How To Have a Healthy Heart, Part I: Take "Vitamin L"
Cardiologist Joel Kahn, M.D., FACC, FSCAI serves as Clinical Professor of Medicine at the Wayne State University School of Medicine in Detroit and Director of Cardiac Wellness at Michigan Healthcare Professionals. He has co-authored more than 100 cardiology articles published in medical journals. His first book, The Whole Heart Solution: Halt Heart Disease Now with the Best Alternative and Traditional Medicine, was published by Reader’s Digest Books in September 2014 and in March 2015 he published Dead Execs Don’t Get Bonuses: The Ultimate Guide to Surviving Your Career with a Healthy Heart.
HHN: You say in The Whole Heart Solution that more than 75% of heart disease diagnoses could be prevented. That’s an outstanding figure. How do we know this is true?
JK: Predominantly from studies that were designed this way: Let’s take 20,000 people that on entry have no detectable heart disease—no chest pain, no bypass, no stents, etc. Then let’s take detailed histories of their lifestyle—do they smoke, what do they eat, do they sleep well, etc. Let’s follow them for 15−20 years, and at the end of that time period, reassess: Who’s had a stroke, a heart attack, a bypass, a stent. And let’s look at the lifestyle that predicts freedom from having a heart event.
Many of these studies have been done and reported on in the last 10 years. They’re from all over the world: from England, Sweden, the U.S. They encompass well over 100,000 people, and they all have remarkably similar findings, which are: With a simple pattern of habits that are not expensive and not exotic, you can achieve more than 75%, an even up to 85% heart-attack free, stroke-free life.
The results are pretty conclusive, and personally I think we’re likely to get even better results, higher than 85%, if we add in medical evaluations, which these studies didn’t require.
I’m very excited that lifestyle, or what I like to call Vitamin L, is the key factor in heart disease prevention.
HHN: What’s the protocol for "Vitamin L"— the healthy lifestyle habits that give up to 85% heart disease protection?
JK: Six essential lifestyle habits consistently appeared across all the studies:
- Don’t smoke. We don’t know and still debate what about smoking is so dangerous, but all the studies reinforce the now 40-year-old notion that smoking is an extremely bad habit.
- Be active. We’re talking moderately active. These studies didn’t ask how many pounds you can clean jerk or how many spinning classes you took last week. They asked, "Do you walk 30−40 minutes a day on average?"
- Control weight. The weight parameters aren’t extreme either. The general guideline is to maintain a relatively healthy weight. The most consistent finding is a prediction of freedom from heart attack for men who keep their waists under 40 inches and women who keep theirs under 35. These also predict freedom from diabetes, and, to a lesser extent, freedom from stroke and cancer.
- Consume alcohol in moderation. This finding is very controversial, but the data is the data: Almost every study showed that some consistent use of alcohol was favorable in predicting up to 85% freedom from heart attack. And it’s interesting, because different countries have different alcohol cultures, but the results indicate that one ounce of hard liquor, five ounces of wine, and eight ounces of beer are relatively equivalent in protection. Some studies showed positive results with a few drinks a month; others supported as much as daily ingestion of one drink.
- Seven hours of sleep on average. This relatively novel finding, assessed in just a few of the studies, is that if you average fewer than seven hours of sleep a night, you’re at significant increased risk of heart attack. The Morgen Study of 1,000 people, for example, found that the people who did all the lifestyle habits we’re talking about but typically slept under seven hours had about a 65% chance of being heart attack-free, compared to up to 85% for those who got seven hours. Good sleep offers a substantial amount of heart attack freedom.
- Five or more servings of vegetables and fruits a day. I saved this habit for last because it’s the one people hit the least--only 1−3% of Americans do it—but it’s the most important. Every single one of these studies said that five plus servings of vegetables and fruits a day is that "special sauce" in achieving the up to 85% number. And there’s no reason we can’t do it. It’s simple and very doable. It’s not expensive, no one specified you have to eat organic produce, although we could talk about whether or when going organic might be helpful in some instances.
That’s the program. And we should be teaching it as the "holy grail" of heart disease prevention in this country, where heart disease is the #1 killer of both men and women over 30.
HHN: This fact that all of us have considerable say in whether or not we get heart disease seems in line with the twin heart study research you discuss: If one identical twin develops heart disease, there’s only a 30% chance of the remaining twin getting it as well.
JK: Professor Tim Spector has done many series of twin studies, some with 700 twins, others with 2,000; some identical twins and some fraternal twins. Overall, we can say with certainty the risk is under 30% that if one twin has a heart attack, the other will too.
Now, certain genetic features do put twins at risk. There’s a condition called familial hypercholesterolemia or FH that affects about 1 in 450 people; and Lipoprotein (a), is also a relatively obscure risk factor. But most other cardiovascular risk factors are lifestyle choices. They’re like the joke: "Diabetes runs in my family, ‘cause no one runs in my family.""If you improve your lifestyle in just three months, you can affect 500 genes involving cancer and up to 120 genes involving cardiovascular disease."Today, an entire new field called epigenetics is exploring how lifestyle factors can turn our genes on and off. It started in 2003, after the major scientific breakthrough, the Human Genome Project, gave us a full description of the human genetic code, which contains about 23,000 genes. Looking at the code, scientists discovered that we humans have a very complex system that controls if our individual genes are dormant or active. In the last decade they’ve realized that lifestyle is extremely important—what you eat will directly speak to your genes. Elegant studies document that if you improve your lifestyle—eat lots of fruits and vegetables, exercise regularly, etc.—in just three months, you can affect 500 genes involving cancer and up to 120 genes involving cardiovascular disease, which will produce different proteins to fight these diseases.
All of this speaks to why 30% of twin studies show a genetic component of cardiovascular risk, but lifestyle is going to determine 70%.
The Ornish Evidence
HHN: The new evidence seems to support Dean Ornish’s research of 17 years ago. He was the first to report that changes in lifestyle could reverse coronary heart disease.
JK: I’ll respond with a story. In 1990 I’d concluded my cardiology schooling with a year-long angioplasty training alongside the world’s most famous angioplasty cardiologist. After my training, I got a great job in a cath lab, where I was cleaning out people’s arteries. I felt on top of the world.
And then I read in a medical journal that another cardiologist, Dr. Dean Ornish from California, was also cleaning out people’s arteries, but he was doing it by changing their diet and lifestyle! I reviewed the research and saw it was solid: it was from a prominent university, the science was good, the other authors were well-known, well-respected scientists. I was intrigued. And as his subsequent studies came out, all published in medical journals with the highest standards, I became a student of his research.
In essence, in that 1990 study, Ornish disproved the then-common notion that once you have a clogged artery, it’s always going to be clogged and will only worsen over time. The vast majority of the people who followed his lifestyle program had improvements in both their plaque and their arteries.
Here’s what he did: A few dozen patients with moderate to severe coronary heart disease were randomized into two groups. The control group received standard heart disease care. The intensive lifestyle change group was instructed to:
- eat a 10% fat whole foods vegetarian diet
- practice meditation, yoga, or something else to reduce stress--there was group stress management training
- exercise—walk every day up to an hour to address fitness
- stop smoking
- participate in a social support system. Group psychosocial support meetings encouraged fraternity and a positive attitude about making the lifestyle changes.
After five years, the 20 control group patients had 45 cardiac events, significantly more than the 25 cardiac events in the 28-member experimental group. And on average the lifestyle members' heart conditions improved over time, and the control group’s worsened over the years, despite taking standard heart medicine.
HHN: Viewing this a little differently, while Dr. Ornish’s results are impressive, still, there were 25 cardiac events in the experimental group. How do you account for this?
JK: When you look at the raw numbers, there was a range of adherence to the lifestyle program, despite the social support. As many as 90% of people were willing to participate, but when undertaking a difficult lifestyle program like this one, which basically meant giving up all animal-based products, it was hard to get complete adherence. The data showed that those who followed the program the most had better outcomes than those who wavered in their commitment.
But to your larger point: It’s true, we cannot say that Dr. Ornish’s program is 100% effective—that's an oversell. We can say that it will significantly increase your chances of a cardiac-event-free life.
HHN: There weren’t many participants in Dr. Ornish’s original study. How do we know those findings are applicable to the larger population?
JK: Afterwards, Dr. Ornish continued the same research with more heart patients. He found similar results studying 2,000+ people. Finally, in 2010, as a result of the additional research, his lifestyle program received Medicare approval, which means this program to stop and reverse serious heart disease is now being prescribed to patients and being covered by insurance."Dean Ornish’s lifestyle program to stop and reverse serious heart disease is now being prescribed to patients and being covered by insurance."This research alone would have been enough for us to say, "Dean Ornish has changed the paradigm of medicine." But he didn’t stop there. He went on to tackle prostate cancer. He asked, "If I apply my Ornish lifestyle program with low-grade prostate cancer, can I shrink the cancer?" And, studying this with some of the world’s most prestigious researchers, he showed he could—that prostate cancer is a very lifestyle-sensitive tumor.
Subsequently, about two years ago, he asked, "Can I slow down a marker of aging?" One marker of aging is the length of our telomeres, the stretches of DNA that appear on the tips of our chromosomes and enable our cells to divide. Each time a cell divides, the telomeres get shorter. When they get too short, cells no longer divide. This shortening process is associated with aging, cancer, and a higher risk of death.
Ornish did a series of elegant studies—one co-author won the Nobel Prize in medicine—and demonstrated that eating a plant-based diet, reducing stress, quitting smoking, exercising, and receiving social support can stop and even reverse the aging process, as measured by telomere length.
Now he’s embarking on studies of breast cancer.
These studies are strong evidence that the best health medicine you can find is in your pantry and in your walking shoes. They’re also confirmation of the health benefits of a vegetarian, plant-based diet. Whenever I meet someone who recommends another diet, I ask, "Has your diet been proven to reverse heart disease, reverse prostate cancer, and reverse the aging process?" The answer is, you can’t say yes for any other diet or lifestyle program.
HHN: Isn’t it also true that other diets might show comparable results, let’s say, a diet that includes healthy fish as well as 5 daily servings of fruits and vegetables, but we don’t know if that will work as effectively because it hasn’t been studied in all these ways?
JK: Yes, that’s true. The Mediterranean diet is rich in both fish and produce, and there are a lot of positive things to be said about it. For example, the 2014 Health Professionals Follow-Up Study and the Nurses' Health Study found that patients with cardiovascular disease who followed the diet had an overall lower risk of mortality from all causes. My sense is what’s good about it is the concentration of minerals, fiber, and phytonutrients you get from eating a variety of fruits and vegetables.
There are also many versions of the Mediterranean diet: nuts or no nuts, more or less olive oil, etc. Some data—it's controversial, but I believe it—shows the olive oil component may actually be detrimental to people with serious heart disease.
HHN: Are there scientific studies showing that olive oil is not good for the heart?
JK: Yes, there are, but like much of medical science nowadays, you can stack 5 or 6 studies showing it’s bad for the heart against the same number of studies coming to the opposite conclusion.
Personally, I support the study, published in a good journal, which was conducted by a professor of medicine I worked with many years ago. He measured the response of arteries before and after meals rich in olive oil, without confounding factors, and found that arterial health and function deteriorated after oil consumption.
Now I’m not saying this finding is applicable to the whole world, but for those patients who seek to halt or reverse serious cardiovascular disease, I believe eliminating added oils is supported by the literature.
Pare Down Blood Pressure with Produce
HHN: Let’s talk about foods that you believe serve as a kind of heart medicine, such as those that help people reduce their blood pressure naturally. First, why is reducing blood pressure so important in heart disease prevention?
JK: The Framingham Heart Study, in which thousands of people outside of Boston were followed for 60+ years, showed that persistently elevated blood pressure is a very powerful predictor of stroke and heart attack.
Why? The repeated pounding of high blood pressure on the arteries appears to cause mechanical damage, directly injuring the artery lining.
HHN: You’ve written that the nitrates in certain vegetables are chemically similar to those found in blood pressure drugs—and one study found that the patients who consumed nitrate-rich beetroot juice had a drop in blood pressure that "rivals the best results of powerful and widely prescribed blood pressure drugs." Which drugs are you referring to, and how do the results compare?
JK: From juicing beets, basically ingesting a nutritional source of nitric oxide, the same 10 — 12-mmHg drop in blood pressure was seen as we could expect from an average dose of any of the blood pressure drugs—a beta blocker, a calcium blocker, an ACE inhibitor. This study, published in 2013 in a good medical journal, showed that blood pressure dropped within a few hours and lasted the whole day.
HHN: How do we know that the blood-pressure reduction was because of the nitrates and not another not-yet-recognized component of beetroot juice?
JK: Some new evidence points to nitrates in particular. Researchers have found a way to remove dietary nitrate from beetroot juice, and in a recently published study in the same good cardiology journal, subjects who drank the beetroot juice with nitrates lowered their blood pressure and those who drank the nitrate-free version did not. The study continued for a number of weeks, and the greatest blood pressure drop occurred in the last week.
Now, although the theory here is that beets enhance nitric oxide, beets themselves may support blood pressure control or other aspects of heart disease prevention. That’s the beauty and the amazing thing about food: It’s complex. It has hundreds of thousands of chemicals. Beets are very rich in a chemical called betaine, which helps a process called methylation, which has a major effect on our genes. Betaine may turn out to be a factor, and we just haven’t studied it yet.
HHN: Would you recommend that readers who have high blood pressure consider adding beetroot juice to their diets?
JK: If people are looking for better blood pressure control without additional medication, for better artery health—which, I would say, verges over to men’s better sexual health—I would heartedly endorse beets or beetroot juice, the entire beet plus root, in a smoothie as a regular part of their diet.
HHN: Heartedly… that's a good endorsement from a cardiologist. Have other nitrate-rich foods been found to reduce blood pressure?
JK: There are others. Watermelon is very high in what’s called citrine, which helps lower arginine, which lowers blood pressure. Actually, yellow watermelon does it better than red watermelon. Pine nuts have a lot of nitric-oxide-donating effects too.
Many leafy greens are also high in nitrates. Here are some with the highest nitrate concentrations which have been found to reduce blood pressure in healthy women: arugula (352mg), chard (236mg), spinach (189mg), lettuce (187mg).
Add these into your mix of five fruits and vegetables a day, stir in the rest of "Vitamin L," and, odds are, you’ll be up to 85% heart disease free."The standard U.S. physical is not going to tell you everything you need to know about your heart health."And, to even better these chances, don’t delay: Find out the true state of your heart right now. The standard U.S. physical is not going to tell you everything you need to know, and what most people have learned about LDL and HDL cholesterol is too simplistic to accurately assess their heart health.
Read Part II to learn what you need to know and do.by