CHAPTER 24
The average heart weighs just 1.2 pounds and beats 100,000 times a day and almost 40 million times a year to move 38.3 million gallons of blood during the average seventy-five-year lifetime. Now that we got those basic facts covered, here’s the bad news: Heart disease is a leading cause of death in the United States and a major problem throughout the industrialized world. Chronic inflammation may be the most common precipitating factor for heart disease since there is a strong association between it and other cardiovascular problems, including sudden cardiac death, peripheral arterial disease, and stroke.
Other unhealthy lifestyle factors significantly increase the risk of heart disease. These include smoking, being overfat, and hypertension. Diabetes, an end-stage problem of carbohydrate intolerance, is a major risk element. Prolonged inactivity and no exercise also put you at nearly as great a risk for heart disease as smoking.
Heart disease is commonly known as cardiovascular disease. Both terms refer to conditions that involve narrowed or blocked blood vessels that can lead to a heart attack; when it happens in the brain, it’s called a stroke.
In the United States, heart attack and stroke accounts for more than 34 percent of all deaths each year, divided equally among men and women. Here are some other grim statistics:
• Over 80 million Americans have some form of cardiovascular disease—most are unaware of it.
• About 1.3 million Americans, equally among men and women, will have a heart attack this year, and about half will die. It will cost well over $300 billion to care for those who survive.
• About 800,000 strokes occur annually and about 150,000 of these results in death, slightly more women than men. Stroke is a leading cause of serious long-term disability, which costs about $70 billion each year.
Setting aside the rare cases of congenital cardiac conditions, almost all these heart attacks and strokes are preventable. How? Simply by following a healthy lifestyle that includes eating well and exercise.
Ask the average person, and even most physicians, what food group first comes to mind regarding cardiovascular disease, and the answer is usually fat. But despite the abundance of low-fat and low-cholesterol foods and diets, heart disease remains the most common cause of death. Researchers and mainstream medicine are quietly, and perhaps embarrassingly, moving away from the fat-and-heart disease camp.
While the four most common problems contributing to heart disease are an unhealthy diet, lack of exercise, being over-weight, and smoking, there’s a single factor involved in virtually all those with this condition. Chronic inflammation may be the most common cause of cardiovascular disease. If you have chronic inflammation, your risk for having a heart attack is doubled. Studies show that the more inflammation—as indicated with a simple blood test called C-reactive protein—the greater your risk of having a heart attack. Chronic inflammation is an easily preventable condition, and the food most often associated with it is refined carbohydrates.
Unhealthy conditions such as hypertension and diabetes, each a consequence of long-term carbohydrate intolerance, are traditionally seen as raising the risk for heart disease. This is due in large part to increased chronic inflammation.
Of course, other unhealthy factors coexist, which can increase the risk of cardiovascular disease. Among them is an imbalance of dietary fat, which also contributes to chronic inflammation. In other words, eating healthy foods such as olive oil, nuts and seeds, and wild fish can actually promote heart health.
Aerobic exercise is also obviously important for the heart; inactivity puts you at almost as great a risk as smoking. The heart is a muscle and, as such, requires physical activity for optimal long-term function. Blood vessels also contain smooth muscle, which is “exercised” during the elevations in heart rate during regular workouts.
The general public is understandably confused when it comes to the big three—cholesterol, fat, and salt—and their relationship to cardiovascular disease. Conflicting “news” articles and stories in the media do little to lessen the misunderstanding. So let’s examine each of these dietary concerns.
For decades, the public was repeatedly told that cholesterol was viewed as the villainous cause of heart disease, so it stayed away from high-cholesterol foods, particularly egg yolks. Moreover, food companies began coming out with “low” or “no-cholesterol” products, ranging from TV dinners and dishes one could microwave to instant packaged food eaten out of the box or by just adding water. But by the 1970s, it was clear to me and many other clinicians around the world that cholesterol is not the culprit. Yet simple cholesterol blood tests for total cholesterol—often done inside shopping malls—frightened millions of people away from eating eggs for breakfast, despite the research showing that eating them won’t raise blood cholesterol. Instead, people switched to a breakfast of processed cereal, which has been shown to contribute to the overfat epidemic and a much greater risk for heart disease.
Abnormally high levels of cholesterol can be a risk factor for heart disease, although your total cholesterol is not the best—or only—measure for heart disease risk. Many people who have heart attacks or strokes also have normal total cholesterol numbers, and many with high cholesterol never develop a cardiovascular disease.
Perhaps the greatest misconception about cholesterol is that eating foods containing it significantly raises levels in the blood. In truth, most studies have shown that eating cholesterol does not alone substantially increase blood cholesterol levels. Moreover, some studies show that not eating cholesterol can prompt your body to make more—and that eating eggs can improve your cholesterol numbers! (This is because eating egg yolks can raise the “good” HDL cholesterol, which lowers your ratio and risk.)
While there is a correlation between higher total cholesterol in the blood and incidences of heart attacks, evaluating cardiac risk calls for a complete fasting blood lipid profile that measures at least total HDL and LDL cholesterol and triglycerides.
The most important thing to know about cholesterol is that, by itself, it isn’t “bad,” but rather something to be kept in balance. It’s also important to understand that most of the cholesterol in the bloodstream is actually made by your liver. If you eat more cholesterol, your body prompts the liver to make less of it. But if you take in less, your liver makes more. That’s why many people on a low-cholesterol diet still have high blood cholesterol levels.
Actually, all cells in the body—including those of the heart—make cholesterol every day. That’s because cholesterol is necessary for many essential processes that keeps one healthy. For example, the outer surfaces of cells contain cholesterol, which helps regulate which chemicals enter and exit. And cholesterol is used to make many hormones, including sex hormones and those that control stress. Cholesterol is also a key component of the brain and nerve structure throughout the body and a key compound in the skin, allowing one to make vitamin D from the sun. As you can see, cholesterol is necessary—and good—for optimal health. It’s only bad when out of balance.
HDL cholesterol—high-density lipoprotein—is called “good” cholesterol because it protects against disease by removing accumulated deposits of cholesterol and transporting them back to the liver for disposal (through the gut). So higher HDL numbers are generally healthier. It’s best if you can divide your total cholesterol figure by your HDL number and get a ratio below 4:0, which is about the average risk for heart disease. Aerobic exercise, monounsaturated fats, fish oil, and moderate alcohol can increase HDL. Excess stress and anaerobic exercise, hydrogenated fats and excess consumption of saturated fats, and refined carbohydrates lower it.
BYPASSING BYPASS SURGERY
A healthy and fit body has arteries that are flexible, strong, and elastic. With poor health, the arteries can become stiff with buildup of plaque, which restricts blood flow to your organs, glands, and other tissues, including the heart. This process is called arteriosclerosis, or hardening of the arteries.
Atherosclerosis, a specific type of arteriosclerosis (the terms are sometimes used interchangeably), refers to the buildup of fats in and on an artery’s walls—called plaque. It hardens as calcium deposits with the fat. This can restrict blood flow.
In the heart, restricted blood flow can cause reduced pumping of the heart, chest pain (called angina), and lead to death. A common treatment of this end-result problem is bypass surgery. In this procedure, narrowed, diseased arteries are replaced by vessels that are taken from other parts of the body. These and similar surgeries are performed on over a million Americans annually, with an individual cost of up to $50,000 (over $50 billion nationwide with much higher costs being incurred for long-term follow-up care).
Plaque can also burst, causing a blood clot affecting arteries elsewhere in the body, including the brain, resulting in a stroke.
Atherosclerosis, like other cardiovascular conditions, is a preventable condition—as this chapter discusses. Its risk increases with unhealthy aging, especially when other problems exist, such as high blood pressure, obesity, and smoking.
More importantly, the recommendation that people substitute polyunsaturated fats for saturated can be devastating for HDL levels. If the ratio of polyunsaturated fat to saturated fat exceeds 2 (a ration of 2:1), HDL levels usually diminish, raising your cardiac risk. If your A, B, and C fats are balanced, as discussed in chapter x, you avoid disturbing this ratio. Due to the heavy marketing of polyunsaturated oils since the 1970s, American diets now contain twice the polyunsaturated oil compared to diets of the 1950s and ‘60s. In addition, body fat samples today show that levels of linoleic acid (an A fat) are at twice what they were forty years ago.
LDL cholesterol—low-density lipoprotein—is known as the “bad” cholesterol. A recent trend in preventative medicine is to stress-lowering LDL cholesterol with drugs. But it’s really not the LDL itself that causes the potential harm or risk. It’s only when LDL oxidizes that it deposits in your arteries. Oxidation of LDL results from free radicals, in much the same way that iron rusts. While lowering LDL levels can make less of it available for oxidation, antioxidants from vegetables and fruits can help prevent oxidation. In addition, many of the factors just mentioned that raise HDL also lower LDL, the reason these foods can significantly lower your risk of heart disease. LDL is best measured when blood is drawn after a twelve-hour fast for an accurate evaluation.
Excess dietary carbohydrates can especially adversely affect LDL levels. This is due to excess triglycerides from carbohydrates producing more, smaller, dense LDL particles, which are even more likely to clog arteries.
In addition, a lower intake of dietary cholesterol is linked to an increase of these more dangerous LDL particles. And to make matters worse, these types of LDL particles are also associated with the inability to tolerate moderate to high levels of dietary carbohydrates (i.e., insulin resistance) even in relatively healthy individuals.
One of the worst scenarios for your cholesterol is if the HDL is lowered and the LDL and total cholesterol are elevated. Hydrogenated and partially hydrogenated fats (trans fat) do this, and the reason trans fat is a risk factor for heart disease. So read labels and avoid all products containing this dangerous substance.
Eating too much saturated fat can raise LDL and total cholesterol levels. An excess intake of dairy foods such as butter, cream, cheese, and milk may be the worse offender. Red meat such as beef, while it does contain saturated fat, can actually improve cholesterol levels. This is partly because, just as in eggs, about half the fat in beef is monounsaturated. Grass-fed beef has the best balance of fats compared to most beef, which is corn fed and contains higher levels of stearic acid, a saturated fatty acid that won’t raise cholesterol and may actually help reduce it.
Fiber and fiberlike substances are also an important factor in decreasing total cholesterol and improving total cholesterol/HDL ratios. Most people don’t eat enough fiber, especially from fresh vegetables and fruits. Eating at least one large raw salad daily in addition to other raw and cooked vegetables and one to three servings of fresh fruit or berries—totaling ten servings—will provide significant amounts of fiber. These foods also provide natural phytosterols, which help reduce cholesterol and may be the reason early humans, who ate very large amounts of saturated fat, may have been well protected.
Studies also demonstrate that more-frequent eating lowers blood cholesterol, specifically LDL cholesterol. This means eating healthy snacks.
One of my patients, Fred, had a long history of high blood cholesterol. At forty-eight years old, he was an engineer for the phone company. His blood tests revealed some interesting numbers. When he was first tested several years prior to seeing me, his total cholesterol was 288 and his HDL was 52. That’s a ratio of 5:5—too high a risk factor. Fred tried lowering his dietary cholesterol for six months and then had his cholesterol tested again. This time, the total was very similar, 276, but the HDL diminished too much, down to 41. That drastically increased his risk to 6:7. His doctor recommended taking a cholesterol-lowering drug, which he did. Six months later, the tests showed his total cholesterol down to 213, along with his HDL, which decreased to 31. Now his risk was even worse, with a ratio of about 6:9. Fred was finally convinced to try another approach and stopped his medication. He started a program of easy aerobic exercise, walking each morning, lowering his carbohydrate intake, essentially eliminating all refined carbohydrates, and eating healthy fats, including eggs and olive oil. After six months, his blood test showed total cholesterol of 191, and HDL of 58, giving a much better ratio of 3:3. A year later, maintaining his healthy habits, Fred’s test was even slightly better.
Most people love the taste of eggs, whether scrambled, poached, soft- or hardboiled, or in a fancy soufflé. As I discussed in chapter 6, eggs are one of the best sources of quality protein and also contain a wide variety of other important nutrients, including choline, important to help control stress (another risk for heart disease). But egg yolks contain cholesterol. Today, most experts agree that for most people, eating eggs every day is not going to worsen blood cholesterol. (If you’re one of a very small number of people who can’t metabolize cholesterol, it could be a problem. But if that’s the case, most likely you already know your cholesterol is too high—above 250 or 300.)
Cholesterol-lowering Drugs and Inflammation
Studies show that some cholesterol-lowering drugs (the statins) can reduce inflammation. But considering the potential side effects of these drugs and their high cost, statins are an inefficient way to lower cardiac risk by reducing inflammation. The study found the popular drugs Pravachol, Zocor, and Lipitor significantly reduced inflammation, thereby reducing the risk of heart attack and stroke.
However, the long list of side effects for these drugs include liver damage and problems with neurological, intestinal, and muscular function, to name just some. In addition, patients must take this medication for many years and avoid alcohol. These drugs are also contraindicated for children, nursing mothers, and women of childbearing age.
The irony is that the anti-inflammatory actions of these drugs may be more important than lowering cholesterol. It’s a lot less expensive and safer to use appropriate dietary and lifestyle adjustments in combination with omega-3 fat supplementation to reduce inflammation. Indeed, the American Heart Association recommends first using more conservative means before prescribing medication, including the right foods, balanced nutrition, and exercise.
After decades of medical research, studies have never linked egg consumption to heart disease. Stephen Kritchevsky, PhD, director of the J. Paul Sticht Center on Aging at Wake Forest University, states, “People should feel secure with the knowledge that the [medical] literature shows regular egg consumption does not have a measurable impact on heart disease risk for healthy adults. In fact, many countries with high egg consumption are notable for low rates of heart disease.”
In most healthy people, the body normally compensates to keep cholesterol in balance, even when you eat whole eggs every day. In fact, as you eat more cholesterol, your body absorbs a smaller percentage.
Consider these other points about consumption of eggs and other foods high in cholesterol:
• Data from the Framingham Study revealed no relationship between cholesterol consumption and blood levels in sixteen thousand participants tracked over the course of six years.
• The fat in egg yolks is nearly a perfect balance, containing mostly monounsaturated fats and about 36 percent saturated fat. Monounsaturated fat has been shown to raise HDL cholesterol levels. Studies published in the New England Journal of Medicine and the Journal of Internal Medicine indicate that eating whole eggs daily significantly raised the good HDL cholesterol.
• Egg yolks contain linoleic and linolenic acids, which are as important as all other vitamins and minerals and are crucial in the regulation of cholesterol. The study also showed that without these fats in your diet, your risk for heart disease is increased.
• Egg yolks are high in lecithin, which assists the action of bile from the gallbladder in regulating cholesterol. Cholesterase, an important enzyme in egg yolks, may also help control cholesterol.
With all this scientific evidence, there seems to be little logical reason to avoid eating eggs. But if that’s insufficient proof for you, consider the clinical case of the Egg Man. As reported in the New England Journal of Medicine and on popular talk shows a number of years ago, an eighty-eight-year-old man with a documented history of eating twenty-five eggs per day was evaluated and found to be in excellent health, including normal weight and no signs, symptoms, or history of heart disease, stroke, or gallbladder problems. His serum cholesterol over the years has ranged from 150 to 200, despite the fact that he eats about 5,000 mg of cholesterol per day! He is an example of the fact that increasing cholesterol intake, even by significant amounts, may not affect serum cholesterol levels.
Will egg phobia end soon? More people are realizing that eating eggs doesn’t raise their cholesterol and that consuming too many carbohydrates and trans fats can be much more of a risk factor for cardiovascular disease. For those who still want more information, visit the Egg Nutrition Center’s website at www.incredibleegg.org.
Another fat that’s just as important to measure is the level of triglycerides in the blood. High levels can significantly increase the risk of cardiovascular disease. Some studies show that the increase in heart disease risk from elevated triglycerides may rival that of LDL cholesterol.
Triglycerides come from the conversion of carbohydrates into fat. Normally, 40 percent or more of carbohydrates are converted to fat. Some of these triglycerides end up stored as plaque on your artery walls. Many people focus on eliminating saturated fat and are unaware that eating too many carbohydrates is also associated with a higher risk for heart disease.
Triglycerides, like LDL cholesterol, must be measured in the fasting state for accuracy. Levels ideally should be under 100 mg/dl, though 150 is considered normal by most labs. If your triglyceride level is above 100, and especially 150, there’s a good chance you’re carbohydrate intolerant and need to cut back on eating these types of foods, especially those made with refined flour and highly processed sugars. Those with very high triglycerides often will see a dramatic reduction, sometimes to normal, after a successful Two-Week Test. (See chapter 2.)
One factor associated with cardiovascular disease is high blood pressure, or hypertension. It’s not only a risk factor for heart disease, but overall mortality. Hypertension is generally defined as blood pressures above about 140/90 (the first number is the systolic pressure, and the second diastolic, as measured in millimeters of mercury or mm Hg).
Intense marketing of hypertension drugs, corresponding with newer definitions of hypertension, has resulted in more people being medicated and even those with normal blood pressure being told they are in a prehypertensive state. Indeed, doctors are now reading in medical journals that cardiovascular risk begins with blood pressures as low as 115/75 and that the blood pressure classification of prehypertension is a systolic pressure between 120–139 and diastolic between 80–89 mm Hg.
To make matters worse, most patients are prescribed medication for hypertension without seeking the cause of the problem. And most patients are not given appropriate diet and lifestyle guidelines that may reduce their blood pressure to the point where medication may no longer be needed.
Among the problems that may contribute to hypertension is carbohydrate intolerance due to its influence of raising insulin levels. During the Two-Week Test it was recommended that if your blood pressure is high, have it evaluated before, during, and after the test. That’s because for many people, significantly reducing refined carbohydrates and sugars, which reduces insulin levels, will lower blood pressure—often dramatically. As a result, if you’re taking medication to control blood pressure, your doctor may need to reduce or even eliminate it.
The vast majority of hypertensive patients I initially saw in practice were able to reduce their blood pressure significantly just by strictly avoiding refined carbohydrates and sugars, especially when easy aerobic exercise was implemented. Most of these patients were able to eliminate their medication. Other important factors include balancing fats, various nutrients that can be obtained from a healthy diet, and controlling stress.
Poor aerobic conditioning can also contribute to hypertension. Recall that those who are inactive have a significant number of blood vessels shut down (these are the vessels in the aerobic muscle fibers). Aerobic exercise is an important factor in both prevention and treatment of hypertension. Even one easy aerobic workout can reduce blood pressure for up to twenty-four hours. Anaerobic exercise may not be nearly as effective and could even aggravate high blood pressure. It’s important to discuss your particular exercise needs with a health care professional—especially one who is aware of the potential benefits of food, nutrition, and exercise.
Other dietary factors that can prevent or help hypertension include eating sufficient amounts of vegetables and fruits. When certain nutrients are low, such as calcium and vitamins A and C, the blood pressure may elevate. Basically, by increasing overall fitness and health, blood pressure can be normalized in the majority of people.
It’s also important to look at the whole person, as hypertension often means other problems exist. For example, kidney problems and narrowed or clogged arteries are commonly associated with hypertension.
A common notion about high blood pressure is that sodium causes it. In some people with existing high blood pressure, too much dietary sodium—above an individual level—can magnify the problem. And that amount is very individual. About 30 to 40 percent of those with hypertension are sodium sensitive. For these individuals, even moderate amounts of sodium can increase their blood pressure further. Obviously, these patients should regulate their sodium intake, which is most easily done by avoiding packaged and processed foods and maintaining a diet high in fresh fruits and vegetables and other natural items. But salt modification for those who have normal blood pressure is not necessary as sodium will not raise blood pressure in healthy individuals.
Sodium is a necessary nutrient, essential for good health. One-third of the body’s sodium is contained in the bones, and most of the remaining two-thirds surrounds the cells throughout the rest of the body, where this mineral is a major player in their regulation. Balanced with potassium, sodium acts as an “electrochemical pump” in accomplishing this remarkable feat. Sodium also helps regulate the acid/alkaline balance, water balance, the heartbeat and other muscle contractions, sugar metabolism, and even blood-pressure balance.
In a study on salt and the heart, Jan A. Staessen, MD, PhD, and colleagues from the University of Leuven in Belgium reported in the May 4, 2011, issue of the Journal of the American Medical Association that higher sodium intakes did not translate into a greater risk of hypertension or cardiovascular disease. In fact, their study showed that those with lower sodium had an increased risk of cardiovascular mortality. They studied 3,681 men and women, and after about eight years, there were fifty deaths in the low-sodium group and ten deaths in the high-sodium group. The authors state, “Our current findings refute the estimates of computer models of lives saved and health care costs reduced with lower salt intake” and that they do not support the popular recommendations of a generalized and indiscriminate reduction of salt intake. These so-called recommendations come from the American Heart Association and the U.S. government.
HYPOTENSION—LOW BLOOD PRESSURE
Low blood pressure is called hypotension and is abnormal and unhealthy. It results in less blood getting to the heart muscle, brain, intestine, and virtually all the body’s cells. Low blood pressure is considered below 90/60 mm Hg, but many individuals have signs and symptoms when systolic pressure falls under 100.
Hypotension can cause muscle weakness, sleepiness, fatigue, and dizziness and even fainting. In severe cases, low blood pressure can cause blurry vision, confusion, and be life-threatening.
Hypotension could be caused by various drugs, including alcohol, antidepressants and antianxiety medications, painkillers, and diuretics. In addition, dehydration, diabetes, certain heart problems like arrhythmias, and fainting can cause low blood pressure.
A specific type of low blood pressure is called orthostatic hypotension. It occurs following a sudden change in body position, most often from lying down to standing, although sometimes sitting up after lying down or just bending over to pick something off the floor while standing can trigger it. Symptoms include dizziness and light-headedness that usually lasts only a few seconds or minutes. Technically, orthostatic hypotension occurs with a pressure drop of 20 mm Hg or more, but many patients get symptoms with much less of a drop in blood pressure. (Postural hypotension that occurs after eating is called postprandial orthostatic hypotension.)
An imbalance in the nervous system (autonomic dysfunction) and poor adrenal function can also contribute to hypotension, especially the orthostatic type. Treatment involves finding the cause and eliminating it.
Following exercise of various intensity and duration, there is typically a normal drop in blood pressure into the lower ranges of normal. This postexercise hypotension is defined as a pressure that is lower than the pre-exercise value and can persist for minutes or hours after an exercise session. This phenomenon is one of the reasons exercise can help improve the health of those with cardiovascular disease.
When the topic of nutrition and the heart comes up, many people still think taking a vitamin E (alpha-tocopherol) supplement is a healthy habit for their heart. But research shows that the typical dose of vitamin E, 400 IU, can significantly increase the risk of death, including those who die of cardiovascular disease! Like other nutrients, food doses of vitamin E are very important for the heart (and the whole body), but as part of the whole E complex, which includes three other tocopherols and four tocotrienols.
Normal Blood Pressure Variations
The force of blood pushing against the walls of the arteries as the heart pumps blood creates pressure. This blood pressure is always changing. It lowers during sleep and relaxation and rises when you’re awake, stressed, and excited. It even changes slightly from minute to minute to compensate with the body’s need for increased or decreased blood supply. During the course of a twenty-four-hour cycle—the circadian rhythm—blood pressure is usually lowest in the early-morning hours, rises to reach a peak in mid- to late afternoon, then gradually lowers.
Normally, the systolic blood pressure range can vary 10 to 15 mm Hg while the diastolic can vary from 5 to 10.
In those with hypertension, because the blood vessels are not healthy, wider ranges of blood pressure reading most often occur. This includes the condition called “white-coat hypertension,” where the stress of a visit to the doctor’s office causes an elevation in blood pressure. This can result in a normal blood pressure of, say, 120/8, to jump to 136/90, leading your doctor to claim you have “prehypertension.”
Blood pressure tends to rise with age because in most individuals, overall health declines with passing decades. By remaining healthy and fit, you can maintain normal pressures.
Lower levels of certain B vitamins can significantly increase your risk of heart disease. Inadequate folic acid especially, and also vitamins B6 and B12, can elevate homocysteine levels in the blood, itself a significant risk for heart disease. High homocysteine reflects inadequate levels of these nutrients. Folic acid may be the most important, but many people are unable to benefit from synthetic folic acid and only respond to natural versions.
Vitamin D is also important for the heart, with low levels associated with an increased risk of heart disease. The best source of vitamin D is from the sun, with fortification of foods being quite inadequate.
Other nutrients are important for optimal heart function, including vitamins B1 (thiamin) and B2 (riboflavin), magnesium, and many others. I could make a good argument that all the vitamins and minerals have a significant impact on the heart and blood vessels.
LOW SODIUM: A SERIOUS PROBLEM
While health care organizations such as the American Heart Association encourage low-sodium intakes, millions of people are sodium depleted. It’s a serious problem that can not only reduce quality of life but also contribute to death. And it’s a very common problem. The condition is called hyponatremia and is associated with sodium levels that fall below 135 mmol/liter in a simple blood test. The cause is poor sodium regulation, controlled by the hormonal system, and could be aggravated by low-sodium intake. One particular hormone condition that most often causes hyponatremia is the syndrome of inappropriate secretion of the antidiuretic hormone—SIADH. Antidiuretic hormone (ADH) is secreted by the brain’s pituitary gland and regulates water and sodium as does the adrenal gland hormone aldosterone.
In the United States, three to five million people are diagnosed with hyponatremia annually. Because many individuals with this condition are without significant symptoms, there could be millions more who are undiagnosed. Signs and symptoms can include muscle dysfunction, irregular gait, impaired cognitive (brain) function, and bone loss. As a result, the risk of falls is high, and since sodium plays an important role in bone health, osteoporosis is common. Even in those with mild hyponatremia, nausea, vomiting, and abdominal pain can result.
Infections (tuberculosis, pneumonia), brain injury, cancer, and prescription medications (antidepressants, antiepileptic drugs, diuretics, certain antihistamines) are common contributors to the type of hormone imbalance leading to increased sodium loss and hyponatremia.
While hospitalized patients with hyponatremia have significantly higher rates of mortality, the increased risk of death is also high in those with mild hyponatremia who are unaware of its existence.
While many cases of hyponatremia are found in those past middle age, young, seemingly healthy individuals can acutely develop hyponatremia as well, typically from excessive consumption of water.
The overconsumption of water can worsen hyponatremia and lead to water toxicity, a condition where the body is unable to eliminate excess water through the kidneys. This disorder is sometimes found in athletes, especially marathon runners, who become overhydrated by drinking too much water and sports drinks before and during competition. The lethal combination of hyponatremia and water toxicity can even lead to death. In recent years, more than a dozen endurance athletes have died from this condition.
WHEN FIT PEOPLE HAVE HEART ATTACKS
Tragically, an undetected heart problem can sometimes lurk as a ticking time bomb even inside an athlete’s body. At the 2008 U.S. Olympic marathon trials, Ryan Shay, one of America’s best runners at age twenty-eight, collapsed and died about five miles into the race. New York City’s chief medical examiner said that Shay’s death was caused by “cardiac arrhythmia due to cardiac hypertrophy with patchy fibrosis of undetermined etiology. Natural causes.”
“Natural causes”? There’s nothing natural about a twenty-eight-year-old elite athlete whose heart stops in the middle of competition. Shay’s irregular heartbeat stemmed from an abnormally enlarged and scarred heart.
Media coverage of athletes dying in sports as diverse as basketball, football, triathlon, and running is not uncommon. While we take physical injury in sports as an intrinsic part of competition, we’re bewildered when a seemingly healthy and active person drops dead.
Sudden cardiac arrest, for example, is the primary cause of death in triathlon; it usually strikes during the swim. In the span of three weeks in 2008, three male triathletes suffered fatal attacks during the swim. Their ages were sixty, fifty-two, and thirty-two.
There have been nearly thirty deaths in triathlons since 2004 as recorded by the national governing body USA Triathlon. Close to 80 percent of these fatalities occurred during the swim. The average age of those who died was forty-three years.
And therein lies the irony: Triathlon’s popularity is driven by a continuing revolving door of new participants who are eager to prove to themselves, family, friends, and work colleagues that they are fit. Yet there’s something markedly wrong with this scenario. First, the meaning of health is self-limiting and wrong if one only considers fitness as its sole criterion.
Additionally, neither youth nor middle-age athleticism automatically confers health. Death comes when things go terribly wrong inside the body—what caused the heart to stop or artery to clog? Second, these occurrences are preventable. Third, it is important to differentiate between those young athletes who die in their twenties and younger and those in their thirties, forties, and older age-groups who make up the majority of competitive endurance athletes. Fourth, whenever the issue of fatality surfaces following a sudden death in a marathon or triathlon, the lifestyle habits of the person are almost never mentioned as a possible cause—especially those factors that can contribute to heart disease, including diet, stress, and overtraining.
In a 2011 study in the Journal of Applied Physiology, researchers in Britain tested national and Olympic-level endurance athletes, comparing them to both age-matched controls and younger endurance athletes. Half of the top athletes had fibrosis in their hearts—a condition of scarring that could lead to pathological changes in the heart muscle, abnormal cardiac function, and even death. Both the control group and the younger endurance athletes were without fibrosis.
A new study by Dr. Beth Parker and her colleagues from Hartford Hospital in Connecticut that was published in the Journal of Sports Medicine in 2011 assessed Boston Marathon runners. They compared those who traveled to the race by air (four or more hours) and those who lived within two hours of the race and traveled by car. This study showed that those who had spent more time traveling had even higher cardiovascular risk.
Studies have also demonstrated that endurance exercise can trigger the development of inflammation in the heart. Inflammation is not just a localized concern when, say, the knee gets injured. In 2010, Laval University’s Dr. Eric Larose presented his frightful research findings on the topic of endurance and inflammation at the Canadian Cardiovascular Congress 2010 in Montreal. He had followed a group of twenty marathoners—fourteen men and six women, ages twenty-one to fifty-five, before and after their race. He showed that racing was associated with an inflammatory condition that raised the risk of death by a factor of seven. Most of these runners had significant inflammation that reduced heart function, with dehydration exacerbating the problem. While these runners all recovered by their three-month follow-up evaluation, this appears to be an indication that many runners have serious inflammatory problems that’s due to the stress of competition.
But not all endurance athletes experience this risk. In Larose’s study, just one runner did not have the inflammatory problem. The reason for this was not known, but those with a better balance of fats generally have lower risks of chronic inflammation. This appears to be the same ratio in athletes that I examined during my many years of private practice—the vast majority had some level of abnormal inflammation when they first visited me. Fortunately, most were easily able to resolve the problem by improving their health, especially as it related to dietary fats and reduction of refined carbohydrates.
Immune dysfunction and oxidative stress are also associated with inflammation. Diets high in vegetables and fruits provide adequate antioxidants to control these potential imbalances. Instead, many athletes regularly take supplements in hopes of making up for a poor diet.
The answer to the apparent paradox—how can athletes be fit but unhealthy?—is one of taking personal responsibility, especially considering that most ill health, including athletic deaths, are preventable. In an ideal world, it’s best for athletes to take responsibility for their own health to assure they lower their risk of serious illness and death, which, not coincidentally, will also help them reach their athletic potential.
While most of the deaths in endurance sports occur in those over the age of thirty, the situation is different for younger athletes. About 30 percent of the deaths of young athletes are due to a heart condition called hypertrophic cardiomyopathy (HCM). In the United States each year, several dozen young athletes die during training or competition from this problem (with another six thousand nonathlete deaths among the more than six hundred thousand people with HCM). Prevalence of HCM is significantly higher in dark-skinned individuals and in men, although African American female athletes have a relatively high incidence. These conditions are considered congenital, acquired before birth during heart development.
About half of the young athletes who die have some other type of unhealthy heart condition, which is also preventable. This includes coronary artery abnormalities, abnormally enlarged ventricles, myocarditis (inflammation of the heart), and coronary artery disease. A smaller number, probably less than 2 percent, die from asthma, with prescription and recreational drugs representing about 1 percent of the deaths.
Accidental death of young athletes that is not associated with disease occurs in about 20 percent of cases. These are mostly due to blunt force trauma to the chest, which can immediately stop the heart. This occurs when the chest is hit by a ball or other object, or by another person, at a very precise point in the cardiac cycle. Adhering to specific rules in every sport can reduce the incidence of death by blunt force trauma.
Electrocardiograms (ECGs) are simple and inexpensive tests that can help diagnose many potentially fatal heart problems. Abnormal ECGs are present in 40 percent of trained athletes, including those without detectable disease; they are also twice as common in men and are more prevalent in endurance athletes such as runners, swimmers, and cyclists. Most cardiologists would consider these heart abnormalities related to so-called normal physiological changes due to training. However, in some highly trained athletes, irregular ECGs are identical to nonathlete patients with heart conditions such as HCM and other abnormalities. Whether these changes are due to overtraining, poor lifestyle, or are actually normal may be determined by further evaluations.
Both the International Olympic Committee (IOC) and the European Society of Cardiology (ECS) have advocated that all young competitive athletes be screened routinely and completely (including an extensive history, physical exam, and 12-lead ECG). But the latest guidelines of the American Heart Association do not make this recommendation, saying there is no law in the United States defining legal requirements of sports governing bodies and educational institutions with regard to the screening of competitive athletes. However, in some European countries, local law requires cardiovascular screening, and physicians are considered criminally negligent if they improperly clear an athlete with an undetected cardiovascular abnormality that ultimately leads to death. These strategies have been successful, with about a 90 percent reduction in death from heart disease in competitive athletes.
Many athletes fear cardiovascular screening because if a problem is found, they can be banned from competition. Twenty-three-year-old college basketball superstar Hank Gathers died during a game in March of 1990; the cause appeared to be myocarditis. Writing in the New England Journal of Medicine, Dr. Barry Morano of the Minneapolis Heart Institute Foundation, an expert in this field, stated, “It is possible that had Gathers been withdrawn from competitive sports, his heart disease might have resolved within six to twelve months, permitting him to return safely to competition.”
For athletes in their midthirties or older, and at every level of sport, sudden death is primarily due to atherosclerotic coronary artery disease—also known as clogged arteries. What’s so remarkable is that this preventable condition can develop through a less-than-healthy lifestyle that begins during one’s childhood. Triggers include poor diet, excess stress, and overtraining.
The aging process typically causes a buildup of plaque in the blood vessels—but this too can be remedied with a healthy lifestyle. Even in those with so-called genetic predispositions, lifestyle factors can turn on or turn off the gene for heart disease.
In addition, stress in its broadest definition can be a significant contributing factor in the development of heart disease. Stress can come from an imbalanced diet, from trying to squeeze too much training into a day that is also filled with work and family obligations, and from emotional pressures, including competition.
Overtraining causes an imbalance in the brain, nervous, and hormonal systems (through increased sympathetic activity); it can increase chronic inflammation as well. Any of these problems can contribute to heart disease and increased risk of death. Stress and abnormal cardiac changes can be measured in overtrained athletes, even in the early stages. These include peripheral vascular resistance, high blood pressure, high cortisol levels, and abnormal heart rate variability.
Heart rate variability is a measurement of the time between each heartbeat while resting and provides much more information than just knowing the resting rate. The heart, in fact, speeds up when you inhale and slows down when you exhale. A healthy, well-rested body will produce a larger gap and higher HRV than a stressed-out, overtrained body. While more detailed measurements of HRV (along with other factors) is best achieved by an ECG (electrocardiogram) evaluation by a cardiologist, anyone can measure HRV at home using a simple, practical, and useful method.
A new and relatively inexpensive device called the “ithlete” is compatible with iPhones and touch-screen iPods, allowing you to record your resting heart rate for one minute using a standard chest-strap heart monitor and accurately calculate your HRV. The device provides great animation of the heart and lungs in action, graphs of your results, stores your personal information, and allows for daily testing, comparing your weekly and monthly results. As such, it warns you if HRV worsens, indicating the need for additional rest that day or an easy rather than hard workout. (For more information on HRV and the ithlete, go to www.ithlete.net.)
Overtraining in its early stage, just beyond the normal overreaching aspect of training, can produce abnormalities; ironically, this can result in short-term improvements in athletic performance. Many athletes who experience this phenomenon continue pushing themselves, mistakenly thinking their training is successful. Continuing on this path brings further ill health, including clearer indications of overtraining. For example, abnormal blood markers (such as plasma cardiac troponin T and I) have been found in triathletes and marathon runners following long races. These tests are indicative of a transient myocardial problem—a heart injury. Experts say they are still unsure about the seriousness of this problem. Immune markers are also distorted in many athletes following competition and during periods of hard training, even following a single long training session. This is associated with an increased frequency of upper respiratory illness in athletes. Some have severely compromised immune function, making them vulnerable to more serious health problems. Overtraining ultimately results in a declining performance.
The acceptance of poor health, by both athletes and even their coaches, is well documented in all sports. This has led to an epidemic of physical injuries. There is even a name for athletic cardiac changes: athlete’s heart. Other overtraining outcomes have special names too and are often glorified: runner’s knee, swimmer’s shoulder, and runner’s anemia.
When looking at the overall picture of maintaining good heart health, it’s relatively simple: Get more healthy and fit and you’ll significantly lower your risk for heart disease. Three key issues that increase the risk of heart problems include carbohydrate intolerance, chronic inflammation, and low levels of physical activity. Like most other lifestyle factors, successfully managing these is entirely under your control. Don’t procrastinate either.
HEART DISEASE AND THYROID DYSFUNCTION—A FREQUENTLY MISSED CONNECTION
The thyroid gland resides in the front of the neck and produces hormones important for regulating sugar and fat burning, protein and calcium, and other metabolic functions. Thyroid hormones are closely related to the function of the heart and blood vessels, affecting oxygen uptake, blood flow, heart contractions, and even blood volume. These factors are important for a healthy cardiovascular system. So it’s no surprise that in patients with heart disease, there may be an accompanying thyroid condition that compounds the problem. Typically, this is hypothyroidism, and often it’s subclinical, meaning that the problem is subtle and often missed by health care professionals in their assessment. Hypothyroidism is considered by many to be a risk factor for heart disease.
In hypothyroid patients, low levels of thyroid hormones can lead to an increased level of homocysteine, high blood pressure, and elevations in both LDL and total cholesterol, all of which can raise the risk of heart disease.
An overactive thyroid—hyperthyroidism—can induce a different kind of stress on the heart and blood vessels, including a faster resting and exercise heart rate and the risk of atrial fibrillation.
Thyroid dysfunction is relatively common, more so with advancing age. Hypothyroidism occurs in about 4.6 percent of U.S. adults (4.3 percent in the subclinical form). Hyperthyroidism is present in 1.3 percent of the population (the subclinical form in 0.7 percent).
Data from the Framingham Heart Study demonstrates that some degree of hypothyroidism, as evidenced by elevated serum thyroid-stimulating hormone (TSH) levels (>5 mU/L), is present in 10.3 percent of individuals over age sixty years, with a higher prevalence in women than in men—13.6 versus 5.7 percent. (In hyperthyroidism, TSH levels are below normal.)
Those individuals being evaluated for thyroid function should be tested for TSH (also called thyrotropin), a pituitary hormone that stimulates the thyroid to produce free thyroxine (T4) and free triiodothyronine (T3), an iodine-dependent hormone. TSH may be the best single blood test for thyroid dysfunction, with T4 and T3 also easily tested in the blood (although even in under- and overactive thyroid conditions, T4 and T3 levels are sometimes within normal ranges). The results of these blood tests can help determine (or rule out) four situations: hyperthyroidism or its sub-clinical form and hypothyroidism or its subclinical form.
If T3 or T4 levels are high, a more clear indication of hyperthryoidism, another test should be performed, that of thyroid antibodies (which could indicate an associated autoimmune condition). In patients with hypothyroidism, low body temperature is a common sign, with under-the-tongue levels well below the normal of 98.6°F, sometimes as low as 96°F.