's young, with a couple of risk factors such as low HDL cholesterol and a strong family history of premature heart attacks, their overall risk calculation may put them in the low or intermediate risk group. If their LDL cholesterol isn't that high, the guidelines might indicate that you do not need to treat them. But if you found that their CRP level or another one of the emerging risk factors that you're concerned about is positive, you might use it to upgrade their risk and go ahead and treat them.
If someone has high levels of homocysteine, you can treat them with the vitamin supplement folic acid. Even though we don't really have definitive evidence yet that it reduces the risk, I think patients concerned about the risk of cardiovascular events, if they have an elevated homocysteine, treating it with folic acid is probably a reasonable approach.
What is your advice to people at risk for heart disease?
People should be aware that there are effective ways to prevent cardiovascular events, and they should be proactive and make sure that they get screened for the major risk factors, particularly if they have a family history.
There have been studies to look at how much you miss if you just use the major risk factors, and it varies, but some of these studies say that you can pick up 80 percent of the people at risk just by using the traditional risk factors. I think the real issue is that we aren't even screening enough for the traditional risk factors, and then we're not implementing an appropriate treatment.
So the place to start is with the traditional risk factors. If your traditional risk factors put you in a high-risk category, then you need to take preventive measures, which include lifestyle modification in addition to medications.
When you look at what's happening now in terms of obesity in our country, this is going to create a huge increase in the number of patients who have diabetes and are at risk for cardiovascular disease. And a lot of that is due to our lifestyles, which involve physical inactivity and a high-caloric, high-fat diet. These are things that we can modify, along with cigarette smoking. This seems to be something that's widely known but hard for people to put into practice.
Want to Dodge Heart Disease With Diet? Eat Like an Ape By Christine Haran
People with elevated cholesterol have heard the mantra from their doctors: eat a healthy diet and exercise more, or you may increase your risk of a heart attack. But as anyone who has struggled to lower their cholesterol through diet knows, it is no easy task. Cholesterol can be obtained when you eat foods high in cholesterol, but it is also made by the liver. Consequently, it has been thought that dietary changes could not lower cholesterol as effectively as the cholesterol-lowering medications known as statins. But a recent study that compares the two approaches shows that a diet that includes almonds and several other specific plant foods can lower cholesterol—specifically LDL, the "bad" cholesterol—as significantly as a leading cholesterol-lowering medication.
In the study, which was published in the July 23, 2003, issue of the Journal of the American Medical Association, researchers divided participants into three diet groups. One group ate a diet low in saturated fat, the second group received the same diet, along with a statin and the third group ate a diet containing specific cholesterol-lowering foods. Below, lead researcher Cyril Kendall, Ph.D., a research associate in the department of nutritional science at the University of Toronto, discusses how diet can quickly and safely reduce cholesterol levels, and whether people can learn to stick with it.
Why did you and your colleagues decide to conduct this study?
There are a number of reasons. Obviously, heart disease is the number-one killer in North America. I think there's been a growing trend to treat the disease with drug therapy, and there is nothing wrong with this. The medications are quite effective and work well, but if you look at the American Heart Association guidelines and the National Cholesterol Education Program (NCEP) guidelines, the first strategy for primary prevention of the disease is diet and other lifestyle modification.
We had some interest in looking at the evolution of the human diet. The thinking was that for much of our evolutionary development over the last 10 or 15 million years, we would have been predominantly vegetarian. And if you look at the great apes living presently, they are, for the most part, eating a vegetarian diet. So genetically we're designed for basically a fruit, nut and vegetable diet.
This led to a study that we conducted about three or four years ago looking at that sort of diet, a simian diet. We had about a 35 percent reduction in LDL cholesterol. So we knew the diet could achieve a much greater reduction than that which was generally recognized by health professionals.
The problem with a simian diet was that it's a full-time job. You were basically eating about 5.5 kilos of food a day, which took about eight hours a day, so for our modern-day lifestyle, that's completely impractical. So what we wanted to do was take the four main components of that diet—vegetable proteins, plant sterols, almonds and soluble fibers—and put those into foods or into a diet that is better adapted to our modern lifestyle. So that's what we've done with the current portfolio diet, as we call it.
What did you study compare?
Our control diet was one that is low in saturated fat and dietary cholesterol. It has about seven servings of fruits and vegetables per day, which is what is recommended by American Heart Association and the NCEP for reducing the risk of heart disease.
We also fed that diet to our positive control, so that group had the very healthy diet, plus a statin. For our portfolio diet group, we took the NCEP diet as a template, but we increased the soluble fiber, soy and plant and vegetable proteins, almonds and plant sterols. Each of those four components has independently demonstrated 5 percent to 10 percent reductions in cholesterol in clinical studies. And the FDA now has health claims for each of those four components.
What did your study measure, and what kinds of reductions were seen?
Our primary outcome measure was LDL cholesterol, and that has been demonstrated quite consistently to be a risk factor for heart disease. We know that if you lower LDL cholesterol either through dietary means or through drug therapy, your risk of heart disease is greatly reduced.
In the group taking a low-dose, first-generation statin, we had a reduction in LDL of around 31 percent. The NCEP diet by itself had a reduction of around 10 percent, and then our portfolio diet had a reduction of 29 percent in LDL.
We also looked at the C-reactive protein (CRP), because it is an inflammatory biomarker. It has been demonstrated in some studies to increase the risk for heart disease. We did see a nice reduction, and basically it was the same level of reduction achieved through the use of statins.
Is there a certain group of those people who should still go on a statin?
What we were trying to demonstrate is the effectiveness of the diet. I think that any dietary change that one does should be done in consultation with your physician. And if the physician thinks that medication is the best approach, then by all means discuss medication. Some people with very high cholesterol must be on a statin. I think that's very important. What we're trying to do is give people options.
Some of the super-statins are reporting reductions of around 50 percent in cholesterol. If an individual needs that level of reduction, then they should be on a statin. But it's also good to be on a healthy diet. That's not going to hurt people.
There are some potentially negative side effects with of statins such as muscle aches and pains. Some people have liver trouble. So I think even if you can adapt some of these dietary factors into your daily eating pattern, maybe you can lower the dose of the statins somewhat and possibly reduce some of the potential negative side effects.
Do you think people can manage this diet on their own?
All of the three studies on this diet that we've conducted are tightly controlled studies, and that means that the subjects are basically eating the foods that we tell them to eat, and we are supplying most of those foods at this point. So under very controlled conditions, this diet is extremely effective.
A number of the subjects who have completed the study have continued purchasing the foods themselves and have apparently maintained that level of cholesterol reduction. This has not been closely monitored, however, and we are planning on running these kinds of studies very shortly.
Additionally, not everybody needs a 30 percent reduction in cholesterol. Others have mildly elevated cholesterol, and maybe they just need a 10 percent or 15 percent reduction. So maybe they can incorporate the almonds in their diet, or maybe they like the plant sterol margarine or particular soluble fiber foods.
How quickly were the reductions seen?
The reduction in LDL was observed in two weeks. So you're seeing a very rapid reduction. You also see that type of reduction with a statin. The thing is, you have to maintain that diet. You don't stay on the diet for two weeks to get your cholesterol down and then go back to your old diet because your LDL is going to shoot up just as rapidly.
Can you give examples of some of the cholesterol-lowering foods that were added to the diet?
The almonds were basically just raw almonds, and they were either eaten as a snack or put on salads or into different entrees. Some of the soluble fiber sources were oat bran. We also had different bean entrees, such as Mexican-style bean entrees or Indian curries with legumes, which are high in both vegetable protein and soluble fiber. Some vegetables that are high in soluble fiber are okra and eggplants.
In terms of the plant sterol, there is a plant sterol margarine known as ProActiv in the United States, and that was basically just used as the spread instead of butter or another type of margarine. And then the soy products were incorporated into some vegetable-based entrees. We also had soy burgers, hotdogs, cold cuts and soy milk.
What might be included in your follow-up studies?
The next stage in the testing for this research is to say, "Okay, can we give people dietary advice? Can we tell them to go out and can they purchase their own foods and survive on this diet happily for longer periods of time and still achieve the same level of reduction in cholesterol?" Those studies still have to be undertaken.
A Drink to Your Health? By Christine Haran
Over the last five years, the health benefits of moderate drinking have been widely celebrated in the headlines. To those who think everything enjoyable must be bad for you, this news might seem like a dream come true. Of course, there are many caveats—and these studies don't indicate that teetotalers should take up drinking or that infrequent drinkers should start drinking more. The operative word here is drinking in moderation. Studies show, for example, that health benefits only come with moderate drinking and are greatest for older men. And even moderate drinking is not recommended to women who are pregnant or thinking of becoming pregnant, or to people who are under 21.
The strongest medical evidence exists for the link between moderate drinking and a reduced risk of heart disease. Kenneth Mukamal, MD, MPH, an internist at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School in Boston, was the lead author of a New England Journal of Medicine study examining the roles of drinking patterns and heart disease that found, after 12 year of follow-up, that men who consumed alcohol between three and seven days a week had fewer heart attacks than men who drank once a week. Below, Dr. Mukamal discusses the risk and benefits of moderate drinking.
Do we know why moderate drinking lowers heart disease risk?
We think that a lot of the benefits of alcohol are on the blood vessels and on blockages in the arteries to the heart and to the brain. This might be related to alcohol's effect on the good cholesterol, the HDL cholesterol. In fact, alcohol affects HDL levels just about as strongly as any other lifestyle factor. People also think that alcohol may lower heart attack risk by acting as a blood thinner.
What are some of the other health benefits associated with moderate drinking?
A wide variety of health issues has been attributed to moderate drinking. A lower risk of diabetes has been seen in women and men. There actually have been experiments done in which alcohol was administered over a couple of months to people without diabetes. In those studies, most of which have been conducted in women interestingly, it looks like moderate drinking improves the body's sensitivity to insulin. It may actually lower insulin levels altogether and may prevent diabetes through that mechanism.
More recently we've done some work on moderate drinking and dementia. We looked at a group of older adults in the United States—average age was in the mid-70s—and found a reduced risk. There has been some work in slightly younger populations from Europe, and those studies have fairly consistently suggested that older adults who were drinking moderately may have a lower risk of dementia. We're not exactly sure what the mechanisms may be behind that. Some of it may very well be that drinking tends to occur in social settings and just the process of getting out and socializing may be an important way to prevent dementia.
There is also evidence that moderate drinking may prevent silent strokes or other subtle types of brain injury that we know over time can predispose to dementia. I think it's still an area where we need some more investigation.
Is the pattern of alcohol consumption important?
In most of the studies that look at this issue, people have been asked; "How much alcohol do you usually drink?" When that question is asked, people take an average. For example, I drink 10 drinks a month. But 10 drinks a month is very different from someone who has them all on one night vs. someone who has them on 10 different nights of the month.
That kind of detail surprisingly hasn't been available in most of the studies that have been devoted to this topic. In our study, we tried to figure out the drinking pattern that's most closely tied to lower heart attack risk. What we found in a study of about 38,000 men was that the key factor wasn't what men were drinking, or frankly even so much how much they were drinking at a time, but how frequently they were drinking alcohol.
We found that men who were drinking. at least. three to four days a week or more had lower heart attack risks than people who had one drink a week. We also have some very strong studies showing that heart disease risk, while lower amongst moderate drinkers, can be substantially higher amongst people who drink to excess even occasionally. They don't have to be drinking excessively every single night to potentially have a greater heart attack risk.
Many of the effects of drinking in moderation, such as thinning the blood, are only true at moderate levels of drinking. Those effects actually go away and reverse if people drink too much.
What constitutes one drink?
What doctors usually consider a drink is basically a medium glass of wine, a 1.5 oz shot of spirits, or a can or bottle of beer. All of those have roughly similar amounts of pure alcohol in them. We usually define moderate drinking as up to one drink per day for adult women who aren't pregnant and up to two drinks per day for adult men. Some guidelines recommend that moderate drinking among adults over 65 be limited to one drink per day.
Are the heart benefits of alcohol consumption the same for men and women?
In general, when we're thinking about the putative health benefits of moderate drinking, they mostly apply to older people and to men. Issues for women and for younger individuals are much more difficult to sort out.
The role of alcohol consumption in heart disease varies strongly by gender. The reason for that is twofold. On the one hand, women at any given age tend to have lower risks of heart disease than men do. As a result, the benefits of moderate drinking accrue disproportionately to men. At the same time, there are some particular risks of drinking for women that don't exist for men. There is some evidence that women may be particularly prone, for example, to liver disease related to drinking. Even moderate drinking may increase breast cancer risk. And, while the effects on heart attack risk are roughly similar in men and women, I think it's even more difficult to determine what the ideal level of drinking ought to be for women than it is for men.
I think it is fair to say that if young women, in general, are drinking with the expectation that there is some health benefit to it for them, they're probably mistaken. Young women are a group of people for which, as of now, we basically have no clear proof that the overall balance of alcohol's risks and benefits is going to work in their favor.
What are some of the risks of moderate drinking?
There is fairly consistent evidence that breast cancer rates are higher amongst women who drink moderately. I think that's important because obviously breast cancer is a very common disease. I certainly think women at high risk for breast cancer should talk with their doctors about whether they should be drinking any alcohol.
Another important risk, which is unrecognized for many people in this country, is that even moderate drinking amongst people with hepatitis C may increase their risk of permanent liver damage. Anybody who is known to have hepatitis C shouldn't be drinking any alcohol at all. People who have risk factors for hepatitis C ought to be tested because it will very substantially impact what the potential risks are related to moderate drinking.
In addition, although we don't think moderate drinking necessarily clouds our judgment, it turns out that it probably does. In simulated driving tests that were done as far back as the 1950s, people have realized that at very low blood alcohol levels, simulated driving performance is impaired. When I say low blood alcohol, what I'm talking about is as low as .02 percent.
Some studies, for example, the analysis of the National Alcohol Survey, showed something similar. You begin to see higher risks of injury even when people are reporting one drink a day. That's why we still recommend that even moderate drinking occur in the home, preferably tied to meals. That is not so much because we find that that drinking with a meal is more likely to lower heart disease risk, for example, but because it's the safest way to prevent high blood alcohol levels that can get people into accidents.
What about people with a history of alcohol abuse?
Although it has been bantered back and forth, most people think that people who have a personal history of alcoholism very rarely can return to social drinking. People who, for personal or family reasons have never had alcohol before, at least as of now, probably shouldn't start drinking for any health reason.
What is your advice for an individual who is weighing the risks or benefits of moderate drinking?
It's hard to give any single piece of advice because of all the things we've learned about moderate drinking. The potential risks and benefits are going to vary by a person's health history, their age, sex and family history. The number of factors that would have to go into the decision is really very substantial. As a primary care doctor myself, these are long discussions that people should have with their doctor. I would not recommend that anybody go out tomorrow and start drinking alcohol simply on the basis of results that we and others have presented.
I would say that for people who are drinking moderately and are able to control it and don't have any of the absolute reasons why they shouldn't be drinking alcohol, that there is no evidence now that that's a bad thing to do. Beyond that, I don't think right now we have enough evidence to say that anybody should take up drinking just for any particular benefit unless their doctors recommend that they do so.
Treating and Controlling Hypertension By Steven Smith, MD
Most of the patients I see in the office with hypertension feel "healthy." So for them, it is disturbing to hear from a doctor that they are "sick." I explain that hypertension is a condition that does not necessarily imply ill health and that the goals of treatment are to prevent the development of serious problems such as heart attack and stroke. In fact, since the 1970s, it is estimated that treatment of hypertension has reduced the occurrence of heart disease and stroke by 50%. For those skeptical of medical science, an example from the business world is highly persuasive. Insurance companies, who directly depend on assessing life expectancy for profit, determined long ago that the presence of hypertension predicts an increased risk of death. In an age of numerous effective treatments for hypertension, no one has to be an insurance statistic.
Does Exercise Improve Blood Pressure Control?
Daily aerobic exercise can lower blood pressure in patients with hypertension, and exercise has the additional benefit of improving lipid levels and decreasing weight. I routinely recommend exercise to my patients as long as there is no serious heart condition that could make it dangerous. Remember to speak with your doctor before undertaking a new exercise program.
If I Have Hypertension, Should I Restrict Salt Intake?
Many patients experience a decrease in their blood pressure when they reduce the amount of sodium (salt) in their diet. The effect of salt restriction is not uniform, however, and some patients seem to be more "salt sensitive" and achieve greater benefit from sodium restriction than others do. In general, African-Americans, the elderly, and patients with more severe hypertension experience a greater reduction in blood pressure with salt restriction. In patients with established hypertension, I recommend a moderate sodium restriction of 5 to 6 grams per day. After one month this may allow a decrease in or elimination of the medications needed for their blood pressure control.
You should be aware that a small minority of physicians disagrees with this approach; they maintain that salt restriction is not useful and might even be harmful. Their opinion is based on some research studies that I feel are questionable and which have created great controversy and debate in the medical community. Unfortunately, the popular press has picked up on this "salt debate," leaving the general public confused as well as many of my patients.
Click Here For The Treatments