How Not to Die from Heart Disease
Imagine if terrorists created a bioagent that spread mercilessly, claiming the lives of nearly four hundred thousand Americans every year. That is the equivalent of one person every eighty-three seconds, every hour, around the clock, year after year. The pandemic would be front-page news all day, every day. We'd marshal the army and march our finest medical minds into a room to figure out a cure for this bioterror plague. In short, we'd stop at nothing until the terrorists were stopped.
Fortunately, we're not actually losing hundreds of thousands of people each year to a preventable threat ... are we?
Actually, we are. This particular biological weapon may not be a germ released by terrorists, but it kills more Americans annually than have all our past wars combined. It can be stopped not in a laboratory but right in our grocery stores, kitchens, and dining rooms. As far as weapons go, we don't need vaccines or antibiotics. A simple fork will do.
So what's going on here? If this epidemic is present on such a massive scale, yet so preventable, why aren't we doing more about it?
The killer I'm talking about is coronary heart disease, and it's affecting nearly everyone raised on the standard American diet.
Our Top Killer
America's number-one killer is a different kind of terrorist: fatty deposits in the walls of your arteries called atherosclerotic plaque. For most Americans raised on a conventional diet, plaque accumulates inside the coronary arteries — the blood vessels that crown the heart (hence "coronary") and supply it with oxygen-rich blood. This buildup of plaque, known as atherosclerosis, from the Greek words athere (gruel) and sklerosis (hardening), is the hardening of the arteries by pockets of cholesterol-rich gunk that builds up within the inner linings of the blood vessels. This process occurs over decades, slowly bulging into the space inside the arteries, narrowing the path for blood to flow. The restriction of blood circulation to the heart muscle can lead to chest pain and pressure, known as angina, when people try to exert themselves. If the plaque ruptures, a blood clot can form within the artery. This sudden blockage of blood flow can cause a heart attack, damaging or even killing part of the heart.
When you think about heart disease, you may think of friends or loved ones who suffered for years with chest pain and shortness of breath before they finally succumbed. However, for the majority of Americans who die suddenly from heart disease, the very first symptom may be their last. It's called "sudden cardiac death." This is when death occurs within an hour of symptom onset. In other words, you may not even realize you're at risk until it's too late. You could be feeling perfectly fine one moment, and then an hour later, you're gone forever. That's why it's critical to prevent heart disease in the first place, before you even necessarily know you have it.
My patients often asked me, "Isn't heart disease just a consequence of getting old?" I can see why this is a common misconception. After all, your heart pumps literally billions of times during the average life span. Does your ticker just conk out after a while? No.
A large body of evidence shows there were once enormous swaths of the world where the epidemic of coronary heart disease simply didn't exist. For instance, in the famous China-Cornell-Oxford Project (known as the China Study), researchers investigated the eating habits and incidence of chronic disease among hundreds of thousands of rural Chinese. In Guizhou province, for example, a region comprising half a million people, over the course of three years, not a single death could be attributed to coronary artery disease among men under sixty-five.
During the 1930s and 1940s, Western-trained doctors working throughout an extensive network of missionary hospitals in sub-Saharan Africa noticed that many of the chronic diseases laying waste to populations in the so-called developed world were largely absent across most of the continent. In Uganda, a country of millions in eastern Africa, coronary heart disease was described as "almost non-existent."
But were the people of these nations simply dying early of other diseases, never living long enough to come down with heart disease? No. The doctors compared autopsies of Ugandans to autopsies of Americans who had died at the same age. The researchers found that out of 632 people autopsied in Saint Louis, Missouri, there had been 136 heart attacks. But in 632 age-matched Ugandans? A single heart attack. The Ugandans experienced more than one hundred times fewer heart attacks than the Americans. The doctors were so blown away that they examined another 800 deaths in Uganda. Out of more than 1,400 Ugandans autopsied, researchers found just one body with a small, healed lesion of the heart, meaning the attack wasn't even fatal. Then and now, in the industrialized world, heart disease is a leading killer. In central Africa, heart disease was so rare it killed fewer than one in a thousand.
Immigration studies show that this resistance to heart disease is not just something in the Africans' genes. When people move from low-risk to high-risk areas, their disease rates skyrocket as they adopt the diet and lifestyle habits of their new homes. The extraordinarily low rates of heart disease in rural China and Africa have been attributed to the extraordinarily low cholesterol levels among these populations. Though Chinese and African diets are very different, they share commonalities: They are both centered on plant-derived foods, such as grains and vegetables. By eating so much fiber and so little animal fat, their total cholesterol levels averaged under 150 mg/dL, similar to people who eat contemporary plant-based diets.
So what does all of this mean? It means heart disease may be a choice.
If you looked at the teeth of people who lived more than ten thousand years before the invention of the toothbrush, you'd notice they had almost no cavities. They never flossed a day in their lives, yet no cavities. That's because candy bars hadn't been invented yet. The reason people get cavities now is that the pleasure they derive from sugary treats may outweigh the cost and discomfort of the dentist's chair. I certainly enjoy the occasional indulgence — I've got a good dental plan! But what if instead of the dental plaque on our teeth, we're talking about the atherosclerotic plaque building up in our arteries? We're not just talking about scraping tartar anymore. We're talking about life and death.
Heart disease is the number-one reason we and most of our loved ones will die. Of course, it's up to each of us to make our own decisions as to what to eat and how to live, but shouldn't we try to make these choices consciously by educating ourselves about the predictable consequences of our actions? Just as we could avoid sugary foods that rot our teeth, we can avoid the trans fat, saturated fat, and cholesterol-laden foods that clog up our arteries.
Let's take a look at the progression of coronary heart disease throughout life and learn how simple dietary choices at any stage may prevent, stop, and even reverse heart disease before it's too late.
Heart Disease Starts in Childhood
In 1953, a study published in the Journal of the American Medical Association radically changed our understanding of the development of heart disease. Researchers conducted a series of three hundred autopsies on American casualties of the Korean War, with an average age of around twenty-two. Shockingly, 77 percent of soldiers already had visible evidence of coronary atherosclerosis. Some even had arteries that were blocked off 90 percent or more. The study "dramatically showed that atherosclerotic changes appear in the coronary arteries years and decades before the age at which coronary heart disease (CHD) becomes a clinically recognized problem."
Later studies of accidental death victims between the ages of three and twenty-six found that fatty streaks — the first stage of atherosclerosis — were found in nearly all American children by age ten. By the time we reach our twenties and thirties, these fatty streaks can turn into full-blown plaques like those seen in the young American GIs of the Korean War. And by the time we're forty or fifty, they can start killing us off.
If there's anyone reading this over the age of ten, the question isn't whether or not you want to eat healthier to prevent heart disease but whether or not you want to reverse the heart disease you very likely already have.
Just how early do these fatty streaks start to appear? Atherosclerosis may start even before birth. Italian researchers looked inside arteries taken from miscarriages and premature newborns who died shortly after birth. It turns out that the arteries of fetuses whose mothers had high LDL cholesterol levels were more likely to contain arterial lesions. This finding suggests that atherosclerosis may not just start as a nutritional disease of childhood but one during pregnancy.
It's become commonplace for pregnant women to avoid smoking and drinking alcohol. It's also never too early to start eating healthier for the next generation.
According to William C. Roberts, the editor in chief of the American Journal of Cardiology, the only critical risk factor for atherosclerotic plaque buildup is cholesterol, specifically elevated LDL cholesterol in your blood. Indeed, LDL is called "bad" cholesterol, because it's the vehicle by which cholesterol is deposited into your arteries. Autopsies of thousands of young accident victims have shown that the level of cholesterol in the blood was closely correlated with the amount of atherosclerosis in their arteries. To drastically reduce LDL cholesterol levels, you need to drastically reduce your intake of three things: trans fat, which comes from processed foods and naturally from meat and dairy; saturated fat, found mainly in animal products and junk foods; and to a lesser extent dietary cholesterol, found exclusively in animal-derived foods, especially eggs.
Notice a pattern here? The three boosters of bad cholesterol — the number-one risk factor for our number-one killer — all stem from eating animal products and processed junk. This likely explains why populations living on traditional diets revolving around whole plant foods have largely remained free from the epidemic of heart disease.
It's the Cholesterol, Stupid!
Dr. Roberts hasn't only been editor in chief of the American Journal of Cardiology for more than thirty years; he's the executive director of the Baylor Heart and Vascular Institute and has authored more than a thousand scientific publications and written more than a dozen textbooks on cardiology. He knows his stuff.
In his editorial "It's the Cholesterol, Stupid!," Dr. Roberts argued (as noted earlier) that there is only one true risk factor for coronary heart disease: cholesterol. You could be an obese, diabetic, smoking couch potato and still not develop atherosclerosis, he argues, as long as the cholesterol level in your blood is low enough.
The optimal LDL cholesterol level is probably 50 or 70 mg/dL, and apparently, the lower, the better. That's where you start out at birth, that's the level seen in populations largely free of heart disease, and that's the level at which the progression of atherosclerosis appears to stop in cholesterol-lowering trials. An LDL around 70 mg/dL corresponds to a total cholesterol reading of about 150, the level below which no deaths from coronary heart disease were reported in the famous Framingham Heart Study, a generations-long project to identify risk factors for heart disease. The population target should therefore be a total cholesterol level under 150 mg/dL. "If such a goal was created," Dr. Roberts wrote, "the great scourge of the Western world would be essentially eliminated."
The average cholesterol for people living in the United States is much higher than 150 mg/dL; it hovers around 200 mg/dL. If your blood test results came back with a total cholesterol of 200 mg/dL, your physician might reassure you that your cholesterol is normal. But in a society where it's normal to die of heart disease, having a "normal" cholesterol level is probably not a good thing.
To become virtually heart-attack proof, you need to get your LDL cholesterol at least under 70 mg/dL. Dr. Roberts noted that there are only two ways to achieve this for our population: to put more than a hundred million Americans on a lifetime of medications or to recommend they all eat a diet centered around whole plant foods.
So: drugs or diet. All health plans cover cholesterol-lowering statin drugs, so why change your diet if you can simply pop a pill every day for the rest of your life? Unfortunately, as we'll see in chapter 15, these drugs don't work nearly as well as people think, and they may cause undesirable side effects to boot.
Want Fries with That Lipitor?
The cholesterol-lowering statin drug Lipitor has become the best-selling drug of all time, generating more than $140 billion in global sales. This class of drugs garnered so much enthusiasm in the medical community that some U.S. health authorities reportedly advocated they be added to the public water supply like fluoride is. One cardiology journal even offered the tongue-in-cheek suggestion for fast-food restaurants to offer "McStatin" condiments along with ketchup packets to help neutralize the effects of unhealthy dietary choices.
For those at high risk for heart disease who are unwilling or unable to bring down their cholesterol levels naturally with dietary changes, the benefits of statins generally outweigh the risks. These drugs do have side effects, though, such as the potential for liver or muscle damage. The reason some doctors routinely order regular blood tests for patients on these drugs is to monitor for liver toxicity. We can also test the blood for the presence of muscle breakdown products, but biopsies reveal that people on statins can show evidence of muscle damage even if their blood work is normal and they exhibit no symptoms of muscle soreness or weakness. The decline in muscular strength and performance sometimes associated with these drugs may not be such a big deal for younger individuals, but they can place our seniors at increased risk for falls and injury.
More recently, other concerns have been raised. In 2012, the U.S. Food and Drug Administration announced newly mandated safety labeling on statin drugs to warn doctors and patients about their potential for brain-related side effects, such as memory loss and confusion. Statin drugs also appeared to increase the risk of developing diabetes. In 2013, a study of several thousand breast cancer patients reported that long-term use of statins may as much as double a woman's risk of invasive breast cancer. The primary killer of women is heart disease, not cancer, so the benefits of statins may still outweigh the risks, but why accept any risk at all if you can lower your cholesterol naturally?
Plant-based diets have been shown to lower cholesterol just as effectively as first-line statin drugs, but without the risks. In fact, the "side effects" of healthy eating tend to be good — less cancer and diabetes risk and protection of the liver and brain, as we'll explore throughout the rest of this book.