Nutritional Program for Cardiovascular Disease Prevention

Well, this is the biggie! With a little effort on each of our parts and a willingness to change, we can make a big difference in the incidence of this nation’s number one killer, cardiovascular disease (CVD). Heart and blood vessel disease are not inevitable; in fact, they are preventable in most cases. It is very clear from every major study in the last decade that diets high in saturated fats and cholesterol, which would consist of regular intake of red meats, dairy foods, and eggs, are directly correlated to the incidence of CVD and its complications, whereas a low saturated fat, low cholesterol diet greatly lowers the risk of these diseases.

The main disease process at the base of the cardiovascular diseases is atherosclerosis, or hardening and clogging of the arteries. (Arteriosclerosis is the generic term referring to hardening of the arteries. Atherosclerosis refers to the disease process of artery plaqueing and is the term I will use in this text.) Atherosclerosis involves the thickening and narrowing of our blood vessels that occurs somewhat in most people, but with certain risk factors it can progress very rapidly and lead to early demise, even in their 40s or 50s. Atherosclerosis commonly affects the coronary arteries, which deliver blood to the heart muscle itself. This biggest cardiovascular concern causes a great deal of limitation and chest pain, or angina pectoris. When advanced, this coronary artery disease can result in a myocardial infarction (MI, heart attack, or “coronary”). Heart attacks are clearly the most common cause of death in the United States and the Western world. Other areas of the body may also be affected with atherosclerosis. Disease of the carotid arteries of the neck affects our mental faculties; atherosclerosis of the leg arteries decreases our ability to walk without pain; and clogging of the pelvic arteries affects our sexual performance.

Hypertension, or high blood pressure, is often a hidden multifactorial problem and the most common CVD; the main pathologic process involved in hypertension is atherosclerosis. The narrowing and hardening of the arteries increase their resistance and pressure and makes the heart work harder, which can then wear down this vital muscle. Untreated hypertension may lead to further heart disease including heart attacks and congestive heart failure, as well as to cerebrovascular accidents (stroke).

For nearly half a century, cardiovascular disease has been the number one cause of mortality and morbidity in the United States and in most of the Western world. At the turn of the century, it was not even in the top ten. In underdeveloped countries where people live on a more natural, “native” diet, there is a low incidence of CVD. In the United States, the many CVDs account for over 50 percent of all deaths. Of course, people live longer now, which allows for the development of more degenerative disease, but there is also more middle-age weight gain in a more sedentary population that eats more fats and refined foods than in the past. These last three factors are fairly easy to change (if change is ever easy) and form the basis of preventing these now common diseases.

Hypertension and heart disease are not inevitable results of aging. In countries where populations eat a diet low in fats, cholesterol, and salt there is very little or no hypertension in comparison to countries whose people eat those richer foods. The 90-year-olds in Hunza society appear to be free of CVD and have normal blood pressure. To keep the blood pressure low with age and minimize the atherosclerotic process we need to do the following:

• Eat a diet low in saturated fats, cholesterol, salt, and processed, refined foods (both fats and sugars).
  
• Eat high-fiber foods.
  
• Eat plenty of whole grains, fruits, and vegetables.
  
• Exercise or have a regular, active lifestyle, especially including walking.
  
• Keep body fat low.

There has already been some progress; in the last twenty years, the previous rapidly rising death rate from CVDs began leveling off and decreasing, likely due to better coronary care, CPR education, public education, and drug control of high blood pressure. Since 1968, there has also been greater dietary awareness, an interest in exercise, and an effort to diminish cigarette smoking. It is clear that a good (lower fat, more vegetarian) diet, regular exercise, weight reduction, and stress modification can reduce the symptoms of atherosclerosis, hypertension, and angina pectoris as well as decrease the risk and incidence of CVD in general. So why is it still so prevalent? Often, people must be hit over the head before they will acknowledge new information and change long-term patterns. On both an economical and educational level, the big industries fight changes that might affect their status and income. The meat, dairy, and egg megabusinesses still try to deny the relationship between their foods and high cholesterol levels and cardiovascular disease?advertising their products as being good for everybody and providing literature to young children to encourage the regular use of their foods. Now other businesses, such as fast food chains, are getting into the educational act claiming that a hamburger, fries, and a milkshake are a balanced meal. Kids are already influenced by advertising for sugary and refined food products.

Even with the improvement of the last 20 years, there are still well over a half million deaths per year from heart attacks and strokes (down from the previous 1 million yearly). About a third of the 1.5 million people who have “coronaries” each year die from those attacks. Nearly 50 million Americans have some CVD, mostly high blood pressure (over 35 million) and coronary artery disease (CAD, about 5 million), with many more people who are undiagnosed. Our cholesterol level, a key contributing factor in CVDs, can only be determined with a blood chemistry analysis, while hypertension often does not reveal itself prior to its being found on a physical exam. When either elevated cholesterol levels or high blood pressure are found, cardiovascular damage may already have begun. Because it is difficult for people to know if they have high blood pressure, it has been labeled the “silent killer.” Here, we will first look at the many risk factors for CVD, and then examine the underlying disease process, atherosclerosis.

The cardiovascular risk factors are commonly classified into the primary factors?of which there are three: cigarette smoking, high cholesterol, and high blood pressure?and the secondary of which there are many. Some of these significant factors in the genesis of CVD include obesity and being overweight, genetics, stress, a sedentary lifestyle, diabetes, and alcohol abuse. Many authorities feel that, even more than the moderate or high fat and cholesterol intake, it is the many nutritional deficiencies that arise from our present-day nutrition and that affect our cholesterol metabolism which lead to increased atherosclerosis. Deficiencies of vitamins C, E, and B6 and selenium are the main concerns. Other relevant nutrients are magnesium, chromium, niacin, essential fatty acids, and fiber. The types of fats consumed in the diet and the deficiency of the essential fatty acids, linoleic and linolenic, are felt by some authorities to be the source of the CVD problem. Udo Erasmus describes this in his book, Fats and Oils, in which he also suggests that the heated and hydro-genated “modern” oils used for cooking and frying are a big concern. Thus, margarines are a concern in regard to the atherosclerotic process. The increased consumption of homogenized milk fat in the standard milk appears to be linked with cardiovascular problems. An article by Wayne Martin in the November 1989 Townsend Newsletter for Doctors provides a great deal of support for the theory that cholesterol itself is not the culprit it is thought to be in the atherosclerotic process, but it is the hydrogenated and homogenized fats used and consumed in so many foods that are the disease-causing factors.

Regarding minerals, the calcium-magnesium interchange and the sodium-potassium relationship affect hardening of the arteries and blood pressure. Even copper and zinc deficiencies and imbalance may be related. It is clear however, that the saturated fats and cholesterol in the diet are linked to CVD in all animals studied, including the human species. Carnivorous animals, such as dogs and cats, seem relatively immune to high-fat diets. Possibly understanding their protection will give us further insight into CVD prevention.

The relationship of cholesterol has been and continues to be the biggest controversy in this area. Current thinking is that high blood cholesterol, especially with higher LDL cholesterol (the “bad” kind) and lower HDL cholesterol (the “good” kind, because it picks up used cholesterol and carries it back to the liver), is a significant factor correlated with atherosclerosis, coronary artery disease, and early death. The very large Framingham study showed that people with a blood cholesterol level of 260 mg. had three times the incidence of myocardial infarctions that those with levels of 195. Lowering cholesterol levels by whatever means?diet, weight loss, exercise, and even drugs?decreased the risk of heart attacks. Yet there may be other variables; this cholesterol picture may just be the surface factor.

Some authors, such as Richard Kunin, M.D. and Michael Lesser, M.D., feel that the metabolism of cholesterol, which uses many vital nutrients, is the real problem. With adequate nutrient levels, reasonable amounts of dietary cholesterol will not cause the problems we are seeing. Our liver makes cholesterol, which we need for many functions such as the production of hormones (estrogen and testosterone), vitamin D, and bile. A natural feedback mechanism should reduce our production when we consume cholesterol-containing foods. There may be certain factors, yet unknown but possibly genetic and nutritional, that interfere with this feedback mechanism. B vitamins, vitamins C and E, magnesium, manganese, and zinc are all needed for cholesterol metabolism, and if these are low, this waxy fat cannot as easily get into the cells to function and sludges around in the blood, clogging up our vessels. This is rather like the process in adult diabetes, where the sugar cannot get into the cells and stays in the blood, causing problems.

In Mega Nutrition, Dr. Kunin suggests that the rapid rise in CVD was associated with three important dietary changes besides an increase in fat intake that were as significant as or even more significant than cholesterol. First was the refining and milling of flour which removed many of the nutrients that are important to cholesterol metabolism. Second was the use of chlorinated water which was popularized and spread throughout the country. Chlorine tends to bind and reduce levels of vitamin E which acts as an important protector of the vascular lining. Third, homogenized milk also hit in the 1940s. Homogenization changes the fat composition of milk so that it is not as easily metabolized and passes more readily through the liver. This, I believe, is a big factor in the increase in CVD.

These theories have some backing, but are not generally accepted. More research is needed to verify that we can still eat a reasonable amount of high-fat and high-cholesterol foods such as eggs, meats, milk, and butter, and still not develop CVD, as long as our diet is nutrient-rich and meets all of our needs. Until then, I believe that there is more than enough research evidence to prove that eating a diet low in fat, especially saturated fat, and cholesterol, along with the other changes that I suggest, is still the best thing to do. We still need fats in our diet, but mainly the natural essential fatty acids found in nuts and seeds, fish, and grains and beans. These oils are necessary for many vital functions and also help release bile products from the liver and gallbladder. Bile is made from cholesterol and thus is one of the ways to eliminate cholesterol from the body.

Cholesterol is part of many of the foods that omnivores eat. It is contained only in animal foods, such as meats, eggs, and milk products. The average daily intake in the United States is 500 mg. for men and about 350 mg. for women. Women are somewhat protected from CVD during their child-bearing years by their female hormones. The new suggested maximum for cholesterol intake is 300 mg., not much more than contained in one egg yolk (275 mg.). It is probably ideal, especially for those at risk for CVD, to consume less than 150 mg. of cholesterol daily. That is the reason for the big push to a more vegetarian diet. (A strict vegetarian diet, meaning no eggs or milk products, can sharply reduce an elevated cholesterol level in one month, possibly as much as 100 mg./dl. (deciliter), or 100 mg. percent.)

Cholesterol is easy to absorb and hard to eliminate. It appears that the higher our blood cholesterol level, the greater our risk of CVD. Below 180 mg. percent poses a low risk; 180?200 mg. percent is a good range; over 200 mg. percent clearly increases our CVD risk, while over 250 mg. percent gives us a high risk. (LDL and HDL levels are also important within the total cholesterol value; see discussion below.) The average adult has a blood cholesterol level between 200 and 220 mg. percent. So there is work to be done. There is no known deficiency disease with cholesterol; many people apparently do well with little or no cholesterol intake. The body still makes it, though with certain chronic illnesses or liver impairments, blood cholesterol levels may fall to very low and probably functionally deficient levels. Cholesterol helps in tissue repair and other important functions mentioned previously.

Many doctors feel comfortable working with the total cholesterol value alone. Reducing it through smoking cessation, control of diabetes, hypertension, or obesity, dietary changes, or exercise programs can offer some security in disease prevention. It is now known that even a small increase in cholesterol can lead to a marked increase in coronary disease and heart attacks; the main research studies suggest that every 1 percent we lower a high cholesterol, we reduce our heart disease risk by 2 percent.
So even mild decreases in cholesterol are helpful.

In recent years, more practitioners are using the cholesterol subfractions?HDL and LDL (VLDL may also be significant). These represent lipoproteins, or fat-protein molecules, that carry the nonimmersible fats through the blood. The high-density lipoprotein (HDL) carries cholesterol back to the liver from the bloodstream and is thought to be protective by taking the extra cholesterol out of the blood. Low-density lipoproteins (LDLs) transport cholesterol through the blood to the cells and usually comprise most of the blood cholesterol. Very low density lipoproteins (VLDLs) also keep cholesterol in circulation and may contribute to atherosclerosis. The total cholesterol/HDL ratio and/or the LDL/HDL ratio can be observed as a relative measurement of CVD risks.

Smoking, being sedentary, and consuming saturated fats in the diet lower protective HDLs. Exercise, a high-fiber diet, and alcohol increase HDL, though alcohol also produces irritating effects on the liver and vascular system, and may increase total cholesterol. Increased LDL levels can be caused by increased consumption of saturated fats and sugar, deficient levels of vitamin C or chromium, and high copper or iron levels. The various fats have different effects on cholesterol. Saturated fats lead to more LDL and VLDL. The monounsaturated fats tend to have a neutral influence on cholesterol levels, while the polyunsaturated fats tend to lower total cholesterol but may also likewise lower the good HDLs.

Other fats contained in foods that have beneficial effects on cholesterol are the omega-3 fatty acids, EPA and DHA, found in coldwater fish such as salmon, mackerel, and sardines. This fairly recent important discovery, as well as other essential nutrients, especially magnesium and pyridoxine, are discussed in more detail below.

Smoking is another crucial factor and an instigator of not only our number one killer, cardiovascular disease, but also our number two life destroyer, cancer. Day-to-day smoking sensitizes our vascular system and heart. Nicotine damages the vascular lining, increases heart rate, and decreases oxygen delivery, with further carbon monoxide intoxication. Smoking also increases LDL cholesterol levels and possibly poses an additional risk of increased levels of beta-VLDL (currently under research). Cadmium, which is a blood pressure elevator, and other toxic minerals are also found in cigarette smoke. Nicotine also increases arterial constriction, which further limits oxygen and nutrient delivery to the cells and tissues. And chronic cigarette smoking clearly increases our chances of having atherosclerosis and hypertension with all of their complications. Thus, cigarette smoking by itself includes all three primary risk factors for CVD.

Hypertension is not only another major risk factor, but also occurs as a result of atherosclerosis itself. High blood pressure is defined as one over 140/90 mm Hg (millimeters of mercury, a pressure reading). Normal blood pressure (BP) should range from 100/70 to 120/80. The higher number represents the systolic BP, the BP while the heart pumps; while the lower number represents the diastolic BP during the rest between beats. The blood pressure itself is basically the pressure that the blood exerts on the arterial walls. An elevated diastolic pressure has a worse affect on the genesis of atherosclerosis than does a high systolic pressure. Even a diastolic pressure between 80 and 90 is associated with an increased risk. High blood pressure puts strain on the blood vessels, the heart, and the kidneys (especially important in controlling the BP).

Many doctors consider a BP in the range from 140/90 to 160/95 to be only mildly elevated, though it definitely increases risk. This is the area of “borderline” hypertension that we can do most about. Hypertension, like CVD in general, is affected by a number of risk factors. Weight, diet, family history, gender, race, stress, smoking, and lack of exercise are some of the main ones; there are many more. Suffice it to say here that it is a major disease, limiting and shortening the lives of nearly 50 million people in the United States and many more times that in the entire world. And it is a disease we can do something to prevent. The CVD prevention program applies to high blood pressure as well, and clearly, lowering elevated blood pressure by whatever means possible reduces the risk of heart disease, heart attacks, and strokes.

Obesity is another major risk factor in CVD, contributing to both atherosclerosis and hypertension. Being overweight raises blood pressure, increases blood fats, reduces HDL, and usually minimizes exercise, as well as increasing diabetes incidence. This all speeds up the atherosclerotic process and the occurrence of coronary artery disease. By decreasing obesity, we can decrease many of the above-mentioned CVD risk factors at one time.

Stress factors also contribute to CVD. The type A personality has an increased risk, more indirectly, through poor diet, caffeine use, and increased adrenaline output, which raises blood pressure. The hard-driven, ambitious type A person is constantly creating his or her life under the pressure of time, with the attitude that there is never enough time to do all there is to do, or that it should be done faster. Some authorities further attribute to this personality a low awareness of spiritual or philosophical values, or a low religious orientation, with a perspective basically geared toward work and running around the world. These type A people could benefit from stress reduction to help them in relaxation, and from exercise, especially with a sense of fun, to aid in letting go of the ever-riding tensions.

Lack of exercise is also a problem in CVD. The heart and circulation need regular, even vigorous exercise to keep them strong. Remember, the heart is a muscle that needs to work out. We will look more at exercise as a positive preventive to cardiovascular disease in the discussion below.

Drinking “soft” water is definitely a risk. It replaces the minerals calcium and magnesium in normally CVD-protective water with sodium mainly, which has a tendency to increase blood pressure and worsen atherosclerosis. Areas where people drink “soft” water have higher incidences of CVD and heart attacks. It is best to drink spring or well water for its beneficial minerals as well as to prevent chemical exposure. And water is definitely better for us than caffeine and alcohol. Caffeine increases heart rate and blood pressure and adds the risk of cardiac arrhythmia. Alcohol is a suppressant but also an irritant and is a minor risk factor itself in CVD.

Family history is not something we can do much about, but our knowledge of it can motivate us to take extra special care of ourselves and more diligently apply the program outlined here. Certain genetic traits may influence cholesterol metabolism and levels of production of cholesterol and other fats. It appears that some people actually make more cholesterol (or perhaps clear less or use less) than others. This increases their risk of vascular problems. Specific genetic (familial) problems of fat levels are described in medicine. These are termed “hyperlipidemias,” the lipid disorders, and include five types. Types II and IV, the most common, cause high cholesterol and high triglyceride levels, respectively. Type IV is the most common and is thought to result more from familial eating patterns than from genetics. It also can proceed to problems in sugar metabolism. These disorders can be revealed by a blood test.

A history of hyperlipidemia disorder or a family history of coronary heart disease, high blood pressure, diabetes, or obesity put us at increased risk for developing some type of CVD. This means we need to enhance our prevention efforts, which may require many changes, depending on our current lifestyle. Cardiovascular disease really needs to be prevented in childhood. Atherosclerosis often starts in children, as can hypertension. Avoiding the typical high-fat, high-sugar, and high-salt foods and snacks and fried oils can make a big difference. Keeping the weight normal and getting plenty of exercise is the way to go. In some manner, television is a cardiovascular disease risk as it encourages a sedentary life and poor food choices are highly advertised. Dietary suggestions for children with CVD risk and obesity will be discussed later in this section.

It is important to remember that effects of risk factors are cumulative. Just being overweight is not a big problem if our cholesterol and diet are okay or if we do not smoke, but if we are an overweight, sedentary smoker with high blood pressure and a poor diet, we will not be living on that path very long.

I would like to discuss the process of atherosclerosis so that we have a clearer picture of this basic degenerative disease affecting the lives of millions. Atherosclerosis is the hardening of the inner arterial walls with lipids (mainly cholesterol), smooth muscle cells from the blood vessel walls themselves, and calcium. This process, which is stimulated and added to by platelets and white blood cells, forms the plaque, or atheromas. Atherosclerosis can begin early with these fatty streaks in the blood vessel walls. Many teenagers with high-fat diets have plaque in their arteries. The fries, shakes, burgers, and hot dogs that are so prevalent in our culture?s diet, along with the deficiencies that arise from high intake of sugar and refined foods (there often is not much room left for many nutrient-rich foods), predispose our youth to this early hardening of the arteries.

The basic process of atherosclerosis is thought to begin with minor microinjuries to the vascular linings. These tiny wounds stimulate the overgrowth of muscle cells and attract and attach the fat/cholesterol and platelet aggregation along with calcium precipitation to eventually form a small fibrous scar that begins to narrow the opening of the artery. (Cholesterol is a waxy fat/sterol that is attempting to heal the irritated or injured tissues; it?s really trying to help!) This arterial plaque reduces the blood flow and also decreases the strength and elasticity of the vessel wall. This can predispose us to increased blood pressure and aneurysms (ballooning of the artery), which can then lead to bleeding, strokes, or other, milder consequences.

These tiny injuries to the blood vessels involve many contributors, but the mechanism by which they occur is via free-radical pathology, not dissimilar to most inflammatory and cellular changes. We discussed the formation of these irritating molecules in the Anti-Aging and Anti-Stress programs, and the development of diseases such as arthritis and cancer.

Free-radical formation and the process of atherosclerosis involve many factors, most of which we have discussed. Saturated and hydrogenated fats in diet, elevated fats and cholesterol in the blood, hypertension, smoking, carbon monoxide, and deficiencies of nutrients such as vitamins C and E, chromium and selenium, are some of the main ones. Other contributing factors include infection, allergy, particularly from antigen-antibody complexes formed from food proteins, and abnormal platelet activity. Platelet function is important; it helps our blood to clot when this is needed. However, an increased adhesiveness can be a big problem, especially in those with already thicker, fatty blood or with irritated tissue linings (saturated fats thicken the blood). Platelets produce a substance called thromboxane A2, which increases platelet stickiness and stimulates clot formation. It also stimulates increased productivity of the smooth muscle cells in the blood vessel walls. Contributors to increased platelet adhesiveness are smoke, excess fats, especially LDL cholesterol, diabetes (high blood sugar), and many nutritional deficiencies, such as vitamins A, C, E, B3, and B6 and the minerals calcium, magnesium, zinc, and manganese. This overfunction of platelets is thought to increase the progress of certain diseases, mainly cardiovascular in nature, and especially atherosclerosis, but also arthritis, diabetes, and cancer.

Atherosclerosis can be a slow process. The disease may not cause problems for many years and then the symptoms can begin and progress rapidly, as a blood vessel usually must be more than half (more like 70?80 percent closed before it creates difficulty. A full clot?that is, a thrombosis?will lead to blocked circulation and often death of the tissues to which the blood vessel leads, unless there is existing collateral circulation to that area. This is how a heart attack develops, with atherosclerosis in the significant coronary arteries. In coronary artery disease, 70?80 percent closure will more likely lead to chest pain, the symptom of angina pectoris. If an atheroma or clot breaks off from its blood vessel attachment, it will move through the blood until it reaches a vessel that it is too large to pass through and then clog up that vessel, which can be disastrous. Clots in the blood vessels also can stimulate arterial spasm, which often worsens symptoms.

Atherosclerosis affects the vascular, mainly the arterial, system and commonly leads to problems in the heart, kidneys, brain, ears, and sexual organs. The heart, or coronary, blood vessels are the biggest area of concern. The effect on the kidney (renal) circulation can lead to hypertension. Carotid artery disease directly influences brain circulation, which can lead to memory problems, hearing loss, perhaps dizziness or vertigo, senility, and strokes. Transient ischemic attacks (TIAs) affect the state of consciousness with intermittent loss of blood flow. Poor circulation is the biggest cause of decreased sexual function and impotence in middle-aged or older men.

The best way to evaluate the presence or state of CVD is by a thorough workup. A history will describe any possible symptoms tied to circulatory compromise or blockage, the result of atherosclerosis. A physical exam will not usually tell much unless there is some heart abnormality, poor circulation, or elevated blood pressure. The blood pressure (BP) should ideally be under 120/80 in adults and 110/70 in children. Any elevation puts a patient at higher risk, and calls for closer follow-up. The BP can go up just from the nervousness of being in a doctor?s office, so it needs to be checked under more normal circumstances if it is abnormal. However, if it goes up under the stress of visiting a doctor, it likely goes up with other stress also.

An electrocardiogram, or EKG, is a measurement of the heart rhythm and electrical activity. This is positive only after problems already exist. Neither an EKG nor a chest x-ray is preventive; they simply show the presence of disease after it occurs and offer very few cues that would point out potential future problems, as can the blood pressure or blood level of cholesterol, HDL, and LDL. Many doctors are encouraging patients to treat cholesterol levels over 200 mg./dl. with diet, exercise, and even drug therapy. Increased blood levels of triglycerides, sugar, and uric acid are also of concern. A more extensive test for the heart is an echocardiogram using ultrasound, which can pick up more subtle changes in the heart muscle and its internal valves. Angiography, the injection of dye into the blood to study the circulation through the heart or any area of the body, is done more commonly these days to measure the circulatory status. It is performed before cardiac bypass surgery and is itself very risky, expensive, and possibly painful.

The best approach to cardiovascular disease is, of course, prevention. To prevent CVD, our overall plan includes not smoking; preventing and/or controlling obesity, high blood pressure, and diabetes; exercising and staying fit; eating a low-fat, more vegetarian diet; and monitoring and keeping our levels of cholesterol low, both in our diet and in our blood. For high-risk people, the program needs to be more vigorous. They need clear dietary guidelines and good follow-up care if they are to have a good chance of reducing development of CVD potential and its associated morbidity and mortality of later years. Not smoking, more aggressive control of obesity, hypertension, or diabetes, and a more strict low-fat diet are really mandatory.

Much research is being conducted to investigate whether atherosclerosis is reversible. There is no question that its progress can be slowed through diet and exercise. However, whether it is possible to actually reverse it and clear the vessels of plaque is still questionable, although many authors, including myself, feel that it is possible and recent studies suggest this. Some studies show that a low-fat, low-cholesterol diet can result in increased cardiac output and a reduction of blood fats, which it is thought will decrease fatty plaques over time. A comprehensive research experiment conducted by, among others, Dean Ornish, M.D. and discussed in Stress, Diet and Your Heart suggests that exercise, stress reduction, and better diet result in marked improvement in almost all patients with CVD, in terms of both symptom reduction and enhanced performance ability. This is now proven in his new book, Dr. Ornish?s Program for Reversing Heart Disease.

Many of the significant risk factors contributing to CVD can be lessened through dietary influences. These risks include high blood pressure, high cholesterol, (especially high LDL levels), high triglyceride levels, and obesity, as well as many cases of diabetes. High fat consumption, low fiber intake, and excess salt and sodium intake are influential nutritional risks. Proper diet alone can decrease cholesterol levels by 30 percent or more, although this usually requires some radical dietary shifts. Smoking and lack of exercise, the main nondietary habits (cardiovascular risk factors) involved, often require similar changes of willpower as does diet; and furthermore, we need a feeling of positive self-worth to even gather the force to make these successful changes.

The primary dietary focus of the cardiovascular disease prevention diet is fat intake. The diet should be low in fat in general and particularly low in saturated fats (animal fat plus coconut and palm oils) and the hydrogenated fats (all margarines) and oils such as used for frying foods. These are mainly poor-quality vegetable oils used so commonly in commercial food preparation and restaurant cooking. Avoiding these oils is highly recommended. It is clear that a diet high in saturated fats and cholesterol leads to increased blood cholesterol levels and increased atherosclerosis. In my clinical experience, homogenized, pasteurized milk and dairy fats seem to drive cholesterol to high levels. A quart or more of whole milk daily or regular intake of ice cream can lead to cholesterol levels over 300 mg./dl.; and thus, going off these foods can dramatically lower the cholesterol.

To prevent atheroschlerosis, a low-fat, low-cholesterol, and high-fiber diet is recommended. Fiber reduces CVD risk in many ways. It binds cholesterol and fats and lessens their absorption. It subsequently decreases blood cholesterol and LDL and increases protective HDL cholesterol. Increased fiber levels?and we are talking about 20?30 grams daily, which often requires supplemented fiber?will also help reduce blood pressure levels in those with elevations.

Fat intake should be reduced from the average 40?45 percent to a maximum of 25?30 percent of total calories; even lower levels, 15?20 percent, are suggested. With supplemental fatty acids or the use of good-quality cold-pressed vegetable oils to obtain our necessary linolenic acid, even lower fat intake can be consumed safely. This, however, is very difficult unless we eliminate a wide variety of common foods, including all fried foods, meats, milk products, butter, cheese, eggs, nuts, and seeds, which also clearly reduces protein intake.

Currently, the average American fat intake ranges from about 100?150 grams per day. Of course, men usually consume more than women, and many people with some food awareness consume less. In diet analyses, however, I commonly see this range, even up to and over 200 grams daily. At 9 calories per gram, 125 grams means 1,125 calories per day of fat. If that represents the average of about 40 percent of total calories, it would mean a diet of about 2,800 calories a day, which would add weight to most folks other than athletic men. If we eat 100 grams (900 calories) of fat daily, and that is one-third of our total calories, that means a total of 2,700 calories a day; if fats are a more healthful 25 percent of the diet, that means a total of 3,600 calories, more than most people consume. Realistically, fat intake levels must be no higher than 50?75 grams a day to create a calorie range of 1,800?2,700 with a diet containing 25 percent fat.

The types of fat consumed are also important. More unsaturated (poly- and monounsaturated) than saturated fats are suggested; that means a higher intake of vegetable oils and polyunsaturated-fat-containing foods. Beef, for example, has a ratio of saturated to polyunsaturated fat (S:P) of around 15:1, whereas the ratios in poultry and fish are closer to even. Vegetable fats found in nuts or seeds have an even lower S:P ratio. The polyunsaturates tend to be more beneficial to our levels of fat and cholesterol than the saturated fats found in milk, eggs, and meat. However, the polyunsaturated fats are unstable and not only lower total cholesterol but may also reduce the important HDL; the monounsaturated fats are probably better. Be careful of the hydrogenated polyunsaturates (many margarines and cooking oils); they have increased saturated fats and unusable, trans-fatty acids (mirror image molecules of the natural cis-fatty acids), and are even less desirable than the fats from butter, milk, or meat. Excess polyunsaturates also have added cancer and heart disease risks, possibly because of oxidation and the potential formation of free radicals. Overall, a minimum of fats is suggested, with avoidance of many of the less healthful unsaturated fats, such as refined cooking oils, margarines, mayonnaise, and artificial dressings and creamers, which also contain questionable chemicals. It is fairly clear that the total fat intake has an important influence on blood cholesterol as does the proportion of saturated fats or cholesterol-containing foods, so this needs to be an important area of focus.

Particularly helpful oils are contained in the coldwater fish such as salmon, mackerel, sardines, and herring. These contain EPA (eicosapentaenoic acid) and DHA (dicosahexaenoic acid), which have a positive effect on lowering cholesterol and triglycerides. It is now considered that these are CVD-prevention nutrients and that consuming these oil-containing fish two or three times a week will be to our cardiovascular benefit. EPA can also be used as a supplement to the diet.

In addition to a low-fat and high-fiber intake, a low-salt and low-sugar diet is also suggested. Avoiding salted and pickled or cured foods, especially meats, is suggested for health. Excess sugar, because it increases calories, weight, and blood fats, is an indirect risk factor in CVD; it is not healthy for many other reasons. More complex carbohydrates, including mostly whole grain and vegetable foods, are definitely in our favor for CVD prevention. The starch-centered diet, along with exercise, is the basis of the Pritikin program to reduce and prevent CVD. Nathan Pritikin was one of the more vigorous proponents of this excessively low-fat diet.

Children and Cardiovascular Disease

CVD prevention may need to start in young people, even preteens and adolescents, particularly if there is early obesity or a family history of heart disease. Weight, blood pressure, and cholesterol levels can be followed in these higher risk children. Diet modifications may be begun early with a lower-fat diet, primarily by reducing the animal fat and fried food consumption; this is accomplished by minimizing the intake of such foods as burgers, hot dogs, french fries, chips and excessive cheese, ice cream, and even milk products overall. Low-fat or nonfat dairy products can be used with these young people, yet still be a diet which contains adequate levels of protein, essential oil-containing foods, calcium foods, and even eggs, though these should not be consumed excessively. Encouraging more fruits, vegetables, whole grains, nuts and seeds, and some low-fat dairy foods will provide an adequate fiber, lower-fat diet with adequate calcium and calories. Some fish and poultry and occasional meat will support the protein needs very well, yet there are now many more vegetarian-oriented teenagers and young adults in our society who do very well.

With children who eat a lot of fast foods, ice cream, pizza, cookies, sodas, and other exciting modern day treats, the challenge is to get them to eat more wholesomely. Parents should provide these “treat” foods to their children only after they eat their more nutritious foods, and then only occasionally. Wholesome suggestions include replacing some soda and cookie snacks with low-fat milk, yogurt, and crackers; adding oat bran to cereals, meat loaf, or casseroles; using whole grain cereals in place of sugary ones as well as using cooked whole grains at meals; substituting Popsicles and fruit juice bars for fattier ice cream; using some low-fat cheeses such as cottage cheese or mozzarella (pizza with cheese and vegetables, not with fatty meats, is acceptable, even once or twice weekly); encouraging vegetables and fruits, with skins, even green salads when possible; and buying cookies and treats with low saturated fats and low sugar, such as fig bars, animal or graham crackers, ginger snaps, or the newer fruit-juice-sweetened cookies. We as parents also need to set a good example ourselves by our good food choices and by not overeating. Also, not snacking while watching television is suggested.

There is some controversy among authorities about the diet of the young in regard to CVD risk. Some believe that all children should be on a low-fat diet, at least lower than our current 40 percent national average. Most definitely, many of the poor-quality, refined foods should be avoided. Clearly, children who are obese or who have cholesterol levels over 200 mg./dl. should work to correct these states, and those who have families with CVD should be watched more closely. But overall, the higher-protein, higher-fat diet so consistent throughout the Western world does lead to increased growth and size of children and adults. Many cholesterol-rich foods, such as milk, cheese, meats, and eggs support the growth spurts. Yet, consumption of these foods are also associated with reduced longevity secondary to degenerative disease. My inclination has been to feed children this richer diet with more protein-fat foods, though it would still need to be a wholesome one, avoiding the junk, sweets, and fried oils. Then, as they move into their later teens and early adulthood, prepare them to shift their diet focus to a more natural, lower-fat, more vegetarian plan, with regular exercise supported along the way.

Herbs and Supplements

In addition to the oily coldwater fish, specific CVD-prevention foods include garlic, which has a fairly strong cholesterol- and blood-pressure-lowering effect, and onions and cayenne pepper, which have milder effects. These three foods are also herbs that are used in blood cleansing and thinning; garlic specifically lowers blood clotting potential. Soybeans and soy products such as tofu and tempeh may have a positive effect on cholesterol and atherosclerosis; besides all are low in fat and high in protein. Paavo Airola suggests other good foods for reducing CVD risk. These include the grains millet and buckwheat, sunflower seeds, okra, potatoes, asparagus, apples, and bananas, as well as yeast, lecithin, and linseed oil. Linseed (flax) oil has a high amount of the omega-3 fatty acids, such as EPA and DHA, and is a less expensive supplement to help reduce cholesterol levels. Linseed oil also contains the essential fatty acids (EFAs), linoleic and linolenic, which may help reduce blood fat levels and fatty deposits. Cold-pressed flaxseed oil is also readily used by our bodies in the important EFA functions, but it is a very fragile oil and must be fresh and then protected from light, heat, and oxidation.

Most of the common vegetable oils are high in the omega-6 fatty acids, as are borage seed and evening primrose oil, though they contain mainly gamma-linoleic acid (GLA). Soybean oil and walnut oil are higher in the omega-3s, and linseed oil is highest. All of the EFAs, both omega-3 and omega-6, help in cell membrane support and prostaglandin synthesis. They also help in the transfer of oxygen in the lungs and are essential to growth in the young.

Fruits are also recommended. They have some nutrients, and are high-water-content cleansing foods that make the diet more alkaline. A diet of only fruit and vegetables for a week or two is a good way to realkalinize our body and blood, which aids detoxification and lowers blood fats. A more acidic, richer diet creates more mucus, and thicker, more viscous blood, and lymphatic congestion.

I think of atherosclerosis as being much like the crud that builds up in water pipes because of various chemical or mineral imbalances that allow particle precipitation. I then think of fasting on juice or water as a means of cleaning that sludge from the blood vessels and organs. Fasting definitely reduces blood fats and blood viscosity so that blood flows be