Last week, I explained how preventing heart disease has very little to do with simply lowering cholesterol with statin drugs. Our current thinking about how to treat and prevent heart disease is at best misguided, and at worst harmful. We believe we are treating the causes of heart disease by lowering cholesterol, lowering blood pressure, lowering blood sugar with medication. But the real question is what causes high cholesterol, high blood pressure and high blood sugar in the first place. (i) It is certainly not a medication deficiency!
If you say your genes are responsible, you are mostly wrong. It is the environment working on your genes that determines your risk. In other words, it is the way you eat, how much you exercise, how you deal with stress and the effects of environmental toxins (ii) that are the underlying causes of high cholesterol, high blood pressure and high blood sugar. That is what determines your risk of heart disease, not a lack of medication.
The research clearly shows that changing how we live is a much more powerful intervention for preventing heart disease than any medication. The "EPIC" study published in the Archives of Internal Medicine studied 23,000 people's adherence to 4 simple behaviors (not smoking, exercising 3.5 hours a week, eating a healthy diet [fruits, vegetables, beans, whole grains, nuts, seeds, and limited amounts of meat], and maintaining a healthy weight [BMI <30]). In those adhering to these behaviors, 93% of diabetes, 81% of heart attacks, 50% of strokes, and 36% of all cancers were prevented. (iii)
And the INTERHEART study, published in the Lancet in 2004, followed 30 000 people and found that changing lifestyle could prevent at least 90% of all heart disease. (iv)
These studies are among a large evidence base documenting how lifestyle intervention is often more effective in reducing cardiovascular disease, hypertension, heart failure, stroke, cancer, diabetes, and deaths from all causes than almost any other medical intervention. (v) It is because lifestyle doesn't only reduce risk factors such as high blood pressure, blood sugar, or cholesterol. Our lifestyle and environment influence the fundamental causes and biological mechanisms leading to disease: changes in gene expression, which modulate inflammation, oxidative stress, and metabolic dysfunction. Those are the real reasons we are sick.
The good news is that by fixing the problem at its root results creates benefit for most chronic disease and it makes you feel more alive, healthy and has no side effects.
Disregarding the underlying causes and treating only risk factors is somewhat like mopping up the floor around an overflowing sink instead of turning off the faucet, which is why medications usually have to be taken for a lifetime. When the underlying lifestyle causes are addressed, patients often are able to stop taking medication and avoid surgery (under their doctor's supervision, of course). Now I am going to tell you how to lower your heart disease risk as well as your cholesterol using a comprehensive dietary and lifestyle approach.
Dietary Recommendations to Help Prevent Cardiovascular Disease
The first step in preventing heart disease is to eat a healthy diet. Increase your consumption of whole foods rich in phytonutrients, plant molecules that give your body the nutrients it needs. Here are some practical tips:
2. Use lean animal protein like fish, turkey, chicken, lean cuts of lamb, and even vegetable protein such as nuts, beans, and tofu.
3. Combine protein, fat, and carbohydrates in every meal. Never eat carbohydrates alone.
4. For the same reasons, avoid white flour and sugar.
5. Eat high-fiber foods, ideally at least 50 grams per day. Beans, whole grains, vegetables, nuts, seeds, and fruit all contain beneficial fiber.
6. Avoid all processed junk food, including sodas, juices, and diet drinks, which impact sugar and lipid metabolism. Liquid sugar calories are the biggest contributors to obesity and diabetes and heart disease.
7. Increase omega-3 fatty acids by eating cold-water wild salmon, sardines, herring, flaxseeds, and even seaweed.
8. Reduce saturated fat and use more grass-fed or organic beef or animal products, which contain less saturated fat.
9. Eliminate all hydrogenated fat, which is found in margarine, shortening, and processed oils, as well as many baked goods and processed foods.
10. Instead use healthy oils, such as olive (especially extra virgin olive oil), cold pressed sesame, and other nut oils.
11. Avoid or reduce alcohol, which can increase triglycerides and fat in the liver and create blood sugar imbalances.
12. Don't allow yourself to get hungry. Graze -- don't gorge -- by eating every three to four hours to keep your insulin and blood sugar normal.
13. Try not to eat three hours before bed.
14. Have a good protein breakfast every day. You can start with a protein shake or may use eggs. Some suppliers offer omega-3 eggs, which are ideal.
15. Include flaxseeds by using two to four tablespoons of ground flaxseeds every day in your food. This can lower cholesterol by 18 percent. Flax is tasty in shakes or sprinkled on salads or whole grain cereal.
16. Drink green tea, which can help lower cholesterol.
17. Use soy foods such as soymilk, edamame, soy nuts, tempeh, and tofu, which can help lower cholesterol by 10 percent.
18. Eat at least eight to ten servings of colorful fruits and vegetables a day, which contain disease fighting vitamins, minerals, fiber, phytonutrients, antioxidants, and anti-inflammatory molecules. (vi)
Supplements Can Help Reduce Your Risk
Supplements are important. Along with a healthy diet and exercise program, they can dramatically affect your risk of cardiovascular disease. Combining these together can have the greatest impact on your cholesterol.
Here are the supplements I have found most useful in my practice to lower cholesterol and even prevent and reverse heart disease:
1. Everyone must take a good multivitamin and mineral, as well as a purified fish oil supplement that contains 1000 to 2000 grams a day of EPA/DHA. More may be necessary for those with low HDL and high triglycerides. (vii)
2. Red rice yeast (two 600-mg capsules twice a day), which is another powerful cholesterol-lowering herbal formula. (viii)
3. Plant sterols (beta-sitosterol and others) can help lower cholesterol. Take 2 grams a day.
4. Try policosanol (10 mg to 20 mg twice a day), which is from sugarcane wax and can help lower cholesterol. (ix)
5. A soy protein isolate shake can be helpful in lowering cholesterol by about 10 percent.
6. Fiber supplements such as WellbetX PGX (Konjac fiber or gluccomanan) -- 4 before each meal with a glass of water -- can both lower cholesterol and balance blood sugar metabolism. (x)
There are other suggestions and therapies, but these will work for most people. Working with a doctor specializing in nutritional therapy can help sort out questions or difficulties that arise.
Lifestyle and Exercise Changes for Heart Health
I encourage 30 to 45 minutes of cardiovascular exercise at least six times a week. You may try interval training (also known as wind sprints) if you are feeling stronger. I also encourage strength training to build muscle and reduce body fat composition.
Exercise is a necessity, not a luxury, in preventing almost all chronic disease, from heart disease to cancer, from dementia to diabetes, from osteoporosis to osteoarthritis. You cannot age successfully without it. It is how we are designed.
Stop Stressing Out Your Heart
Stress alone can cause a heart attack. It is often the trigger that leads to the cascade of events that causes that final, fatal heart attack. But all along the way, it contributes to heart disease by creating inflammation, raising your cholesterol and blood sugar, causing high blood pressure and even making your blood more likely to clot.
Therefore, finding ways to manage stress, to relax, and to find the pause button is essential for dealing with nearly all chronic health conditions, including high cholesterol.
Learn to reduce stress by doing regular relaxation exercises such as yoga, tai chi, meditation, breathing, guided imagery, or whatever it takes to engage the relaxation nervous system, which can lower cholesterol, reduce your overall level of inflammation, balance your blood sugar, increase metabolism, and help with your overall health.
Try classes, buy tapes, try therapy, or just go out and have fun. But you must do something to switch daily out of the alarm response to maintain your health.
Occasionally I will recommend medications if I feel that my patient is swimming upstream genetically, or if there is significant heart disease present already. Then I can carefully weigh the risks and the benefits of medications.
However, it is possible to achieve most of the benefits of medications through lifestyle changes. Dr. David Jenkins from the University of Toronto compared treatment with statin drugs (the number-one cholesterol medication) to a diet high in viscous fiber, almonds, soy, and plant sterols and found they were equal, although the diet was more effective in lowering inflammation and homocysteine. (xi)
In fact, many of my patients have lowered their cholesterol over 100 points by following the comprehensive program I outline above.
In the rare occasions when I do need to use medications, here are the ones I have to choose from:
1. Statins -- These work by blocking the production of cholesterol in the liver. They can also lower inflammation and very high doses may even reverse plaque or fatty deposits in the arteries.
Though now widely prescribed, statin medications do have significant side effects, in that they deplete the body's stores of the vital component Coenzyme Q10. If you're on statins, it's a good idea to supplement with at least 100 mg of CoQ10 a day.
Many patients have to stop taking statins because of muscle pain and aching, known as statin myopathy. It is more common that most people think.
And you must have your liver function checked regularly and have your muscle enzymes (CPK) measured to make sure you can continue the medications safely. However you can have symptoms, pain, and muscle injury without having an abnormal CPK test.
2. Niacin -- This is also known as vitamin B3, and in very high doses (1000 to 3000 mg a day) can be very helpful for raising good cholesterol (HDL) and lowering high triglycerides -- something that statins are not very effective at.
I use niacin often in my patients who have insulin resistance or pre-diabetes. The major side effect is flushing (sort of like hot flashes), which are benign, subside after an hour, and reduce completely over a few weeks. You can stop flushing by taking a baby aspirin (81mg) half an hour before your take the niacin.
I usually recommend long-acting Niaspan and build up slowly over the course of 2 to 6 weeks to the desired dose of 1500 to 2000 mg daily. This needs to be done only under a doctor's supervision.
3. Ezetimbe (Zetia) -- This drug prevents absorption of cholesterol from the intestine. It can interact with the statins to increase the risk of liver toxicity. However recent studies have shown that combining Zetia with a statin actually increases plaque in the arteries even though it lowers cholesterol. Another reason to not assume that lowering cholesterol is what protects us against heart disease.
4. Fibrates -- This class of medications includes drugs such as fenofibrate (Tricor) and gemfibrozil (Lopid) and helps to lower triglycerides and raise HDL. These drugs also act on a class of receptors that control inflammation and blood sugar called PPAR.
The verdict is still out on their effectiveness and safety. I prefer to use niacin, which achieves the same results, at lower cost with less risk.
5. Bile Acid Binding Agents -- Drugs like Questran and WellChol bind up bile in the gut and promote the elimination of cholesterol from the body. Bile is comprised of cholesterol among other things, and getting rid of bile helps lower your cholesterol. These are somewhat difficult to take, and not often used.
Remember, cholesterol is only one of many factors that lead to cardiovascular disease, and it may not even be the most important one. Inflammation and insulin resistance or pre-diabetes are much more important. There are many causes. We have to look at all of them. We focus on cholesterol because it is what we have the best medication for. But remember if all you have is a hammer, then everything looks like a nail.
Comprehensive diet, supplements, exercise, and other lifestyle approaches can have a huge impact your risk of heart disease and can dramatically improve cholesterol. And this approach reduces your risk of nearly all chronic diseases.
Medications are available as a last resort, but I never start them without trying an integrated approach to cholesterol management and heart disease prevention. In fact, the cholesterol comes way down as a side effect of changing lifestyle. You often don't have to treat it directly.
If you are willing to make the changes in diet and lifestyle and take a few supplements, your health, and your numbers, may change dramatically ... and so will your life.
Now I'd like to hear from you ...
Have you taken medications to lower cholesterol? Have you had any side effects?
Have you tried any of the lifestyle measures mentioned here?
What do you plan to do to lower your risk of heart disease?
Please share your thoughts by adding a comment below.
To your good health,
Mark Hyman, M.D.
(i) Mozaffarian D, Wilson PW, Kannel WB. Beyond established and novel risk factors: lifestyle risk factors for cardiovascular disease. Circulation. 2008;117(23):3031-3038.
(ii) Menke A, Muntner P, Batuman V, Silbergeld EK, Guallar E. Blood lead below 0.48 micromol/L (10 microg/dL) and mortality among US adults. Circulation. 2006 Sep 26;114(13):1388-94.
(iii) Ford ES, Bergmann MM, Kroger J, Schienkiewitz A, Weikert C, Boeing H. Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study. Arch Intern Med. 2009 Aug 10;169(15):1355-1362.
(iv) Yusuf S, Hawken S, Ounpuu S, et al; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):937-952.
(v) American College of Preventive Medicine. Lifestyle Medicine--Evidence Review. June 30, 2009. Available at: http://www.acpm.org/LifestyleMedicine.htm. Accessed September 18, 2009.
(vi) Kottler BM, Ferdowsian HR, Barnard ND. Effects of plant-based diets on plasma lipids. Am J Cardiol. 2009 Oct 1;104(7):947-56.
(vii) Micallef MA, Garg ML. Anti-inflammatory and cardioprotective effects of n-3 polyunsaturated fatty acids and plant sterols in hyperlipidemic individuals. Atherosclerosis. 2009 Jun;204(2):476-82.
(viii) Becker DJ, Gordon RY, Halbert SC, French B, Morris PB, Rader DJ. Red yeast rice for dyslipidemia in statin-intolerant patients: a randomized trial. Ann Intern Med. 2009 Jun 16;150(12):830-9, W147-9.
(ix) Chen JT, Wesley R, Shamburek RD, Pucino F, Csako G. Meta-analysis of natural therapies for hyperlipidemia: plant sterols and stanols versus policosanol. Pharmacotherapy. 2005 Feb;25(2):171-83. Review.
(x) Sood N, Baker WL, Coleman CI. Effect of glucomannan on plasma lipid and glucose concentrations, body weight, and blood pressure: systematic review and meta-analysis. Am J Clin Nutr. 2008 Oct;88(4):1167-75. Review.
(xi) Jenkins DJ, Kendall CW, Marchie A, Faulkner DA, Wong JM, de Souza R, Emam A, Parker TL, Vidgen E, Lapsley KG, Trautwein EA, Josse RG, Leiter LA, Connelly PW. Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein. JAMA. 2003 Jul 23;290(4):502-10.
Mark Hyman, M.D. practicing physician and founder of The UltraWellness Center is a pioneer in functional medicine. Dr. Hyman is now sharing the 7 ways to tap into your body's natural ability to heal itself. You can follow him on Twitter, connect with him on LinkedIn, watch his videos on Youtube and become a fan on Facebook.
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