Transcript A Lifestyle for Wellness

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,
o
o
o
o
fibrates, etc.
CRP – statins?
Aspirin, plavix, aggrenox, etc.
ACEI’s
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
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o
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Relaxation/Stress Reduction
Social Connection/Intimacy
Tobacco
Exercise
Diet
Lipids
Homocysteine and CRP
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 States
Washington
1995
2001
1995
2001
Heart Disease
280.7
245.8
208.6
188.2
Stroke
60.1
57.4
60.7
62.8
All cancers
204.9
194.4
183.0
180.2
Source: National Center for Health Statistics, 2003
Actual Causes of Death
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
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
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
o stress and isolation might be added to inactivity,
poor diet, and tobacco as actual causes of this
illness
The Essential 8
o
o
o
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Air and Breathing
Water and Moisture
Food and Supplements
Exercise and Rest
o
Play/Passion/Purpose
o
Gratitude/Prayer/Meditation
Intimacy & Connection
Forgiveness
o
o
Body
Mind
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
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.
o
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
General Adaptation Syndrome
(GAS)
o
The Response to Stress, in 3 Phases:
o Alarm Reaction
o Stage of Resistance
o Stage of Exhaustion
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
General Adaptation Syndrome
(GAS)
o
The Response to Stress, in 3 Phases:
o Alarm Reaction
o Stage of Resistance
o Stage of Exhaustion
Adrenal Exhaustion
Coping responses cannot sustain their response if
stressor is sufficiently severe and prolonged
o “Diseases of adaptation" may arise
o
o Hypertension
o Ulcers
o Heart disease
Symptoms that disappeared during the stage of
resistance may reappear
o Death possible
o
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
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Cold Hands and Feet
Palpitations
Diarrhea or Constipation
Decreased sleep
Maladaptive Changes with Chronic
Stress
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Worsened blood sugar control/increased
insulin resistance
Increased visceral fat deposition (appleshaped weight gain)
Increased inflammation
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
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
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
o
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Hormonal Effects as described for cortisol
Vasoreactive effects with adrenaline
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”
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Therefore, some simple physical relaxation
techniques can help to alleviate
mental/emotional stress
Abdominal Breathing
The Relaxation Response
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Counterbalancing mechanism to the Fight-orFlight Response
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Metabolism decreases
Heart rate decreases
Blood Pressure decreases
Breathing Rate decreases
Muscle Tension decreases
May be consciously elicited
o Generally needs to be practiced
o
Techniques Which Can Elicit the
Relaxation Response
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Diaphragmatic
Breathing
Meditation
Body Scan
Mindfulness
Repetitive exercise
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Repetitive prayer
Progressive muscle
relaxation
Yoga Stretching
Imagery
(Music)
Common Elements of Techniques Used to
Elicit the Relaxation Response
o
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Focusing of attention through repetition of
words or physical activity
Passive disregard of everyday thoughts
when they occur, and return to the repetition
Benefits of the Relaxation Response
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Immediate:
o Getting through procedures and short-term stress
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Long-term:
o Used consistently, there are carry-over effects
Spirit
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Meditation/Prayer/Gratitude
Intimacy and Connection
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:
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4S trial – RR 0.67 after 5.4 years treatment with
simvastatin Circulation. 1998;97:1453-1460
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
LIPS – RR 0.78 after 3-4 years post PCI on fluvastatin 80
mg vs. placebo JAMA Vol. 287 No. 24, June 26, 2002
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
Spirit
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Meditation/Prayer/Gratitude
Intimacy and Connection
Forgiveness
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
Study of women with children –
Major illness developed over a 30 year period in
o
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
Yes
No
Yes
No
your religious or spiritual faith?
Yes
Yes
No
No
Risk of dying 6 months later
3%
9%
8%
22%
in organized social groups?
2.
Do you draw strength from
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
Spirit
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Meditation/Prayer/Gratitude
Intimacy and Connection
Forgiveness
Health Benefits of Forgiveness
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
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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
o
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No intervention
Information/advice
Support group
28.2%
21.2%
12.9%
It turns out hostility, cynicism, suspicion are
more important than multitasking , time
urgency, etc)
Some Resources for Patients
Center for Attitudinal Healing
o Multiple religious organizations and volunteer
organizations
o Bibliotherapy:
o
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Love and Survival, Dean Ornish, M.D.
Forgive for Good, Fred Luskin PhD
The Feeling Good Handbook, David Burns,MD
The Wellness Book, Benson et. al.
Many others
Body
Health of the Body
Air and Breathing
o Water and Moisture
o Exercise and Rest
o Food and Supplements
o
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
Health of the Body
Air and Breathing
o Water and Moisture
o Exercise and Rest
o Food and Supplements
o
Water
o
o
o
Scientists are finding in ground water—along with industrial
pollutants—minute amounts of pesticides, estradiol,
acetaminophen, herbicides, codeine and caffeine.
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
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.
Health of the Body
Air and Breathing
o Water and Moisture
o Exercise and Rest
o Food and Supplements
o
Exercise
o
Reduces the risk of dying from or developing:
o
o
o
o
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Coronary heart disease – 3x decrease in risk of
death from heart disease if able to go 4.4 minutes
longer on the treadmill
High blood pressure
Colon cancer
Breast cancer
Diabetes.
Helps maintain healthy bones, muscles, and
joints.
o Helps control weight, build lean muscle, and
reduce body fat.
o
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 NormalWeight, 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. . .
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.
o
Bottom Line for Exercise
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.
o
Start Low, Go Slow
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
o
Motivation?
o
Intrinsic
o Energy level improves
o Chronic pain improves
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
o
Motivation and Adherence
o
o
Solitary vs. Group vs. “Buddy”
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
Our lifestyle encourages sleep deprivation
as a tool for doing too much
o
. . . The subject of another talk
o
Health of the Body
Air and Breathing
o Water and Moisture
o Exercise and Rest
o Food and Supplements
o
Modifiable, Measurable Biochemical
Risk Factors
o
Cholesterol, esp. LDL cholesterol
o LDL deposits in artery walls when oxidized
Homocysteine – a pro-oxidant
o CRP – a marker for inflammation
o And, fibrinogen, LpA, etc. . .
o
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
o
o
o
o
reduce nitric oxide
Reduce prostacyclin synthesis and activity
endothelial dysfunction through oxidative damage
increased oxidation of low-density lipoprotein
stimulation of smooth muscle cell proliferation, prothrombotic
effects, and impaired thrombolysis
Homocysteine as Predictor of Risk
TABLE 1 -- Relation between plasma total homocysteine (tHcy) levels and over-all mortality and death
due to coronary artery disease (CAD)
Relative risk (and 95% CI)
Plasma tHcy level, No. of subjects n = Overall mortality,
μmol/L
587
%
Death *
CAD-related
death †
<9
130
3.8
1.0
1.0
9–14.9
372
9.9
1.9 (0.7–5.1)
2.3 (0.7–7.7)
15–19.9
59
25.4
2.8 (0.9–9.0)
2.5 (0.6–10.5)
ge;20
26
26.9
4.5 (1.2–16.6)
7.8 (1.7–35.1)
Note: CI =confidence interval.
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
o
o
Vitamin therapy
regresses carotid
plaque in patients
with H(e) levels both
above and below 14
micromol/L
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.
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.
Health Nutrition (2007), 10:266-272
Public
CRP
o
o
o
1.0 to 3.0 mg/L: moderate risk of
cardiovascular disease
>3.0 mg/L high risk of cardiovascular
disease
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
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
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, 2003
Inflammation Benefits of
Aerobic Exercise
o
o
o
o
o
o
Regular aerobic exercise can decrease risk of having
elevated CRP.
Most significant drop in CRP is when sedentary adults move
from sedentary lifestyle to regular, low to moderate intensity
exercise program.
As exercise intensity, frequency, and duration increase, the
CRP continues to drop.
Anaerobic high intensity training (interval training) may
elevate CRP temporarily.
Colbert LH et al: J Am Geriatr Soc. 2004 Jul;52(7):1098-104.
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
o
o
o
o
o
Omega-3 fatty acids: studies are mixed
Diets high in plant sterols, soy protein, viscous fiber, and almonds
Exercise
Statins – 15% lowering
Fibric acid derivatives
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
No change in fat advice or fiber advice groups
o 29% reduction in all-cause mortality in fish group
o
Diet Interventions Post-MI
Cardioprotective Diet Trial
o
o
o
o
o
o
505 subjects with suspected AMI. Randomized, singleblind; both groups on a low fat diet. The intervention group
(Group A) was advised to eat more fruit, vegetables, nuts,
and grain products
Cholesterol fell by 0.74 mmol/L in group A versus 0.32
mmol/L in group B
Weight fell by 7.1 versus 3.0 kg, (CI 95%, 0.52–7.68).
Cardiac events lower in group A than group B (50 versus
82 patients, P<0.001)
Lower total mortality (21 versus 38 died, P<0.01) in group
A than group B
Cardioprotective Diet Trial 1992 BMJ. 1992 Apr 18;304(6833):1015-9
Angiographic Trials
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
o
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
Weight
TC
LDL-C
HDL-C
Homocysteine
Lipoprotein(a)
Fibrinogen
LF
$18.4%
$39.1%
$52%
h9%
$13.6%
$7.4%
$11.0%
Phase II
$12.6%
$30.4%
$38.8%
h3.6%
$14.6%
$10%
$6.3%
MF
$2.6% NS
$5%
$6.1%
$1.5%
h9.7%
h4.7%
$0.6%
HF
$13.7%
h4.3%
h6%
$5.8%
h12.4%
h31.%
h11.9%
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
o
11- year OR for mortality in strict
German vegetarians was .66 v. the
general population
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
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)
Best off were fish eaters and lactoovovegetarians
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-outcomefree 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
Effect of ingredients of Polymeal in reducing risk of cardiovascular disease
Percentage reduction (95% CI) in risk
of CVD
Ingredients
Source
Wine (150 ml/day)
32 (23 to 41)
Di Castelnuovo et al (MA)6
Fish (114 g four
times/week)
14 (8 to 19)
Whelton et al (MA)7
Dark chocolate (100 g/day)
21 (14 to 27)
Taubert et al (RCT)8
Fruit and vegetables (400
g/day)
21 (14 to 27)
John et al (RCT)10
Garlic (2.7 g/day)
25 (21 to 27)
Ackermann et al (MA)11
Almonds (68 g/day)
Combined effect
12.5 (10.5 to 13.5)
Jenkins et al (RCT),15 Sabate et al
(RCT)16
76 (63 to 84)
BMJ. 2004 December 18; 329(7480): 1447–1450.
Optimal Diet
o
o
o
o
Primitive: use the fuel for which the
machinery was designed
Emphasize Fruits Vegetables and Nuts
Very Limited or No Meat
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
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
o
o
o
5-9 or more servings of Fruits and Veggies
per Day
High fiber
Low Glycemic Index
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
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)
Recommended by the AHA to prevent heart
disease and stroke
Fruits, Veggies and Cancer
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
o
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
o
o
o
o
- Selenium
Dithiolthiones - Glucosinolates
Isothiocyanates- Flavonoids
Limonene - Protease inhibitors
Allium compounds
- Dietary fiber
- Indoles
- Phenols
- Plant sterols
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
o
o
o
o
antineoplastic agents
Dilution and binding of carcinogens in the
digestive tract
Alteration of hormone metabolism
Antioxidant effects
Others.
Why Not Just Take a Vitamin?
o
o
o
Lung Cancer and b Carotene – the Finnish
study
Cervical Dysplasia and Folic acid
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
o
Recommended by the NCI to help prevent
lung, breast, colon and prostate cancers by
50% or more
Recommended by the AHA to prevent heart
disease and stroke
Veggies and Stroke
In 832 healthy Framingham men, 20year 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
o
o
o
o
27% lower stroke incidence
42% lower stroke mortality
24% lower ischemic heart disease mortality
27% lower cardiovascular disease mortality
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
o
Fiber
Antioxidants
Fiber
o
Filling
o replaces higher caloric density foods
o
o
o
Maintains normal colonic flora
Glycemic Index (more later)
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:

o
mutations that activate oncogenes
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
o
Protect our cells from oxidation by
accepting free radicals
Work in groups
o Chain of acceptance of free radicals
• Implications: single vitamins may be counterproductive
Glutathione
C
?
?
?
E
?
?
b
?
Antioxidant Strategies
o
o
5-9 Fruits and veggies
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
5-9 Fruits and veggies
o Supplements Made from Whole Foods
o
o Food For Life
o Juice Plus+




o
Decreases oxidation of LDL
Decreases homocysteine
Decreases lipid peroxides in the urine
Decreases DNA Damage in circulating lymphocytes
Herbals:
o Grape seed extract, pycnogenol
o Ginkgo biloba
o Etc.
Features of Optimal Diet
o
o
o
o
5-9 Servings Fruits and Veggies per Day
High fiber
Low Glycemic Index
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
Lentils
29
Apple
36
Spaghetti, ww
37
Tortilla, corn
38
All-bran cereal
Orange
o
42
43
Think Primitive!
Corn
49
Spaghetti, durum
55
Rice, white
59
Ice Cream
61
Macaroni and cheese
64
Grape-nuts cereal 67
French baguette
95
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
o
Low Glycemic Index Diet can assist weight
loss by lowering insulin levels and
decreasing the impulse to snack
Low Glycemic Index Diet can decrease the
lifetime risk of developing diabetes
Features of Optimal Diet
o
o
o
o
5-9 Servings Fruits and Veggies per Day
High fiber
Low Glycemic Index
Low Fat; Omega-3 fats emphasized
Functions of Fats
o
o
o
Energy Storage
Membrane components
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
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 allcause 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
o
Omega 3 Bottom Line
Fish oil is most certain source
o Increasing omega-3’s can improve:
o
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
o
Information
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
o
Cost
“Willpower” – Emotional decisions about what
to eat, when, and how much
o
o
Digestive Problems
Knowledge
o Knowing what to eat
o Knowing how to prepare healthy food
Cost
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
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
o
Cost
“Willpower” – Emotional decisions about what
to eat, when, and how much
o
o
Digestive Problems
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
Obstacles to Change
o
o
Cost
“Willpower” – Emotional decisions about what
to eat, when, and how much
o
o
Digestive Problems
Knowledge
o Knowing what to eat
o Knowing how to prepare healthy food
Digestion
o
o
o
Chewing – dental health and taking time
Digestion – stomach acid, enzymes, bean-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)
Obstacles to Change
o
o
Cost
“Willpower” – Emotional decisions about what
to eat, when, and how much
o
o
Digestive Problems
Knowledge
o Knowing what to eat
o Knowing how to prepare healthy food
Tips to Increase Fruits & Veggies
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.
o
More Tips
o
o
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.
Use sauces to improve palatability for
veggies you do not like
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)
Soup recipes
o Steamed Greens
o Salads with low-fat dressing
o
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
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.
The risk of CVD beginning at 115/75
mmHg doubles with each increment of
20/10 mmHg
Hypertension and Pre-hypertension
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.
o
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
RECOMMENDATION
APPROXIMATE SBP
REDUCTION
(RANGE)
Weight reduction
Adopt DASH eating plan
Maintain normal body
weight
5–20 mmHg/10 kg
weight loss
Consume a diet rich in
8–14 mmHg
fruits, vegetables, and
lowfat dairy products
with a reduced content of
saturated and total fat.
Dietary sodium reduction Reduce dietary sodium
intake to no more than
100 mmol per day (2.4 g
sodium or 6 g sodium
2–8 mmHg
Lifestyle Modifications to
Control Hypertension
MODIFICATION
RECOMMENDATION
APPROXIMATE SBP
REDUCTION
(RANGE)
Physical activity
Engage 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 2–4 mmHg
than consumption 2 drinks (1
oz or 30 mL ethanol; e.g., 24 oz
beer, 10 oz wine, or 3 oz 80proof whiskey) per day in most
men and to no more than 1
drink per day in women and
lighter weight persons.
Natural Medicine for
Hypertension
o
o
o
o
Hawthorn – extract must include the leaf
Magnesium – especially if diabetic or
treated with diuretics
Meditation
Others
o Olive leaf extract
o Linden and others
Meds for Lowering Cholesterol
o
o
Statins – beware, these can lower coenzyme
Q10 (and supplementing it can decrease
muscle pain, fatigue associated with their
use).
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
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
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
o
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;
Form: cooked garlic, powder (most research) or aged
garlic extracts (odourless); oil is not as effective
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
TABLE 1 . Recommended Therapies for Prevention of Coronary Heart Disease (CHD) and Stroke Risk and Estimated Risk Reduction Benefits in Patien
Cardiovascular Disease Over Approximately Five Years
Relative Risk
Relative Risk
Source o
Risk Factor and Goal
Recommended Agent(s)
Change in Risk Factor
Reduction (Major
Reduction
Recommendat
CHD events)**
(stroke)
Evidenc
LDL cholesterol <70 mg/dl High-dose statin + diet
≥↓50%
48%
38%
References11, 20, 3
Blood pressure <140/90
3-drug combination: diuretic (1/2
Systolic ↓20 mm Hg or diastolic 46%–49%*
63%–66%*
References19, 30
mm Hg except <130/80 mm dose), β blocker, ACE inhibitor or
↓10 mm Hg
Hg with diabetes
calcium channel blocker
Platelet function
Aspirin 75–81 mg/d
CHD pts. 42%Stroke
CHD pts.
Reference1
pts. 17%
25%Stroke pts.
19%
β blocker post-MI
Noncardioselective; no intrinsic
23% CHD death†
Reference32
sympathomimetic activity
ACE inhibitor post-MI
20%‡
32%‡
References33, 64
Sudden death post-MI
Omega-3 fish oil 1,000 mg/d
30%§
References8, 61
30% CHD
death
Cardiac rehabilitation
Individual prescription
↑Moderate acrobic physical
26% CHD death§
Reference65
activity
Diet
Mediterranean
↑Fruits, vegetables, legumes,
52%–72%∥
References66, 67, 6
nuts, whole grains, fish,
33% CHD
monounsaturated oils
death (25%
total mortality)
ACE = angiotens-converting-enzyme; pts = patients; ↓ = decreased; ↑ = increased.
* Based primarily on trials in patients without cardiovascular disease; 3 drugs at half dose is lower estimate and 3 drugs at full dose the higher estimate.
† Mean study follow-up 6 to 48 months; risk reduction independent of length of follow-up.
‡ Mean study follow-up 4 years.
§ Independent of duration of follow-up; mean study follow-up 3.5 years.
∥ Approximately 2-year intervention.
** Nonfatal MI and CHD death.
Poly-portfolio for Prevention
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 CHD
Post-MI
Major CHD events
with combined
drug therapy
84%NNT = 10
91%NNT = 9
Major CHD events
with addition of
lifestyle therapy
92%NNT = 9
96%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
Stroke
77%NNT = 11
83%NNT = 21
The American Journal of Cardiology - Volume 95, Issue 3 (February 2005)
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
Source of
Recommendation or
Evidence
Relative Risk Reduction
(Major CHD events)**
Relative Risk Reduction
(stroke)
≥↓50%
48%
38%
References11, 20, 30
Systolic ↓20 mm Hg
or diastolic ↓10 mm
Hg
46%–49%*
63%–66%*
References19, 30
Aspirin 75–81 mg/d
CHD pts. 42%Stroke
pts. 17%
CHD pts. 25%Stroke
pts. 19%
Reference1
Noncardioselective;
no intrinsic
sympathomimetic
activity
23% CHD death†
Risk Factor and Goal
Recommended Agent(s)
LDL cholesterol <70
mg/dl
High-dose statin +
diet
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
Platelet function
β blocker post-MI
Change in Risk Factor
ACE inhibitor postMI
20%‡
Sudden death postMI
Omega-3 fish oil
1,000 mg/d
Cardiac rehabilitation
Individual
prescription
Diet
Mediterranean
Reference32
32%‡
References33, 64
30%§
30% CHD death
References8, 61
↑Moderate acrobic
physical activity
26% CHD death§
Reference65
↑Fruits, vegetables,
legumes, nuts, whole
grains, fish,
monounsaturated oils
52%–72%∥
33% CHD death
(25% total mortality)
References66, 67, 68
The American Journal of Cardiology - Volume 95, Issue 3 (February 2005)