Cardiovascular Disease Prevention and Options

Age

Aging increases the risk for cardiovascular disease. Men are considered to be at higher risk after the age of 45 years. Women are usually at low risk for cardiovascular disease until after menopause, and are considered at high risk only after age 55.¹

Alcohol

Moderate drinking (one to two drinks per day) increases protective HDL cholesterol.² This effect is not further affected by the type of alcohol-containing beverage consumed.^{3, 4} Alcohol also acts as a blood thinner,⁵ an effect that probably lowers the risk of heart disease. However, alcohol consumption can cause liver disease, cancer, high blood pressure, alcoholism, and, at high intake, an increased risk of heart disease. As a result, many healthcare practitioners never recommend alcohol, even for people with high cholesterol. Nevertheless, those who have one to two drinks per day are clearly less likely to have heart disease.⁶ Therefore, some people at very high risk of heart disease who are not alcoholics, have healthy livers and normal blood pressure, and are not at an especially high risk for cancer, may benefit from light drinking. In deciding whether light drinking might do more good than harm, people with high cholesterol should consult a healthcare practitioner.

Male Pattern Baldness

Men over 40 who have male pattern baldness on the vertex (the topmost part of the skull) have been found to be at increased risk for coronary heart disease-related events, such as nonfatal heart attack and angina pectoris, especially if they have hypertension or high cholesterol levels.⁷ Depending on the extent of the baldness, the increase in risk ranged from 23% to 36%.

Cardiovascular Disease (pre-existing)

People who have already had a heart attack,⁸ or have been diagnosed with arterial disease in the heart,⁹ arms, legs, abdomen,¹⁰ or neck,¹¹ are at very high risk of having a heart attack. These people should reduce their blood cholesterol levels—even if those levels are in the normal range¹²—and also lower other risks of cardiovascular disease.

Cholesterol (high)

Although it is by no means the only major risk factor, elevated serum cholesterol is clearly associated with a high risk of heart disease in most people. More specifically, a high level of LDL, the “bad” cholesterol, raises heart disease risks significantly,¹³ while a high level of HDL, the “good” cholesterol, lowers the risk.¹⁴ Strategies that lower LDL¹⁵ or raise HDL¹⁶ reduce the risk of heart disease in most people.

High blood cholesterol does not raise heart disease risk as much in the elderly as it does in younger adults,¹⁷ though some increased risk is evident.¹⁸ Elderly people who already have heart disease may benefit from cholesterol-lowering treatments,¹⁹ but whether elderly people with no heart disease symptoms benefit from lowering their cholesterol levels remains unclear.^20,21

Diabetes

People with diabetes are at unusually high risk for cardiovascular disease.²² Having diabetes increases a woman’s heart disease risk more than a man’s.²³ Controlling blood sugar and reducing other cardiovascular disease risks are important ways for people with diabetes to reduce their risk of heart disease.

Diet: Cholesterol

Diets high in cholesterol have increased the risk of cardiovascular disease in several reports.^{24, 25} Most dietary cholesterol comes from egg yolks. Egg consumption can not only increase serum cholesterol,²⁶ but it can also make LDL (“bad”) cholesterol more susceptible to free radical damage,²⁷ a change linked to high risk of heart disease. However, eating eggs (and therefore consuming a diet high in cholesterol) does not increase blood levels of cholesterol as much as eating foods high in saturated fat;²⁸ and eating eggs does not appear to increase serum cholesterol at all in people who eat an otherwise low-fat diet.²⁹ Moreover, a recent study found no relationship between the number of eggs eaten per week and the risk of heart disease.³⁰ More research is needed to resolve these conflicting pieces of evidence. As a result, a consensus does not exist among nutritionally oriented doctors regarding the relative importance of removing eggs from the diet.

Diet: Fish and Fish Oil

Eating fish has been reported to increase HDL (“good”) cholesterol³¹ and is associated with a reduced risk of heart disease in most,³² but not all, studies.³³ Fish contain very little saturated fat, and fish oil contains EPA and DHA, omega-3 oils that may help protect against heart disease.³⁴

Diet: Nuts

Although nuts are a source of omega-6 oils and most healthcare practitioners do not advocate increased intake of omega-6 oils, research consistently shows that people who frequently eat nuts have a dramatically reduced risk of heart disease^{35, 36} due in part to a lowering of cholesterol levels caused by eating nuts.^{37, 38} Nuts may also reduce the risk of heart disease by replacing harmful foods in the diet.^{39, 40} The most protective nuts may be almonds, walnuts, hazelnuts, and pistachios, while macadamia nuts may be the least beneficial.^{41, 42, 43}

Diet: Olive Oil

People from countries that use significant amounts of olive oil are at low risk for heart disease.⁴⁴ Olive oil lowers LDL (“bad”) cholesterol,⁴⁵ especially when the olive oil replaces saturated fat in the diet.⁴⁶ Olive oil also contains antioxidants that protect LDL cholesterol particles from free radical damage.⁴⁷ Oxidized LDL has been linked with increased heart disease.⁴⁸ Diets enriched with olive oil increase LDL protection in human studies.^{49, 50}

Diet: Omega-6 Oils

Many vegetable oils, nuts, and seeds contain omega-6 polyunsaturated fatty acids that lower total and LDL (“bad”) cholesterol.⁵¹ Most research has suggested that diets high in omega-6 fatty acids can help prevent heart disease.^{52, 53, 54}

Paradoxically, a few studies have actually associated polyunsaturated fat intake with an increased risk of atherosclerosis in humans.^{55, 56} Israelis, who have a high intake of omega-6 fatty acids, have a very high risk of cardiovascular disease, though this relationship might be caused by other factors.⁵⁷ Animal research has suggested that omega-6 fats could also contribute to cancer risks.⁵⁸ Finally, a higher fat intake from any source makes weight loss more difficult to achieve, an important health goal for overweight people trying to reduce their risk of heart disease.⁵⁹ For these reasons, most nutritionally oriented doctors and many cardiologists no longer recommend increasing dietary omega-6 polyunsaturated fat for the prevention of heart disease.

Diet: Saturated Fat

Diets high in animal foods containing saturated fat are associated with high serum cholesterol,⁶⁰ plaque, excessive blood clotting in the arteries of the heart,⁶¹ and heart disease.⁶² Significant amounts of animal-based saturated fat are found in beef, pork, veal, poultry (particularly in poultry skins and dark meat), cheese, butter, ice cream, and all other forms of dairy products not labeled “fat free.” Avoiding consumption of these foods reduces cholesterol and has even been reported to reverse existing heart disease in conjunction with other lifestyle changes.⁶³ In addition to large amounts of saturated fat from animal-based foods, Americans eat small amounts of saturated fat from coconut and palm oils. Palm oil has been reported to elevate cholesterol.^{64, 65} Research results regarding coconut oil are mixed, with some studies finding no link to heart disease⁶⁶ and other trials finding that coconut oil elevates serum cholesterol.^{67, 68}

Diet: Trans Fatty Acids

Trans fatty acids (TFAs) are found in many processed foods containing hydrogenated oils and in restaurant foods fried in these oils. Margarine often contains particularly high levels of TFAs, and margarine consumption is associated with increased risk of heart disease.⁶⁹ Eating TFAs increases the ratio of LDL to HDL cholesterol.⁷⁰ While the relative importance of TFAs as a cause of heart disease is still debated,⁷¹ most authorities now agree that reducing trans fatty acids along with saturated fats will likely help prevent heart disease.^{72, 73} Butter contains high amounts of saturated fat and is therefore not a healthful replacement for margarine; many healthcare practitioners now recommend using olive oil instead.

Diet: Vegetarian

Vegetarians have lower blood levels of cholesterol⁷⁴ and lower risk of heart disease⁷⁵ than do meat eaters, in part because they avoid animal fat. Vegans (people who eat no meat, dairy, or eggs) have the lowest cholesterol levels,⁷⁶ and switching to a vegan diet has reversed heart disease when combined with other lifestyle changes.⁷⁷

Family history of premature coronary artery disease

A person who has an immediate family member who either suffered a heart attack or was diagnosed with premature heart disease is at increased risk for heart disease.^{78 79 80} Coronary heart disease is considered premature when it occurs in men before the age of 55 or in women before the age of 65.⁸¹ People with a family history of premature heart disease should strive to minimize all of their other cardiovascular disease risk factors.

Fiber

Soluble fiber from beans,⁸² oats,⁸³ psyllium seed,⁸⁴ and fruit pectin⁸⁵ has lowered cholesterol levels in most trials.⁸⁶ Healthcare practitioners often recommend that people with elevated cholesterol eat more of these high soluble fiber foods. However, even grain fiber (which contains insoluble fiber and does not lower cholesterol) has been linked to protection against heart disease, though the reason for that protection remains unclear.⁸⁷

Gender

Though cardiovascular disease is the leading cause of death in both male and female Americans, adult men of any age have a higher risk of heart disease than do younger (premenopausal) women. Following menopause, women gradually develop heart disease risks closer to that of men.^{88, 89}

Homocysteine (high)

Blood levels of an amino acid called homocysteine have been linked to atherosclerosis and heart disease in most research,^{90, 91} though uncertainty remains about whether elevated homocysteine actually causes heart disease.^{92, 93} Homocysteine can be measured by a laboratory test, and elevated levels can be treated with vitamins.

Hypertension

Hypertension is the medical term for high blood pressure. Hypertension is a major risk factor for cardiovascular disease, and the risk increases as blood pressure rises.⁹⁴ Even after blood pressure has normalized as a result of drug treatment, people with a history of high blood pressure are still at higher risk for cardiovascular disease compared to people who never had high blood pressure.⁹⁵ Many dietary and lifestyle changes can lower blood pressure and should be adopted by people with high blood pressure.

Iron (excess)

In 1992, a Finnish study found a strong link between unnecessary exposure to iron and increased risk for heart disease.⁹⁶ Since then many studies have not found that link,^{97, 98, 99} though several have confirmed the outcome of the original report.^{100, 101} One 1999 analysis of 12 studies looking at iron status and heart disease found no overall relationship,¹⁰² but another 1999 analysis of published reports came to a different conclusion.¹⁰³ While the effect of unnecessary exposure to iron, including iron supplements, on the risk of heart disease remains unclear, there is no benefit in supplementing iron in the absence of a deficiency. Nutritionally oriented doctors recommend that people who are not iron deficient avoid iron supplements, at least until more is known.

Meal Frequency

Studies have found that people who eat small, frequent meals during the day (sometimes called “grazing”) have lower cholesterol levels compared with those who eat two or three large meals per day.^{104, 105, 106} One study also found evidence of reduced atherosclerosis (hardening of the arteries) in people eating small, frequent meals.¹⁰⁷ Redistributing the contents of two or three large meals per day into four or five smaller meals may be beneficial for reducing cardiovascular disease risk.

Obesity

Excess body fat increases heart disease risk,¹⁰⁸ in part because obesity can lead to diabetes, hypertension, low HDL (“good”) cholesterol, and high LDL (“bad”) cholesterol—all risk factors for heart disease. Abdominal weight gain is especially likely to increase heart disease risk.^{109, 110} Losing excess body weight reduces many risk factors for heart disease. Unfortunately, unsuccessful long-term weight control resulting in large fluctuations in body weight (often called “yo-yo dieting”) may also increase risk of heart disease, according to some,¹¹¹ but not all, reports.^{112, 113}

Quercetin

Quercetin, a flavonoid, protects LDL (“bad”) cholesterol from damage.¹¹⁴ Some,^{115, 116, 117} but not all,^{118, 119} studies have reported an association between consumption of foods high in quercetin and a low risk of heart disease. Quercetin is found in apples, onions, black tea, and as a supplement. In some studies, the dietary level of quercetin associated with protection from heart disease has been as low as 35 mg per day.

Sedentary Lifestyle

A sedentary lifestyle has been reported to double the risk of cardiovascular disease.¹²⁰ Conversely, moderate exercise, including brisk walking for 30 minutes per day, has a well-known protective effect against cardiovascular disease.^{121, 122} The benefits of exercise are at least partially attributable to reductions in body weight, blood pressure, triglycerides, cholesterol, and glucose intolerance.

Selenium

In some studies, people who consume more selenium from their diet have a lower risk of heart disease.^{123, 124} In one double-blind report, individuals who already had one heart attack were given 100 mcg of selenium per day or placebo for six months.¹²⁵ At the end of that trial, four deaths from heart disease occurred in the placebo group, compared with none in the selenium group (although the numbers were too small for this difference to be statistically significant). Some nutritionally oriented doctors recommend that people with atherosclerosis supplement with 100200 mcg of selenium per day.

Smoking

Both smoking¹²⁶ and exposure to second-hand smoke¹²⁷ significantly increase cardiovascular disease risk. If you are a smoker, you should quit—a critical step in reducing the risk of cardiovascular disease and many other health conditions. Both smokers and nonsmokers should avoid exposure to second-hand smoke.

Triglycerides (high)

A person with high blood triglycerides most often also has either a high total cholesterol level and/or a low HDL (“good”) cholesterol level. Perhaps as a result, researchers have had a hard time hunting for the effect of high triglycerides on heart disease independent of the effect of high total cholesterol or low HDL cholesterol.^{128, 129, 130} Nonetheless, a recent analysis of previous studies has shown that high triglycerides are associated with an increased risk for heart disease independent of other factors.¹³¹ The outcome of some research suggests that triglyceride levels in the high range of normal parameters should also be lowered to reduce the risk of heart disease.¹³²

Vitamin C

Experimentally increasing homocysteine levels in humans has led to temporary dysfunction of the cells lining blood vessels. Researchers are concerned that this dysfunction may be linked to atherosclerosis and heart disease. Vitamin C has been reported to reverse the dysfunction caused by increases in homocysteine.¹³³ Vitamin C also protects LDL (“bad”) cholesterol from oxidative damage.¹³⁴

Despite these protective mechanisms attributed to vitamin C, researchers have been unable to consistently associate high vitamin C intake to a reduced risk of heart disease. Trials failing to find vitamin C protective have mostly been conducted in groups of people that all consume at least 90 mg of vitamin C per day—a level beyond which further protection of LDL cholesterol may not occur. Studies comparing people whose diets contain lower amounts of vitamin C to people whose amounts are significantly higher than 90 mg per day, however, have found an association between increasing dietary vitamin C and protection from heart disease. Therefore, leading vitamin C researchers have begun to suggest that vitamin C may be important in preventing heart disease, but only up to modest levels: perhaps 100200 mg per day.¹³⁵

Vitamin E

Vitamin E is an antioxidant that protects LDL (“bad”) cholesterol from oxidative damage¹³⁶ and has been linked to prevention of nonfatal heart disease in double-blind research.¹³⁷ Many doctors recommend 400800 IU of vitamin E per day to lower the risk of atherosclerosis and heart attacks. However, a large double-blind trial recently found no benefit from vitamin E supplementation in the prevention of non-fatal heart attacks among people at high risk.¹³⁸ Participants, who had a history of diabetes or existing cardiovascular disease, took 400 IU of natural vitamin E for 4.5 years. It is not known why these results so strongly contradict previous findings of a protective effect from vitamin E.^{139, 140, 141} Further studies are needed to resolve the conflicting findings of these large trials.

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