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UNIT 3
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Atherosclerosis
Fight Cholesterol
Take Simple Steps
Why Not Just Use diet?
Is Low Cholesterol Dangerous?
The Heart Healthy Oils
Article Review
  • Lyon Heart Study
  • Lifestyle Heart Trial
  • Interheart Study
Video Review
REFERENCES:
  • Undo It, Dean Ornish, Anne Ornish
  • Prevent and Reverse Heart Disease, Caldwell Esselstyn, MD
  • Nutrition Guidelines for Clinicians, Neal Barnard, MD
  • Nutrition Facts, Michael Greger, MD

ATHEROSCLEROSIS 

The human heart is a miraculous organ.  In an average lifetime, it will faithfully beat around 3 billion times, transporting blood, with oxygen and nutrients it contains, to where they are needed around the body.  In simple terms, the heart is a pump, pumping blood through the tens of thousands of mils of our circulatory system.

As we have seen, the main cause of cardiovascular disease is atherosclerosis and this occurs when cholesterol, fat and other substances build up inside the blood vessel walls.  The vessels become narrow or even completely block up, so little or no blood can travel through to the brain, heart and other organs.

ATHEROSCLEROSIS is a disease in which plaque builds up inside the arteries.  This plaque is made up of fat, cholesterol, calcium, and other substances found in the blood.  The body naturally produces NITRIC OXIDE, which helps keep arteries healthy and flexible, and blood flowing freely.  however, when plaque oxidizes on the artery walls, it causes damage that stops this natural process from occurring.  This contributes to the build-up of plaque, associated with inflammation, a loss of flexibility and a thickening of the walls of the artery.

Over time, plaque continues to build up, hardening and narrowing the arteries.  This limits the flow of oxygen-rich blood to your organs and other parts of the body where they they are so vitally needed.  Not to be taken lightly, atherosclerosis as we already know, can lead to heart attack, stroke and even sudden death.  It is harmfully "silent."  We cannot feel it developing and the first sign of it can be sudden death!  We now know that it is a progressive disease that builds up over many years beginning in childhood.

FIGHT CHOLESTEROL

Cholesterol in the diet comes only from foods derived from animals.  Plant foods do not contain cholesterol.  In fact, many plant foods contain a type of fiber that helps lower cholesterol.  However, there's no need to eat foods high in cholesterol as the body is very good at making its own and can make all it needs.  Too much cholesterol in the diet can be a key contributor to the formation of arterial plaques.

WHAT IS A HEALTHY BLOOD CHOLESTEROL LEVEL?
In different parts of the world, cholesterol is measured in either milligram per deciliter (mg/dL) - or millimoles per liter (mmol/L) - of blood.  Commonly recommended cholesterol levels to aim for are:
  • Less than 210 mg/dL (5.5 mmol/L) total blood cholesterol
  • No more than 115 mg/dL (3 mmol/L) for LDL cholesterol
  • More than 40 mg/dL (1 mmol/L) for HDL cholesterol

But as we have learned from the discussions we had in the previous units, we see that studies are suggesting real benefits can be obtained by aiming for lower cholesterol targets, with data showing a further reduction of cardiac risk by achieving levels lower than those commonly rcommended:
  • Less than 150 mg/dL total cholesterol
  • Les than 80 mg/dL for LDL cholesterol

Remember that we can reduce the risk of developing atherosclerosis by reducing excess LDL cholesterol, as well as reducing the risk of the the LDL cholesterol being oxidized.  Research suggests that the two components in the formation of atherosclerotic plaques are cholesterol and oxidation.  So it makes sense to try to keep our blood cholesterol levels down and reduce the amount of oxidative stress inside our body.  The great news is that diet and activity can play a large role in achieving this.
  • By minimizing consumption of cholesterol and dietary fats, we can help reduce our risk of excess LDL cholesterol circulating in the blood.
  • The key to limit our LDL cholesterol is to limit the saturated fat and trans fats in our diet.  Most of these foods are either processed foods or foods of animal origin.  In contrast, a whole food, plant-based diet is naturally low in saturated and trans fats and will reduce the amount of LDL cholesterol in our blood.
  • A diet that is low in fat-particularly saturated fats and trans fats - and cholesterol can also help reduce the risk of LDL becoming oxidized.  A whole foods, plant-based diet is also naturally high in potent antioxidants, such as vitamin C and E, and polyphenols, and can also help protect against oxidative stress.  Research has also shown a type of soluble fiber called beta-glucans found in oats and barley, can actively work to help reduce blood cholesterol levels.

TRIGLYCERIDE COUNT
Triglycerides are another type of fat in the blood.  Levels are not as stable as cholesterol levels and, in most cases, they can easily be inifluenced by diet from one day to the next.  However, if higher than 500 mg/dL (5.7 mmol/L), you have to visit your doctor.
  • Ideal = less than 150 mg/dL (1.7 mmol/L)
  • Elevated = 150-199 mg/dL (1.7-2.2 mmol/L)
  • High =  200-299 mg/dL  (2.3 - 3.4 mmol/L)
  • Very High = 300 - 499 mg/dL (3.5 - 5.7 mmol/L)
  • Extremely high = >500 mg/dL (5.7 mmol/L)

TAKE SIMPLE STEPS

No one achieves and maintains total blood cholesterol of 150 mg/dL and LDL levels below 80 mg/dL - using strict plant-based nutrition and, where necessary, low doses of cholesterol-reducing drugs - experiences progression of heart disease.  Many in fact, are able to clear medical evidence that they have actually reversed the effects of their disease.

Remember that three-quarters of the population of this planet has never known heart disease in their lifetime.  Your cholesterol metabolism and, with it, your resistance to the insidious progression of heart disease, can come to resemble those of the rural Chinese, the residents of Okinawa, the Tarahumara Indians of Northern Mexico, the Papua Highlanders of New Guinea, and many native Africans.  Among these peoples, because of the plant-based diets they have always consumed, heart disease is virtually unknown.

NUTRITION PLAN TO REVERSE HEART DISEASE (Esselstyn, 2007)
  1. Avoid anything with a face or a mother.  This includes meat, poultry, fish and eggs.  You may be aware that arginine and omega-3 fatty acids, which are essential to endothelial health and other bodily functions, are plentiful in fish  But there are other, healthier sources of these substances.
  2. Avoid dairy products.  That means butter, cheese, cream ice cream, yogurt, and milk - even skim milk.
  3. Avoid refined grains.  These, unlike whole grains, have been stripped of much of their fiber and nutrients.  You should avoid white rice and "enriched" flour products, which are found in many pastas, breads, bagels, and baked goods.
  4. Avoid Nuts.  Those who have heart disease should avoid all nuts.  Those without disease can consume in moderation.  
  5. Eat vegetables.  This is by no means a complete list, but it gives you a good sense of the variety of vegetables that you can eat.  Weet potatoes, yams, potatoes (but never French fried or prepared in any other way that involved adding fats).  Broccoli, kale, spinach.  Asparagus, artichokes, eggplant, radishes, celery, onions, carrots.  Brussels sprouts, corn, cabbages, lettuces, peppers.  Bok choy, Swiss chard, and beet greens.  Almost any vegetable you can imagine is legal on this plan, with a single exception, for cardiac patients: avocados, which carry a high fat content unusual for vegetables.  Those without heart disease can eat avocados as long as their blood lipid levels are not elevated.
  6. Eat legumes.  Beans, peas, and lentils of all kinds.  This is a wide-ranging family of plants, and you are almost certain to discover delicious varieties you may never have encountered before embarking on this nutrition plan.
  7. Eat whole grains.  Whole wheat, whole rye, bulgur wheat, whole oats, barley, buckwheat, whole corn, cornmeal, wild rice, brown rice, popcorn, quinoa, amaranth, and millet.  There is a marvelous variety of choices, both familiar and new.  You can also eat cereals that do not contain added sugar and oil.  Old-fashioned oats, for instance (not the quick-cooking variety).  Bread should be whole grain, and should not contain added oil.  Whole-grain pastas are allowed.
  8. Eat fruits.  Fruits of all varieties are permitted.  It is best to avoid drinking pure fruit juices as it carries a high sugar content, and consuming too much of it rapidly raises the blood sugar.  The body compensates to the sugar high with a surge of insulin from the pancreas - and the insulin, in turn, stimulates the liver to manufacture more cholesterol.  it may also elevate triglyceride levels.  Be careful of sugar-laden desserts, which can have the same effect.
  9. Beverages.  Water, oat milk, no-fat soy milk is allowed.

Consuming the full range of plant-based nutrition does not require supplemental calcium or a multivitamin.  However, for all those who are consuming plant-based nutrition, the following supplements may be recommended:
  • Vitamin B12.  About 1000 mcg daily.
  • Omega-3 fatty acids.  You can fulfill your daily requirement by consuming 1-2 tablespoons of flaxseed meal or 1-2 tablespoons of chia seeds each day.  Be sure to refrigerate flaxseed meal.
  • Cholesterol lowering drugs.  These must be taken under a physician's supervision.  One of the statin cholesterol-lowering drugs, can be started when beginning the nutrition program.  Together, the drug and the new way of eating will usually reduce the total cholesterol level to less than 150 mg/dL in just fourteen days.  With the physician's help, one should monitor the progress over the first two months.  if total cholesterol is reduced to well below 150 mg/dL, one may reduce the drug dosage - and in some cases, eliminate it altogether.
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ORNISH SPECTRUM PROGRAM FOR HEART DISEASE
Ornish's approach to nutrition is all about feeling good and enjoying life.  When a people adopt a plant-based way of eating,  they have to make healthy eating sustainable with feeling deeply nourished and revitalized. 
  • Eat Real Foods.  Dr. Dean Ornish described the parameters of the diet they've proven can reverse the progression of heart disease and other types of chronic disease.  It includes abundantly enjoying a variety of plant-based foods that are low in fat and sugar, such as fruits, vegetables, whole grains, legumes, and soy products as close as possible to the way they come in nature, with minimal processing - in other words, what are known as real foods or whole foods.
  • Just Plants.  These include a wide variety of fruits, vegetables, whole grains, legumes (beans, lentils, and dried peas such as chickpeas and black-eyed peas), and soy products.  The only plant-based foods that they recommend to minimize or eliminate are those that are especially high in fat.  This includes all oils, since oils are 100 percent fat, and avocados, which are 85 percent fat and contain about 322 calories, of which 265 calories are from fat (30 grams of fat).
  • Not too much sugar.  This include concentrated sweeteners such as sugar, high fructose corn syrup, honey, maple syrup, and so on.  They also include the "whites" - that is, white flour and white rice.  When you go from whole-wheat flour to white flour, or from brown rice to white rice, you turn a good carb to a bad carb because you've removed the fiber and bran that keep you healthy.
  • Not too much Fat.  The way of eating that Dr. Ornish found can reverse most chronic diseases is much lower in fat than what most people eat - closer to 10-15 percent fat than to the 40 percent in a typical American diet.  This is the percentage of fat found in the diet in countries such as in rural China where prevalence of heart disease and other chronic diseases was quite low.  In practical terms, there's no need to track the amount of fat you're consuming if you only eat plant-based foods as they come in nature (other than very high-fat foods such as oils, avocados, seeds, and nuts).  If you're eating commercially processed foods, try to limit your overall fat consumption to 10-15 percent of your total calories.  If you're a woman eating 1600 to 2400 calories per day, then 10 percent fat would include about 18-27 grams of fat per day, and 15 percent fat would be about 27-40 grams of fat per day.  If you're a man eating 2000 to 3000 calories per day, then 10 percent fat would include about 22-23 grams of fat per day, and 15 percent fat would be about 33-50 grams of fat per day.  You only need 4 percent of calories from fat to provide the essential fatty acids, so it's relatively hard not to get enough fat in your diet.  Most people get too much.
  • Nuts.  Although nuts and seeds are high in fat and thus in calories, Dr. Ornish include them because numerous studies have shown that consuming these in small quantities is beneficial.  Several largest cohort studies, including the Adventist Health Study, the Iowa Women's health Study, the Nurse's Health Study, and the Physician's Health Study, have shown that consuming nuts and seeds correlates with a consistent 30-50 percent lower risk of cardiovascular disease, heart attacks, sudden cardiac death, and stroke.  Also, consuming nuts in small quantities recues insulin secretion, oxidative stress, and chronic inflammation.
  • Just a spoonful of sugar.  The general consensus for sugar intake is to limit added sugars to no more than 25 grams per day (which is equivalent to 6 teaspoons) for women and less than 38 grams per day for men.  Consider this as maximums;  less is better.  To give a perspective of how much sugar does Dr. Ornish recommended, 1 teaspoon of sugar (4 grams).
  • Eat less sodium.  Just a teaspoon of salt has 2300 mg of sodium.  Many foods that contribute a significant amount of sodium in the diet do not taste particularly salty at all.
  • More fiber.  For the average intake of 2000 calories per day is equivalent to about 25-30 grams daily.  

WHY NOT JUST USE DIET?

Why not just use the diet for a number of months and add the cholesterol-reducing drug only if it is needed to force the cholesterol below the 150 mg/dL threshold?  With severe coronary disease, we don't always have the luxury of time.  it is essential to start the healing of the endothelium, that vulnerable inner lining of the coronary arteries, as rapidly and completely as possible.  Used as adjuncts to the nutrition plan, these remarkable statin drugs help to do just that.

But remember, drugs alone are not enough.  In the study reported in the New England Journal of Medicine, in which huge doses of statins successfully reduced patient's cholesterol levels well below 150 mg/dL.  But even so, as their diet never changed, one out of four of the subjects experienced a new cardiovascular event or died within thirty months.

Unlike drugs, plant-based nutrition has beneficial effects far beyond reducing cholesterol levels.  It has a mighty impact on a host of other risk factors, as well: obesity, hypertension, triglyceride, and homocysteine levels.  It enables the endothelium to heal and renew itself, and allows once-clogged arteries to dilate and replenish the heart muscle they serve.  It makes a person heart-attack-proof.  it doesn't get much better than that.

IS LOW CHOLESTEROL DANGEROUS?

The newer research makes it clear that otherwise healthy individuals who achieve low blood cholesterol through proper low-fat nutrition will enhance their health, not harm it.  The West Coast Family Heart Study found a reduction in both depression and aggressive hostility among those on a low-fat, cholesterol-lowering program compared to the control group eating the standard high-fat diet.  And in a large study from Scandinavia, patients with coronary artery disease were randomly chosen to receive either cholesterol-lowering drug or placebo, a harmless pill containing no medication.  The members of the group that took the drug lowered their cholesterol by an average of 35 percent.  After five and half years of follow-up evaluation, they had experienced significantly fewer deaths, fewer new heart attacks, and fewer angioplasties and by-passes than those who took the placebo, and they showed no increase at all in deaths from accidents, suicide, or cancer.

WHAT IF CHOLESTEROL WON'T GO BELOW 150 mg/dL?
A minority of the population, no more that 5 percent of all Americans, has an inherited cholesterol disorder that makes it impossible for them to reduce total cholesterol below 400 to 500 mg/dL, even with careful nutrition.  Such patients need to be monitored by highly qualified cholesterol specialists, and in rare cases, may require liver transplants to help them regain ability to reduce cholesterol.  

But for the great majority of persons, that is not a problem.  it is true that there are some people without heart disease who strictly adhere to a plant-based diet - no lapses at all - and even so, cannot reduce their cholesterol below 165-170 mg/dL.  Some researchers have suggested that years of eating fat and cholesterol may compromise the body's natural capacity to reduce cholesterol levels.  For these people, a modest dose of a cholesterol-lowering medication under a physician supervision should take care of the problem.  It is worth noting, however, that anyone who achieves a cholesterol level of 165-170 mg/dL by eating strictly no-fat, plant-based diet is already doing wonders for his or her health, even without reaching the optimal level.  That person, by definition, consuming large quantities of natural antioxidants, which prevents the body from oxidizing LDL cholesterol into its most dangerous, artery-clogging form.

THE HEART HEALTHY OILS

During the 1990s, the headlines were suddenly filled with the wonders of "the Mediterranean Diet."  It was widely hailed as a much more heart-healthy approach to eating than the average American diet, largely on the basis of research by a group of French scientists.  Known as the Lyon Diet Heart Study, the research spawned score of magazine and newspaper articles and Mediterranean-style cookbooks.

For this study, the French researchers assembled 605 subjects - all of whom had survived a first heart attack - and divided them into  two groups.  The profiles of the two were very similar when it came to risk factors for coronary artery disease, including cholesterol and other blood lipid levels, blood pressure, and tobacco use.

About half of the subjects - 302 - were asked to consume a Mediterranean-style diet, which the American Heart Association defines as follows:
  • High in fruits, vegetables, bread and other cereals, potatoes, beans, nuts, and seeds
  • Includes olive oil as an important source of monounsaturated fat
  • Dairy products, fish, and poultry consumed in low to moderate amounts, little red meat
  • Eggs consumed zero to four times weekly
  • Wine consumed in low to moderate amounts

Participants in this group agreed to consume a diet that averaged 3- percent of daily calories from fat - 8 percent from saturated fat, 13 percent from monounsaturated fat, 5 percent from polyunsaturated fat - and just 203 milligrams a day of cholesterol.  

The other participants in the study, 303 people in all, functioned as a group, and were given no particular dietary advice beyond being asked by their physicians to eat prudently.  On average, they are a diet that the American Heart Association describes as "comparable to what is typically consumed in the United States."  It derived about 34 percent of its calories from fat - 12 percent from saturated fat, 11 percent from monounsaturated fat, and 6 percent from polyunsaturated fat - and included about 312 milligrams a day of cholesterol.

After a little more than a year, the researchers noted that those following Mediterranean-style diet were doing much better than the control group.  The results, they reported, were "striking."  After nearly four years, the results were clearer than ever.  Those on the experimental diet were 50 to 70 percent less likely to experience all the cardiac ailments the researchers recorded, from minor events that required hospitalization to major emergencies such as angina, stroke, or heart failure, to heart attacks and even death.

Impressive results.  It is not surprising that they received such great attention and that the Mediterranean diet attracted many adherents.  And it is also not surprising that many patients are puzzled by the fact that nutrition plan does not permit monounsaturated oils such as olive oil or canola oil to be part of an arrest and reversal program for coronary artery disease.  Because of the Lyon Diet Heart Study, the media have taken to referring to these oils as "heart healthy."

Well, nothing could be further from the truth.  They are not healthy.  Between 14 to 17 percent of olive oil is saturated, artery-clogging fat - every bit as aggressive in promoting heart disease as the saturated fat in roast beef.  And even though a Mediterranean-style diet that allows such oils may slow the rate of progression of coronary artery disease, when compared with diets even higher in saturated fat, it does not arrest the disease and reverse its effects.

There is no question that the group consuming the Mediterranean-style diet did not fare nearly as badly as those in the control group.  But there is another way to look at the results of the Lyon Diet Heart Study.  By the end of the study, nearly four years after it start, fully 25 percent of the subjects on the Mediterranean diet - one out of four -had either died or experienced some new cardiovascular event.

BOTTOM LINE

Heart disease begin in childhood, as early as 10 years of age fatty streaks are already found the coronary arteries.  And so anyone who is 10 years and older are at risk of heart disease.  The next best approach is to halt the progression of the disease process and reverse as much as possible through limiting fat intake and increasing antioxidant laden whole food plant-based diet.  This must be coupled with careful monitoring of biomarkers and the help of your health care provider.

Article Review

lyon diet heart study
lifestyle heart trial
interheart study

Video Review


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