Opening the Heart and Opening the Arteries

1
Opening the Heart and Opening the Arteries

• Cardiovascular Disease A Holistic Approach to
  Reducing the Risk

2
The typical talk on this subject

• Cardiovascular Disease Prevention Risk Factor
  Modification
• Tobacco
• Lipids diet for a 15 drop, drugs for more,
  statins, fibrates, etc.
• CRP statins?
• Aspirin, plavix, aggrenox, etc.
• ACEIs
• Exercise

3
The Green Medicine talk on this subject

• Cardiovascular Disease Prevention Risk Factor
  Modification
• Tobacco
• Lipids add in red yeast rice extract, CoQ10
  with statins, etc.
• CRP some herbal anti-inflammatory combos
• Other blood thinners (garlic, vitamin E, fish
  oil, etc.)
• Exercise

4
This talk

• A Whole Person talk on Heart Disease primary and
  secondary prevention
• Mind-body Medicine and Heart Disease
• Diet and Exercise changes
• If time allows, the subject matter of the green
  medicine talk natural medicines for treatment
  of specific risk factors

5
Basic Principles of Holistic Medicine

• The Body is a Self-Healing Organism
• If we remove toxic influences and provide basic
  needs, people will often get better
• Unconditional Love is Lifes Most Powerful Healer
• Do not underestimate the power of this factor
  (data to follow)
• People behave as they do for good reasons
• 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

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A Broader Approach to Cardiovascular Disease
Prevention Risk Factor Modification

• Relaxation/Stress Reduction
• Social Connection/Intimacy
• Tobacco
• Exercise
• Diet
• Lipids
• Homocysteine and CRP
• Fish oil

7
Sickness

8
Causes of Death
Causes of death Trauma is 1 age 1-44
Cardiovascular leads cancer
9
Causes of Death
Mortality Rates, 1995 and 2001rates per 100,000 Mortality Rates, 1995 and 2001rates per 100,000 Mortality Rates, 1995 and 2001rates per 100,000 Mortality Rates, 1995 and 2001rates per 100,000 Mortality Rates, 1995 and 2001rates per 100,000
  United States United States Washington 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 Source National Center for Health Statistics, 2003 Source National Center for Health Statistics, 2003 Source National Center for Health Statistics, 2003 Source National Center for Health Statistics, 2003
10
Actual Causes of Death
Source McGinnis JM, Foege WH. Actual causes of
death in the United States. JAMA 1993
270220712. (1990 data). Note The percentages
used in the figure are composite approximations
derived from published scientific studies that
attributed death to these causes.
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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.

12
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.)

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Healing the HeartFurther Broadening the
Discussion

• The heart is a metaphorically important organ as
  well as physiologically important
• Interestingly, science is showing that caring for
  our metaphorical heart is important for the
  health of the physical one
• stress and isolation might be added to
  inactivity, poor diet, and tobacco as actual
  causes of this illness

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The Essential 8

• Air and Breathing
• Water and Moisture
• Food and Supplements
• Exercise and Rest
• Play/Passion/Purpose
• Gratitude/Prayer/Meditation
• Intimacy Connection
• Forgiveness

Body
Mind
Spirit
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Mind and Spirit

• 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 (plt.001)
• Peters RW et al. Circulation 1996 941346

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Stress

• A Definition

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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.
• 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.

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General Adaptation Syndrome (GAS)

• The Response to Stress, in 3 Phases
• Alarm Reaction
• Stage of Resistance
• Stage of Exhaustion

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Alarm Reaction Fight-or-Flight

• Evolutionary Role escape from predator or acute
  physical danger

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Alarm Reaction

• Physiological changes Adrenal hormones
  adrenaline (epinephrine) and norepinephrine
• Metabolism increases
• Heart rate increases
• Blood Pressure increases
• Breathing Rate increases
• Muscle Tension increases

21
General Adaptation Syndrome (GAS)

• The Response to Stress, in 3 Phases
• Alarm Reaction
• Stage of Resistance
• Stage of Exhaustion

22
Stage of Resistance

• HPA (hypothalamo-pituitary-adrenal axis Cortisol
  increases when stress becomes chronic
• Block energy storage and help mobilize energy
  from storage sites
• Increase cardiovascular tone
• Inhibit anabolic processes such as growth,
  repair, reproduction and immunity

23
General Adaptation Syndrome (GAS)

• The Response to Stress, in 3 Phases
• Alarm Reaction
• Stage of Resistance
• Stage of Exhaustion

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Adrenal Exhaustion

• Coping responses cannot sustain their response if
  stressor is sufficiently severe and prolonged
• Diseases of adaptation" may arise
• Hypertension
• Ulcers
• Heart disease
• Symptoms that disappeared during the stage of
  resistance may reappear
• Death possible

25
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)

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Maladaptive Symptoms with Acute Stress Hormones

• Cold Hands and Feet
• Palpitations
• Diarrhea or Constipation
• Decreased sleep

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Maladaptive Changes with Chronic Stress

• Worsened blood sugar control/increased insulin
  resistance
• Increased visceral fat deposition (apple-shaped
  weight gain)
• Increased inflammation
• Decreased immunity

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Documented Relationship of Illness to Chronic
Stress

• 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 325606-612 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.
• 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, 495499 (2003)

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Blaming or Taking Responsibility

• 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

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Mind-Body and Body-Mind Interactions in Chronic
Illness

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How Emotions and Stress Affect Disease Risk

• Hormonal Effects as described for cortisol
• Vasoreactive effects with adrenaline
• Sleep disruption causes multiple physiological
  effects
• (Shift work increases the risk of CHD by up to
  50. Scand J Work Environ Health. 1997
  Aug23(4)257-65)

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How the Body Affects Emotions and Stress

• Body tension is perceived as emotional by the
  brain
• Pen demonstration
• I have so much to do
• Therefore, some simple physical relaxation
  techniques can help to alleviate mental/emotional
  stress
• Abdominal Breathing

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The Relaxation Response

• Counterbalancing mechanism to the Fight-or-Flight
  Response
• Metabolism decreases
• Heart rate decreases
• Blood Pressure decreases
• Breathing Rate decreases
• Muscle Tension decreases
• May be consciously elicited
• Generally needs to be practiced

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Techniques Which Can Elicit the Relaxation
Response

• Diaphragmatic Breathing
• Meditation
• Body Scan
• Mindfulness
• Repetitive exercise

• Repetitive prayer
• Progressive muscle relaxation
• Yoga Stretching
• Imagery
• (Music)

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Common Elements of Techniques Used to Elicit the
Relaxation Response

• Focusing of attention through repetition of words
  or physical activity
• Passive disregard of everyday thoughts when they
  occur, and return to the repetition

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Benefits of the Relaxation Response

• Immediate
• Getting through procedures and short-term stress
• Long-term
• Used consistently, there are carry-over effects

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Spirit

• Meditation/Prayer/Gratitude
• Intimacy and Connection
• Forgiveness

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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
  1572213

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Just for Comparison

• 4S trial RR 0.67 after 5.4 years treatment with
  simvastatin Circulation. 1998971453-1460
•  MIRACL Trial (higher risk patients, like the
  relaxation trial) RR 0.84 in 16 weeks on
  atorvastatin 80 mg vs. placebo JAMA. 20012851711
  -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

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Religious Expression

• 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

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Spirit

• Meditation/Prayer/Gratitude
• Intimacy and Connection
• Forgiveness

42
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

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• On follow up, 35 years later, the outcomes were
  as follows
• If relationship with Mother was
• Tolerant or strained - 91 had significant health
  issue
• Close and Warm - 45 had significant health issue
• If relationship with Father was
• Tolerant or strained - 82 had significant health
  issue
• Warm and close - 50
• If relationship with both parents was
• Strained - 100 incidence of significant health
  risk
• Warm and close - 47 had a significant health
  risk

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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 gt 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.

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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

46
Social Connection Altruism

• Tecumseh Community Health Study
• 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
• Science 1988, 241540-45

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Social Connection Altruism

• Study of women with children
• Major illness developed over a 30 year period in
• 36 of women who were members of volunteer
  organizations
• 52 of women who were not members of volunteer
  organizations
• Successful Aging, American Journal of Sociology,
  1993, 971612

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Connection Heart Surgery Outcome

• U Texas study on people having heart surgery
•  
• Do you participate
• in organized social groups? Yes No Yes No
• Do you draw strength from
• your religious or spiritual faith?
  Yes Yes No No
•  
• Risk of dying 6 months later 3 9 8 22

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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

50
Pets

• Having a pet CAST trial which looked at
  flecainide and encainide
• Death rate 1.1 of people who owned dogs
  6.7 of people who did not own dogs
• 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

51
Touch - Physical Intimacy

• Humans need to touch and be touched, just as we
  need food and water
• Saul Schanberg, M.D., Ph.D.
• 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

52
Touch

• Even rabbits are more resilient to the effects of
  a high fat diet when stroked and handled
• 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

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Spirit

• Meditation/Prayer/Gratitude
• Intimacy and Connection
• Forgiveness

54
Health Benefits of Forgiveness

• U of Tenn forgivers had decreased blood
  pressure, muscle tension, and heart rates.
• U of Wisconsin positive correlation between
  forgiving and having fewer illnesses and fewer
  chronic conditions.
• 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.
• People who even think about forgiving have
  improved functioning in their cardiovascular and
  nervous systems.

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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

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Type A Intervention

• Type A intervention (followed 4 1/2 years after
  a heart attack)
• Heart attack Recurrence
• No intervention 28.2
• Information/advice 21.2
• Support group 12.9
• It turns out hostility, cynicism, suspicion are
  more important than multitasking , time urgency,
  etc)

57
Some Resources for Patients

• Center for Attitudinal Healing
• Multiple religious organizations and volunteer
  organizations
• Bibliotherapy
• 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

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Body

59
Health of the Body

• Air and Breathing
• Water and Moisture
• Exercise and Rest
• Food and Supplements

60
Tobacco

• Cigarette smoke second hand smoke exposure
  (living with a smoker) increases the risk of
  heart attack by 30 at age 65.
• Smoking 20 cigarettes per day increases the risk
  of ischemic heart disease by 80

61
Tobacco Cessation

• The subject of another talk, but I would note
  that coping skills for emotional issues are
  helpful with any addiction needing treatment
• Chantix has worked wonderfully in some of my
  patients who failed everything else

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Health of the Body

• Air and Breathing
• Water and Moisture
• Exercise and Rest
• Food and Supplements

63
Water

• Scientists are finding in ground wateralong with
  industrial pollutantsminute 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 251487-1488, 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.pdfpage50
• If you arent drinking filtered water, your body
  becomes the filter.

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Health of the Body

• Air and Breathing
• Water and Moisture
• Exercise and Rest
• Food and Supplements

65
Exercise

• Reduces the risk of dying from or developing
• 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.
• Helps control weight, build lean muscle, and
  reduce body fat.

66
Fitness in Perspective

• 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).
• Relationship Between Low Cardiorespiratory
  Fitness and Mortality in Normal-Weight,
  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. 19992821547-1553

67
But still. . .

• More than 60 of American adults do not engage in
  levels of physical activity necessary to provide
  health benefits.
• More than one-fourth are not active at all in
  their leisure time.
• Activity decreases with age and is less common
  among women than men and among those with lower
  income and less education.

68
Bottom Line for Exercise

• Physical activity need not be strenuous to
  achieve health benefits.
• 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 1520 minutes of jogging).
• Additional health benefits can be gained through
  greater amounts of physical activity.

69
Start Low, Go Slow

• Start with short intervals (510 minutes) of
  physical activity and gradually build up to the
  desired level of activity.
• Swimming, Elliptical trainers, and Ski machines
  have the least impact for those with joint, back,
  or neck pain

70
Motivation?

• Intrinsic
• Energy level improves
• Chronic pain improves
• Social support from family and friends has been
  consistently and positively related to regular
  physical activity.
• Altruism find someone else who needs to get out
  for walks and make them your project

71
Motivation and Adherence

• Solitary vs. Group vs. Buddy
• Keeping it interesting
• Conversation
• Books on tape
• Moving meditation
• Exercise equipment and television/VCR

72
Rest

• Insomnia affects 30 of people over a year
• Our lifestyle encourages sleep deprivation as a
  tool for doing too much
• . . . The subject of another talk

73
Health of the Body

• Air and Breathing
• Water and Moisture
• Exercise and Rest
• Food and Supplements

74
Modifiable, Measurable Biochemical Risk Factors

• Cholesterol, esp. LDL cholesterol
• LDL deposits in artery walls when oxidized
• Homocysteine a pro-oxidant
• CRP a marker for inflammation
• And, fibrinogen, LpA, etc. . .
• Inflammation and Oxidation are central to
  Atherogenesis, and may explain the results of
  dietary intervention trials

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Homocysteine

• Homocysteine is an amino acid for which higher
  levels are associated with
• Stroke
• Heart attack
• Dementia
• Effects of homocysteine on endothelial cells
• 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

78
Homocysteine as Predictor of Risk
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 19973372306
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Homocysteine Metabolism

• Breakdown of homocysteine requires
• B6 (Pyridoxine)
• Folic acid
• B12
• And sometimes betaine is helpful

81
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.
• Decreased rate of coronary restenosis after
  lowering of plasma homocysteine levels. Schnyder
  G - N Engl J Med - 29-NOV-2001 345(22) 1593-600

82
Homocysteine and Carotid Plaque

• 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
HCYgt14 0.21 /- 0.41 cm2/year -0.049 /- 0.24 cm2/year Plt0.001
HCY lt14 0.13 /- 0.24 cm2/year -0.024 /- 0.29 cm2/year P0.022
83
On the other hand. . . .

• 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)

84
Homocysteine and Lifestyle

• 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
• Higher fruit and vegetable intake is associated
  with lower homocysteine. Public Health Nutrition
  (2007), 10266-272

85
CRP

• 1.0 to 3.0 mg/L moderate risk of cardiovascular
  disease
• gt3.0 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

86
CRP vs. Cholesterol as a Risk Factor

• 77 of all future cardiovascular events occurred
  in women with LDL cholesterol lt160 mg/dL (lt4.1
  mmol/L) and 45 occurred in those with LDL
  cholesterol lt130 mg/dL (lt3.4 mmol/L).
• hs-CRP proved to be a stronger predictor than
  LDL cholesterol
• 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
• 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
  20023471557-65

87
CRP Lowering with Multivitamin

• 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.
• 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

88
Inflammation Benefits of Aerobic Exercise

• 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
  Jul52(7)1098-104.
• Tomaszewski M et al Arterioscler Thromb Vasc
  Biol. 2003 Sep 123(9)1640-4.

89
Lowering CRP

• Diet-induced weight loss
• Adipocytes synthesize interleukin 6, the
  principal activator of C-reactive protein
  production
• Low Glycemic Index Diet
• Insulin resistance, which is common in obese
  patients, is also associated with elevated
  C-reactive protein levels
• 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

90
Is a theme emerging?

• Rather than a pill for each risk factor, what if
  there were one general intervention that could
  lower many of them?

91
Diet Interventions after MIDART

• DART 1989 Diet and Reinfarction Trial
• 2033 men post MI Duration 2 years Randomized
• 1. Eat fatty fish 2-3 x per week
• 2. Increase cereal fiber
• 3. Decrease total fat, increase polyunsaturated
  fat
• No change in fat advice or fiber advice groups
• 29 reduction in all-cause mortality in fish group

92
Diet Interventions Post-MICardioprotective Diet
Trial

• 505 subjects with suspected AMI. Randomized,
  single-blind 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,
  0.527.68).
• Cardiac events lower in group A than group B (50
  versus 82 patients, Plt0.001)
• Lower total mortality (21 versus 38 died, Plt0.01)
  in group A than group B
• Cardioprotective Diet Trial 1992 BMJ. 1992 Apr
  18304(6833)1015-9

93
Angiographic Trials

• Lifestyle Heart
• 28 men and women duration 1 year
• Randomized Very low fat (lt10) 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

94
Diet Post-MI - Mediterranean DietLyon Diet Heart
Study

• 605 men and women post myocardial infarction
  Duration 27 mo. Also follow-up report with mean
  46 months per patient
• Randomized, single-blind dietary habits of
  controls not investigated and recorded at start
  of study
• Canola oil margarine enriched in linolenic acid
  fewer fat calories, more fiber, monounsaturated
  fatty acids less saturated fat and dietary
  cholesterol
• 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
• 76 reduction in rate of fatal and nonfatal CHD
  at end of 27 months
• Lyon Diet Heart Study Circulation 199999779-85

95
Diet Interventions after Heart AttackMediterranea
n Diet

• 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 11343(8911)1454-9

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97
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
98
Vegetarian Diet and Mortality

• 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
  22228

99
Vegetarian Diet and CAD

• Meta-analysis of 5 studies and 76,000 subjects,
  11-year OR for mortality from CAD was 24 lower
  in vegetarians than in nonvegetarians (plt.01)
• Best off were fish eaters and lacto-ovovegetarians
  
• Key TJ et al. Am J Clin Nutr 1999516S

100
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.
• 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).
• Patients receiving dietary intervention had
  better primary-outcome-free survival (85 of 101)
  than usual-care controls (61 of 101) (log-rank p
  lt0.001), with unadjusted and adjusted odds ratios
  of 0.33 (95 confidence interval 0.18 to 0.60, p
  lt0.001) and 0.28 (95 confidence interval 0.13 to
  0.63, p 0.002), respectively.
• The American Journal of Cardiology - Volume 101,
  Issue 11 (June 2008)

101
The Polymeal
Effect of ingredients of Polymeal in reducing
risk of cardiovascular disease
Ingredients Percentage reduction (95 CI) in risk of CVD 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) 12.5 (10.5 to 13.5) Jenkins et al (RCT),15 Sabate et al (RCT)16
Combined effect 76 (63 to 84)
BMJ. 2004 December 18 329(7480) 14471450.
102
Optimal Diet

• Primitive use the fuel for which the machinery
  was designed
• Emphasize Fruits Vegetables and Nuts
• Very Limited or No Meat
• Fish in moderation

103
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 200211330

104
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 5110

105
Features of the Optimal Diet

• 5-9 or more servings of Fruits and Veggies per
  Day
• High fiber
• Low Glycemic Index
• Low Fat Omega-3 fats emphasized

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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

108
5-9 Servings of Fruits and Veggies Per Day

• 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

109
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
• 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
• Significant inverse relationships were observed
  for liver, pancreas, prostate and urinary sites

110
How They Work

• A large number of potentially anticarcinogenic
  agents as well as anti-inflammatory agents are
  found in these food sources
• Carotenoids - Selenium - Dietary fiber
• Dithiolthiones - Glucosinolates - Indoles
• Isothiocyanates- Flavonoids - Phenols
• Limonene - Protease inhibitors - Plant sterols
• Allium compounds

111
Mechanisms

• Complementary and overlapping mechanisms of
  action
• Induction of detoxification enzymes
• Inhibition of nitrosamine formation
• Provision of substrate for formation of
  antineoplastic agents
• Dilution and binding of carcinogens in the
  digestive tract
• Alteration of hormone metabolism
• Antioxidant effects
• Others.

112
Why Not Just Take a Vitamin?

• 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

113
5-9 Servings of Fruits and Veggies Per Day

• 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

114
Veggies and Stroke

• In 832 healthy Framingham men, 20- year 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 2731113

115
Fruits, Veggies, and Cardiovascular Morbidity and
Mortality

• Consuming fruit and vegetables 3 times/d
  compared with lt1 time/d was associated with
• 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

116
Why More Fruits Veggies?

• Fiber
• Antioxidants

117
Fiber

• Filling
• replaces higher caloric density foods
• Maintains normal colonic flora
• Glycemic Index (more later)
• Binds things
• Enterohepatic Circulation of Cholesterol
• Toxins produced by bacterial fermentation

118
Fiber

• In 25 hyperlipidemic volunteers, LDL-C fell
• 29 (plt.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 511596

119
Oxidation a byproduct of metabolism

• Damages DNA
• Cancer genesis
• mutations that activate oncogenes
• Damages Fats and Membranes
• CAD
• LDL-C must be oxidized to deposit in arterial
  walls
• Dementia
• Damages Structural Components
• Arthritis
• Damage to joint components

120
Antioxidants

• Protect our cells from oxidation by accepting
  free radicals
• Work in groups
• Chain of acceptance of free radicals
• Implications single vitamins may be
  counterproductive
• Glutathione

C
?
?
?
E
?
?
b
?
121
Antioxidant Strategies

• 5-9 Fruits and veggies
• Supplements Made from Whole Foods
• Food For Life
• Juice Plus
• Decreases oxidation of LDL
• Decreases homocysteine
• Decreases lipid peroxides in the urine
• Decreases DNA Damage in circulating lymphocytes

122
Antioxidant Strategies

• 5-9 Fruits and veggies
• Supplements Made from Whole Foods
• Food For Life
• Juice Plus
• Decreases oxidation of LDL
• Decreases homocysteine
• Decreases lipid peroxides in the urine
• Decreases DNA Damage in circulating lymphocytes
• Herbals
• Grape seed extract, pycnogenol
• Ginkgo biloba
• Etc.

123
Features of Optimal Diet

• 5-9 Servings Fruits and Veggies per Day
• High fiber
• Low Glycemic Index
• Low Fat Omega-3 fats emphasized

124
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 (2plt.001)
• Oettle GJ et al. Am J Clin Nutr 1987 4586

125
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 42
• Orange 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

126
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 103E26

127
Bottom Line on Glycemic Index

• 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

128
Features of Optimal Diet

• 5-9 Servings Fruits and Veggies per Day
• High fiber
• Low Glycemic Index
• Low Fat Omega-3 fats emphasized

129
Functions of Fats

• Energy Storage
• Membrane components
• Precursors to prostaglandins and other
  hormones/messenger molecules
• Latter two are affected by types of fats consumed

130
Omega 3 Fats fish, walnuts, flax

• Omega 3 fats are
• Anti-inflammatory
• Anti-thrombotic
• Anti-arrhythmic

131
Fish Oil Effects on Cardiovascular Disease

• At higher doses (3-5 grams per day)
• BP-lowering effect
• Improve the lipid profile decreasing
  triglycerides and very-low-density lipoproteins
  and slightly raising the cardioprotective
  high-density lipoprotein cholesterol
• Alter prostaglandin metabolism by inhibiting the
  production of thromboxane A2 and inflammatory
  cytokines, reducing the likelihood of acute
  coronary thrombosis
• At dietary doses
• Decrease arrhythmias

132
Fish Oil and Arrhythmia

• 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 all-cause mortality.
  
• United States Physician's Health Study 20,551
  men
• One serving of fish per week resulted in 52
  decrease in sudden cardiac death

133
Omega 3 Bottom Line

• Fish oil is most certain source
• Increasing omega-3s can improve
• Memory
• Mood
• Heart disease
• Eating fish once a week cuts risk of sudden death
  from heart attack by 50
• Cancer risk
• Inflammation/Auto-immune disease

134
Supporting People in Dietary Change

• Information
• Change Theory

135
Stages of Change

• Stages of Change Big lifestyle changes like a
  change in the diet require preparation, emotional
  as well as logistical

136
Contemplation - Obstacles to Change

• Cost
• Willpower Emotional decisions about what to
  eat, when, and how much
• Digestive Problems
• Knowledge
• Knowing what to eat
• Knowing how to prepare healthy food

137
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.
• Beans and grains are low cost, however
• Black beans are 69-99 cents/lb dry(about 10
  servings)
• 0.16/serving 140 calories, 0 fat, 18g protein,
  30 g fiber
• Extra lean ground beef 2.49/lb,
• 0.62/serving (4 oz) 256 calories, 19g fat, 21
  g protein, 0 fiber

138
Obstacles to Change

• Cost
• Willpower Emotional decisions about what to
  eat, when, and how much
• Digestive Problems
• Knowledge
• Knowing what to eat
• Knowing how to prepare healthy food

139
Motivation(Contemplation and Pre-Contemplation)

• For those who will not change what they eat for
  health reasons, weight loss can be a motivator
• Eat to Live by Joel Fuhrman is a great resource
• Sense of well-being
• Ornishs 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

140
Emotional Choices About What to Eat

• There is a difference between wanting food and
  being hungry
• Mindfulness when hungry/reaching for food can be
  very illustrative
• 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

141
Obstacles to Change

• Cost
• Willpower Emotional decisions about what to
  eat, when, and how much
• Digestive Problems
• Knowledge
• Knowing what to eat
• Knowing how to prepare healthy food

142
Digestion

• 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)

143
Obstacles to Change

• Cost
• Willpower Emotional decisions about what to
  eat, when, and how much
• Digestive Problems
• Knowledge
• Knowing what to eat
• Knowing how to prepare healthy food

144
Tips to Increase Fruits Veggies

• Pre-cut vegetables and salad mixes, even fruit
• 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
• When its snack time, grab an apple or orange, or
  make a ready-to-eat bag of sweet cherries.

145
More Tips

• 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

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147
Action

• Changing behavior

148
Logistics/Planning for Good Nutrition

• It is generally easier to add good foods than
  to eliminate the bad ones we crave
• Stock easy healthy foods, do not keep junk food
  in your home
• Cook ahead
• Use appliances (cuisinart)
• Make trades

149
Some Food Preparation Ideas

• 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
• Soy sauce/sesame oil/
• Thai curry paste with low fat coconut milk
• Diced tomatoes with Italian seasoning blend or
  rosemary (no ginger)
• Soup recipes
• Steamed Greens
• Salads with low-fat dressing

150
Maintenance

• 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.

151
Hypertension JNC-7

• 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

152
Hypertension and Pre-hypertension

• People who are normotensive at age 55 have a 90
  percent lifetime risk for developing
  hypertension.
• People with a systolic blood pressure of 120139
  mmHg or a diastolic blood pressure of 8089 mmHg
  should be considered as prehypertensive and
  require health-promoting lifestyle modifications
  to prevent CVD.

153
Remember the Rules of Tacks
154
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
155
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)

156
Lifestyle Modifications to Control Hypertension
MODIFICATION RECOMMENDATION APPROXIMATE SBP REDUCTION (RANGE)
Weight reduction Maintain normal body weight 520 mmHg/10 kg weight loss
Adopt DASH eating plan Consume a diet rich in fruits, vegetables, and lowfat dairy products with a reduced content of saturated and total fat. 814 mmHg
Dietary sodium reduction Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). 28 mmHg
157
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). 49 mmHg
Moderation of alcohol Limit consumption to no more than consumption 2 drinks (1 oz or 30 mL ethanol e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter weight persons. 24 mmHg
158
Natural Medicine for Hypertension

• Hawthorn extract must include the leaf
• Magnesium especially if diabetic or treated
  with diuretics
• Meditation
• Others
• Olive leaf extract
• Linden and others

159
Meds for Lowering Cholesterol

• 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

160
Natural Substances for Lowering Cholesterol
161
Fiber

• LDL 7-10 drop in LDL with taking psyllium
  before meals Am J Clin Nutr. 2000 Feb71(2)472-9
  
• Hypertension, weight Clin Exp Hypertens. 2007
  Aug29(6)383-94.
• Glycemic control Lowered glucose and HgbA1C in
  diabetic outpatients J Ethnopharmacol. 2005 Nov
  14102(2)202-7. Epub 2005 Sep 8.
• Avoid using this with your fish oil, may
  interfere with absorption of some other meds and
  supplements

162
Niacin

• Niacin lowers triglycerides, raises HDL, lowers
  LDL, is also anti-inflammatory Med Hypotheses.
  200769(1)90
• Lowers atherosclerotic complications and total
  mortality in trials Curr Cardiol Rep. 2003
  Nov5(6)470-6.
• Do not use time-release niacin can cause liver
  damage
• Causes flushing aspirin before dose reduces
  this, and tolerance to flushing develops
• May worsen blood sugar control

163
Plant Sterols (Phytosterols)

• 2g/d provides 10 reduction in total cholesterol
  and 13 reduction in LDL cholesterol levels Am J
  Med. 1999 Dec107(6)588-94
• Eating foods low in saturated fat cholesterol
  and high in stanols or sterols can reduce LDL by
  20
• Adding sterols or stanols to statin medication is
  more effective than doubling the statin dose.
  Mayo Clin Proc. 200378965-978

164
Red Yeast Rice Extract

• Red Yeast Rice Extract similar to statins, but
  a mixture of compounds and lower potency results
  in fewer side effects. I still monitor LFTs. Can
  produce 25-30 lowering in LDL.

165
Garlic (Allium Sativum)

• 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

166
Probably not worth using

• Policosanol mixed clinical trials, and I have
  had no success with this from a reputable company
• 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

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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),