Statistics show that heart disease is one of the leading causes of death, across the globe. In India many more people are developing severe Coronary Artery Disease (CAD) at an earlier age than ever before. This increase in incidence has been attributed to changes in lifestyle, smoking and the stresses of modern life interacting with a genetic vulnerability.
Studies from UK, US and Indonesia indicate that people of Indian origin are developing heart disease at a rate higher than the locals. In UK and USA we have a 40-50% higher rate of heart disease than the local population. In the age group under 40 the incidence of heart disease is 4-6 times higher. This increased incidence is especially marked in the middle classes and has been attributed to a genetic vulnerability that manifests when the person has rich diet and higher levels of stress.
Research also shows that adopting a western lifestyle is one of the major causes for the increased incidence of heart disease among Asian peoples. The Japanese, for example, have one of the lowest rates of heart disease in the world. Once they migrate to the West and adopt an American lifestyle their rates of heart disease increase 5 times, to reach American rates. The Japanese who move to America and maintain their Japanese lifestyle experience no such ill effects.
In this section we will look at some of the risk factors that contribute to the development of heart disease. Many of these can be modified to either prevent heart disease or at least reduce the risk of progression and in some cases reverse the changes in the arteries.
We will mainly focus on the physical risk factors that can be modified. In the next chapter we will examine the psychological and behavioural factors that many maintain are as if not more important in the development of heart disease. It is crucially important that you understand the role of these risk factors well, so that you can take preventive action by modifying them.
If you have heart disease, it is likely that you have some or all of these risk factors. Remember that these factors have a multiplier effect on each other. The more risk factors you have, the greater the rate of progression of your disease.
If you have, for example, three risk factors the risk is not increased threefold (3+3+3=9) it is more like (3×3×3=27). You must also remember that it is these risk factors that are responsible for a recurrent heart attack or the arteries closing up again after bypass surgery.
One of the most important studies to determine risk factors in the development of coronary artery disease was the Framingham study in America. This study began in 1940s and 5000 residents of a small town in Massachusetts were examined regularly over 40 years to discover the factors responsible for the development of heart disease. This has been confirmed in numerous other subsequent studies.
The Framingham study showed that cholesterol, smoking, high blood pressure, obesity and a sedentary lifestyle were the main risk factors. Many other subsequent studies in a number of countries have confirmed this. Several other risk factors have since been identified but those mentioned here are the major ones that need to be modified.
Despite all the protestations of the merchants of death who run the cigarette industry, there is no doubt that cigarette smoking is a major preventable cause of premature death and heart disease today. For years the tobacco industry has used all types of methods to hide this information from consumers. Worse they continue to use unethical marketing methods to induce the youth, especially girls, to start smoking particularly in third world countries.
The larger the number of cigarettes smoked, the greater the risk of developing coronary artery disease. Smokers are 3-9 times more likely than non-smokers to develop heart disease. People who smoke have a greater risk of developing stroke, cancer, asthma and clotting disorders of the blood. Even the family member and children of smokers have a greater risk of developing these diseases due to the second hand smoke they are exposed to.
Cigarette smoke contains cancer causing tar and high levels of carbon monoxide. The carbon monoxide binds to the haemoglobin in the blood replacing oxygen, and this reduces the oxygen carrying capacity of the blood. In addition cigarette smoke contains powerful free radicals that damage the walls of the artery and hasten the deposition of cholesterol in the walls.
The nicotine in cigarettes is a powerful and addictive stimulant. When inhaled it leads to an outpouring of the fight and flight catecholamine hormones and a rapid rise in blood pressure. These hormones often trigger arrhythmias (irregular heart-beats) which in some cases can be fatal. A cigarette smoker has a 5 times higher risk of a second heart attack than a non-smoker.
It is very important to remember that even if you continue smoking a cigarette a day your risk levels remain elevated. Hence if you smoke it is vital that you stop smoking completely. For someone with a heart problem smoking is like committing suicide slowly.
The chapter on smoking will provide you with effective techniques to stop smoking. Remember that if you continue to smoke after developing heart disease it is like holding a loaded gun to your head.
High blood pressure or hypertension is a common problem today. The increasing stress of modern life has lead to large numbers of people developing hypertension. A genetic predisposition, obesity and a high salt intake are risk factors for hypertension.
Blood is pumped into the arteries by the heart under pressure. This pressure is determined by the force with which the blood is pumped with and the resistance offered by the arterial system. The resistance is determined by the bore of the blood vessels. The smaller the bore, the higher the resistance and the more force required to propel the blood through it.
The smooth muscle in the arterial wall is under the control of the sympathetic nervous system. In response to stress the sympathetic system is stimulated and the catecholamine hormones noradrenaline and adrenaline are released. This causes the blood vessel to contract which leads to an increase in the blood pressure.
Normal blood pressure is about 120 by 80 mm of mercury. The first figure is the systolic blood pressure, the level the pressure rises to when the heart pumps blood into the arteries. The second figure is the diastolic blood pressure or the blood pressure in the arteries when the heart is refilling with blood from the venous system.
Raised blood pressure is one of the major causes of the thickening of the arterial wall due to atherosclerosis. Both systolic and diastolic hypertension are an important cause of atherosclerosis, though a raised diastolic level is of greater significance.
Blood pressure above 140/90 mm of mercury (Hg) is considered to be high and requires medical treatment. However recent studies (2003) indicate that it is wise to begin intervening naturally as blood pressure levels rise above 120/80. Remember the higher your blood pressure the faster the progression of the disease and the greater the damage to your arteries. Since high blood pressure by itself rarely causes any symptoms, do not be under the mistaken impression that if you do not have any symptoms, your blood pressure is normal.
Keeping a regular check on your blood pressure is necessary. This can be done frequently at home if you have hypertension. Your doctor can teach you how to take your own blood pressure at home.
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Raman’s case is typical. He went to see his doctor because he was feeling stressed and could not sleep properly. His doctor found that his blood pressure was slightly high at 150/90 mm of mercury (Hg) and as a first step recommended that Raman cut down his intake of salt, take things easy and get his blood pressure checked every few days. Within a week Raman’s blood pressure had returned to normal without medication.
Raman will now have to have his blood pressure checked frequently. Had Raman’s blood pressure been any higher, he might immediately have been prescribed medication. Unless your blood pressure is very high, your doctor will probably give you advice similar to that given to Raman.
In about 10% of cases hypertension is caused by a hormonal or kidney disorder. In the remaining majority (90%), no physical cause is detected and this type is called Essential Hypertension. Many doctors believe that personality and stress are the two most important factors in the development of Essential Hypertension. In fact the Type A personality (described later), is one of the personality types that has a greater risk of developing high blood pressure and heart diseases.
There is little doubt that controlling your blood pressure will reduce chances of further progression of your heart disease. Therefore do not neglect to have your blood pressure checked regularly.
Try reducing your intake of salt as a first step. About 30% of people are salt sensitive and a low salt diet will result in a significant fall in blood pressure in these people. For those who are not salt sensitive, a reduction of salt may not reduce hypertension but in any case it is a good idea to reduce your salt intake.
High blood pressure is much more common in an overweight person. Many overweight people find that with weight reduction, their blood pressure returns to normal. If your doctor has started you on medication you may find that as you lose weight you need less medication.
Seema’s case is informative. She suffered severe hypertension, which would not come under control. The doctor advised her to lose weight as she was 20 kilos overweight. Afraid that something would happen Seema started on a fairly strict diet and in two months had lost most of her excess weight. At this time she started developing attacks of giddiness and nearly had a serious accident while driving. Her doctor, finding that her blood pressure had fallen to very low levels stopped her medication completely.
In a hot country like ours, one can lose quite a lot of salt through perspiration. Therefore you should be careful to get enough salt particularly if your job requires you to go out in the sun a lot or if you sweat a great deal while playing games. You may also develop symptoms of salt depletion if your doctor has prescribed a diuretic medication that removes salt from the body. Be careful if you develop symptoms such as cramps or giddiness. They could indicate sodium depletion.
Mr Das discovered that he had blood pressure of 160/110 mm of mercury. Despite dietary and salt restriction Mr Das required large doses of medication as his hypertension was resistant and difficult to control. Unfortunately Mr Das developed uncomfortable side effects to the medication, the worst of which was impotence. His doctor tried a number of changes but could not overcome his impotence. Finally his doctor recommended that he should try a stress management programme using intense hypnotherapy. In a few months his blood pressure started going down and in six months Mr Das was able to dispense with his medication.
For most people with hypertension, modifying Type A personality traits (described later) and deep relaxation or self hypnosis practised regularly for a few months will cause a substantial fall in raised blood pressure. If this is combined with exercise, weight loss and salt restriction, it is possible in many cases to discontinue anti-hypertensive medication or at least reduce the dose substantially. Another technique called biofeedback has also been found to be very useful for reducing elevated blood pressure.
These are a group of fatty substances that circulate in the blood in various forms i.e. cholesterol and triglycerides. The levels of these fats have been found to have a significant influence on the risk of your developing coronary artery disease. You must get them measured regularly and know the risk they pose to you.
Cholesterol is a fatty substance found in the blood. It is required for the maintenance of the integrity of nerve and other cells. The liver manufactures enough cholesterol for the body’s requirements from fat. Some amount of cholesterol is absorbed from food, especially organ meats such as liver and egg yolk which are rich in cholesterol. The more saturated fats (such as butter or ghee) one eats, the greater the amount of cholesterol produced by the liver and the higher the levels in the blood.
A serum cholesterol level below 200 mg per 100 ml (mg/dl) is considered to be normal and up to 220 mg/dl as borderline (earlier 240 mg/dl). Anything above that is high. The higher the level of cholesterol, the greater is the risk of an infarction. To be safe you should aim for a Total Cholesterol (TC) level of 150 mg/dl or below. Remember that about a third of patients who have a heart attack have a blood cholesterol level between 150 to 200 mg/dl so you will need to work on the programme even if your cholesterol is in this range. Dr William Castelli has found that it is rare for any one with a TC below 150 mg/dl to develop CAD, hence one should aim for this:
Fig. 5
People have genetic differences in the amount of cholesterol that they can clear from their blood. Some people can eat a high fat, high cholesterol diet and still have a serum cholesterol level of 150 mg/dl. These lucky people are unlikely to develop heart disease. On the other hand there are many people who develop high cholesterol levels when they consume small amounts of fat or cholesterol in their diet; they have a higher chance of developing heart disease. If you have heart disease it is likely that you are in the latter group. You can greatly reduce your risk levels by strictly controlling your diet.
The Total Cholesterol (TC) in your blood is made up of various sub-fractions. These are the subtypes of cholesterol: High Density Lipoproteins (HDL cholesterol) and Low Density Lipoproteins (LDL cholesterol) and Very Low Density Lipoproteins (VLDL).
HDL has been called the good cholesterol and the higher the levels the better. This type of cholesterol transports of cholesterol away from the walls of the artery to the liver. If your HDL cholesterol level is below 35 mg/dl it is a poor sign. Ideally one should aim for levels above 45 mg/dl. The higher the levels of HDL cholesterol, the less the chances of your having a heart attack in the future. Moderate exercise is the best way of raising HDL cholesterol.
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Aerobic exercise is the best way of raising HDL cholesterol. Moderate consumption of alcohol can also increase the levels of HDL cholesterol but this is not a recommended way of trying to raise HDL levels. Alcohol leads to weight gain and hypertension. Heavy drinking increases the risk of alcoholism and heart disease. A small glass of red wine daily or one small drink is acceptable on this programme but if you can do without it, so much the better.
LDL cholesterol has been called the ‘bad’ cholesterol and is involved in transporting cholesterol into the wall of the arteries and causing atherosclerosis. The higher the level of LDL cholesterol in your blood the greater the risk of your disease progressing and of having a heart attack. LDL cholesterol can be lowered by decreasing one’s intake of fat, especially saturated fats and trans-fatty acids and losing weight.
Fig. 7
In recent years researchers have become aware of the fact that if LDL is oxidised it becomes more dangerous and causes more damage in the walls of the artery. Oil rich in poly unsaturated fatty acid such as safflower oil, cigarette smoking and pollutants increase levels of oxidised LDL in blood. Certain natural antioxidants in food especially fresh fruit and vegetables reduce levels of oxidised LDL. This is discussed in further detail in the chapter on diet.
The ratio of total cholesterol to HDL cholesterol is a better indicator of risk than total cholesterol. You can calculate your value by dividing your Total Cholesterol by your HDL cholesterol level. Most healthy males have a value of below 5, a value of 7 doubles the risk. The lower the value, the less the chance of your heart disease progressing. Aim for a level of 3-4, the lower the better. If your Total Cholesterol is between 150 to 200 mg/dl, a TC/HDL ratio of 3 may offer the same protection as offered by having a TC level below 150 mg/dl.
Apart from dietary and genetic factors, emotions play an important part in the genesis of high cholesterol levels in the blood. Scientists have found that under stress cholesterol levels rise. Studies on accountants before the Accounting Year End show that their cholesterol levels often double because of the extra stress they are under. Individuals who keep their feelings to themselves especially when upset or angry (repressive coping) have also been found to have higher cholesterol levels.
Diet plays the most important role in the management of a high cholesterol level. A very low fat vegetarian diet is the most effective way of reducing your blood cholesterol levels. Within a few weeks of starting on a low fat, low cholesterol diet such as The Save Your Heart, Pritikin or Ornish diet, most patients find that their cholesterol level decreases. With this their symptoms often become less. Patients frequently report that their exercise tolerance has increased, pain has decreased and that they feel more energetic.
I have noticed that the cholesterol level of some obese patients only starts going down without medication when they lose weight. Hence if you are overweight it would be well worth your while to work at getting rid of the extra weight.
Other ways of reducing your cholesterol levels include eating food rich in soluble fibre such as oats, peas, lentils (dals) and fruit. A diet rich in fibre can reduce your cholesterol levels by around 10%. Therefore you may want to increase the amount of fibre in your diet. Garlic can also lead to a 5-9% decrease in cholesterol levels.
A natural substance, psyllium, is rich in fibre and is very useful for reducing the cholesterol levels in the blood. It is freely available as Isabgol and a tablespoon or two can be taken daily. It also has the advantage of preventing constipation. Similarly some people find that purified guggul gum is an effective way of reducing cholesterol.
Stress management and personality modification can also help reduce cholesterol levels. Studies on CAD patients who practise yoga showed a significant reduction of blood cholesterol. Similarly stress management using self-hypnosis or meditation can also help reduce cholesterol levels elevated due to stress.
If you have elevated cholesterol you may find that after starting on a very low fat diet, your cholesterol level does not go down to 150 mg/dl. This should not be a cause for concern if you are strictly adhering to the diet and lifestyle programme, especially if your Total Cholesterol is below 200 mg/dl and TC/HDL ratio is less than 4. Some doctors may want to put you on cholesterol lowering medication if this happens.
In his study, Dr Dean Ornish found that patients who adhered to his programme and stayed on the diet with less than 10% of calories from fats obtained significant reduction in the fatty deposits in the arteries. This was even though their serum cholesterol levels remained elevated above 150 mg/dl.
Some cardiologists now recommend that patients with a TC above 210 mg/dl (or even lower levels if people with multiple risk factors) start on the statin group of cholesterol lowering medication. It is a good idea to ask your doctor if you can first try lowering it with a very low fat diet and a programme of stress management. Be aware that quite a few doctors do not believe that individuals can stick to a low fat diet and would rather prescribe medication to be safe. Once medication has been started, most doctors are reluctant to stop it unless the patient develops side effects.
If, despite adequate dietary modifications for a period of a few months your serum cholesterol still remains elevated, your doctor may prescribe cholesterol lowering medication. There is evidence to indicate that cholesterol reducing medication can also help reduce the mortality from a heart attack and in many cases cause a regression in the atherosclerotic process.
Cholesterol lowering medication may also be necessary for a person who is not able to or is unwilling to switch to a low fat vegetarian diet. It may take a number of years for the cholesterol lowering medication to cause regression in the atherosclerotic plaque.
There is another type of fatty substance in the blood called triglycerides. High levels (above 150 mg/dl) can also increase the risk of coronary heart disease. You should aim to keep your levels below 130 mg/dl (ideally 100 mg/dl or below if you aim to be safe and reverse your heart condition).
Fig. 8
The best way to reduce the triglycerides levels is to lose weight using a low fat vegetarian diet. If you have elevated levels it is very important that you drastically reduce your intake of sugar and alcohol. Replace white rice with brown rice, refined white flour (maida) with whole wheat (atta). In addition stop smoking if you have not already done so. Tofu and fish also help reduce triglycerides. Triglyceride levels respond to weight loss and dietary modification in a short time. As a last resort you may require medication. Nowadays most cardiologists will prescribe Atorvastatin or other specific medication for this purpose.
Sometimes when you change over to a low fat vegetarian diet triglyceride levels may rise above your baseline level. As long as you really stick to a low fat diet and the level is below 150 mg/dl you need not worry about it.
The levels of serum cholesterol, triglycerides and the amount of dietary fat recommended in this book are much lower than what most doctors advise. This is because the aim of this programme is to promote positive health and reverse the atherosclerotic process. Many doctors suffer from therapeutic nihilism and do believe that people can make lifestyle and personality changes required to achieve these aims. They would rather prescribe medication and avoid the risk of losing the patient by making demands that challenge them.
Research has shown that people who are more than 20% overweight, have a higher risk of developing coronary artery disease than their normal weight counterparts. This is especially true if the fat is deposited around the belly (apple shaped). Overweight people who accumulate their fat around their thighs (pear shaped) have a smaller risk than apple shaped people.
The obese person also runs a higher risk of developing hypertension, diabetes and certain types of cancer. Hence it is worthwhile losing weight as this leads to a reduction of raised blood pressure, cholesterol and risk of further progression of your disease.
As with exercise it is necessary that you maintain the weight loss. Once you lose weight you must plan to keep off the excess weight permanently. It has been found that those who keep gaining and losing weight (yo-yo dieting) are at a greater health risk than those who remain slightly overweight. A gradual weight loss of about half or at the most one kilogram per week is recommended.
If you stick to the diet and exercise programme outlined in this book you will lose weight automatically. The exercise and stress control programme will help make it easier to adhere to your diet. Hypnosis is one of the most effective ways of promoting weight loss even in patients who are massively obese.
Diabetes is a condition where the blood sugar level in the blood is higher than normal. If your fasting blood sugar is higher than 110 mg/dl your doctor will need to evaluate you for diabetes. Diabetics are at a much greater risk of developing arteriosclerosis especially if their diabetes is not well controlled.
There are two types of diabetes — The first (Type 1) due to damage to the insulin secreting cells in the pancreas, leading to insulin deficiency. The second (Type 2) is due to the peripheral tissues not responding to the insulin in the blood. The second type is more common in overweight adults and can often be reversed by weight reduction and dietary control.
It is important that your diabetes be treated under the close supervision of a physician specialising in this condition. Uncontrolled diabetes can lead to the damage of your blood vessels, kidneys, eyes and heart. One must aim for rigorous control of one’s blood sugar levels. Many doctors have fairly relaxed standards, which makes it easy for the patient and puts them at risk.
Should you decide to follow the lifestyle changes outlined in this book, you must do it in conjunction with your doctor. It is likely that your requirement of anti-diabetic medication will decrease significantly after you start this programme. If the medication is not adjusted you may find that your blood sugar falls to a very low level causing hypoglycaemia. The symptoms of hypoglycaemia include sweating, anxiety and faintness. It can also trigger off an arrhythmia. Beta blockers prescribed for coronary artery disease or hypertension can block the symptoms of hypoglycaemia and you may not realise that you have hypoglycaemia, which can damage your brain.
A related condition in obese people is called hyperinsulinism, which has also been blamed for accelerated atherosclerosis. Here the blood sugar levels are normal but the insulin levels circulating in the blood are higher than normal. As in Type 2 diabetes the peripheral tissues are not sensitive to insulin. In response the pancreas releases more insulin into the blood. This condition is common in Asians and some cardiologists blame it for the higher incidence of heart disease among us. If you are overweight, weight loss with a low fat diet and with very little simple sugars often brings back the normal responsiveness of the cells to insulin. With this the levels of circulating insulin usually fall back to normal.
Some people especially from South Asia (India, Pakistan, Bangladesh) suffer from a condition called metabolic syndrome or Syndrome X. They have hyperinsulinism, high blood pressure, high levels of triglycerides and low levels of HDL cholesterol. They have a much higher risk of developing heart disease and of having recurrent attacks. People with this condition need aggressive dietary and medical treatment.
Research shows that people who have a diet rich in fat, especially animal fat, have a higher incidence of heart disease and stroke. The Finns and the Danes have perhaps the highest incidence of heart disease in the world due to the large amounts of animal fat in their diet. At the other end of the spectrum, the Japanese islanders with their low intake of fat have the lowest incidence of heart disease. Recent studies show that people with a high intake of Trans-fatty Acids are at high risk. Hydrogenated oils are rich in them and used in cakes, biscuits, certain breakfast cereals and many other processed foods. Hence these foods should be avoided at all costs. Research shows that people who have a high intake of polyunsaturated fatty acids, especially the omega-6 fatty acids in their diet (present in cooking oil), run a greater risk of having a heart attack. The chapter on diet contains more information on this.
Dr Ralph Paffenberger studied 17,000 Harvard Alumni in the United States, for over 20 years. He found that those who exercised regularly, burning about 2000 extra calories per week, had a 28% lower annual death rate than their sedentary counterparts. About 40% of this lower death rate was due to a reduction in heart disease. Research has shown that walking as little as half an hour, 3 to 4 times a week can provide significant protection against heart disease.
Dr Paffenberger clearly found that those who had exercised regularly and then gave it up were at a higher risk of developing cardiac disorders. Because of this it is important to continue exercising regularly especially if you are an athlete or used to exercise regularly. Also you should only plan to do as much exercise as you know you can realistically continue doing in the future.
Homocysteine is a breakdown product of the amino acid methionine, which is one of the building blocks of proteins. High levels of homocysteine have been linked to damage of the arteries and increase the risk of stroke and heart attacks. Research shows that many Indians have raised levels of this substance in their blood for genetic reasons. This may be one of the factors responsible for the higher incidence of heart disease in us.
Homocysteine levels may be lowered by increasing one’s daily intake of vitamin B-complex. One must get at least 400 mcg (micrograms) of folic acid, 2 to 4 mg (milligrams) of vitamin B6 and 4 to 6 mcg of vitamin B12. A multivitamin or vitamin B-complex supplement should provide enough B-complex vitamins to do this. However this may not help reduce the increased risk and there are some concerns that even high doses of synthetic vitamin supplements may marginally increase the risk of a stroke or heart attack.
This is one of the few risk factors that cannot be modified at present. Another marker of a raised risk is Lipoprotein A or Lp (a), which is also associated with a higher risk of heart disease. It prevents the dissolution of small clots that often form in the blood. Levels above 20 are associated with a slightly increased risk but when they rise above 30 the risk increases greatly. If you have raised levels of Lp(a) you will need to be much more careful about controlling all the other risk factors. Some authorities believe that for patients with a raised Lp(a), Trans-fatty Acids that are present in hydrogenated oil and margarine are deadly. Avoid hydrogenated oil, margarine and foods made from these such as, cakes, biscuits, snacks and even chocolates.
Other markers of a higher risk of recurrence are apoliporotein A and B. High levels of a substance called C-reactive protein which indicates the presence of inflammation have also been found to predict a higher risk of having a heart attack or recurrence. Remember if you have unhealthy levels of these genetic markers of high risk it would be advisable to be very aggressive in your adoption of lifestyle and behavioural changes.
