Risk factors for heart disease are divided into two groups: modifiable and non-modifiable. All of the risk factors shown are modifiable except for age, menopause and heredity. The risk factors highlighted in yellow are specific to women or a greater risk for women than men.
These are the goals for total cholesterol, LDL, HDL and Triglycerides. It is important that people ask their healthcare providers for their actual numbers and not accept a general “your cholesterol is good.” Everyone should “Know Their Numbers” and work to get them to the above goal levels.
AS with cholesterol numbers, patients should ask their healthcare providers for their blood pressure numbers when they get their blood pressure checked. It is recommended that everyone have a blood pressure under 120/80 mmHg, even those taking antihypertensive medications.
The Metabolic Syndrome (MS) is also known as “pre-diabetes.” If a person has 3 or more of these risk factors, they are classified as having the MS. This increases a persons risk of developing diabetes and heart disease in the future. The good news is that all of these risk factors are modifiable through healthy lifestyle changes.
High protein diet, initially no carbs, then low carb- to force the body into ketosis-burning fat as the major energy source. All fats/protein are allowed-no restriction on saturated fats. Proved to promote weight loss, other claims not scientifically proven. O long term data as far as safety of this diet and long term effects of high fat diet.
Even one high fat meal can have a negative effect on CV risk factors. 2 hours after the high fat meal, blood pressure elevates.
Other effects of a high saturated fat meal. In addition to detrimental effects on CV risk factors, there is an effect on endothelial and HDL function.
A low carb diet that allows the “healthy or good” carbs-fruits, vegetables, whole grains. Fat intake is restricted to “good fats” which are the lean proteins-fish, poultry, etc. The South Beach Diet has been proven to decrease the MS.
The Ornish diet is strictly vegetarian so it is therefore high in carbohydrates. This diet does include regular exercise and stress management which are very important features of an overall healthy lifestyle. There is no scientific data supporting the claim of reversing heart disease and plaque regression even though there has been data showing decreased angina in people with heart disease. This diet will decrease LDL.
A very heart healthy diet. It includes smaller more frequent high quality meals-lean proteins, fish, fruits and vegetables. It also includes a glass og wine daily and exercise. It has been proven that this diet decreases LDL,BP,FBS,Weight and also prevents re-current cardiovascular events.
2 studies of the Mediterranean diet-both very positive results. Lyon Heart Study showed that this diet decreased cardiovascular events from 50-70%. Lifestyle is a very powerful “medicine.” There aren’t any prescription medications that decrease CV risk by that amount.
DASH (Dietary Approaches to Stop Hypertension) diet has been proven to effectively lower BP. It is a low-fat and low sodium diet.
Many people follow advice from television and magazine articles. The Dr. Oz and Best Life Diet became very popular from the Oprah show. They are similar to the Mediterranean Diet with high fiber, small, frequent meals and lifestyle changes. These diets do promote weight loss, but there isn’t any scientific data confirming a decreased risk of CAD or DM.
The American Heart Association Diet stresses a low fat diet, high in fruits and vegetables and whole grains. It also recommends limiting salt and sugars. It is a heart healthy diet plan.
A diet high in whole grains has been shown to decrease abdominal fat, CRP and riak of CVA. Many products now have whole grain varieties such as breads, pastas and rice. Especially in people with high triglycerides, whole grains should be chosen over white flour products. The ingredient list should have the whole grain as the first or second item listed and it should not be listed as “enriched” whole wheat.
A high fiber diet decreases the absorption of cholesterol in the intestines and can be as effective as a low dose statin medication at lowering cholesterol. Diabetics should choose carbohydrates that have a higher fiber content to help prevent sudden increases in blood sugar that occurs when low fiber carbohydrates are ingested. Fiber also gives you a full feeling which helps with weight loss.
Unhealthy lifestyles/diet can greatly increase your risk for MI, CVA, and Diabetes.
Serving sizes today are much larger than they were 20 years ago. The following slides compare portion sizes, the difference in the number of calories people are consuming today, and the amount of activity required to burn it off.
In the day of specialty coffees with artificial flavors and whipped toppings, people do not realize that they may be taking in the amount of calories in a small meal with every “coffee.” Liquid calories add up too!
Visualization of a “Healthy Plate.” The majority of your plate should be fruits and vegetables (50%). The other 50% should be divided between the protein and carb/starch sources.
There is no nutritional value in salt and many people add salt to their food. Some also believe that Sea Salt is a better alternative. Sea Salt still contains sodium and by adding it to foods, it can increase blood pressure. Some good alternatives are Potassium Salt, Mrs. Dash, or other spices.
The majority of sodium intake comes from food processing (which is why these foods should be avoided by hypertensive patients). There is also an inherent amount of sodium in most foods. The smallest amount of sodium intake is from adding salt during cooking and at the table, but this is the only amount that can be controlled.
Recent research has indicated that adding potassium to the diets of patients with hypertension can help lower blood pressure. When potassium intake is increased, the body tends to excrete more sodium. There are many good food sources of potassium or another option would be to use potassium salt instead of regular salt (sodium).
Added free sugars should be limited to 12 tsp. per day-this is the amount of sugar added to 1 soda! Added free sugars do not include naturally occurring sugars in fruits/vegetables/milk products.
Tea has a lot of heart healthy benefits – white, green and black tea but there is not enough data to support the benefits of tea supplements. Also the research shows that fresh tea made with tea leaves is beneficial. There is no data to support the benefit from commercial processed teas.
The research on black tea heart health benefits.
Research summary of green tea benefits.
Research does support some heart healthy benefits with daily coffee consumption, but not more than 3 cups of coffee.
Alcohol does provide some heart healthy benefits when consumed in moderation (one drink per day for women and not more than two drinks per day for men). There are adverse effects that occur with higher amounts of alcohol (hypertension, cardiomyopathy) – so patients who do not drink alcohol should not be encouraged to start.
Dark chocolate in moderation is heart healthy. For some reason when milk is added or consumed at the same time as chocolate the heart healthy benefits are diminished.
There is presently no standardized garlic dose.
Garlic research studies have reported inconsistent results.
There is a lot of good scientific data to support the heart health benefits of omega 3 fatty acids.
AHA recommends obtaining omega 3 fatty acids from food: fish, soy, nuts. For some reason it is believed the heart health benefits are diminished when fish is fried.
Nuts are a good source of omega 3 fatty acids (especially almonds, walnuts, peanuts, pistachios). One ounce of nuts (handful) five times per week was reported to decrease the risk of heart disease by 25 to 39%. Nuts do have a lot of calories so moderation is key.
These are the current AHA recommendations for omega 3 intake.
Flaxseed (seeds not oil) has high fiber content. Flaxseed (seeds and oil) are good source of ligans and omega 3 fatty acids.
Red Yeast Rice acts just like a HMG-CoA (statin) and should never be taken with a statin. Patients who take red yeast rice should be closely monitored by a healthcare provider because adverse effects like myopathies and elevated liver enzyme can occur with red yeast rice.
Two grams a day of a plant stanol/sterol can help lower LDL cholesterol by 9 to 20%.
Antioxidant vitamin supplements should NOT be used for heart health prevention. This is a list of primary and secondary heart disease prevention studies that found NO benefit with antioxidant supplements.
Obtain b complex vitamins from food sources NOT supplements.
Two large studies that reported NO heart health benefit with b complex vitamins.
There is a lot of recent data that reports an increased heart disease risk when vitamin D levels are low.
Coenzyme Q10 is a free radical scavenger and generates ATP. CoQ10 is a naturally occurring substance. People with heart failure, people taking statins have been reported to have lower levels of CoQ10. Also as we get older our body makes less CoQ10.
People with heart failure may benefit from CoQ10 supplements. Also patients taking statins who develop myopathic pain may experience relief of pain when treated with CoQ10 supplements.
Soy products are everywhere!!
Soy research studies have been inconclusive and most experts agree that presently there is no reliable data to support the claims that soy can reduce cholesterol levels or lower heart disease risk.
Patients taking prescription medications should not start taking any herbal supplements without first discussing the potential adverse interactions with their healthcare provider or pharmacist.
Total CholesterolTotal Cholesterol < 200< 200
LDLLDL (Bad “Lousy” Cholesterol) < 100(Bad “Lousy” Cholesterol) < 100
HDLHDL (Good “Healthy” Cholesterol)(Good “Healthy” Cholesterol)
> 60 in women> 60 in women
>50 in men>50 in men
TriglyceridesTriglycerides < 150< 150
NORMALNORMAL < 120< 120 < 80< 80
HIGH NORMALHIGH NORMAL 120-139120-139 81-8981-89
HYPERTENSIONHYPERTENSION >> 140140 >> 9090
NCEP-ATP III definitionNCEP-ATP III definition::
Waist circumference >35” inWaist circumference >35” in
women, >40” in menwomen, >40” in men
HDL <50 mg/dl in women,HDL <50 mg/dl in women,
<40 mg/dl in men<40 mg/dl in men
TriglyceridesTriglycerides >>150 mg/dl150 mg/dl
Glucose > 100Glucose > 100
Blood pressureBlood pressure >>130/85 mmHg130/85 mmHg
Atkin’s Diet (Low Carb)
Eat Protein, Fats (all fats)Eat Protein, Fats (all fats)
Causes Ketosis – burns fatCauses Ketosis – burns fat
Promotes Weight LossPromotes Weight Loss, Lowers TG, Improves, Lowers TG, Improves
HDL, Lowers BP (No effect LDL)HDL, Lowers BP (No effect LDL)
? Questionable Long Term Effects/Safety ?? Questionable Long Term Effects/Safety ?
Increases Urinary Excretion Calcium =Increases Urinary Excretion Calcium =
Increased RiskIncreased Risk Osteoporosis, Kidney StonesOsteoporosis, Kidney Stones
Single Fatty Meal Stresses the Heart
(42 Grams Fat)
Cereal, Skim Milk
(1 Gram Fat)
2 Hours Later – Blood Pressure Higher
After High Fat Meal
Journal of Nutrition (137) 2007
3 Hours Later – arteries unable dilate3 Hours Later – arteries unable dilate
6 Hours Later – anti-inflammatory6 Hours Later – anti-inflammatory
properties HDL diminishedproperties HDL diminished
“Effects of ONE Saturated Fat Meal”
Caffeinated CoffeeCaffeinated Coffee::
1 to 3 cups decrease CV risk1 to 3 cups decrease CV risk ( in women)( in women)
S/P MI – no increased risk with espressoS/P MI – no increased risk with espresso (GISSI(GISSI
– Prev Study)– Prev Study)
Increased risk HTNIncreased risk HTN
Decreased FMD/Endothelial functionDecreased FMD/Endothelial function
Decaffeinated CoffeeDecaffeinated Coffee::
Increases cholesterolIncreases cholesterol (ApoB)(ApoB)
Overweight – Increased HDLOverweight – Increased HDL
Am J Clin Nut (83) 2006 Am J Clin Nut (86) 2007
Circ (107) 2007 AHA 2005 Scient Session 2005 (abstract 3852)
Increases HDL, Lowers BPIncreases HDL, Lowers BP
Decreases blood clotsDecreases blood clots
Reduce risk CVA, MI, DiabetesReduce risk CVA, MI, Diabetes
Decrease mortality after MIDecrease mortality after MI
Women – one drink/dayWomen – one drink/day
Men – two drinks/dayMen – two drinks/day
If You Don’t Drink, Don’t Start
HTN, Alcoholic Cardiomyopathy
“Take 2 Hershey Kisses or BonBons
to Lower Your Blood Pressure ??”
Potent Antioxidant/Plant Phenols/FlavonoidsPotent Antioxidant/Plant Phenols/Flavonoids
Decreases Arterial Stiffness/Dilates VesselsDecreases Arterial Stiffness/Dilates Vessels
Lowers Blood Pressure (2 to 5 mmHg)Lowers Blood Pressure (2 to 5 mmHg) Similar BPSimilar BP
med effectmed effect
Inhibits Platelet ActivationInhibits Platelet Activation
““Hold the Milk” – Benefits lost ifHold the Milk” – Benefits lost if
drink milk with chocolate ??drink milk with chocolate ??
Arch Intern Med (167) 2007
Garlic Dose ???Garlic Dose ???
1 to 2 cloves raw garlic1 to 2 cloves raw garlic
(chopped, wait 15 minutes then use, do(chopped, wait 15 minutes then use, do
not cook at high temperatures)not cook at high temperatures)
300 mg freeze dried powder 2 – 3 x’s/day,300 mg freeze dried powder 2 – 3 x’s/day,
must be enteric coated avoid breakdown inmust be enteric coated avoid breakdown in
7.2 grams aged extract7.2 grams aged extract
Side effects – bad breath, body odor, GI upset,Side effects – bad breath, body odor, GI upset,
antiplatelet effect (D/C high doses beforeantiplatelet effect (D/C high doses before
surgery – increases bleeding risk)surgery – increases bleeding risk)
Garlic Trials = Inconsistent Results
May haveMay have short-termshort-term effect on loweringeffect on lowering
cholesterol ???cholesterol ???
May lower BP 3 to 5% ???May lower BP 3 to 5% ???
Mild antiplatelet effectMild antiplatelet effect
Arch Intern Med. 2007;167:346-353
Amer Fam Physician. July 1, 2005
Journ Agric & Food Chemistry June 2006
Omega 3 Intake Recommendations:
No CHDNo CHD:: Fish twice/week and oils/foodsFish twice/week and oils/foods
rich alpha-linolenic acidrich alpha-linolenic acid (flaxseed, walnuts)(flaxseed, walnuts)
Patients with CHDPatients with CHD:: 1 Gm EPA+DHA1 Gm EPA+DHA
per dayper day (preferably from fish: 2- 4 ounces salmon, 4-(preferably from fish: 2- 4 ounces salmon, 4-
12 ounces canned tuna, 7 ounces flounder/sole)12 ounces canned tuna, 7 ounces flounder/sole)
Patients with High TriglyceridesPatients with High Triglycerides:: 2 to 42 to 4
Gm EPA+DHA per dayGm EPA+DHA per day (High Doses May Cause(High Doses May Cause
AHA Scientific Statement, Circulation 2002
Lowers CholesterolLowers Cholesterol
9% drop Total Cholesterol, 18% drop LDL (Seeds NOT Oil)9% drop Total Cholesterol, 18% drop LDL (Seeds NOT Oil)
Reduces Platelet AggregationReduces Platelet Aggregation
Reduces Inflammatory MarkersReduces Inflammatory Markers
Improves Glucose ToleranceImproves Glucose Tolerance
J Clin Endo & Metab, 90 2005
Acts like HMG-CoA (Statin - Lovastatin), Contains
• Reduces Total Cholesterol 15-20%, LDL 20-30%,
Increases HDL 15 to 20%
•Dose 600 mg BID = 10mg HMG-CoA reductase inhibitor daily
•Contraindications – same as Statins, DO NOT TAKE WITH STATIN,
•Can cause myopathies
(2 Grams/Day Lower LDL 9 to 20%)
Competes with Cholesterol for Absorption in Intestines
“Get antioxidants from food,
At this time, there is little reason to adviseAt this time, there is little reason to advise
that individuals take antioxidantthat individuals take antioxidant
supplements to reduce their risk ofsupplements to reduce their risk of
cardiovascular disease.cardiovascular disease.
AHA Scientific Advisory
So far,So far, no study has shown that folic acidno study has shown that folic acid
supplements reduce the risk of CADsupplements reduce the risk of CAD or that takingor that taking
these vitamins affects the development orthese vitamins affects the development or
recurrence of cardiovascular disease.recurrence of cardiovascular disease.
Food SourcesFood Sources::
Fortified cereals, Dark Leafy Green VegetablesFortified cereals, Dark Leafy Green Vegetables
Lowers Homocysteine Levels But May NotLowers Homocysteine Levels But May Not
Decrease Risk CV Disease ??Decrease Risk CV Disease ??
HOPE – 2 Trial Shows NO HOPE for High Dose
B Complex Vitamins in Decreasing
Heart Disease Risk
•Over 5,000 High Risk Patients
NORVIT Trial Demonstrated Possible Harm
•Over 3,700 Post MI Patients
•Decreased Homocysteine Levels BUT Increased Adverse
N Engl J Med 2006
Framingham Heart StudyFramingham Heart Study
62% Higher Risk Heart Disease events62% Higher Risk Heart Disease events
(especially in people with HTN)(especially in people with HTN)
Recommended Daily DoseRecommended Daily Dose 800 and 1,000 IU of800 and 1,000 IU of
Vitamin D3 (cholecalciferol)Vitamin D3 (cholecalciferol)
AHA recommends getting Vitamin D from foodAHA recommends getting Vitamin D from food
sources (milk, salmon, mackerel, sardines, fortifiedsources (milk, salmon, mackerel, sardines, fortified
Science Daily March 2008
Am J HTN (20) 2007
(Generates ATP, Free Radical Scavenger)
• Produced naturally in body ubiquinone
• Food Sources: Organ Meats, Beef, Sardines, Mackerel, Nuts
Improves QOL, Decreases Heart FailureImproves QOL, Decreases Heart Failure
HospitalizationsHospitalizations (CHF patients may have lower(CHF patients may have lower
CoQ10 levels?)CoQ10 levels?)
Improves myopathic pain in StatinImproves myopathic pain in Statin
Treated PatientsTreated Patients (Statins may decrease CoQ10(Statins may decrease CoQ10
Take supplements with fatty meal (toTake supplements with fatty meal (to
improve absorption)improve absorption)
Recommended dose 50 to 200 mg/dayRecommended dose 50 to 200 mg/day
Possible interaction with CoumadinPossible interaction with Coumadin