You can skip a song on your playlist. You can skip stones across a pond. Heck, skip around the block if you like. But—please—do not skip this chapter.
Although some of the conditions in this book may not apply to you (and we encourage flipping around to find the ones that do), protecting your heart applies to everyone, whether or not you think you’re at risk of heart disease.
That’s because heart disease and stroke are the number one causes of death in the United States and in the world.28 So this is a must-read chapter if you’re a prime candidate for heart disease, that is, if you’ve either already suffered some sort of heart issue or you eat the standard American diet. But here’s something that will surprise you more than a Game of Thrones cliff-hanger: Even if you think you’ve done everything right—from diet to exercise to ohm’ing with the best of ‘em—heart disease is still a threat. That means we all have room to improve the way our tickers work.
You probably already know that your heart is your body’s workaholic organ; 24/7, it’s pumping blood to deliver the oxygen your organs and muscles need to do their jobs. Your heart needs blood, too, and it gets it from the tiny coronary arteries that cover its surface. When the inner surfaces of these arteries become damaged, the body attempts to repair them with a mix of cholesterol, fats, and clotting factors. Think of it like spackling that small hole in your wall to get your deposit back when you move out of your apartment. In your heart, we don’t know exactly what causes the damage in the first place. But we do have some good suspects, like high blood pressure, high blood sugar, smoking, or just generalized inflammation. Researchers at the Cleveland Clinic have also found that animal products, including meat and eggs, contain carnitine, choline, and lecithin, which can be metabolized by bacteria in the gut to create a substance that causes injury to your arteries.29,30,31
These plaques can start building up in childhood, and can affect all your arteries, including those of your heart, brain, kidneys, gonads, and skin. That’s why impotence or wrinkles are often the first sign of arterial aging. These plaques tend to increase more rapidly after your 30s. As they grow, they can start to limit the amount of blood that is able to flow through your blood vessels.
That, you may suspect, is a problem. Your hardworking and hungry heart needs oxygen to pump blood to the rest of your bod. When it can’t, you may feel that as chest pain. And when it gets really bad, it can cause a heart attack.
In addition, as plaques grow, the repair process can be sloppy (like unlicensed contractors cutting corners). As a result, these plaques can become unstable. That means that when a wave of inflammation hits, either after that big pulled pork platter or the flu, they can break or rupture.
When this happens, the tissue underneath the plaque becomes exposed and the body needs to rapidly repair the raw surface (after all, a damaged vessel could start leaking blood). In these circumstances, a clot rapidly forms. This clot can cause a blood vessel to completely close off, leaving the portion of the heart muscle typically served by that vessel completely without blood. That scenario usually results in a heart attack.
Now, it’s true that some heart disease risk is genetic. But the majority is related to lifestyle choices. Hypertension (high blood pressure), type 2 diabetes (high blood sugar), a high blood LDL cholesterol, and smoking all greatly increase your risk. These risk factors (assuming you don’t smoke) are all attributable to diet, stress, and other lifestyle changes. But diet is the big factor here. So although we have procedures that can help address clogged arteries, you can also reverse arterial disease with food.
Where you fall on the spectrum for heart disease risk can help determine the best way to eat. To find out your status, answer the questions in the following quiz and add up your points.
1. Have you ever had a heart attack?
No (0)
Yes (16)
2. Has your doctor diagnosed you with angina (chest pain on exertion or at rest)?
No (0)
Yes (16)
3. Are you overweight?
No (0)
Yes (2)
4. Do you have high blood pressure?
No (0)
Yes (4)
5. Do you have diabetes?
No (0)
Yes (4)
6. Do you have high (lousy) LDL cholesterol (greater than 190)?
No (0)
Yes (3)
7. Have you had your flu shot every year for the last 10 years? (A recent bout of influenza has been determined to be a risk factor.)
Yes (0)
No (3)
8. Have you ever smoked regularly within the past 15 years?
No (0)
Yes (5)
9. Does heart disease run in your family?
No (0)
Yes (3)
If you scored: 16 points or more: Follow the When Way Diet Plus If you scored: 11 to 15 points: Follow the When Way Diet Hybrid If you scored: 10 or fewer points: Follow the When Way Diet
When Way Diet: The When Way is a modification of a Mediterranean style diet, but with just as much focus on the time you are eating as the what. It’s based on getting most of your calories from plants, healthy plant-based fats (like extra-virgin olive oil, avocados, and nuts), and a few fish choices like salmon and ocean trout. It’s also very low in both sugar and saturated fats (found in red meat, dairy, and egg yolks). These are the main culprits in raising your lousy LDL cholesterol and increasing inflammation—two important contributors to heart and arterial disease risks. The filling high-fiber vegetables, lack of added sugar, and focus on plant-based proteins, rather than animal proteins, should meet all of your nutritional needs. This choice is also key because it helps you feel full and maintain a healthy weight, which can reduce the risk of type 2 diabetes, hypertension, and inflammation.
Compared with a low-fat diet, Mediterranean diets rich in olive oil and nuts have been shown to reduce the risk of high blood pressure, high lousy cholesterol, and diabetes.32,33 An important study of the Mediterranean diet published in the prestigious New England Journal of Medicine also found that it could reduce the combined risk of heart attacks, stroke, and death from cardiovascular disease (heart disease, stroke, and other arterial diseases) by up to 30 percent.34 Another study showed that this kind of diet improved health outcomes for people already on medications for heart-related problems, and who are judged optimally managed with medications.35 Without a diet discussion and change, you aren’t optimally managed.
When Way Diet Plus: The low-fat diet that became somewhat of medical dogma in the 1980s was based on the fact that a diet rich in saturated fat was a major risk for heart disease. Unfortunately, the low-fat diet oversimplified the concept and led to treating all fats the same, both the good (such as omega-9s in extra-virgin olive oil and those omega-3s from walnuts, flaxseeds, and salmon) and the not-so-good (animal) fats. In addition, with the major focus on fat, people also tended to focus less on another important culprit in chronic disease: sugar and foods that quickly turn into sugar in your body like carbs stripped of their fiber. Eating the When Way is not a low-fat diet, but for those at the highest risk of heart disease, you’re going to want to cut fats from about 35 percent down to about 10 percent.
Why? A low-fat vegetarian diet is probably the healthiest diet you can be on and has been shown in studies to reverse heart disease in people with proven pathology and multiple risk factors.36,37 Admittedly, it can be harder to enjoy as you need a lot of cooking education to add spices that keep the flavors exciting. But if you’re at a high risk, you owe it to yourself and your loved ones to try. Dean Ornish and Caldwell Esselstyn pioneered the following guidelines:
EAT: Vegetables, fruits, legumes, soy, whole grains, one to two tablespoons of ground flaxseeds or chia seeds, or an ounce of walnuts a day for omega-3s.
DON’T EAT: Meat, poultry, dairy, eggs, and fish (basically avoid anything with a face or a mother), as well as oils and sugar.
We know, we know, this plan looks tougher than a hockey puck-cooked steak. But we know lots of people who’ve been on this diet (including a few close relatives of Dr. C’s). Once you get used to it, it becomes much easier. We also like to think it’s better than the alternatives: getting cut open or death. Think of oil in cooking as the ingredient that adds moisture and keeps foods from burning when heated. With that in mind you can substitute wine, vegetable broth, vinegar, or even water in the initial cooking steps for many dishes, including soups, braises, roasted and grilled vegetables, and even sautés. Salads and vegetable-based sandwiches can be dressed with vinegar or other acids like lemon and lime instead of oil.
When Way Diet Hybrid: The hybrid plan is to eat the When Way Plus Diet four days a week and the standard When Way for the other three. This allows you a little flexibility, but also helps you take advantage of a plant-based diet for the majority of the week.