Heart disease is epidemic in the United States and around the world. It might seem self-evident, but your lifestyle habits have a huge impact on your health, especially heart health. You may think you can wait until later, maybe until you get into late middle age, to live more healthfully. While adopting good habits at any point in your life can be beneficial, why not start right now to keep yourself as young as possible for as long as you can? Research that has followed people for very long periods time, tracking their health, diets, and activity levels, has shown that following the DASH or the Mediterranean diet is associated with lower risks for heart attacks, stroke, and heart failure. We know that the DASH diet specifically improves blood pressure, and that it is associated with lower “bad” (LDL) cholesterol and better “good” (HDL) cholesterol. Follow-up DASH research showed that replacing refined carbs with monounsaturated fats (MUFA) or extra protein improved blood pressure and HDL, while lowering triglycerides.1 This is a particularly beneficial improvement on the DASH diet, and it has been fully implemented in this Med-DASH diet plan.
Let’s learn a little bit about heart disease. Your arteries can take decades to get to the point of being so blocked that they can start to limit blood flow to parts of your heart muscle and other areas of your body. Long before you are close to having a major blockage and a potential heart attack, you may notice you feel very tired and are easily fatigued. You may think you are just getting older and need to slow down, but in reality, it may be time to go see a cardiologist for a battery of tests. He or she will likely do an EKG, which may lead to a stress test and possibly a nuclear stress test. While we would prefer not to need either, it’s much better to discover you have a blockage via a test, rather than finding out during a heart attack. That heart attack will leave part of your heart muscle with dead tissue. You may never be the same; the majority of women who have heart attacks will never fully recover to their level of health before the attack. The best prevention strategy is to change your habits now. I will make this easy, and at the same time provide you with guidance on how to enjoy delicious food using this eating pattern.
When I worked at a Navy hospital, I was shocked to hear some of the sailors say they were starting to slow down because they were in their late thirties or early forties and ready to retire from their military career. I was in my fifties at the time, and I was much more energetic and fit than these young men. I saw retirees and their spouses who were younger than me but looked twenty years older. Using canes, with limited mobility, these men and women were much too old before their time. But on the positive side, I also saw a retired couple who were in their late nineties, very physically fit and full of life, always planning their next trips. They stopped by once a year to be sure that they were doing the best they could to stay young. And they were not alone. I saw many people who were in their seventies, eighties, and nineties and doing their best to stay active. One of our friends is a ninety-three-year-old man with an encyclopedic knowledge of baseball and a ready collection of jokes. In addition to joining our coffee group every morning for his social well-being, every day he walks in his community pool for an hour. He says that if he didn’t do that, he wouldn’t be able to walk at all. He has decided to stay young. Another friend is an eighty-seven-year-old former Marine who golfs eighteen holes (without a cart!) three to five times per week, early in the morning before he joins the group at coffee. Being active, social, and fit is a choice, and helps give pleasure to life. These experiences are seared into my brain and have reinforced my actions to extend my own health and longevity. We need to take another look at our expectations and decide to stay young and healthy for our entire lives. We can do it. Even if heart disease or diabetes runs in your family, you can change what happens to you. Having a genetic disposition toward heart disease is like having a bare piece of land. You can plant seeds and tend the garden, or you can let it go to weeds. It’s up to you. Following the Med-DASH diet will prevent those heart disease “weeds” and reduce your risk for developing cardiovascular problems by letting your good health and well-being grow.
One of the reasons the DASH-Med plan is so important is the very high prevalence of diseases that can be managed by it. The most recent estimates2 of the impact of these lifestyle-related diseases in the United States are:
• Cardiovascular disease: 93 million people, or about 37 percent of the U.S. adult population, at a cost of about $330 billion per year. Cardiovascular disease is the number one cause of death in the United States, higher than all types of cancer combined, for men and for women.
• Hypertension: 86 million Americans, with an annual healthcare cost of $53 billion.
• Type 2 diabetes: about 30 million people, including those who are undiagnosed, plus 82 million people with prediabetes. The annual cost is about $245 billion.
• Metabolic syndrome: almost 35 percent of adult Americans.3
While these are statistics, the consequences are far more devastating: heart attack, stroke, kidney failure, amputations, blindness, intolerable nerve pain. You don’t want to go down this road. Your life will never be the same. Let’s get out in front of this!
When we consider our personal risk for heart disease, we have factors that we can and cannot change, as shown in table 1.
The major concerns around cardiovascular disease include heart attacks, peripheral artery disease (PAD), strokes, and heart failure. The important measures we use to judge whether we are doing the right things to manage heart health include monitoring blood pressure, cholesterol, triglycerides, pulse rate, etc. Having high blood pressure, also called hypertension, makes you much more likely to have a stroke or heart failure (and kidney failure). Hypertension is a particularly debilitating disease. If your heart becomes less efficient, it may end up having a hard time pushing your blood through your circulatory system. Then fluid starts building up in your lungs, making it difficult to breathe. This disease, if not well managed, typically results in frequent hospitalizations. Heart failure will make you feel much older and can severely limit your activities and even lead to premature death.
These conditions are often called silent killers because if you don’t have regular physical exams, you will probably not be aware of having elevated blood pressure, cholesterol, and/or triglycerides until you have an event like a stroke or a heart attack. Just because you feel all right does not mean you can or should avoid regular checkups with your doctor. You would much rather prevent a problem than have to deal with very severe consequences.
A key objective of this book is to help you keep your heart healthy. The primary problems that we are trying to manage or avoid are atherosclerosis, high blood pressure, and metabolic syndrome. The main numbers you need to know include your total cholesterol, LDL cholesterol (the bad type), HDL cholesterol (the good type since it helps to clean up arteries), and triglyceride, all of which are collectively known as blood lipids. Blood glucose and blood pressure are the other important numbers to know.
Your physician will set targets for your blood lipids depending on your personal medical history. Atherosclerosis is the buildup of cholesterol and triglycerides in the arteries (plaque) and can occur even in small blood vessels throughout your body. You are probably most familiar with the blockage of a coronary artery resulting in a heart attack, but plaque can also cause blockages in your carotid artery or other arteries in your brain, potentially leading to a stroke if oxygen-rich blood can’t get to a site because of the blockage. Or the lipids may narrow an artery or vein, making you more susceptible to a stroke from a blood clot. Cholesterol buildup can cause blockages in your femoral artery, which can trigger severe pain when you try to walk or even at rest. This type of blockage will interfere with the blood flow to your entire leg and can lead to infections, including gangrene.
Cholesterol is the main component in the plaque, and it is primarily oxidized LDL cholesterol that causes problems. Triglycerides and their metabolic by-products are also involved in this process. The proteins in HDL are packages that clean up cholesterol in your bloodstream and deliver it to the liver to be eliminated. Elevated triglycerides depress HDL levels, resulting in higher LDL-cholesterol and more plaque. Again, it’s not just the large arteries that can get cholesterol deposits. Your eye doctor may be able to see cholesterol crystals in the back of your retina, which may be related to risk for age-related macular degeneration. Cholesterol can also block the small blood vessels in sex organs and lead to erectile dysfunction or to lower responsiveness.
Blood glucose is an important number to know for your heart, especially since elevated glucose can be an early warning sign of metabolic syndrome. If caught early, metabolic syndrome and higher blood sugar (elevated glucose) can often be managed by lifestyle changes in what you eat and your activity level. These lifestyle changes will have benefits for your health even beyond your heart. Your blood glucose level should be under 100 (5.6 mmol/L) to be considered healthy. (Being closer to 80 would be perfect.) If your glucose is between 100 and 125 (5.6 to 7.0 mmol/L), you are considered to have prediabetes, which is a component of metabolic syndrome.
Blood pressure indicates how your heart is functioning to move blood through your arteries and veins. Elevated blood pressure is an indicator that your heart is having to work harder than it should in order to move blood around your circulatory system. If your blood pressure is mildly elevated, you may be able to reverse it through changes to your diet (especially with the DASH diet) and adding regular activity that gets your heart beating a little faster, to improve your entire cardiovascular system.
To better understand your blood pressure health at the start of this program, let’s look in greater detail at what some of these conditions look like and how they are assessed. The 2017 blood pressure guidelines from the American Heart Association (AHA) and the American College of Cardiology, generated by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC8), have the following blood pressure categories:
Surprisingly, someone who has normal blood pressure at age fifty-five still has a 90 percent risk of developing hypertension at some point in their lifetime. However, while this is common, it is not a normal, healthy part of aging. There are populations in the world where blood pressure stays in the healthy range for their whole lives. And that is the goal here, too. We want to have all the blood pressure benefits of the DASH diet and all the heart-protective benefits of the Mediterranean diet. We want to stay healthy for our whole lives.
Stage 1 hypertension can be treated with lifestyle changes. Along with exercise, reaching and maintaining a healthy weight, the DASH diet and the Mediterranean diet are both recommended for optimal blood pressure. So, if these diets are so beneficial, why don’t doctors recommend them more often? Unfortunately, many physicians think that taking a pill may be easier for their patients than changing their eating and exercise habits. We are going to change that perception.
Foods that are good sources of fiber, calcium, potassium, protein, and unsaturated fats are associated with improved blood pressure. Fortunately, the Med-DASH plan is rich in these key nutrients. By focusing on the important foods to include, you will easily be getting the right minerals, vitamins, antioxidants, and anti-inflammatory compounds to help you reach and maintain healthy blood pressure.
Throughout your life, your initially clean arteries are gradually developing plaque that can eventually create a blockage in a vein or artery. As the result of autopsies done on service members during the Vietnam and Korean Wars, even young men of eighteen or nineteen were seen to have the beginnings of plaque buildup in their arteries. In servicemen killed in the Korean War, 77 percent had atherosclerosis (plaque), while 45 percent of Vietnam War casualties had plaque.
Today the medical profession is much more aggressive in monitoring and treating elevated cholesterol and other heart disease risk factors. Fewer people are smoking. Service members killed in combat today have much lower levels of plaque, with only 8.7% showing blockages.4 Statins are standard therapy for elevated cholesterol for everyone. They substantially reduce LDL cholesterol but can also lower HDL cholesterol, the “good” cholesterol. It has been shown that statins reduce the risk of heart attack even more than just the reduction in LDL would suggest. Statins have a side benefit of lowering systemic inflammation, which provides additional benefits. And we can get many of these same benefits and more from diet and lifestyle changes. If we can’t avoid the statins altogether, we can at least do everything we can with diet and activity to minimize the dosage we need to take.
If lowering cholesterol is as simple as taking a pill, isn’t that enough? Actually, it would be even more beneficial to have your HDL cholesterol be high, at least over 60, while at the same time having your LDL cholesterol be as low as possible. Depending on your personal medical history, you should probably have an LDL level less than 100; if you have diabetes or have had a heart attack, your doctor will want you to be under 70. Although these guidelines are not as cut-and-dried as they used to be, they are most likely the standards that your doctor will use. And while statins lower cholesterol, they do nothing for triglycerides. Fortunately, the Med-DASH plan will cover all the bases, augmenting your medical treatment for elevated lipids (cholesterol and triglycerides) with a diet that also promotes heart health, including helping to lower bad cholesterol and triglycerides and increase good cholesterol.
The first step in developing plaque is a small buildup of fats (mostly LDL cholesterol) on the surface of artery walls.5 This initial step can start to happen as early as childhood and adolescence. Factors that can speed this process include smoking, hypertension, diabetes, obesity, and genetics. The LDL can become oxidized and contribute to mild inflammation of the artery lining. Inflammation is a factor in making these deposits stickier, thus attracting more buildup. Later in the process, a thin fibrous layer will cover the plaques. These layers can rupture, exposing the fats and cholesterol, and potentially creating pieces that can plug an artery, known as thrombosis. In many cases, the rupture heals and becomes the base for a larger deposit of plaque. Sudden cardiac death can result when there have been multiple cycles of rupture and healing. Calcium is also a component in these plaques. New research is suggesting that calcium from supplements may be associated with increased risk for heart disease.6 However, a diet that is rich in naturally occurring calcium, like the DASH diet, seems to be protective for heart disease as well as bone health.
When we measure the effectiveness of statins, we especially look at LDL. Cardiologists have found that the LDL reduction provides a window into evaluating the amount of plaque reduction. For example, if LDL is lowered from 160 to 100, that would reflect a significant reduction in plaque, therefore a big improvement in lowering cardiovascular disease (CVD) risk. Statins also seem to stabilize the remaining plaque and reduce the likelihood of rupture. In as little as four months, statins can reduce the risk of potentially life-altering consequences such as heart attacks, strokes, and TIAs (transient ischemic attacks, or mini strokes). This seems to result from a combination of lowering LDL and reducing inflammation. The benefit of statins is persistent in reducing heart disease risks, even long after discontinuation of treatment (which I am not encouraging anyone to do). On the negative side, however, the use of statins is associated with increased risk for developing type 2 diabetes, particularly in women, the elderly, and people with a strong family history of diabetes.7 It is to your benefit to make lifestyle changes to minimize the statin dosage you need.
HDL cholesterol can be thought of as a sponge that that helps to soak up cholesterol to help keep our arteries clean. If your HDL level is high, you have a good capacity for reducing LDL cholesterol, which, left untreated, can plug heart arteries. The whole-food, plant-focused Med-DASH plan helps you maintain an HDL level as high as possible. A diet high in refined carbs, sugar, and alcohol is more likely to produce higher levels of triglycerides. These fats are packaged in chylomicrons, which unfortunately have the capability to soak up some of the cholesterol from HDL, shrinking them and lowering HDL, which is the opposite of what we want.
When your blood sugar is under control, you won’t make extra triglycerides from excess glucose. Cardiovascular (aerobic) exercise helps with a whole host of interrelated problems, including excess belly fat, high blood pressure, prediabetes, and heart disease. In the next section, you will learn a lot more about this relationship.
We want to stay healthy for our whole lives. One of the most common and devastating conditions that can ruin our health is metabolic syndrome. This is a particular interest of mine, because on one side of my family, almost everyone has it, so I am also at high risk. It is a combination of at least three diseases: prediabetes or type 2 diabetes, high blood pressure, and undesirable levels of cholesterol and triglycerides, and excess weight around the waist. Fortunately, the Med-DASH plan addresses each of these problems.
It is possible to manage or even reverse metabolic syndrome. In order to understand how to do that, it is important to understand what metabolic syndrome actually is, and how it gets started. (A syndrome is a disease where you do not need to have each of the symptoms to be diagnosed.) At some point in our lives, we might become a little overweight. Perhaps we are not very physically active, and we might be eating too much processed food, especially starchy and added-sugar foods, and foods high in saturated fats. Initially, our body will make extra insulin to keep blood sugar under control. But at some point, our muscles become even less sensitive to insulin (this is called insulin resistance), and we start to wear out our ability to produce enough, leading to higher-than-normal blood sugar. The excess blood sugar causes you to gain extra weight around your waist, which further deteriorates blood sugar control. At this point, you could be diagnosed with prediabetes or diabetes. Our blood pressure gets higher than desirable. The high blood sugar causes triglycerides to increase, which lowers our HDL cholesterol. Each of these symptoms on its own is bad, but when they all happen at the same time, they can be especially problematic. And they can cause additional diseases such as kidney disease from high blood pressure or high blood sugar, fatty liver disease from excess triglyceride production, and nerve damage and pain from high blood glucose. Think of your diagnosis as your early warning, so that you can reverse it.
Metabolic syndrome (and its related sister, polycystic ovary syndrome), unfortunately, is a widespread modern condition. The outward sign is an out-of-proportion waist size, often referred to as an “apple” body shape, or android obesity. The hidden signs are any of the following: elevated fasting blood sugar, elevated blood pressure, low HDL cholesterol, and high triglycerides. Almost one-third of adult Americans have diagnosed or undiagnosed metabolic syndrome. It is a warning sign that you are at elevated risk for heart attack, stroke, and type 2 diabetes. Fortunately, each of these conditions is improved with the Med-DASH program. Using the optional Med-DASH jump-start plan in this book (see here) will help you go a long way toward shrinking your waist size, an easy, visible way to evaluate whether you are taking the right steps to help control this condition.
While we tend to think of heart attacks as being primarily a concern for men, did you know that heart disease is the number one cause of death in women, too? Nearly one in three women will die of heart disease. That is more than those who die from all types of cancer combined.
Women’s heart attack symptoms may be quite different from those of men. Chest pain or pressure are the most common symptoms for both men and women. However, women are more likely to experience shortness of breath, back or jaw pain, or nausea and vomiting as their primary symptoms, and may not recognize these as possible symptoms of a heart attack. Early treatment is critical to recovery. Even today, with all the education about heart health in women (such as the Go Red for Women campaign), women tend to get diagnosed later after the onset of symptoms. Fully two-thirds of women will never fully recover from a heart attack.10
One of the key ways the Med-DASH plan helps you lower your cholesterol is by reducing saturated fats. We can choose lean meats and poultry when we have animal proteins. (Beans are good protein sources and do not contain saturated fats. Additionally, their fiber helps to reduce absorption of cholesterol and fats during digestion.) Avoiding processed foods can limit exposure to trans fats and palm oil, which are very unhealthy for your heart. Both of these fats have been used to make processed foods, such as crackers and cookies, crispier. The primary fat in palm oil is palmitic acid, which is a saturated fat and readily used by the body to make cholesterol.
Reducing cholesterol that comes from food may be beneficial for treating heart disease, but it is not as important as reducing the amount of saturated and trans fats you consume. We normally consume over 100 times more of these fats than we do dietary cholesterol. Limiting saturated and trans fats has a huge payoff.
While many physicians still tell their patients to adopt a low-fat diet, reducing fat intake is actually counterproductive for heart disease and is no longer part of the lifestyle recommendations from the American College of Cardiology and the American Heart Association (AHA). You want to reduce harmful fats, not the beneficial ones. If you limit intake of all fat, it typically gets replaced by processed carbs, which can cause your body to make more cholesterol and more triglycerides. That is not heart healthy. From the AHA Presidential Advisory: “replacement of saturated fat with mostly refined carbohydrates and sugars is not associated with lower rates of CVD and did not reduce CVD in clinical trials.”11
So how do you avoid refined carbohydrates, extra sugar, and harmful fats? Don’t shy away from anything that has a higher fat content—just try to cut down on foods that contain palm oil or coconut oil. Healthy fats, such as those in avocados, nuts, and olive oil, should not be off-limits to you—and they aren’t off-limits on the Med-DASH food plan. In addition to allowing you to enjoy foods that contain helpful fats, the Med-DASH plan has a built-in safety net to help your body process fats. It is super rich in plant foods that are high in fiber. Soluble (or viscous) fiber is great for trapping dietary cholesterol and fats during digestion, and not allowing them to be absorbed. Some of the best sources include beans, oats, barley, apples, pears, orange, berries, stone fruits (peaches, cherries, plums), and many vegetables.
The high levels of antioxidants found in plant-based foods are very beneficial for heart health because they reduce the body’s ability to oxidize cholesterol. It is oxidized LDL cholesterol that is associated with creating plaque and potential blockages. Having a diet rich in antioxidants helps reduce this risk. Antioxidants also help reduce inflammation, which is an initiator for the components of metabolic syndrome. In addition to fruits and vegetables, onions, garlic, tea, and chocolate are also rich in antioxidants. High flavor and high health benefits!
The Mediterranean diet and the DASH diet have each been shown to be associated with lower risk for developing type 2 diabetes, which is a key component of metabolic syndrome.12 Reducing processed foods enhances the risk reduction. Reaching and maintaining a healthy weight is also very beneficial for reducing risk of heart disease. Fortunately, the Med-DASH plan is very satisfying and filling, making it much easier to avoid overeating. Later, we will cover this in detail.
You may have tried to eat healthfully before and either found it too difficult to sustain or never got the results you were expecting. It’s time to expand the possibilities in your life. Have protein and fats to satisfy hunger more easily and longer, while also keeping blood sugar on a more even keel. This is the opposite of the old food guidelines, which had dieters eating foods stripped of precisely the nutrients that are filling and satisfying, making those foods less satisfying. This is what was wrong with the high-carb, low-fat/low-protein diet plans. Everyone became fatter precisely because these plans led to overeating. I am going to present a program that will improve your health and be easy to follow. You will love the food, and at the same time, it will help keep your hunger and cravings from overpowering your new eating plan.