Heart and Health Prevention Newsletter (September 2009)

1. MEDITERREAN DIET: ANATOMY OF HEALTH EFFECTS - RELATIVE IMPORTANCE OF INDIVIDUAL COMPONENTS - British Medical Journal, 2009. 338:b2337.

In the British Medical Journal, June 23, 2009 a review of the Greek segment of the European perspective in the investigation into cancer and nutrition "EPIC". They investigated the related importance of individual components of the Mediterranean diet and the single most important component was moderate alcohol consumption with a 23.5% decrease in mortality. The second one was low consumption of meat and meat products at 16.6% and the third was high vegetable consumption at 16.2%; the fourth was high fruit and nut consumption at 11.2%; the fifth was high mono-saturated lipid ratio (high olive oil) at 10.6%; the sixth was high legume (beans) consumption at 9.7%. The contribution of high cereal and low dairy were minimal and high fish and sea food had a non-significant decrease and had no significant benefit. They mentioned, however, that fish and sea food intake were low in this population.

2. OMEGA 3 FATTY ACIDS AND CARDIOVASCULAR DISEASE - State of the Art Paper - Journal of American College of Cardiology, August 3, 2009

Numerous studies have shown that moderate fish oil consumption decreases major cardiac events; heart attacks, sudden cardiac death, coronary artery disease, atrial fibrillation and most recently death in patients with heart failure. The data started to accumulate as early as 1944 when they described a rare incidence of coronary heart disease in Greenland Eskimos. Their diet was high in whale, seal and fish.

Most studies show a reduction in coronary events between 20 and 30%, but another analysis showed a 45% reduction in sudden cardiac death, evident only after 4 months of ingesting a gram of fish oil every day. They give reference to the large Physicians Health Study published in 2002 which showed that there was up to a staggering 81% decrease in sudden death in physicians who were in the highest quartile of Omega 3 fatty acids.
They commented that the review did not focus on Alpha-linolenic acid (ALA) - the plant-based precursor of EPA which is found in abundance in flaxseed, canola, olive oil, walnuts and tree nuts. ALA is considered inadequate because humans convert typically less than 5% of ALA to EPA/DHA. Although there are some studies that suggest modest benefit of ALA, the overall evidence is much weaker for ALA than EPA/DHA.

Another interesting study showed that there was a 30% reduction of atrial fibrillation over a 12 year period in patients who consumed high quantities of non-fried fish. Frying fish depletes the fish of its benefits. There is a 50% reduction in the development of atrial fibrillation post surgery.

The mechanism of the benefits often refer to a decrease in inflammation and the anti-clotting effects that Omega 3's have and now there is evidence that it is useful in life prolonging therapy for heart failure.

Omega 3's are clearly indicated for the treatment of very high triglycerides, greater than 500, but they need to use levels of at least 3 to 4 grams a day that will reduce triglycerides by 30 to 40 percent.

A chart was in the paper that described that the anti-arrhythmia and anti-thrombosis effect in patients usually occurs in weeks, whereas the triglyceride lowering, blood pressure lowering and heart rate lowering takes months and even perhaps a year. They addressed the methyl-mercury problem and the FDA has advised children and women who are pregnant or nursing to avoid fish with a high content of mercury and there are four: swordfish, tile fish, king mackerel and shark. Nevertheless, a study of nearly 12,000 British women who ate a fair amount of fish during their pregnancy far exceeded the FDA recommendation for fish intake and it showed that their offspring had a substantial better cognitive and behavioral development after 5 to 7 years when the children were tested than with women who ate less fish during their pregnancy. The risk to benefit ratio calculated to be 1 in 400, so mercury has been calculated to be not a big deal. Most EPA/DHA are found in salmon, tuna, sardines, mackerel, oysters and herring and they are also very low in mercury. Fish oil supplements contain no mercury.

Omega 3 - 500 mg is recommended for prevention and 1000 mg is recommended for heart patients and 3 to 4 grams is recommended for triglyceride lowering. We recommend at least 1000 mg of Omega 3's a day for everybody.

3. OMEGA 3 - Reader's Digest, "Fish Made Easy", September, 2009.

An Excellent review for the lay public.

4. ATORVASTATIN RELOAD - (ARMYDA - RECAPTURE) Journal of American College of Cardiology, 4 August 2009, 54:558-565.

This is a very fascinating study of individuals who were on statin therapy but were admitted to undergo an intervention. They were given 80 mg of Atorvastatin 12 hours before the intervention and 40 mg right before the procedure. The striking results showed a decreased risk of major cardiac events at 30 days to be 50% and in those individuals with acute coronary syndrome there was an 82% relative risk reduction. An editorial accompanying this titled "Recapturing the Magic" subtitled was "Revisiting the pleiotropic effects of statins in percutaneous coronary revascularization". They point out the benefit of decreasing inflammation can be "recaptured" by high doses of a statin acutely before the procedure.

5. NOVEL APPROACHES FOR PREVENTING OR LIMITING EVENTS (NAPLES II). JACC, 2009. Epub ahead of print, August 3, 2009. 44% decrease in procedure Myocardial Infarction with 24 hours pretreatment of a single dose of 80 mg of Atorvastatin.

6. ALZHEIMER'S DISEASE - NEW Journal of Neurology, Neurosurgery, and Psychiatry. 19 Aug 2009.

"Dementia was 70% higher in smokers and 60% higher in hypertension and 2.2 fold higher in diabetics." - Dementia Geriatric Cognitive Disorder, August, 2009. 28:75-80.

"What's bad for the heart is bad for the brain." With a cholesterol of 240, Alzheimer's Disease increased by 57%.

7. IDEAL BLOOD PRESSURE MEDICATION - for secondary stroke prevention (Amlodipine). Current Hypertension Reports, August 2009, 11:246-252.

Controlling hypertension is known to be the most important treatment in preventing stroke. Most studies point out that the most important aspect is in attaining blood pressure goal and the effect of reducing blood pressure far out weighs any other effects of reducing stroke risk. In this study, however, they showed the agent that has been most consistently beneficial has been Amlodipine - a calcium channel blocker. It is interesting to note that many pharmaceutical companies have now used combination medications which include Amlodipine added to ace inhibitors, angiotensive perceptive blockers. Lotrel, Azor, & Exforge, and combination meds have resulted in much better medication compliance.

8. REHAB REFERRALS - Journal of American College of Cardiology, 4 August 2009, 54: 515-521.

Data from the American Heart Association "Get with the Guidelines Program" analyzes almost 73,000 individuals discharged after a heart attack and coronary intervention or bypass surgery from 156 hospitals, and despite strong evidence of benefit, only 56% of eligible patients were referred to cardiac rehab. Recent analysis of recent Medicare claims data also indicated that only 19% of Medicare patients were enrolled in cardiac rehab after a heart attack or bypass surgery. Therefore, the utilization of cardiac rehab is dramatically underutilized. The American Association of Cardiovascular Pulmonary Rehabilitation, The American College of Cardiology and The American Heart Assn recently published performance measures stating that ALL hospital patients with cardiovascular disease encompassing heart attacks, coronary intervention (PCI) and bypass surgery, stable angina, transplant and heart valve surgery should be referred to a cardiac rehab program. We are missing the boat for this lifesaving program.

9. BEST KENNEDY QUOTE - EJ Dionne, The Washington Post.

"For his entire career, in season and out, Kennedy had a righteous obsession with the profound injustices and shameful inefficiencies of an American Health care system that bankrupts the sick and inflicts needless agony on those who cannot cross a doctor's threshold. It would be an unforgiveable tragedy if Kennedy's death were to weaken rather than strengthen the forces battling for health care reform, which Kennedy called "the cause of my life."

10. EXERCISE MYTH - Time Magazine, 17 August 2009.

Diet much more important for weight Loss than exercise. A 3 mile jog is undone with half a muffin. Exercise, however is crucial for so many other things. The article points out that physicians encourage even their oldest patients to exercise and this is sound advise for many reasons. People who exercise regularly are at a significantly lower risk for many diseases, particularly cardiac, but often cancer, diabetes, etc.

11. STATIN RELATED MYOPATHY - Annals of Internal Medicine, 16 June 2009, 150: 858-868

The authors and others point out that statins have revolutionized the management of cardiovascular disease and many studies show that they decrease cardiovascular morbidity by about 25%. However, the more potent statins (atorvastatin) show that they drop up to 50% and the biggest single drop was 79%. In the JUPITER trial published in March 2009 showed a 79% drop in cardiac events rates. However, more than 40% of patients eligible for stents are currently not receiving them. Up to 10% of the cases appears to be an intolerance from myopathy. The object for managing statin Myopathy, includes switching brands, particularly to fluvastatin or low dose resuvastatin using statins (on a non-daily regimen) and using it even as frequently as once a week, and supplementing with Coenzyme-Q 10, 100-300 mg, since this important enzyme is depleted when taking statins.

12. RED YEAST RICE FOR STATIN INTOLERANT PATIENTS - Annals of Internal Medicine, 16 June 2009, 150: 830-839.

Some individuals cannot take statins because of muscle pain. Red yeast rice is a dietrary supplement
shown to lower LDL levels. This could be an option for individuals who cannot tolerate statins. Generally statins are very well tolerated but in our experience, approximately 5% cannot take statin drugs. This study gave individuals three 600 mg red yeast rice capsules twice a day for six months and their LDL levels decreased 20 mg - more than a placebo - but muscle pain scores, HDL, weight loss and liver and muscle enzymes were not affected.

13. BOOK - FOOD MATTERS by Mark Bittman.

In Mark Bittman's first paragraph in the book, comments on the United Nation's Food and Agricultural
Organization report two years ago titled "Livestocks, Long Shadow" revealing the stunning statistics that global livestock production is responsible for about 1/5 of all the greenhouse gases, more than all transportation combined!!! "I am just suggesting eating less of some things and more of others."

"People in the US consume a ½ lb of meat per day and we can be persuaded to eat just about anything, including concoctions that contain no naturally occurring food at all."

Mark Bittman points out that about 7% of our calories in the US come from soft drinks, more than we get from vegetables. Soft drinks are the number one food contributing to energy intake in the US population. We live in the world of junk food.

When we look at the top ten food groups contributing to energy intake in the US, number one is sweets and desserts at 12.3% and number two is beef and pork at 10.1%, soft drinks are 7.1%, and vegetables come in at number seven at 6.1% and fruit is number 10 at 3.9%. When we look at the environmental impact on over-consumption, he points out that to produce one calorie of corn that it takes 2.2 calories of fossil fuel but it requires 40 calories to produce one calorie of beef protein!!

The number of animals killed in the US every year is staggering. 9 billion chickens, 36 million cows, 100 million pigs and 250 million turkeys.

Fifty percent of the corn grown in the US is fed to animals and of the remainder, most find its way into junk food, in the form of high fructose corn syrup, corn oil and ethanol.

The Central Intelligence Agency estimates the rank of US life expectancy to be 46th in the world, behind Jordan, South Korea, Bosnia and Herzegovena!!

His principles for diet are simple: the goal is to eat less of certain foods, specifically animal products, refined carbs and junk food and more of others, specifically plants and those foods close to their natural state. The principles are simple, deny nothing, enjoy everything, but eat plants first and most. No gimmick, no diet, no guilt and no food police.

He points out that the root of getting to his diet recommendations was when he realized that at age 57, he weighed 214 lbs, in contrast to when he graduated from college when he weighed 165 lbs. His weight just managed to creep up slowly and slowly each year. He developed high cholesterol, high blood sugar, sleep apnea, a hernia and knee problems. So he stated eating a diet that was "vegan until 6PM". It was just his style and he had very little trouble eating this way. A month later he had lost 15 lbs and in 4 months he had lost 35 lbs. His cholesterol came down 60 points and his apnea was gone, and he was not snoring. His blood sugar was normal and his weight stabilized and he is at home with this new way of eating. He points out that these months of front loading with vegetables and eating less heavier meat dishes has turned out to be "nearly painless." He is super- vigilant all day long and then he relaxes at night. So, it is more plants, fewer animals and as little highly processed food as possible.

He points out that the psychology of weight loss in America is that we have become accustomed to feeding ourselves at the first sign of hunger, this is equivalent to taking a nap every time you get tired, which hardly anyone does. He mentioned that we should think twice before we eat from simple hunger and that we should "embrace" hunger. (We have always pointed out in our practice that the symptoms of hunger is your body using up your fat stores and it is worth seeking hunger.) He suggested that you "wait and hour and then eat an apple, a banana, a mango, tomatoes and your brain will get the message in 20 minutes, and you will tread more lightly on this planet.

He points out the case of simple sugars and it appears that the more fructose you eat, the hungrier you feel. He finishes up suggesting that you should eat all the plants that you can manage, literally gorge on them. There are no limits on fruits and vegetables. Super-size fruits and vegetables.

• Vegan before 6 pm
• Seek Hunger