Everybody knows how to prevent heart disease. Not really. Everybody just thinks they know. In truth, just about everybody is pretty much wrong. OK, admittedly the parts about exercising, shunning cigarettes and not getting too stressed are clear to us all.
Those of you with sharp eyes have noticed that I did not mention diet or medication. Eating well is crucial but “eating well” is probably different from what you think it is. As far as medication, most everyone thinks that lowering your cholesterol with medication, probably a statin drug like LIPITOR, is effective and necessary for many of us, including those don’t like taking medications. Some TO-BE-DETERMINED statin drug was one element of the “polypill”, an almost magical drug mix formulated to prevent most of our major long-term health risks. Many in medicine advocated the polypill. Some were skeptical of such an aggressive medicinal approach to health care. We’ve seen this before. More should have been skeptical, and not just about the medications. Conventional dietary recommendations are almost as suspect. Lets back up and examine our assumptions about heart disease.
First, let’s look at that “eating well” piece of the puzzle. The official “healthy heart” diet is pretty straight forward? Limit your fats. They are bad for you, especially saturated fat. Fats make you fat and that’s not good. Margarine is better than butter because it doesn’t have all that saturated fat. Eat more breads, especially whole grains. I am not going to comment on the avoid salt and eggs recommendations right now, other than to say they are also wrong.
Eating fatty food is supposed to be bad because it bumps up your cholesterol. “Cholesterol is bad if not downright evil. Your cholesterol is high, you are going to die of a heart attack or stroke. We have to get it down, right NOW.”
This advice about diet, cholesterol, eating more grains and medicating away heart disease is wrong. Worse still is that this misguided advice led us astray for decades, wasting an awful lot of well-intentioned effort on the part of patients, and inevitably costing lives.
How could this have come to pass? The core, the heart of our mistaken approach, is pretty simple to identify. Some authorities made bad assumptions and, as often happens, most of us trusted the experts and fell neatly into line behind them. Instead of marching off into a golden sunset, it was over the cliff. When we actually got round to asking the right questions carefully and conducting research on real people instead of lab rats, the answers exposed our misguided and presumptuous conclusions. The scientific evidence shows that we have been badly mistaken.
In the 1980’s the US government, aided and abetted by my profession, began to rant about the evils of fats. In response, the good citizens of this country, wanting to live healthy lives, dropped their fat consumption. Fat helps you feel full. So, Americans got hungry. We felt hungry if we ate “well”, or we felt guilty if we didn’t. Fat-free food also doesn’t taste so good. The food industry eased our pain by adding sweeteners of all sorts to our food, so we would like the taste and buy, buy, buy. Our intake of carbohydrates in all forms (especially those added sweeteners) jumped up, A LOT. Today 80% of the foods on the shelves of your neighborhood grocery store contain sweeteners, added to please your palate and entice you to trade your hard earned dollars for these products. It is naive to call some of them food. Eating fat does not make you fat. As your pants or your scale may have informed you by now, your greatgrandmother was right. Bread and potatoes make you fat. Sugars are worse. If you get fat, your cholesterol WILL go up.
It is an adjustment to say this but, fat is good. Okay, maybe not hand over fist for breakfast, lunch and dinner, but way better than you have been led to believe. Maybe our brains should have known better because our brains are mostly made of fat. A diet high in saturated fat appears to reduce the risk of Parkinson’s Disease. But back to your heart – cholesterol is a kind of fat, so fat must be bad. Um, well…..
The Evil of Cholesterol?
People tend to think that cholesterol is an evil chemical, foreign to our bodies. Actually, your body makes cholesterol. It doesn’t make cholesterol to kill itself. Your body uses cholesterol to make a lot of really important chemicals. Hormones like testosterone, estrogen and cortisol, vitamin D and, ironically perhaps, the bile salts your gall bladder produces to digest fats, are all derived from cholesterol. In other words, you can’t live without it.
To be completely truthful, since World War II science has been telling us that lowering cholesterol is linked to accidental and violent death. We have not been listening too well. Maybe those are consequences of its effects on the brain and nervous tissue. Low cholesterol also might be linked to increased risk of cancer.
But what about cholesterol and heart disease?
Generally speaking, higher levels of cholesterol are associated with higher rates of heart disease, but the impact is small and far more complex. Other factors are more influential, and several studies have even shown that LOW cholesterol is linked to MORE deaths from heart disease, as well as increased overall death rate. There is evidence that some saturated fat, the kind that might raise cholesterol, is associated with REDUCED risk of blocked blood vessels in the heart.
The simple fact is that the great majority of people hospitalized for heart attacks do not have elevated cholesterol. As this disheartening reality was revealed, many physicians dug their heels in. Refusing to accept that a bit more thinking was needed, they stubbornly determined that the reason cholesterol-lowering didn’t work as advertised was that we weren’t pushing it hard enough. The “expert” response to scientific findings which tarnished the cholesterol theory was to increase medication dosages, and lower what we call “normal” cholesterol levels.
Salvation by Medication?
Various medications lower cholesterol, but a class of drugs known as statins are the king of the hill. They are now the second most heavily prescribed drug in the USA. Why are statins the “go-to” class of drugs? Simply, no other medications have been clinically proven to lower heart attacks rates.
Think about that. Many drugs lower cholesterol, but have not been proven to affect the bottom line, which is lowering death rates from heart disease. Lab tests show that niacin is the perfect heart disease drug because it lowers bad cholesterol while raising the good cholesterol.Then again, most people hate it because it makes them feel flushed, nauseated and just plain sick. It also seems to increase the risk of stroke and maybe, you guessed it, heart disease.
What about statins? They do lower cholesterol but, overlooked by many, they have a powerful anti-inflammatory effect. I learned about that affect 20 yrs ago during my research training at UCSF. One of my professors maintained that statins work NOT by lowering cholesterol, but by reducing inflammation. More are now realizing that their anti-inflammatory affects might be the real reason statins lower a person’s risk of dying from a heart attack. Quite possibly the best thing statins do for your heart and blood vessels is to turn down the inflammation that causes the build up and rupture of the plaques (i.e., crud) in our blood vessels, instantly blocking our arteries with the sludge. That sounds good. However, even if they help with inflammation, there are big problems with statins. We will come back to that later.
Another way of looking at statins (and all other medical interventions for that matter) is a statistic called Number Needed to Treat (NNT). NNT means Number Needed to Treat, i.e., the number of patients we must treat to help one person. The rest receive no benefit, not a little, none. Unfortunately, they ARE still subject to adverse effects.
The most profound effect a drug or any other intervention can have is when it is given to those people who need help the most, the individuals who are almost certainly going to suffer unless something (like a statin) saves them from their fate. In these gloomy circumstances, it is easier to see the impact of the drug because it changed what was inevitable.
Drug companies have done trials just like this. Enrolling study subjects from 60 -70 years of age, the highest risk group, their combined studies showed that we have to treat 345 people to prevent one cardiac event of any sort. Studying the very worst of the worst, people who have already had a heart attack, they found that we have to treat 85 to prevent one event.
Using drug company NNT data on the one hand and independent data on the other, if we treat 85 really sick people, we will prevent one heart event and 17 will suffer an adverse reaction. Most of those adverse reactions are not too bad (especially if it happens to someone else) but other are very bad. Now, if we look at preventing a person’s very first heart problem, we have to treat 345 to help one person, but 69 will get sick from the statin. Remember that the NNT data from independent researchers are higher, making this risk benefit balance worse still.
Statins have a long list of adverse effects. Studies performed by the manufacturers of the drugs find that problems are rare, down around 0.1%. However, research that has been conducted independently, unshadowed by drug company money/influence, tells us that as many as 20% of statin users experience significant problems.
What kind of problems? Liver and muscle damage are the old familiar ones. Those might occur because statins deplete CoQ10, a coenzyme crucial to much of our physiology, especially energetic activities like those involving the heart, for example. Statins also increase the risk of diabetes. Ironically, diabetics are much more likely to die of heart disease than the rest of us. A recent analysis of accumulated data suggests that the likelihood of taking a statin, the statin then causing diabetes and then dying of a statin-diabetes-induced heart attack, might be just a little less than not taking the statin in the first place. But then again, maybe not. Also, patient reports of statins causing mental confusion can no longer be discounted. For an aging population already facing an epidemic of dementia, that is highly undesirable effect of statins.
Statins achieved their popularity based upon little more than an unproven idea. The idea is now proven, but proven to be largely false. Statins are not good, but they are still the best of a bad lot. It is not just that the drug manufacturers have let us down by not discovering better drugs, the real problem is that the entire concept is wrong. Heart disease develops as a consequence of living poorly. There is a genetic component. You can’t change your parents, but science is proving that, by living well, you can entirely change your own risks.
How about aspirin? Just like the like the anti-cholesterol drugs, research shows that aspirin does not live up to the hype. If you have had a stroke, a heart attack or you have an irregular heart beat, aspirin or another clot blocker is worth considering. Otherwise, aspirin is unlikely to lower your risk of dying from cardiovascular disease. It does lead to troubles with bleeding as well as increasing macular degeneration, one of the most common causes of visual loss.
What Does Work?
Does this all mean you should just throw in the towel? Far from it. You are not powerless. In fact, the more carefully we investigate, the more potent our behavior proves to be at preventing and treating heart disease, like almost every other disease.
For example, a large study of the impact of consuming a Mediterranean diet on heart disease compared to taking a statin drug had to be stopped. Those eating the tasty mediterranean diet were THREE TIMES LESS LIKELY TO DIE THAN THOSE TAKING A STATIN. The effect of the diet was so dramatic that investigators had to stop the trial for ethical reasons! Like any study, the investigators predetermined how long the study needed to run to answer their study question. However, in the midst of the trial it became glaringly evident that the diet was better, and it was so much better that it was unethical not to give the diet to all of the study subjects. That’s like a “mercy rule” in kid’s sports, where a game is stopped if one team gets so far ahead it would be humiliating to the losing team to continue. In this case, the mercy is for the patient/experimental subject. There is none at all for the humiliated, ineffective treatment.
It really IS up to you.
Preventing Heart Disease – The Bottom Line
Too little water
High carb diets
Don’t worry so much about
Omega-3 oils (fish, nuts)