Dietary considerations: There is more to the dietary approach to atherosclerosis than eliminating fat from the diet. Fat restriction is important, but there are other dietary strategies that can be used to help lower cholesterol. As well, there are a variety of vitamins, nutrients, and micronutrients that can lower the risk of heart disease when consumed as part of a fat-restricted diet. We have placed our dietary recommendations under Complementary and Alternative approaches to treatment not because they are not considered mainstream, but because the level of detail we provide is not the level of detail provided by most mainstream practitioners. Dietary changes such as we describe should certainly be considered a critical, and mainstream, part of your approach to cardiac risk reduction, and should be implemented along with either the Step I or Step II Diet.
HIGH FIBER DIET:
A diet high in fiber has been shown to be very beneficial in lowering total serum cholesterol. The goal for fiber intake is 35 grams per day. See the section on dietary fiber in our handout entitled Health and Wellness Through Nutrition for a list of food items and their fiber content.
PHYTOCHEMICALS AND MICRONUTRIENTS:
There are a number of substances contained in plants, which are called phytochemicals, and substances in some fish, that have been shown to lower cholesterol, in some cases blood pressure, and can lower the risk of developing atherosclerosis. The American Heart Association endorses dietary strategies that promote increased consumption of the plants and fish containing these substances. Those substances include the following:
OMEGA-3 FATTY ACIDS: Omega-3 fatty acids are substances found in cold water fish to include: ocean-raised salmon, mackerel, herring, halibut, and albacore tuna. Omega-3 fatty acids have not been shown to lower cholesterol or to reduce the risk of developing heart disease, but they have been shown to lower blood pressure. To achieve the beneficial effects of Omega-3 fatty acids, one needs only to consume 2 servings of fish per week. There are beneficial effects other than lowering blood pressure which may lead us to recommend a fish oil supplement (which contains Omega-3 fatty acids). And, if your diet does not include 2 servings per week of cold water fish, supplementation should be considered.
STEROLS: A small number of plants contain chemicals known as sterols, which have been shown to lower serum cholesterol by 7-10 percent. A reduction in cholesterol of 1% reduces the risk of heart disease by 2%. The products that contain these sterols include: monounsaturated and polyunsaturated vegetable oils such as olive oil, and a little-used oil known as rice bran oil.
FLAVONOIDS: Flavonoids are chemicals that are known to have antioxidant properties. As such, they have an important impact on our health by effecting a number of organ systems and conditions. With regard to heart disease, flavonoids have been shown to be protective against heart disease without question by protecting the arterial lining from free-radical damage. Flavonoids also inhibit platelet aggregation and oxidation of LDL, both of which are involved in the development of an atherosclerotic plaque. Flavonoids are found in tea, particularly green tea, and in soy, onions, and wine.
SULFUR-CONTAINING COMPOUNDS: This group includes garlic, onions and leeks, which are included in what is known as the Allium family of plants. They have been shown to lower cholesterol by approximately 9 percent, which translates into a reduction of heart disease risk of 18 percent. Garlic is also known to lower blood pressure.
The amount of garlic required to produce this 9 percent reduction is 4000 mg per day, or approximately 1-4 cloves of garlic per day.
ANTIOXIDANTS: There is no question regarding the research involving heart disease and the consumption of antioxidant-containing foods. Such foods significantly lower the risk of heart disease by protecting the arterial lining from damage by free radicals. We strongly encourage you to focus on dietary consumption of antioxidant-containing foods, which include:
-Green leafy vegetables
-Yellow and Orange vegetables and fruits such as carrots, mangoes, squash, apricots, and yams.
-Legumes (peanuts, beans), grains, and seeds.
The FDA has recently endorsed the idea of calling certain foods Functional Foods. Functional Foods are those foods that contain ingredients in amounts that have been shown to lower the risk of developing certain conditions, most commonly heart disease and cancer. In addition to containing ingredients thought to be beneficial, in order to be approved as a Functional Food, they must not contain ingredients in amounts thought to be harmful, such as excess sodium or fat, for example. Once a food is granted status as a functional food, the producer of that food is allowed to sell and advertise that food item with the claim of its’ beneficial effect, and you will see advertising and product labeling with these claims.
Those foods which have been shown to reduce the risk of heart disease, in addition to the above, and which have been approved as functional foods include oat bran and oatmeal.
REFINED SUGARS AND SIMPLE CARBOHYDRATES:
Consumption of refined sugars and simple carbohydrates have been associated with an increased risk of developing atherosclerosis by contributing to increased insulin levels. Our advice is to limit your consumption of refined sugars and simple carbohydrates. See our handout on Health and Wellness Through Nutrition for a listing of items considered as refined sugars or simple carbohydrates
THE IMPORTANCE OF BREAKFAST:
A study known as the National Health and Nutrition Examination Survey II found that the group of people with the lowest cholesterol was the group that ate whole grain cereal for breakfast. The group with the highest cholesterol was found to be the group that skipped breakfast entirely. We suggest you consider implementing this simple dietary change as a way of lowering your cholesterol and reducing your risk of atherosclerosis.
DIETARY SUPPLEMENTS AND ATHEROSCLEROSIS
Before we give you advice on dietary supplements in the prevention of atherosclerosis, we want you to know the following information. The American Heart Association has taken the position that there is insufficient scientific evidence to recommend routinely taking dietary supplements for the prevention of atherosclerosis. Their advice is to obtain adequate amounts of vitamins and nutrients from foods eaten in variety and moderation.
While we support this advice regarding obtaining adequate nutrients from your diet, we would like to explain how it is they came to their position on supplements, and to expand on it.
The first thing you should consider in making your decision to take dietary supplements is whether or not you, personally, can achieve sufficient amounts of these nutrients from dietary sources. That is, whether or not a diet such as this is realistic for you.
Regarding the AHA’s position on dietary supplements, they arrived at it by looking at the scientific evidence that is available. There is overwhelming and convincing evidence that providing certain nutrients from dietary sources is associated with a reduction in the risk of atherosclerosis. There is also evidence from what are called observational studies that those who take certain dietary supplements, such as antioxidants, for example, have lower rates of cardiovascular disease. The concern they have about these observational studies is that observational studies look at groups of people who do or do not take certain things and then analyze the groups for differences in disease rates. What is lacking here is the control over other variables in these groups. The AHA says, for example, that people who take supplements may have lower rates of heart disease not because of the supplements but because they may be generally healthier, that is, more active, less overweight, etc. The type of study the AHA and the general medical community accepts as the gold standard is the prospective, case-controlled study. This type of study, in essence, matches people who are otherwise alike, that is, in this case, patients of similar weight, similar levels of physical activity, etc, and then compares the group who took a supplement to those who did not. The AHA’s position on supplements stems from the fact that studies of this type have not been done.
The AHA also mentions the concern that it may not be the nutrients themselves that lower the rate of cardiovascular disease, but a combination of or interaction of other plant ingredients that are responsible. However, there are literally hundreds of scientific studies that measure blood levels of things like vitamin C, folic acid, and B12, among others, that show a statistically significant reduction in heart disease at higher levels of these nutrients.
Our advice regarding your decision to take dietary supplements is to make your decision based on your cardiovascular risk, your level of concern about cardiovascular disease, and your feeling about the adequacy of your diet to provide the desired nutrients. We believe that the direction the research is going in this area will eventually lead to the kinds of studies that will win over even the American Heart Association to endorse the use of dietary supplements for the prevention of heart disease. This is, we emphasize, just our opinion. However, if this research does pan out, you will then find yourself saying one of two things. The first would be I’m sure glad I’ve been taking those supplements. The second would be I sure wish I had been taking those supplements.
Having said that, we will now outline for you those supplements that have been studied in the prevention of atherosclerosis, and have been found to be helpful.
You may also see niacin referred to as INOSITOL, as the form of niacin that is tolerated the best is Inositol Hexaniacinate. The scientific evidence is clear. Niacin is effective in lowering total cholesterol, LDL cholesterol, Lp(a) (lipoprotein a), triglycerides, and fibrinogen. It also raises HDL. In short, it has a positive effect on all of the lipids involved in the formation of an atherosclerotic plaque.
Studies have been done comparing niacin to the newer cholesterol lowering drugs, such as the statins, as well as to the bile-sequestering agents, such as cholestyramine, and to clofibrate and gemfibrizol. In short, niacin favorably effects blood lipids as well as or better than the more expensive and more commonly prescribed drugs. As well, the effects of niacin appear to last for years even after therapy with niacin is discontinued.
A very important finding appeared in what is known as the Coronary Drug Project, a widely respected and often quoted study on the treatment of atherosclerosis. They found that niacin was the only lipid lowering agent to show a reduction in overall mortality, that is, the mortality rate from all causes combined, not just from heart disease. The explanation appeared to be that patients taking cholestyramine and clofibrate in this study had an increased risk of dying prematurely from cancer, gall bladder disease, and other conditions.
It is for these reasons that many people believe Niacin should be the cholesterol-lowering agent of first choice. It can be combined with other cholesterol-lowering drugs, and the AHA has guidelines including the use of niacin in selected patients. The main drawback of niacin is its’ side-effects, most prominent of which is facial flushing. Other side effects include stomach irritation and nausea. These problems can be minimized by using the form of niacin known as inositol hexaniacinate, by using a gradual increase in dosage, and by taking it with meals. The dosing schedule is to start at a dose of 500 mg of inositol hexaniacinate three times a day for 2 weeks, then increasing to 1000 mg three times a day.
Pantethine is involved in the metabolism of fat into energy. It has been shown to lower total cholesterol, LDL, and triglycerides, and to raise HDL. There appears to be no known toxicity or side effects from pantethine. The dose is 300 mg three times a day.
The subject of antioxidants in the treatment and prevention of atherosclerosis could be an entire handout by itself. We want to remind you of the AHA’s position on antioxidant supplementation as discussed above. We also want to emphasize that dietary sources of antioxidants are best, and no supplement can replace a diet of nutritious foods eaten in variety and moderation. Rather than detail for you the numerous studies outlining the effectiveness of antioxidant supplementation, we would be happy to provide you a list of reference that we and much of the scientific community believe support the use of antioxidants in the prevention of atherosclerosis.
The basic function of antioxidants is to prevent damage to tissues from free radicals. Free radicals are chemical substances that are normally produced by the body in the utilization of oxygen for the production of metabolic energy. If there is not a sufficient supply of antioxidants, free radicals are left unchecked and are felt to be involved in a number of disease processes including atherosclerosis.
When taking antioxidants as nutritional supplements, it is important to take a combination of antioxidants rather than a single antioxidant. The carotenoids, for example, have been shown to actually increase the risk of certain cancers when taken alone without other antioxidants. At a minimum, we believe your choice of antioxidants should contain the following:
You will find some products referred to as a Heart Support Formula, or ones that promote Cardiac Health. These are generally combination of antioxidants such as those listed above combined with other nutritional supplements shown to have beneficial effects on the heart. Those other supplements would include:
– MAGNESIUM: Magnesium has been shown to be especially beneficial for those patients with established Coronary Artery Disease, where the goal would be secondary prevention. Magnesium is known to inhibit the aggregation of platelets, known to be involved in the formation of an atherosclerotic plaque. It also influences coronary vascular tone and reactivity, that is, the regulation of how open or closed the coronary arteries become. The dose of magnesium that can be safely taken is 400-800 mg per day.
-B VITAMINS: The role of B Vitamins in the prevention of atherosclerosis is in the reduction of elevated levels of homocysteine, which is now accepted as an independent risk factor for heart disease. The B Vitamins, especially folic acid, are required for the metabolism of homocysteine, so that a deficiency of folic acid results in elevated levels of homocysteine. Because supplementation with folic acid can mask a deficiency of B12, it is recommended that folic acid be given along with B12. The dose for folic acid supplemenetation is 400 micrograms (mcg) per day, and should be part of a B-Complex supplement,
There are two other groups of substances that should be given strong consideration for supplementation; that would be the Flavonoids and the Essential Fatty Acids. These two groups are discussed above under dietary recommendations. We emphasize again that focusing on dietary sources of these nutrients is best. However, if supplements are considered, the following sources are available:
–ESSENTIAL FATTY ACIDS: Available sources include fish oil, flaxseed oil, and evening primrose oil. It is our opinion that the preferred source is fish oil.
–FLAVONOIDS: Available sources include grape seed extracts, pine bark extracts, green tea, and Ginkgo biloba extract. There are over 500 naturally occurring flavonoids, but some of the more common flavonoids you will see listed in supplements include: quercetin, hesperidin, and rutin.
In addition to the above, we believe everyone should take a high-potency multivitamin and mineral supplement.