Drug Free Heart Disease
Vascular disease is one of the leading killers worldwide. Blood vessels throughout the body narrow and harden as cholesterol plaques build up and accrete calcium. It happens to one degree or other in almost everyone, but there are things you can do about it.
Firstly, it is important to stress that though this is a 'Drug Free' series of articles, there is a lot to be said for drugs in the treatment of established heart disease and also in some circumstances, in its prevention. If you have been advised to take medication for heart disease, you should continue to take them as well as considering the advice we give here. Discuss this with your doctor first though. If you have not yet been started on medication then this is the place to come to get tips on how to stay healthy and hopefully avoid illness.
This article is also aimed primarily at adults aged 20-70 and the evidence referred to is based on studies in this age group - we plan articles on child and older persons health in the near future. Some of the advice here is not suitable for children or older adults so if you are older or younger than our guide age-group, then please speak with your doctor before following our recommendations.
Here are the top things you do to reduce your risk of heart or vascular disease:
There is absolutely solid evidence that exercise reduces heart disease and within reason, the more the merrier.
A 2014 study showed that people who run for 10 minutes twice a week live on average 3 years longer than people who do no exercise.
Other research shows a significant difference between light, moderate and vigorous exercise - we can show that exercising vigorously for up to one hour three times a week has greater benefits than lesser amounts of exercise.
There is probably a small additional benefit from even more exercise, though there is insufficient evidence to recommend this at present. It is also possible to do too much, with the risk of injury rising with increasing activity. As with most health activities, it becomes a matter of balancing not getting enough against the harm of too much. We recommend you work up to 1 hour of vigorous exercise three times per week as there is evidence that this is safe and effective. Any more than this should be discussed with your doctor.
What is exercise?
Exercise is any physical activity that gets you feeling short of breath.
During light exercise, you should not be able to talk easily - short sentences between breaths.
Moderate exercise means being able to say only a few words.
Vigorous exercise means not being able to talk whilst doing it. You should stop if you feel unwell or get chest pains, whatever level you are working at.
It is probably important to maintain the exercise for an appreciable time - at least 20 minutes continuously; though some studies suggest shorter pulses may be as effective.
Top Exercise Tips:
- Try to do something you enjoy as it will be easier to keep to it.
- Habit is everything - once you get used to making time to exercise it gets easier.
- Try cycling to work - it may take a little longer but you don't have to spend that time exercising any other way.
- Swap half an hour of TV or computer time for exercise.
- Don't feel bad that you are not as good or fit as others - if you are doing something, you are probably fitter than many.
Evidence level: Solid. Observational studies, randomised controlled trials.
2. Maintain a healthy weight.
Before you skip this section and put it in the 'too hard' basket, this is not quite what you think.
Yes, there is an advantage in being within the 20-25 body mass index range, but there is more to it than that. It is not just being overweight that is a problem, it is why you get to be overweight. Many people who are overweight get to be so by eating too much and exercising too little. If you can correct the lack of exercise and make healthier food choices, your weight will probably improve without any specific weight loss effort or target and there is some evidence that you will gain many of the benefits of weight loss even if you don't lose a gram.
For those interested in chasing figures, we recommend the following:
Weight: Not more than 100Kg and not less than 50Kg.
Body mass index: 20-25 (weight in kilos divided by height in metres squared)
Waist: under 98cm for women and 102cm for men.
If this seems all too far away, why not try to lose just 5Kg - for anyone who is overweight this has measurable benefits, especially if you have been told you are 'pre-diabetic' or have 'impaired glucose tolerance'
Top weight loss tips:
- The only way to lose weight is to eat less, exercise more or do both. There is no magic bullet.
- If you are overweight, follow all the advice in this article and you will probably lose a lot of weight (10-15% of your bodyweight on average, based on study evidence)
- Give yourself sensible targets - if you are 103Kg, aim for 100 first, not 80- the small steps are easier to visualise.
- Almost all fad diets work but none of them are any better than the advice we give you. Few are healthy in the long term.
- A lot of people gain benefit from the various paid support groups (Weight Watchers and Jenny Craig) and their advice is good for long term health.
- Losing weight with a friend will help both of you.
- Avoid foods that combine fat and sugar - it's easy to eat them all day. Make sure treats are exactly that - not regular items.
- Measure your waist - big reductions occur early on and this helps motivation.
We plan a series of articles on weight loss in the future - stay tuned for more support.
Evidence: Solid - observational trials, randomised trials, World Health Organisation advice.
3. Stop Smoking
Smoking cessation is essential for cardiovascular health. Smokers in their 50s have double the risk of heart disease when compared with non-smokers. Smoking cessation is beyond the scope of this article but:
We provide FREE smoking cessation support - just ask for an appointment with our nurses.
If you prefer, you might also call Quitline 0800 778 778 for good advice and free cessation supplies.
Most pharmacies also provide free smoking cessation advice.
Evidence: Solid - observational trials, randomised trials, World Health Organisation advice.
4. Eat more vegetables
There is strong evidence that people who eat more vegetables get less heart disease. It is not possible at present to be sure whether this effect is due to the vegetables themselves, or to the absence of the kind of foods they tend to replace in the diet, but for now we recommend that non-starchy vegetables should make up at least half of your daily intake of food.
If this is too hard, try to eat at least 3 portions (a portion is your handfull) of vegetables daily. Smokers should aim for 7. Analysis of the dietary patterns of tens of thousands of people over many years shows that
Fruit don't count in this portion count as the evidence suggests that fruits are neither beneficial nor harmful in and of themselves but they are a lot better than many alternatives.
Fruit juice is not recommended as it is too high in sugars.
- Make the change gradually - it is easier to do it a bit at a time, especially if you have to bring other family members along on the journey!
- Cauliflower, broccoli and carrots make a great alternative to potato, rice, taro, kumara and pasta.
- You can hide a lot of pumpkin in dishes containing mince.
- Frozen veg are almost as good as fresh and are much cheaper in winter.
- Try putting the veg on your plate first - then put half as much starch and protein sources on the plate. The Healthy Plate Model is strongly recommended.
- Buy less meat - you'll need more veg to fill up.
Evidence: Strong - observational trials, World Health Organisation advice. There are other benefits of vegetable intake in addition to heart disease reduction.
5. Eat Less Meat
Humans are omnivores and we thrive on meat, especially if vegetables are added, but there is growing evidence that the more meat you eat, the more likely you are to have heart disease and strokes. What gives us strength and drives reproduction on a mass scale does not lead to long term healthy outcomes.
As with all dietary statements, there is a lot of controversy over the exact role played by meat in heart disease but it is likely that a combination of cholesterol, saturated fat, naturally occurring hormones, the particular balance of proteins and many other factors are relevant. What is certain from repeated large scale trials is that subject to other health choices, the more meat you eat, the more likely you are to get cancer or heart disease.
That having been said, the current evidence supports a hierarchy of risk with seafood at the low end of the spectrum, poultry in the middle and red meat or game at the high end.
We recommend that where possible, you keep meat consumption of all kinds to a minimum and prefer lower risk meats when you do eat them.
So should we all be vegetarians?
The evidence tends to suggest we would be healthier overall if we did, though there are a lot of problems with this being outright advice and care needs to be taken not to be too simplistic in approach.
Taken overall in large scale observational studies, vegetarians do not live as long as non-vegetarians, with optimal longevity occurring with moderate meat consumption (about 80g per day) but this trend is not consistent and studies of specific, well-crafted plant based diets show some significant potential for better health. It is possible, even probable that this is due to many vegetarians consuming more calories, more sugar and more dairy products than non-vegetarians, although there is insufficient evidence to be more precise than this. What is clear is that there is no apparent harm from a carefully organised vegan diet.
There is also some evidence that higher protein diets are better for older adults (65+) and lower protein diets better for younger adults. Those with significant illness often have much higher protein needs and may be harmed by a low protein diet so once again, if you are not currently in good health, or over 65 years of age, we recommend you discuss your dietary needs with your doctor before making any changes.
Top Meat Reducing Tips.
- As with any change, don't do it all at once.
- Buy better eat less. Have a small fillet steak rather than a large rump.
- Pad out mince with pumpkin, chickpeas, lentils and any past-its-best veg from the fridge.
- Try having one or more vegetarian days per week 'meat-free monday'
- You will need a fair bit more other foods to feel full if there is no meat so prepare about 1/3 more veg than you normally would.
- Whole grains and nuts make excellent meat substitutes.
Evidence: Moderate. No definitive trials or real consensus opinion but lots of small trials, some of high quality all trend the same way - less meat is better. No evidence contradicts this advice. Large scale observational trials have demonstrated an association between red meat consumption and mortality from heart disease.
6. Reduce Dietary Cholesterol and Saturated Fats - Prefer vegetable fat sources.
Cholesterol and saturated fats were amongst the first dietary substances to be identified as harmful from long term trials. Although there is controversy as to the role played by cholesterol in the diet, there is a solid association between its consumption and average levels of cholesterol in the blood and between levels of cholesterol in the blood and heart disease. To date (Sept 2014), studies have not supported cholesterol lowering alone (by diet) as helpful but neither have they shown it to be harmful and there is a logical reason for considering reducing dietary cholesterol:
Cholesterol is one of the main components in the plaques that cause heart disease. Saturated fats are relatively difficult to break down and so circulate for longer periods of time and may also be found in coronary artery plaque. Plant-derived oils and fats are much lower in saturated fat and generally contain little or no cholesterol, whereas butter and other dairy products are rich sources of both.
The exact role of dietary cholesterol is however disputed:
- Much of the cholesterol in the human body is produced in the liver and in healthy adults, this comprehensively overwhelms dietary cholesterol consumption in almost all dietary circumstances.
Though this is the case, in large scale studies such as the Framingham project, the actual level of cholesterol in the blood is both associated with dietary intake and with heart disease.
- Some people have naturally very high cholesterol levels even if they consume almost no animal fat yet others seem to be able to eat what they like and still have a low cholesterol.
If you naturally have high cholesterol, you are probably at much higher risk of heart disease and vice-versa. It may be that those whose dietary cholesterol intake does not affect their blood cholesterol may be able to ignore dietary saturated fats and cholesterol but no studies have been done to confirm this.
- Only a proportion of people are able to modify their cholesterol significantly by diet even without specialised cholesterol lowering products.
It is possible that these may be the people who gain benefit from dietary intervention specifically aimed at cholesterol. If you can lower your cholesterol by diet then this is certainly not harmful and might be beneficial but no studies have examined this group in isolation.
- Low cholesterol levels are associated with short life expectancy.
This is true, but only in older people. Cholesterol is a marker of liver function and it is likely that older people with very low levels of cholesterol experience this as a disease state, the result of multiple other illnesses and thus are more likely to die sooner. In younger people, low cholesterol is strongly associated with good cardiovascular outcomes.
Given these differences, it is almost impossible to identify the role of dietary cholesterol in isolation from any other so it may be best to stick to what are relatively undisputed facts:
- It is a fact that on average people who have a high cholesterol diet have more heart disease.
- It is a fact that on average people who eat more saturated fat have more heart disease.
- There is no evidence that a diet high in cholesterol or saturated fat is beneficial.
- There is no evidence that a diet low in cholesterol or saturated fat is harmful.
With these four truths, it stands to reason that reducing the consumption of cholesterol and saturated fat is at least not bad advice and may be beneficial.
Beyond using plant-based oils, there is little or no evidence to suggest one is better than another for health. Olive oil, Canola, Rice-Bran, Sunflower, all are much the same.
Cholesterol - lowering spreads do work (by interfering with Cholesterol uptake) but there is no evidence to date that using them reduces the risk of heart disease.
Top Cholesterol Reducing Tips:
- Where possible, prefer vegetable oils and spreads to lard and butter.
- Try to reduce your consumption of dairy prodcuts, and prefer low fat or trim variants whenever possible.
- Reduce egg consumption.
- Cook your own food - most saturated fat in our diet comes from processed foods. Pastry is especially high in saturated fat.
- Reduce meat consumption.
- Increase dietary fibre consumption.
Evidence: Strong. Multiple studies have shown an association between dietary saturated fat/cholesterol intake and cardiovascular disease. World Health Organisation guidelines.
7. Avoid Refined Carbohydrates
Sugar and starch are rich sources of glucose, which is needed to power brain and heart tissue. Without some carbohydrate, we perform poorly and feel dreadful as alternative sources of energy are used, but with too much, we gain weight and get sick, so what is the best advice.
Sugar and starchy foods are much the same in the stomach - there is an enzyme in saliva that starts to convert starch into glucose even before it leaves the mouth so we will treat them the same here. Both cause large rises in blood glucose, which are countered by insulin production.
If the meal is mostly glucose or sucrose (say a fizzy drink) or starch (white bread, pasta, potato, rice, taro) the rise in plasma glucose level is large and fast, but the food is quickly gone giving two problems - first, the blood glucose level was high, which contributes to heart disease and second, the amount of insulin required to deal with a big load of glucose is large leading to relatively low glucose levels later on, lethargy, hunger and potentially to insulin resistance and diabetes down the track.
A 'Low GI' Whole food however, such as beans, whole grains or swede, has less sugar and the carbohydrates are more complex or hidden inside tough casings, taking longer to break down leading to lower peak glucose levels and lower peak insulin levels - the food provides glucose for longer and in a way the body is much better able to cope with. 2 million years as hunter-gatherers, 10 thousand years as farmers - you do the math!
To be clear, we are note advocated the 'paleo' diet, which is mythical in its premise and lacking scientific evidence but its preference for whole foods is a good aspect of the diet.
So why is glucose bad?
Glucose though essential for life is a reactive compound - it binds to proteins in the blood, the blood-vessel walls and other structures, causing inflammation and damage. This can trigger the process of atherosclerosis (blocking of arteries) and thus heart and other vascular diseases. There is robust evidence that even moderately raised average glucose levels are associated with measurable increases in the risk of heart disease and stroke even if diabetes is not present.
Top Low-Refined Carbohydrate Tips:
- Prepare your own food - most sugar in our diet comes from hidden sugars in processed foods.
- Buy whole-grain, Wholemeal products rather than 'white' products.
- Avoid beer and liquers - most are high in sugar.
- Pick products that claim to be 'Low GI' but take care as some are high in fat.
Evidence Level: Moderate. Multiple observational studies. A few controlled trials. No evidence to the contrary. Definitive trials are lacking and taken to excess, carbohydrate avoidance may be harmful
8. Keep treats as treats
Try to avoid sugary foods, especially those combined with fat, such as donuts, biscuits and cakes.
It's a funny thing - sugar alone is not really that appealing and neither is fat, but combine the two in roughly equal proportions (say in a glazed donut or a cheesecake) and they are very hard to resist. In animal studies, rats fed only sugar or only fat gain little weight and naturally limit their consumption to appropriate levels but those who are fed fat and sugar combined gain a lot of weight rapidly. Something about the combination of the two interferes with satiety and makes it very easy to consume excessive quantities of both.
This is made worse by the pack sizes the products are sold in and the short shelf-life once a pack is open. There is no doubt that a diet high in treat foods of this nature is strongly associated with poor health outcomes, diabetes and obesity.
Top treat reducing tips:
- Multibuy special offers are best avoided - do you really want that extra pack?
- Large packs are not always better value, especially if you have a small family.
- Consider healthier alternatives such as sweet fruit.
- Try to avoid the biscuit aisle at the supermarket.
- Only eat treats you have baked yourself.
Evidence: Robust. Multiple large scale observational studies link consumption of these products to weight gain. Randomised trials in animals are conclusive.
9. Keep it all in balance
There is little evidence to support long term use of diets that are extreme in the major food groups. The complete package is required for optimal health.
If you use a very low carboohydrate high-fat diet, you will lose weight but the price will be poor glucose tolerance and possibly an increase in heart disease risk in the long term.
If you cut out carbohydrates completely, you will metabolise muscle to make glucose internally.
Cutting out animal products entirely can lead to lack of fat soluble vitamins and vitamin B12 deficiency if great care is not taken with the blend of foods taken.
If you look carefully at the advice we have given, we have deliberately used terms such as 'limit' or 'moderate' even in places where the evidence would generally suggest 'avoid' might be a better term. This is because what is right for one person is not always right for another and it is wise to seek specialist advice from our nurses if you are contemplating more extreme changes. It is also easier to improve your lifestyle if you do it a little at a time. Remember that to have any benefit you need to stick with these changes for life, or until better evidence comes to light so you have plenty of time - just keep the momentum for change going over time.
10. What? No Red Wine, No chocolate?
Alcohol and chocolate have been the subject of significant debate in recent years and given the publicity that they receive, it may come as a surprise that they are not part of our advice. In fact, if you look carefully, you will see that our advice is more about don'ts than dos. This is quite deliberate as though it would be nice to think that simply by drinking a glass of wine, eating chocolate or taking a supplement we could enjoy good health despite other issues, the evidence simply does not support this. There is no evidence whatsoever to support the suggestion that adding one or more foods to our diet is beneficial and to date all such advice depends on supposition and/or the application of small studies well beyond their inteded scope.
Yes, there are some small scale observational studies that suggest that cocoa is not harmful and may be beneficial, and some studies that show benefits on blood vessel function but there are no quality trials suggesting that adding chocolate to a diet is good. We feel that advising the consumption of high calorie density foods is probably unwise in the context of the prevention of heart disease.
For alcohol, there is some evidence that small amounts of alcohol may reduce blood pressure and improve blood vessel function, and there is a known, plausible mechanism but more than small amounts are harmful and there is considerable dispute over the amounts required to see cardiovascular benefit. A single glass of wine daily would exceed current alcohol consumption guidelines (10 standard drinks per week)
As to supplements - many contain products known or thought to have effects on blood vessel function and most are well-intended but none to date have any decent trial evidence to support their use in cardiovascular disease prevention. Most have no evidence whatsoever. Some supplements also contain ingredients known or suspected of increasing the risk of illness, including heart disease and cancer. Until quality safety and effect trials are conducted we very strongly advise against the use of any dietary supplements intended to reduce heart disease risk, unless you first discuss them with your doctor.
Treadmill image: Military Health
Vegetables: David Saddler
Sunflower: Moyan Brenn
Sugar Cubes: Kurtis Garbutt
Fresh Baked Biscuits: Pen Waggener
Scales Image: Hans Splinter
Red Wine: Jing
Thanks are due to Dr. Mathew Hobbs and Dr. Alessandra Caramello for their insights and research into various aspects of nutrition and heart health.