Opening the Heart and Opening the Arteries Cardiovascular Disease – A Holistic Approach to Reducing the Risk.

Opening the Heart and Opening the Arteries Cardiovascular Disease – A Holistic Approach to Reducing the Risk

The typical talk on this subject: Cardiovascular Disease Prevention: Risk Factor Modification o Tobacco o Lipids – diet for a 15% drop, drugs for more, statins, fibrates, etc. o CRP – statins? o Aspirin, plavix, aggrenox, etc. o ACEI’s o Exercise

The “Green Medicine” talk on this subject: Cardiovascular Disease Prevention: Risk Factor Modification o Tobacco o Lipids – add in red yeast rice extract, CoQ10 with statins, etc. o CRP – some herbal anti-inflammatory combos o Other blood thinners (garlic, vitamin E, fish oil, etc.) o Exercise

This talk o A Whole Person talk on Heart Disease primary and secondary prevention o Mind-body Medicine and Heart Disease o Diet and Exercise changes o If time allows, the subject matter of the “green medicine talk” – natural medicines for treatment of specific risk factors

Basic Principles of Holistic Medicine o The Body is a Self-Healing Organism o If we remove toxic influences and provide basic needs, people will often get better o Unconditional Love is Life’s Most Powerful Healer o Do not underestimate the power of this factor (data to follow) o People behave as they do for good reasons: o Self-destructive behaviors are often coping mechanisms that have become meladaptive Even when looking at more concrete risk factors (diet, exercise), we find that in order to help patients adopt the lifestyle measures that provide for health of the body, we need to be watching out for the health of the mind and spirit

A Broader Approach to Cardiovascular Disease Prevention: Risk Factor Modification o Relaxation/Stress Reduction o Social Connection/Intimacy o Tobacco o Exercise o Diet o Lipids o Homocysteine and CRP o Fish oil

Sickness

Causes of Death Causes of death: Trauma is #1 age 1-44; Cardiovascular leads cancer

Causes of Death Mortality Rates, 1995 and 2001 *rates per 100,000 United StatesWashington 1995200119952001 Heart Disease280.7245.8208.6188.2 Stroke60.157.460.762.8 All cancers204.9194.4183.0180.2 Source: National Center for Health Statistics, 2003

Source: McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993; 270:2207–12. (1990 data). Note: The percentages used in the figure are composite approximations derived from published scientific studies that attributed death to these causes. Actual Causes of Death

Actual Causes of Death Actual Causes of Death Physical inactivity and unhealthy eating are responsible for at least 300,000 preventable deaths each year. Only tobacco use causes more preventable deaths in the United States.

The Rules of Tacks 1. If you are sitting on a tack, it takes a lot of aspirin to make the pain go away. 2. If you are sitting on 2 tacks, removing one does not result in a 50% improvement in symptoms. (It still hurts to sit down.)

Healing the Heart: Further Broadening the Discussion o The heart is a metaphorically important organ as well as physiologically important o Interestingly, science is showing that caring for our metaphorical heart is important for the health of the physical one : o stress and isolation might be added to inactivity, poor diet, and tobacco as actual causes of this illness

The Essential 8 o Air and Breathing o Water and Moisture o Food and Supplements o Exercise and Rest o Play/Passion/Purpose o Gratitude/Prayer/Meditation o Intimacy & Connection o Forgiveness Mind Body Spirit

Mind and Spirit o The role of stress in heart disease : In 683 patients, there was a significant non-uniformity to the distribution of threatening arrhythmias, sudden death, and MIs, with the major peak on Mondays (p<.001) Peters RW et al. Circulation 1996; 94:1346

Stress A Definition

Stress o Homeostasis based definition: stress is the compromise of homeostasis: an imbalance that can lead to changes over time (as the physiological adaptation occurs) or dysfunction. o Adrenal-based definition. The state of adrenal activation stimulated by the influence or detection of an environmental challenge to the body's homeostatic mechanisms that cannot be accommodated within the normal metabolic scope of the animal. Rooted in the observations of adrenal hypertrophy (due to overactivity) in chronically stressed animals.

General Adaptation Syndrome (GAS) o The Response to Stress, in 3 Phases: o Alarm Reaction o Stage of Resistance o Stage of Exhaustion

Alarm Reaction: Fight-or-Flight o Evolutionary Role: escape from predator or acute physical danger

Alarm Reaction o Physiological changes: Adrenal hormones adrenaline (epinephrine) and norepinephrine o Metabolism increases o Heart rate increases o Blood Pressure increases o Breathing Rate increases o Muscle Tension increases

Stage of Resistance o HPA (hypothalamo-pituitary-adrenal axis: Cortisol increases when stress becomes chronic o Block energy storage and help mobilize energy from storage sites o Increase cardiovascular tone o Inhibit anabolic processes such as growth, repair, reproduction and immunity

Adrenal Exhaustion o Coping responses cannot sustain their response if stressor is sufficiently severe and prolonged o “Diseases of adaptation" may arise o Hypertension o Ulcers o Heart disease o Symptoms that disappeared during the stage of resistance may reappear o Death possible

Physical and Psychological Side Effects of Stress The body cannot distinguish physical danger from psychological threat For most modern stressors, the value of increased heart rate, increased muscle tone, etc. is less, and those changes are not utilized for physical exertion, leaving the organism aroused without a release (one part of the solution is cognitive therapy)

Maladaptive Symptoms with Acute Stress Hormones o Cold Hands and Feet o Palpitations o Diarrhea or Constipation o Decreased sleep

Maladaptive Changes with Chronic Stress o Worsened blood sugar control/increased insulin resistance o Increased visceral fat deposition (apple- shaped weight gain) o Increased inflammation o Decreased immunity

Documented Relationship of Illness to Chronic Stress o Susceptibility to the common cold correlates with psychological stress Psychological stress and susceptibility to the common cold S Cohen, DA Tyrrell, and AP Smith NEJM Volume 325:606-612 August 29, 1991. Number 9 Several potential stress-illness mediators, including smoking, alcohol consumption, exercise, diet, quality of sleep, white-cell counts, and total immunoglobulin levels, did not explain the association between stress and illness. Controls for personality variables (self-esteem, personal control, and introversion-extraversion) failed to alter findings. o Timing of heart attacks – as previously mentioned Many studies have shown an excess of cardiovascular events on Mondays. A relative trough has been seen on Saturdays and Sundays compared with the expected number of cases. Highest incidence is within the first three hours of waking on Monday morning. New Insights into the Mechanisms of Temporal Variation in the Incidence of Acute Coronary Syndromes Strike PC, Steptoe A, Clin. Cardiol. 26, 495–499 (2003)

Blaming or Taking Responsibility o Understanding the importance of stress in our medical conditions gives us the power to use stress management to decrease illness and change our experience of it o This concept should not be used to blame people for their illnesses

Mind-Body and Body-Mind Interactions in Chronic Illness

How Emotions and Stress Affect Disease Risk o Hormonal Effects as described for cortisol o Vasoreactive effects with adrenaline o Sleep disruption causes multiple physiological effects o ( Shift work increases the risk of CHD by up to 50%. Scand J Work Environ Health. 1997 Aug;23(4):257-65)

How the Body Affects Emotions and Stress o Body tension is perceived as emotional by the brain o Pen demonstration o “I have so much to do” o Therefore, some simple physical relaxation techniques can help to alleviate mental/emotional stress o Abdominal Breathing

The Relaxation Response o Counterbalancing mechanism to the Fight-or- Flight Response o Metabolism decreases o Heart rate decreases o Blood Pressure decreases o Breathing Rate decreases o Muscle Tension decreases o May be consciously elicited o Generally needs to be practiced

Techniques Which Can Elicit the Relaxation Response o Diaphragmatic Breathing o Meditation o Body Scan o Mindfulness o Repetitive exercise o Repetitive prayer o Progressive muscle relaxation o Yoga Stretching o Imagery o (Music)

Common Elements of Techniques Used to Elicit the Relaxation Response o Focusing of attention through repetition of words or physical activity o Passive disregard of everyday thoughts when they occur, and return to the repetition

Benefits of the Relaxation Response o Immediate: o Getting through procedures and short-term stress o Long-term: o Used consistently, there are carry-over effects

Spirit o Meditation/Prayer/Gratitude o Intimacy and Connection o Forgiveness

Relaxation Practice and the Mind-Body - heart In 107 patients with ischemic heart disease, 38-month risk for cardiac events was 0.26 in those who had undergone sixteen 1.5-hour sessions of stress management cognitive education and relaxation training (p=.04) v. conventionally treated controls Blumenthal JA et al. Arch Intern Med 1997; 157:2213

Just for Comparison: o 4S trial – RR 0.67 after 5.4 years treatment with simvastatin Circulation. 1998;97:1453-1460 o MIRACL Trial (higher risk patients, like the relaxation trial): RR 0.84 in 16 weeks on atorvastatin 80 mg vs. placebo JAMA. 2001;285:1711-1718 o LIPS – RR 0.78 after 3-4 years post PCI on fluvastatin 80 mg vs. placebo JAMA Vol. 287 No. 24, June 26, 2002 o EUROPA and HOPE trials show approximately 20% reduction in risk of events over 4 to 5 years of treatment with an ACEI Lancet 2003 Sep 6; Vol. 362 (9386), pp. 755-7

Religious Expression o Mortality – 39/52 studies – religious persons lived longer – 12/13 more recent (and more rigorous) studies found significantly longer survival, especially among those who were active in the religious community

Connection with Parents The Harvard Mastery of Stress Study 126 male Harvard students were asked questions regarding their relationship with their mothers and fathers. They were then followed for 35 years regarding their own development of health risks and illness. The key question was: Would you describe your relationship with your mother and father as: Very close Warm and friendly Tolerant Strained and cold

On follow up, 35 years later, the outcomes were as follows: o If relationship with Mother was: o Tolerant or strained - 91% had significant health issue o Close and Warm - 45% had significant health issue o If relationship with Father was: o Tolerant or strained - 82% had significant health issue o Warm and close - 50% o If relationship with both parents was: o Strained - 100% incidence of significant health risk o Warm and close - 47% had a significant health risk

Connection in Marriage Angina pectoris among 10,000 men II. Psychosocial and other risk factors as evidenced by a multivariate analysis of a five-year incidence study. Medalie, JH and U. Goldbourt, Am. J of Medicine, 1976, 60(6): 910-21 10,000 men were surveyed and followed for 5 years. The key outcome was the development of angina. Men with substantial risk factors for CAD (elevated cholesterol, age > 45, HTN, diabetes, EKG abnormalities) were 20 times more likely to develop angina than men without those risks. When asked, "Does your wife show you her love?“ men within the high-risk group who said, "Yes" had half the development of angina.

Social Connection The “Alameda County Study” – LF Berkman, LS Syme, L Breslow – multiple publications. 6,900 participants were surveyed and followed for 17 years. Key issues were contact with friends and relatives, church membership, membership in clubs or groups, and marriage. Those without close ties or frequent social contact had an overall death rate 3.1 times higher than those who did have these contacts. Social and community ties were more predictive than smoking (1.8), overeating, physical activity, etc. This has been confirmed in Sweden, Finland, Evans County Georgia and many other communities

Social Connection – Altruism o Tecumseh Community Health Study o Some social activities were more protective than others. Those who volunteered to help others at least once a week were 2 ½ times less likely to die during the 9-12 year study than those who never volunteered o Science 1988, 241:540-45

Social Connection – Altruism o Study of women with children – Major illness developed over a 30 year period in o 36% of women who were members of volunteer organizations o 52% of women who were not members of volunteer organizations Successful Aging, American Journal of Sociology, 1993, 97:1612

Connection & Heart Surgery Outcome U Texas study on people having heart surgery 1. Do you participate in organized social groups? YesNoYesNo 2. Do you draw strength from your religious or spiritual faith? YesYesNoNo Risk of dying 6 months later 3%9%8%22%

Intimacy Into-Me-See – An element of disclosure/trust Social support: simple ratings of feeling loved are more important than number and size of networks Someone special, whom you can lean on, to share feelings with, to confide in, to hold and comfort you

Pets o Having a pet: CAST trial which looked at flecainide and encainide o Death rate 1.1% of people who owned dogs 6.7% of people who did not own dogs o In one study, the effect of a dog on lowering blood pressure reactivity was greater than the presence of a good friend, since the friend was often perceived as being judgmental whereas the dog was not

Touch - Physical Intimacy o Humans need to touch and be touched, just as we need food and water Saul Schanberg, M.D., Ph.D. o Half of 40 preemies were gently stroked 45 min/day; half were not All were fed the same amount of calories After 10 days, stroked babies were 47% heavier than unstroked, and were more active, more alert and more responsive to social stimulation Confirmed in Ind. J. Pediatrics Volume 68, Number 11 / November, 2001

Touch o Even rabbits are more resilient to the effects of a high fat diet when stroked and handled o Significantly fewer arrhythmias were found in one study when the nurse or doctor took the pulse in the ICU Psychosomatic Medicine, Vol 39, Issue 3 188-192, 1977

Health Benefits of Forgiveness o U of Tenn : forgivers had decreased blood pressure, muscle tension, and heart rates. o U of Wisconsin: positive correlation between forgiving and having fewer illnesses and fewer chronic conditions. o Stanford: those who forgave had lower scores on scales for stress and anger and higher optimism. Forgivers reported feeling healthier at the end of the experiment. o People who even think about forgiving have improved functioning in their cardiovascular and nervous systems.

Forgiveness: a Definition The feeling of peace that emerges as you (1) take a hurt less personally (2) take responsibility for how you feel (3) become a hero instead of a victim in the story you tell Dr. Fred Luskin of the Stanford Project

Type A Intervention o Type A intervention: (followed 4 1/2 years after a heart attack) Heart attack Recurrence o No intervention 28.2% o Information/advice 21.2% o Support group 12.9% It turns out hostility, cynicism, suspicion are more important than multitasking, time urgency, etc)

Some Resources for Patients o Center for Attitudinal Healing o Multiple religious organizations and volunteer organizations o Bibliotherapy: o Love and Survival, Dean Ornish, M.D. o Forgive for Good, Fred Luskin PhD o The Feeling Good Handbook, David Burns,MD o The Wellness Book, Benson et. al. o Many others

Health of the Body o Air and Breathing o Water and Moisture o Exercise and Rest o Food and Supplements

Tobacco o Cigarette smoke– second hand smoke exposure (living with a smoker) increases the risk of heart attack by 30% at age 65. o Smoking 20 cigarettes per day increases the risk of ischemic heart disease by 80%

Tobacco Cessation o The subject of another talk, but I would note that coping skills for emotional issues are helpful with any addiction needing treatment o Chantix has worked wonderfully in some of my patients who failed everything else

Water o Scientists are finding in ground water—along with industrial pollutants—minute amounts of pesticides, estradiol, acetaminophen, herbicides, codeine and caffeine. o Water pollution attributable to US agriculture, including runoff of soil, pesticides and manure: Greater than all municipal and industrial sources combined. There is a link between chemical exposure and diabetes (though causality is not yet proven) Diabetes Care 25:1487-1488, 2002 o Lead and other toxic minerals can enter drinking water AFTER it leaves the treatment plant (lead-soldered copper pipes, PVC pipes – dioxin). Heavy metals are also implicated in cardiovascular disease. http://touroinstitute.com/ifm_proceedings_low.pdf#page=50 If you aren’t drinking filtered water, your body becomes the filter.

Exercise o Reduces the risk of dying from or developing: o Coronary heart disease – 3x decrease in risk of death from heart disease if able to go 4.4 minutes longer on the treadmill o High blood pressure o Colon cancer o Breast cancer o Diabetes. o Helps maintain healthy bones, muscles, and joints. o Helps control weight, build lean muscle, and reduce body fat.

Fitness in Perspective o In one study, low fitness was an independent risk factor of as much importance as diabetes, hypertension and smoking (each with RR of 3-5 in obese men, after controlling for other risk factors present). o Relationship Between Low Cardiorespiratory Fitness and Mortality in Normal- Weight, Overweight, and Obese Men Ming Wei, MD, MPH; James B. Kampert, PhD; Carolyn E. Barlow, MS; Milton Z. Nichaman, MD, ScD; Larry W. Gibbons, MD, MPH; Ralph S. Paffenbarger, Jr, MD, DrPH; Steven N. Blair, PEDJAMA. 1999;282:1547-1553

But still... o More than 60% of American adults do not engage in levels of physical activity necessary to provide health benefits. o More than one-fourth are not active at all in their leisure time. o Activity decreases with age and is less common among women than men and among those with lower income and less education.

Bottom Line for Exercise o Physical activity need not be strenuous to achieve health benefits. o The same moderate amount of activity can be obtained in longer sessions of moderately intense activities (such as 30 minutes of brisk walking) as in shorter sessions of more strenuous activities (such as 15–20 minutes of jogging). o Additional health benefits can be gained through greater amounts of physical activity.

Start Low, Go Slow o Start with short intervals (5–10 minutes) of physical activity and gradually build up to the desired level of activity. o Swimming, Elliptical trainers, and Ski machines have the least impact for those with joint, back, or neck pain

Motivation? o Intrinsic o Energy level improves o Chronic pain improves o Social support from family and friends has been consistently and positively related to regular physical activity. o Altruism – find someone else who needs to get out for walks and make them your project

Motivation and Adherence o Solitary vs. Group vs. “Buddy” o Keeping it interesting o Conversation o Books on tape o Moving meditation o Exercise equipment and television/VCR

Rest o Insomnia affects 30% of people over a year o Our lifestyle encourages sleep deprivation as a tool for doing too much o... The subject of another talk

Modifiable, Measurable Biochemical Risk Factors o Cholesterol, esp. LDL cholesterol o LDL deposits in artery walls when oxidized o Homocysteine – a pro-oxidant o CRP – a marker for inflammation o And, fibrinogen, LpA, etc... Inflammation and Oxidation are central to Atherogenesis, and may explain the results of dietary intervention trials

Homocysteine o Homocysteine is an amino acid for which higher levels are associated with o Stroke o Heart attack o Dementia o Effects of homocysteine on endothelial cells: o reduce nitric oxide o Reduce prostacyclin synthesis and activity o endothelial dysfunction through oxidative damage o increased oxidation of low-density lipoprotein o stimulation of smooth muscle cell proliferation, prothrombotic effects, and impaired thrombolysis

Homocysteine as Predictor of Risk Nygård O, Nordrehaug JE, Refsum H, Ueland PM, Farstad M, Vollset SE. Plasma homocysteine levels and mortality in patients with coronary artery disease. N Engl J Med 1997;337:230–6

Homocysteine Metabolism o Breakdown of homocysteine requires o B6 (Pyridoxine) o Folic acid o B12 o And sometimes betaine is helpful

Homocysteine-Lowering Vitamins and Clinical Outcomes Treatment with a combination of folic acid, vitamin B12, and pyridoxine significantly reduces homocysteine levels and decreases the rate of restenosis and the need for revascularization of the target lesion after coronary angioplasty. o Decreased rate of coronary restenosis after lowering of plasma homocysteine levels. Schnyder G - N Engl J Med - 29-NOV-2001; 345(22): 1593-600

Homocysteine and Carotid Plaque o Vitamin therapy regresses carotid plaque in patients with H(e) levels both above and below 14 micromol/L o What level of plasma homocyst(e)ine should be treated? Effects of vitamin therapy on progression of carotid atherosclerosis in patients with homocyst(e)ine levels above and below 14 micromol/L. o Hackam DG - Am J Hypertens - 01-JAN-2000; 13(1 Pt 1): 105-10 Before vitamin treatment After B6,folate, B12 HCY> 14 0.21 +/- 0.41 cm2/year -0.049 +/- 0.24 cm2/year P<0.001 HCY <14 0.13 +/- 0.24 cm2/year -0.024 +/- 0.29 cm2/year P=0.022

On the other hand.... o Supplementing B vitamins to lower homocysteine does not decrease cardiac events in studies to date, though it may decrease stroke risk slightly. Current Opinion in Clinical Nutrition & Metabolic Care. 10(1):32-39, January 2007 (an aside on primary vs. secondary endpoints in research)

Homocysteine and Lifestyle o Exercise decreases plasma total homocysteine in overweight young women with polycystic ovary syndrome. Randeva HS - J Clin Endocrinol Metab - 01-OCT-2002; 87(10): 4496-501 o Higher fruit and vegetable intake is associated with lower homocysteine. Public Health Nutrition (2007), 10:266-272

CRP o 1.0 to 3.0 mg/L: moderate risk of cardiovascular disease o >3.0 mg/L high risk of cardiovascular disease o Subjects in the upper third of C-reactive protein levels have about twice the risk (odds ratio = 2.0; 95% confidence interval: 1.6 to 2.3) of major coronary events

CRP vs. Cholesterol as a Risk Factor o 77% of all future cardiovascular events occurred in women with LDL cholesterol <160 mg/dL (<4.1 mmol/L) and 45% occurred in those with LDL cholesterol <130 mg/dL (<3.4 mmol/L). o hs-CRP proved to be a stronger predictor than LDL cholesterol o hs-CRP and LDL cholesterol tended to identify different high-risk groups, and measurement of both provided better prognostic information than did measurement of either alone o Ridker PM, Rifai N, Rose L, et al. Comparison of C-reactive protein and low-density lipoprotein cholesterol levels in the prediction of first cardiovascular events. N Engl J Med 2002;347:1557-65

CRP Lowering with Multivitamin o Mean change in C-reactive protein levels after 6 months of intervention in the placebo and multivitamin groups, by baseline C-reactive protein level, after adjustment for baseline C-reactive protein level, age, body mass index, sex, hormone replacement therapy, and statin use. Error bars represent 95% confidence intervals. o Reduction of C-reactive protein levels through use of a multivitamin Timothy S. Church, MD, MPH, PhD, Conrad P. Earnest, PhD, Kherrin A. Wood, MS, James B. Kampert, PhD a American Journal of Medicine Volume 115 Number 9 December 15, 2003a

Inflammation Benefits of Aerobic Exercise o Regular aerobic exercise can decrease risk of having elevated CRP. o Most significant drop in CRP is when sedentary adults move from sedentary lifestyle to regular, low to moderate intensity exercise program. o As exercise intensity, frequency, and duration increase, the CRP continues to drop. o Anaerobic high intensity training (interval training) may elevate CRP temporarily. o Colbert LH et al: J Am Geriatr Soc. 2004 Jul;52(7):1098-104. o Tomaszewski M et al: Arterioscler Thromb Vasc Biol. 2003 Sep 1;23(9):1640-4.

Lowering CRP o Diet-induced weight loss o Adipocytes synthesize interleukin 6, the principal activator of C-reactive protein production o Low Glycemic Index Diet o Insulin resistance, which is common in obese patients, is also associated with elevated C-reactive protein levels o Omega-3 fatty acids: studies are mixed o Diets high in plant sterols, soy protein, viscous fiber, and almonds o Exercise o Statins – 15% lowering o Fibric acid derivatives o Multivitamins

Is a theme emerging? o Rather than a pill for each risk factor, what if there were one general intervention that could lower many of them?

Diet Interventions after MI DART DART 1989 Diet and Reinfarction Trial o 2033 men post MI; Duration: 2 years Randomized o 1. Eat fatty fish 2-3 x per week o 2. Increase cereal fiber o 3. Decrease total fat, increase polyunsaturated fat o No change in fat advice or fiber advice groups o 29% reduction in all-cause mortality in fish group

Diet Interventions Post-MI Cardioprotective Diet Trial o 505 subjects with suspected AMI. Randomized, single- blind; both groups on a low fat diet. The intervention group (Group A) was advised to eat more fruit, vegetables, nuts, and grain products o Cholesterol fell by 0.74 mmol/L in group A versus 0.32 mmol/L in group B o Weight fell by 7.1 versus 3.0 kg, (CI 95%, 0.52–7.68). o Cardiac events lower in group A than group B (50 versus 82 patients, P<0.001) o Lower total mortality (21 versus 38 died, P<0.01) in group A than group B o Cardioprotective Diet Trial 1992 BMJ. 1992 Apr 18;304(6833):1015-9

Angiographic Trials o Lifestyle Heart o 28 men and women; duration: 1 year o Randomized Very low fat (<10%) vegetarian diet, exercise, stress management, smoking cessation Significant weight reduction along with 37% decline in LDL-C and 3% decline in HDL-C Progression in 53% of controls, 18% of treatment group; regression in 82% of treatment group

Diet Post-MI - Mediterranean Diet Lyon Diet Heart Study 605 men and women post myocardial infarction; Duration: 27 mo. Also follow-up report with mean 46 months per patient o Randomized, single-blind; dietary habits of controls not investigated and recorded at start of study o Canola oil margarine enriched in linolenic acid; fewer fat calories, more fiber, monounsaturated fatty acids; less saturated fat and dietary cholesterol o Intervention group had increased n-3 fatty acids in blood. There was reduction in CHD death and nonfatal myocardial infarction as well as above plus major secondary end points o 76% reduction in rate of fatal and nonfatal CHD at end of 27 months o Lyon Diet Heart Study Circulation 1999;99:779-85

Diet Interventions after Heart Attack Mediterranean Diet o After first heart attack: Overall mortality was 20 in the control, 8 in the experimental group, an adjusted risk ratio of 0.30 for those placed on a Mediterranean diet vs. traditional AHA diet. Serum lipids, blood pressure, and body mass index remained similar in the 2 groups. Lancet. 1994 Jun 11;343(8911):1454-9

Dietary Intervention - Fleming WeightTCLDL-CHDL-CHomocysteineLipoprotein(a)Fibrinogen LF  18.4%  39.1%  52%  9%  13.6%  7.4%  11.0% Phase II  12.6%  30.4%  38.8%  3.6%  14.6%  10%  6.3% MF  2.6% NS  5%  6.1%  1.5%  9.7%  4.7%  0.6% HF  13.7%  4.3%  6%  5.8%  12.4%  31.%  11.9% MF- moderate fat without calorie restriction LF - low-fat (LF) diet (phase I) Phase II – moderate fat with caloric restriction HF – high-fat diet Fleming RM - Prev Cardiol - 01-JUL-2002; 5(3): 110-8

Vegetarian Diet and Mortality o 11- year OR for mortality in strict German vegetarians was.66 v. the general population o OR for those engaging in moderate/high v. low physical activity was.47 (p=.004) Chang-Claude J et al. Int J Epidemiol 1993; 22:228

Vegetarian Diet and CAD o Meta-analysis of 5 studies and 76,000 subjects, 11-year OR for mortality from CAD was 24% lower in vegetarians than in nonvegetarians (p<.01) o Best off were fish eaters and lacto- ovovegetarians Key TJ et al. Am J Clin Nutr 1999:516S

The optimal diet: Low-fat or Mediterranean? A: Either Randomized, controlled clinical trial, compares dietary intervention per se with usual care in a case-control analysis. First MI survivors were randomized to a low-fat or Mediterranean-style diet. Individual dietary counseling sessions, 2 within the first month and again at 3, 6, 12, 18, and 24 months, along with 6 group sessions. o Primary-outcome-free survival did not differ between low-fat (42 of 50) and Mediterranean-style (43 of 51) diet groups over a median follow-up period of 46 months (range 18 to 72; log-rank p = 0.81). o Patients receiving dietary intervention had better primary-outcome- free survival (85 of 101) than usual-care controls (61 of 101) (log-rank p <0.001), with unadjusted and adjusted odds ratios of 0.33 (95% confidence interval 0.18 to 0.60, p <0.001) and 0.28 (95% confidence interval 0.13 to 0.63, p = 0.002), respectively. o The American Journal of Cardiology - Volume 101, Issue 11 (June 2008)

The Polymeal BMJ. 2004 December 18; 329(7480): 1447–1450. Effect of ingredients of Polymeal in reducing risk of cardiovascular disease Ingredients Percentage reduction (95% CI) in risk of CVD Source Wine (150 ml/day)32 (23 to 41)Di Castelnuovo et al (MA) 6 6 Fish (114 g four times/week) 14 (8 to 19)Whelton et al (MA) 7 7 Dark chocolate (100 g/day)21 (14 to 27)Taubert et al (RCT) 8 8 Fruit and vegetables (400 g/day) 21 (14 to 27)John et al (RCT) 10 10 Garlic (2.7 g/day)25 (21 to 27)Ackermann et al (MA) 11 11 Almonds (68 g/day)12.5 (10.5 to 13.5) Jenkins et al (RCT), 15 Sabate et al (RCT) 16 15 16 Combined effect76 (63 to 84)

Optimal Diet o Primitive: use the fuel for which the machinery was designed o Emphasize Fruits Vegetables and Nuts o Very Limited or No Meat o Fish in moderation

Not Atkins Volunteers on an Atkins-type high fat diet experienced an increase in LDL-C of 7% after six months Westman EC et al. Am J Med 2002;113:30

Not Atkins Not Atkins In 100 people assigned to different diets for a year, weight loss was one pound/week on a 10% fat diet vs. 0.6 pounds/week on an Atkins diet; LDLC fell 52% vs. an increase of 6%, respectively Fleming RM. Prev Cardiol 2002; 5:110

Features of the Optimal Diet o 5-9 or more servings of Fruits and Veggies per Day o High fiber o Low Glycemic Index o Low Fat; Omega-3 fats emphasized

Why a “Campaign”? Only 27% of women and 19% of men eat the recommended five or more servings of fruits and vegetables each day. Of young people, less than 30% eat sufficient fruits/vegies

5-9 Servings of Fruits and Veggies Per Day o Recommended by the NCI to help prevent lung, breast, colon and prostate cancers by 50% or more (As long as we are taking a holistic view) o Recommended by the AHA to prevent heart disease and stroke

Fruits, Veggies and Cancer o RRs in the upper tertile of vegetable intake ranging from 0.2 for esophagus, liver and larynx to 0.7 for breast cancer o RRs in the upper tertile of fruit intake were between 0.2 and 0.3 for oral cavity and pharynx, oesophagus and larynx relative to the lowest tertile o Significant inverse relationships were observed for liver, pancreas, prostate and urinary sites

How They Work o A large number of potentially anticarcinogenic agents as well as anti-inflammatory agents are found in these food sources: o Carotenoids- Selenium - Dietary fiber o Dithiolthiones - Glucosinolates - Indoles o Isothiocyanates- Flavonoids- Phenols o Limonene - Protease inhibitors- Plant sterols o Allium compounds

Mechanisms o Complementary and overlapping mechanisms of action: o Induction of detoxification enzymes o Inhibition of nitrosamine formation o Provision of substrate for formation of antineoplastic agents o Dilution and binding of carcinogens in the digestive tract o Alteration of hormone metabolism o Antioxidant effects o Others.

Why Not Just Take a Vitamin? o Lung Cancer and  Carotene – the Finnish study o Cervical Dysplasia and Folic acid o A long series of disappointing clinical trials in heart disease with antioxidants-in-a-pill

5-9 Servings of Fruits and Veggies Per Day o Recommended by the NCI to help prevent lung, breast, colon and prostate cancers by 50% or more o Recommended by the AHA to prevent heart disease and stroke

Veggies and Stroke In 832 healthy Framingham men, 20- year RR for all types of strokes was progressively lower for each quintile of increased intake of fruits and vegetables established by 24- hour nutritional recall at baseline (p=.01) Gillman MW et al. JAMA 1995; 273:1113

Fruits, Veggies, and Cardiovascular Morbidity and Mortality o Consuming fruit and vegetables 3 times/d compared with <1 time/d was associated with: o 27% lower stroke incidence o 42% lower stroke mortality o 24% lower ischemic heart disease mortality o 27% lower cardiovascular disease mortality o 15% lower all-cause mortality after adjustment for established cardiovascular disease risk factors American Journal of Clinical Nutrition, Vol. 76, No. 1, 93-99, July 2002

Why More Fruits & Veggies? o Fiber o Antioxidants

Fiber o Filling o replaces higher caloric density foods o Maintains normal colonic flora o Glycemic Index (more later) o Binds things o Enterohepatic Circulation of Cholesterol o Toxins produced by bacterial fermentation

Fiber In 25 hyperlipidemic volunteers, LDL-C fell 29% (p<.001) in those randomized to a diet high in plant sterols, soluble fiber and vegetable protein (soy, almonds, okra, eggplant, metamucil, oats, barley, legumes) v. an LDL-C fall of 12% in those on a low fat, low cholesterol diet Jenkins DJ et al. Metabolism 2002; 51:1596

Oxidation – a byproduct of metabolism o Damages DNA o Cancer genesis: mutations that activate oncogenes o Damages Fats and Membranes o CAD: LDL-C must be oxidized to deposit in arterial walls o Dementia o Damages Structural Components o Arthritis: Damage to joint components

Antioxidants o Protect our cells from oxidation by accepting free radicals o Work in groups o Chain of acceptance of free radicals Implications: single vitamins may be counterproductive Glutathione C ? ? ? E ? ?  ?

Antioxidant Strategies o 5-9 Fruits and veggies o Supplements Made from Whole Foods o Food For Life o Juice Plus+ Decreases oxidation of LDL Decreases homocysteine Decreases lipid peroxides in the urine Decreases DNA Damage in circulating lymphocytes

Antioxidant Strategies o 5-9 Fruits and veggies o Supplements Made from Whole Foods o Food For Life o Juice Plus+ Decreases oxidation of LDL Decreases homocysteine Decreases lipid peroxides in the urine Decreases DNA Damage in circulating lymphocytes o Herbals: o Grape seed extract, pycnogenol o Ginkgo biloba o Etc.

Features of Optimal Diet o 5-9 Servings Fruits and Veggies per Day o High fiber o Low Glycemic Index o Low Fat; Omega-3 fats emphasized

Not All Carbs are Created Equal The insulin mobilized over two hours by 10 healthy volunteers after consuming a snack of cola and chips was 75% GREATER than that after ingesting an isocaloric amount of sugar from raisins and peanuts (2p<.001) Oettle GJ et al. Am J Clin Nutr 1987; 45:86

Glycemic Index – Not All Carbs Are Created Equal Yogurt, lowfat, 14 unsweetened, plain Lentils29 Apple36 Spaghetti, ww 37 Tortilla, corn38 All-bran cereal42 Orange 43 o Think Primitive! Corn49 Spaghetti, durum55 Rice, white59 Ice Cream61 Macaroni and cheese 64 Grape-nuts cereal67 French baguette95

Glycemic Index and Snacking Voluntary snack intake in a 5- hour period after a high- glycemic index meal was 81% greater than after an equicaloric low- GI meal Ludwig DS et al. Pediatrics 1999; 103:E26

Bottom Line on Glycemic Index o Low Glycemic Index Diet can assist weight loss by lowering insulin levels and decreasing the impulse to snack o Low Glycemic Index Diet can decrease the lifetime risk of developing diabetes

Features of Optimal Diet o 5-9 Servings Fruits and Veggies per Day o High fiber o Low Glycemic Index o Low Fat; Omega-3 fats emphasized

Functions of Fats o Energy Storage o Membrane components o Precursors to prostaglandins and other hormones/messenger molecules Latter two are affected by types of fats consumed

Omega 3 Fats – fish, walnuts, flax o Omega 3 fats are o Anti-inflammatory o Anti-thrombotic o Anti-arrhythmic

Fish Oil Effects on Cardiovascular Disease o At higher doses (3-5 grams per day): o BP-lowering effect o Improve the lipid profile: decreasing triglycerides and very-low-density lipoproteins and slightly raising the cardioprotective high-density lipoprotein cholesterol o Alter prostaglandin metabolism by inhibiting the production of thromboxane A2 and inflammatory cytokines, reducing the likelihood of acute coronary thrombosis o At dietary doses: o Decrease arrhythmias

Fish Oil and Arrhythmia o Sudden death caused by sustained ventricular arrhythmias accounts for 50 to 60% of all deaths in persons with CHD o GISSI-Prevenzione Trial: 11,324 patients with known CHD who were randomized to receive either 300 mg of vitamin E, 850 mg of omega-3 FA, both, or neither. After 3.5 years, the group receiving omega-3 FA alone had a 45% reduction in sudden death and a 20% reduction in all- cause mortality. o United States Physician's Health Study 20,551 men One serving of fish per week resulted in 52% decrease in sudden cardiac death

Omega 3 Bottom Line o Fish oil is most certain source o Increasing omega-3’s can improve: o Memory o Mood o Heart disease Eating fish once a week cuts risk of sudden death from heart attack by 50% o Cancer risk o Inflammation/Auto-immune disease

Supporting People in Dietary Change o Information o Change Theory

Stages of Change o Stages of Change: Big lifestyle changes like a change in the diet require preparation, emotional as well as logistical

Contemplation - Obstacles to Change o Cost o “Willpower” – Emotional decisions about what to eat, when, and how much o Digestive Problems o Knowledge o Knowing what to eat o Knowing how to prepare healthy food

Cost o Cost per calorie is lower for processed foods and foods high in sugar, however in this country few people are truly lacking in calories. o Beans and grains are low cost, however: o Black beans are 69-99 cents/lb dry(about 10 servings): o $0.16/serving 140 calories, 0 fat, 18g protein, 30 g fiber o Extra lean ground beef $2.49/lb, o $0.62/serving (4 oz) – 256 calories, 19g fat, 21 g protein, 0 fiber

Obstacles to Change o Cost o “Willpower” – Emotional decisions about what to eat, when, and how much o Digestive Problems o Knowledge o Knowing what to eat o Knowing how to prepare healthy food

Motivation (Contemplation and Pre-Contemplation) o For those who will not change what they eat for health reasons, weight loss can be a motivator o Eat to Live by Joel Fuhrman is a great resource o Sense of well-being o Ornish’s program starts in a hotel; most people continue to adhere after leaving because they feel better – try to get a 1-week commitment from patients and have them notice how they feel

Emotional Choices About What to Eat o There is a difference between wanting food and being hungry o Mindfulness when hungry/reaching for food can be very illustrative o Meet needs that are being met by food with other means (and first, figure out what those needs are) The Solution, by Laurel Mellin, is a great resource Deep Healing, by Emmett Miller, also addresses these issues

Digestion o Chewing – dental health and taking time o Digestion – stomach acid, enzymes, bean-o o Elimination – constipation, related to medications or other issues, can be treated with magnesium or try “flax pudding”: Soak 2 tablespoons of flax seeds overnight in water; in the morning, add an equal amount of yogurt (or Cool Whip, in the original recipe) and dried fruit (apricots, prunes, etc.) and mix in the blender. (Can make up for several days and keep in the fridge)

Tips to Increase Fruits & Veggies o Pre-cut vegetables and salad mixes, even fruit o Add fresh fruit and vegetables to foods you already eat - like berries and bananas to yogurt and cereal; vegetables to pasta and pizza; and lettuce, tomato and onion to sandwiches o When it’s snack time, grab an apple or orange, or make a ready-to-eat bag of sweet cherries.

More Tips o Make a quick smoothie in the blender by puréeing peaches and/or nectarines, a touch of your favorite fruit juice, crushed ice, and a light sprinkling of nutmeg. o Use sauces to improve palatability for veggies you do not like o Try stir-fries and stews using lots of veggies and meat “as a condiment”

Action o Changing behavior

Logistics/Planning for Good Nutrition o It is generally easier to add “good” foods than to eliminate the “bad” ones we crave o Stock easy healthy foods, do not keep junk food in your home o Cook ahead o Use appliances (cuisinart) o Make trades

Some Food Preparation Ideas o Sautés/Steams with varying flavors: Assorted veggies (onions, garlic, ginger, yams, broccoli, carrots, zucchini, snow peas, etc.) can be prepared with tofu or skinless chicken breasts using: o Soy sauce/sesame oil/ o Thai curry paste with low fat coconut milk o Diced tomatoes with Italian seasoning blend or rosemary (no ginger) o Soup recipes o Steamed Greens o Salads with low-fat dressing

Maintenance o Continuing the changed behavior and preventing relapse Make note of how your body feels when you eat more healthfully, and remind yourself of this when you feel drawn to other foods. Note the effects on your symptoms when you “fall off the wagon”.

Hypertension – JNC-7 o In persons older than 50 years, systolic blood pressure greater than 140 mmHg is a much more important cardio-vascular disease (CVD) risk factor than diastolic blood pressure. o The risk of CVD beginning at 115/75 mmHg doubles with each increment of 20/10 mmHg

Hypertension and Pre-hypertension o People who are normotensive at age 55 have a 90 percent lifetime risk for developing hypertension. o People with a systolic blood pressure of 120– 139 mmHg or a diastolic blood pressure of 80– 89 mmHg should be considered as prehypertensive and require health-promoting lifestyle modifications to prevent CVD.

Remember the Rules of Tacks

Identifiable causes of Hypertension Sleep apnea Drug-induced or related causes* Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing's syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease

Drugs Contributing to Hypertension *** Nonsteroidal anti-inflammatory drugs; cyclooxygenase 2 inhibitors Cocaine, amphetamines, other illicit drugs Sympathomimetics (decongestants, anorectics) Oral contraceptives Adrenal steroids Cyclosporine and tacrolimus Erythropoietin Licorice (including some chewing tobacco) Selected over-the-counter dietary supplements and medicines (e.g., ephedra, ma haung, bitter orange)

Lifestyle Modifications to Control Hypertension MODIFICATION RECOMMENDATIONAPPROXIMATE SBP REDUCTION (RANGE) Weight reductionMaintain normal body weight 5–20 mmHg/10 kg weight loss Adopt DASH eating plan Consume a diet rich in fruits, vegetables, and lowfat dairy products with a reduced content of saturated and total fat. 8–14 mmHg Dietary sodium reductionReduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). 2–8 mmHg

Lifestyle Modifications to Control Hypertension MODIFICATION RECOMMENDATIONAPPROXIMATE SBP REDUCTION (RANGE) Physical activityEngage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week). 4–9 mmHg Moderation of alcohol Limit consumption to no more than consumption 2 drinks (1 oz or 30 mL ethanol; e.g., 24 oz beer, 10 oz wine, or 3 oz 80- proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter weight persons. 2–4 mmHg

Natural Medicine for Hypertension o Hawthorn – extract must include the leaf o Magnesium – especially if diabetic or treated with diuretics o Meditation o Others o Olive leaf extract o Linden and others

Meds for Lowering Cholesterol o Statins – beware, these can lower coenzyme Q10 (and supplementing it can decrease muscle pain, fatigue associated with their use). o Others – less data suggesting they prolong life

Natural Substances for Lowering Cholesterol

Fiber o LDL: 7-10% drop in LDL with taking psyllium before meals Am J Clin Nutr. 2000 Feb;71(2):472-9 o Hypertension, weight: Clin Exp Hypertens. 2007 Aug;29(6):383-94. o Glycemic control: Lowered glucose and HgbA1C in diabetic outpatients J Ethnopharmacol. 2005 Nov 14;102(2):202-7. Epub 2005 Sep 8. o Avoid using this with your fish oil, may interfere with absorption of some other meds and supplements

Niacin o Niacin – lowers triglycerides, raises HDL, lowers LDL, is also anti-inflammatory Med Hypotheses. 2007;69(1):90 o Lowers atherosclerotic complications and total mortality in trials Curr Cardiol Rep. 2003 Nov;5(6):470-6. o Do not use time-release niacin – can cause liver damage o Causes flushing – aspirin before dose reduces this, and tolerance to flushing develops o May worsen blood sugar control

Plant Sterols (Phytosterols) 2g/d provides 10% reduction in total cholesterol and 13% reduction in LDL cholesterol levels Am J Med. 1999 Dec;107(6):588-94 o Eating foods low in saturated fat & cholesterol and high in stanols or sterols can reduce LDL by 20% o Adding sterols or stanols to statin medication is more effective than doubling the statin dose. Mayo Clin Proc. 2003;78:965-978

Red Yeast Rice Extract o Red Yeast Rice Extract – similar to statins, but a mixture of compounds and lower potency results in fewer side effects. I still monitor LFT’s. Can produce 25-30% lowering in LDL.

Garlic (Allium Sativum) o Garlic (Allium sativum) – 10-15% drop in LDL, 1 clove per day or 4000 mg fresh garlic or 10 mg alliin or 4000 mcg total allicin potential; lowers platelet aggregation, increases fibrinolytic activity, prevents LDL oxidation and may lower blood pressure as well, improved elasticity of the aorta in one trial; o Form: cooked garlic, powder (most research) or aged garlic extracts (odourless); oil is not as effective o Note blood thinning properties – changes platelet membrane structure, lowers thromboxane, increases fibrinolytic activity; should be stopped prior to elective surgery

Probably not worth using: o Policosanol – mixed clinical trials, and I have had no success with this from a reputable company o Guggul (Commiphora mukkul) – 12% drop in cholesterol and LDL in some studies, but 2003 study showed it raised cholesterol; rash, gi side effects; mechanism is antagonism of farnesoid X receptor

Poly-portfolio for Prevention The American Journal of Cardiology - Volume 95, Issue 3 (February 2005) TABLE 2. Estimated Reductions in the Risk of Major Coronary Heart Disease (CHD) Events and Stroke in Patients With Any CHD, Post-myocardial Infarction (MI), and Stroke from Five Years of Treatment With Combined Statins, Antihypertensive, Aspirin, and Omega-3 Therapies and With and Without Lifestyle Therapies Estimated Reduction in Relative Risk of Event Over 5 yrs Type of Patient Any CHDPost-MIStroke Major CHD events with combined drug therapy 84%NNT = 1091%NNT = 977%NNT = 11 Major CHD events with addition of lifestyle therapy 92%NNT = 996%NNT = 9 CHD death with combined drug therapy 93%NNT = 16 CHD death with addition of lifestyle therapy 97%NNT = 15 Stroke with combined drug therapy 83%NNT = 21

TABLE 1. Recommended Therapies for Prevention of Coronary Heart Disease (CHD) and Stroke Risk and Estimated Risk Reduction Benefits in Patients With Cardiovascular Disease Over Approximately Five Years Risk Factor and GoalRecommended Agent(s)Change in Risk Factor Relative Risk Reduction (Major CHD events)**** Relative Risk Reduction (stroke) Source of Recommendation or Evidence LDL cholesterol <70 mg/dl High-dose statin + diet ≥↓50%48%38%References 11, 20, 30 112030 Blood pressure <140/90 mm Hg except <130/80 mm Hg with diabetes 3-drug combination: diuretic (1/2 dose), β blocker, ACE inhibitor or calcium channel blocker Systolic ↓20 mm Hg or diastolic ↓10 mm Hg 46%–49%**63%–66%**References 19, 30 1930 Platelet functionAspirin 75–81 mg/dCHD pts. 42%Stroke pts. 17% CHD pts. 25%Stroke pts. 19% Reference 1 1 β blocker post-MINoncardioselective; no intrinsic sympathomimetic activity 23% CHD death††Reference 32 32 ACE inhibitor post- MI 20%‡‡32%‡‡References 33, 64 3364 Sudden death post- MI Omega-3 fish oil 1,000 mg/d 30%§ 30% CHD death§ References 8, 61 861 Cardiac rehabilitationIndividual prescription ↑Moderate acrobic physical activity 26% CHD death§§Reference 65 65 DietMediterranean↑Fruits, vegetables, legumes, nuts, whole grains, fish, monounsaturated oils 52%–72% ∥ 33% CHD death (25% total mortality) ∥ References 66, 67, 68 666768 The American Journal of Cardiology - Volume 95, Issue 3 (February 2005)

Opening the Heart and Opening the Arteries Cardiovascular Disease – A Holistic Approach to Reducing the Risk.

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Opening the Heart and Opening the Arteries Cardiovascular Disease – A Holistic Approach to Reducing the Risk.

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