Wouldn’t it be great if cardiovascular disease (CVD) were rare? It’s not like traveling to Mars and back. It is something we have the tools to make happen in the present. However, reality is different from the fantasy. Though fewer people are dying from this compilation of diseases (strokes and heart disease), it still tops the list. In fact, a 30-year-old has a one-in-two chance of developing CVD in his or her lifetime (1). Now that we have shock and awe, where are we with this disease?
We know that greater than 90 percent of the patients that will suffer from CVD have at least one risk factor (2). Most of these risk factors are modifiable. They are the seven pillars: blood pressure, cholesterol, weight, diet, exercise, smoking status and blood sugar. If we control them, the risk of CVD goes down dramatically (3). However, very few of us do it without medication (4).
Factors that might positively influence these pillars include HDL “good cholesterol,” activity, exercise, diet and drugs. We will investigate this further.
DO WE HAVE A GOOD PREDICTOR?
What may be the best potential predictor of cardiovascular disease? Is it BMI, waist circumference, waist-to-hip ratio or sticky bun consumption? To be fair, I don’t think there has been a study done on how many sticky buns it takes to predict CVD, but they certainly contribute. The answer is in the study that follows.
In a recent prospective (forward-looking) study, results showed that waist-to-hip ratio was a better predictor of CVD than either BMI or waist circumference (5). The researchers used a biomarker of atherosclerosis (plaques in the arteries) to measure CVD risk. To measure atherosclerosis and confirm which anthropomorphic (body habitus) measurement was most useful, a Doppler of the carotids and a brachial-ankle pulse wave were used. In postmenopausal women, it appeared that waist-to-hip ratio was directly correlated with carotid Dopplers and brachial-ankle measurements. Those with waist-to-hip ratios above 0.86 were considered at higher risk for atherosclerosis and thus CVD. Waist circumference did correlate to brachial-ankle results, but not to carotid Dopplers. This is best explained by a potential postmenopausal redistribution of fat from the hips and buttock to visceral fat in the belly.
SAY NO TO DRUGS
Would you take a pill once a day with no side effects and no cost for the rest of your life if it meant preventing cardiovascular disease? Of course you would — or would you? In a recent study, patients were asked this very question and the results might be a surprise (6). Approximately one-third of participants would rather lose several months of life, about 12 weeks, than take a single once-a-day drug to prevent CVD. In fact, 20 percent of the participants were even willing to go as far as to pay $1,000 not to take such a medication. Mind you, about half of the participants were already taking three medications. Even more intriguing, it was the participants who were already taking pills that were least likely to want to add the hypothetical CVD prevention pill. Therefore, we need to reduce risk factors in other ways with lifestyle.
COMMON SENSE SAYS THAT
HIGH BLOOD PRESSURE INCREASES RISK BUT …
We all know that high blood pressure is a risk factor for cardiovascular disease, and those who are over the age of 60 will have the highest probability of having CVD. However, in a recent observational study, results show that younger patients with isolated high systolic blood pressure (SBP) have a significantly increased risk of CVD (7). Systolic is the top blood pressure reading number, and isolated high SBP means greater than 140 mmHg with a normal <90 mmHg diastolic (bottom number) pressure. Study participants were between the ages of 18 and 45.
Those who had a higher SBP had a significantly greater risk of dying from cardiovascular disease than those who did not have elevated pressure over a 31-year duration. It turned out that 25 percent of the men and about half as many women had isolated high SBP. However, the women had a greater risk of dying. However, there were several confounding factors that make this not the best type of study.
HDL: IS HIGHER BETTER?
For the longest time, we have thought that high levels of HDL had a protective effect against cardiovascular disease. But this paradigm may not be true. In fact, in a recent study, results show that it may have to do more with functionality of HDL than with the actual number (8). The baseline number for HDL had no impact on reducing cardiovascular risk but functionality did.
Functionality is referred to as the cholesterol-efflux capacity. The cholesterol-efflux occurs when HDL helps remove cholesterol from cells in the arterial walls and shifts it back into the liver. The patients with the highest quartile of cholesterol-efflux capacity had a two-thirds reduction in CVD risk compared to the lowest quartile. The better this process is working, the lower risk of CVD. Thus, it does not relate as much to the level of HDL in the blood but as to its functionality. This suggests that raising HDL by drug therapy may not be the most effective approach. To clarify and make for a more vivid image, as Dean Ornish, M.D., professor of medicine at UCSF has written, if you think of HDL as dump trucks, adding more dump trucks at a stoplight only piles up the trucks; it does not make for more effective transport.
THE DIETARY EFFECT IS NOT WHAT IT SEEMS
Many of us try to live a healthy life by managing our diets. However, not all diets are created equal when it comes to cardiovascular risk. In a recent meta-analysis (a group of 12 randomized controlled trials), the results disappointingly show that four popular diets did not decrease the cardiovascular disease risk, nor did they result in a substantial decrease in weight over the long term, compared to the placebo group (9). These diets included Weight Watchers, Atkins, South Beach and Zone.
Though Weight Watchers did show a significant initial weight loss, some of the weight was regained over time. The duration of the studies was between one and two years. There was no significant effect on markers for cardiovascular risk, such as cholesterol levels, blood pressure and sugar control.
It is disheartening to think that some diets don’t have any effect on cardiovascular disease. So what do we do? It turns out that a diet that has high levels of enterolactone, a biomarker for fiber and vegetables, has shown significant 65 percent reductions in cardiovascular events and mortality in men (10). Thus, a plant-based diet rich in vegetables and fiber has an impressive benefit. Diets such as Mediterranean-type and DASH diets are rich in these components.
Therefore, a productive way to make cardiovascular disease rare is to know your risk factors and to make lifestyle changes that include a plant-rich diet and activity. There are simple ways to determine risk, with waist-to-hip ratio as a useful tool. Reduce your waistline and you reduce your ratio, thus your risk. Eliminating these risk factors will make the probability of suffering from CVD that much less likely.
(1) Lancet. 2014 May;383(9932):1899-911. (2) uptodate.com. (3) Circulation. 2010;121(4):586-613. (4) JAMA. 2012;307(12):1273-83. (5) Maturitas. online Jan. 12, 2015. (6) Circß Cardiovasc Qual Outcomes. online Feb. 3, 2015. (7) J Am Coll Cardiol. 2015;65(4):327-35. (8) N Engl J Med. 2014;371(25):2383-93. (9) Circ Cardiovasc Qual Outcomes. 2014;7:815-827. (10) Lancet. 1999;354(9196):2112.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.