EXERCISE:
Participants walked for at least one half hour per day or for one hour three times per week. In chapter 12, I review new research indicating that more exercise than this may not be necessary for a healthy heart and a long life.
One of the most interesting findings of our research was that the more people did, the better they became. The more time people spent practicing these stress management techniques and exercising, and the more carefully they stayed on the Reversal Diet, the more their hearts began to heal. In other words, the degree of adherence to the Opening Your Heart program was directly correlated with the amount of reversal in their coronary artery blockages.
In Summary, the Reversal Diet:
· is very low in fat and has almost no cholesterol
· has less than 10 percent of calories from fat, and little of it is saturated
· excludes foods high in saturated fat (such as avocados, nuts, and seeds)
· is high in fiber
· allows but does not encourage moderate alcohol consumption (less than
2 ounces per day)
· excludes all oils and all animal products except nonfat milk and yogurt
· allows egg whites
· excludes caffeine, other stimulants, and MSG allows moderate use of
salt and sugar
· is not restricted in calories
Most diets don't work for long because people get tired of feeling hungry and deprived. So instead of limiting the amount of food you eat, the Reversal Diet asks you to watch the type of food that you eat, and to select only from vegetarian sources. And there are so many different types of food you can choose from!
In our research study, people have the benefit of meeting two evenings a week to help support each other on the diet and lifestyle program. While this is helpful, many people in other parts of the country have been on the Reversal Diet for several years and plan to continue it indefinitely, even without group support.
Joseph Forgione, for example, had the misfortune of having a cholesterol level as high as 558. At the young age of thirty-nine, he began having chest pains. Shortly thereafter, he underwent coronary artery bypass surgery.
After recovering from surgery, he began to follow the Reversal Diet and the rest of the program with his wife in New Jersey, far from our research in San Francisco. Within six months, his cholesterol level had decreased to 107. "And I feel better than I have in years." On the Reversal Diet, you eat until you are satisfied. And you can eat whenever you get hungry again. Because the fat content is so low, people on the Reversal Diet often get hungry before the next main meal. As a result, many of the people in our study snack in-between meals, what they affectionately call "grazing." But even though they are eating more often, they still lose excess weight and their cholesterol decreases substantially.
The typical American diet is:
40 to 50% fat (mostly saturated) 25 to 35% carbohydrate
25% protein
400 to 500 milligrams cholesterol per day
The Reversal Diet is:
10% fat (mostly polyunsaturated or monounsaturated) 70 to 75% carbohydrate
15 to 20% protein
5 milligrams cholesterol per day
In making this comparison, two things become clear:
First, the Reversal Diet consists primarily of complex carbohydrates, also known as starches. Vegetarian foods in their natural form are primarily complex carbohydrates-for example, grains, beans, vegetables, fruits, and so on. Complex carbohydrates are very filling. In contrast, simple carbohydrates, such as alcohol, honey, and sugar, are "empty" calories-that is, calories without any nutritional value-so it's easy to eat a lot of calories without being aware of it. Because of this, the Reversal Diet asks you to modify (but not eliminate) the use of sugar and alcohol. Sugar is not very strongly linked with coronary heart disease; the real culprits are saturated fat and cholesterol. The problem is that sugar is often found in the company of foods that are high in saturated fat and cholesterol, such as cake and ice cream-guilt by association.
Besides being more filling than simple sugars and lower in calories than fat, complex carbohydrates are hard for your body to convert into fat. In contrast, it is very easy for your body to convert dietary fat into body fat. Studies by K. J. Acheson at the University of Lausanne in Switzerland and by others have demonstrated that very little of the complex carbohydrates a person eats is converted into body fat. Also, it takes many more calories for your body to digest and metabolize complex carbohydrates than it does to digest and metabolize dietary fat.
Important Excerpts from Dr. Bernstein's Book
You can calculate your risk of a heart attack right now
Go to http://hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype=prof and answer the questions using the results from your, most recent blood test and doctor appointment. The result will be your risk over the next 10 years. In the text, I generally refer to your risk within a year, which is derived from this website set up by the National Institutes of Health.
Could you have many vulnerable plaques?
You should answer, "yes" if you:
- Had an angioplasty, heart attack or bypass operation
- Have a history of heart disease in your family
- Have diabetes
- Are a smoker
Are over 50 (or post-menopausal) and have high cholesterol (LDL > 100 or total cholesterol > 160), high blood pressure (> 115/75) or are overweight (> 10% above ideal)
If you could have vulnerable plaques, you need to be treated very aggressively. I hope you have already adopted a healthier lifestyle, because you know that exercising and watching your eating habits help. Unfortunately, a healthy lifestyle doesn't protect you as much as you may think. The Before It Happens Plan will reduce your risk by 50 percent or more whether or not you can change your lifestyle.
The Plan for People with Heart Disease:
- Your LDL needs to be < 80.
- Your blood pressure needs to be < 115/75 (both numbers)
- You need an ACE inhibitor to protect your blood vessels.
- You need, a beta-blocker to prevent sudden death.
- You need to take an aspirin (81 mg) each day.
- You need your HDL > 40 (man) or > 50 (woman).
- If you have had an angioplasty or stint, you need to take clopidogrel.
- If you have diabetes, you need your HgAlc to be < 6%.
What to Do Now
Since you already know you have heart disease, the only kind of medical care you can afford to accept is optimal care. Whether you have coronary artery disease, abnormal cholesterol or high blood pressure, you are in a high-risk group, and you cannot afford to be passive. If you have cardiovascular disease and have not had a heart attack, but have a first-degree relative who has had a heart attack, angioplasty or bypass operation, the time to start with the program is when you are at least 10 years younger than the age of your relative when he or she was first diagnosed.
Your blood pressure needs to be less than 115/75.
Your LDL cholesterol level must be 80 or less if you have had a heart attack, an angioplasty or a bypass operation, or have been diagnosed with even mild to moderate coronary disease on an angiogram or cardiac catheterization. If you have any other form of cardiovascular disease, your LDL should be less than 100.
A beta-blocker will reduce your risk of sudden death if you have coronary disease, high blood pressure, or heart failure. Even if your blood pressure is less than 115/75, if you have any of these conditions you should be started on a low dose (with appropriate dosage adjustments later on).
If you have diabetes, you need to have a doctor who insists on optimal glucose control. That means you are aiming for normal glucose and HgAlc. Even if you can't get there, working toward that goal is crucial. As a diabetic, your risk of a heart attack or dying young is about the same as someone who already has symptoms from coronary artery disease, so you need to follow the strictest components of this plan.
If you smoke, quitting can be the most important thing you can do to stay alive, but it is also the hardest. Develop a plan with your doctor, but realize that the Before It Happens Plan works whether you quit now or 10 years from now.
If you have siblings or children, tell them that they are at risk for heart disease and should visit their doctor and follow this plan in a way that is right for them. Your children should be evaluated at an age 10 years younger than the age at which you were first diagnosed.
These medicines-aspirin, statins, beta-blockers and ACE inhibitors-will reverse functional abnormalities of the cardiovascular system, stabilize and perhaps reverse at least some of the structural changes, and extend your life. They have also been proven to be safe. Despite the strength of their impact, they do not, however, cure you from coronary artery disease or cardiovascular disease in general. Fortunately, they are so effective that they will keep you alive long enough to see the benefits of emerging science, such as gene therapy, that may bring the true cure for cardiovascular disease. And at the very least, this plan will help you avoid a disabling heart attack or stroke, and will give you enough time to figure out how to improve your lifestyle.
Assessing Your Personal Risk
Assessing the amount of excess body fat and its distribution are powerful ways to predict your risk. The tendency of fat to deposit in the central trunk of the body (around the abdomen) more than in the peripheral area (including the buttocks and thighs), is a marker for metabolic abnormalities that are similar to those of diabetes, and leads to some of the same risks of developing more serious heart disease. When fat is deposited predominantly in the central trunk along with various combinations of high cholesterol, high triglyceride levels, high blood pressure or diabetes (or insulin resistance), it is called the metabolic syndrome. People with the metabolic syndrome are at significantly increased risk of cardiovascular disease. Even the conventional guidelines recommend intensive therapy for people with metabolic syndrome.
I disagree with the standard guidelines because the average risk for the general population is not what should determine your care. The only thing that matters about your care is your risk. The standard targets for blood pressure and cholesterol are not good enough for you. The Before It Happens Plan decreases your risks by defining targets that are optimal; targets that all agree are associated with the lowest possible risk, using old medicines that have been studied extensively and used by millions of people for decades. These approaches are safe and are based on scientific proof.
One way to assess your risk is a measure called the waist-to-hip ratio. Measure your waist just above your belly button and your hips at the point where your buttocks protrude the most, and divide your waist by your hip measurement. The higher your ratio is, the more likely you are to develop diabetes (especially if the ratio is greater than 0.95 for a man or 0.85 for a woman). Another simple way to approximate your risk is to measure your waist. If your waist is more than 40 inches (men) or 35 inches (women), you need this plan even more than you may think.
The most, accurate, way to quantify your risk is by calculating your body mass index, or BMI. BMI is equal to your weight (in kilograms) divided by your height (in meters) squared. Of course, you probably don't know your height in meters or how many kilograms you weigh, so you can use this version of the formula instead. BMI is equal to your weight (in pounds) divided by your height (in inches) squared, all multiplied by 703. If your BMI is above 25 you are overweight and if it is above 30 you are obese.
BM1 = weight (pounds)/[height (inches)] z x 703
The Plan for Overweight and Obese People
The Before It Happens Plan protects your blood vessels and reverses their functional and structural abnormalities.
Reduce LDL cholesterol levels. Even if you have no evidence of coronary artery disease, your LDL should be less than 100. If you are obese (body mass index > 30), have diabetes or have been diagnosed with coronary artery disease, are a smoker, have a first-degree relative with heart disease, or have a thickened or weak heart, your LDL should be under 80. Statins are powerful tools that will help you achieve this target.
Achieve optimal blood pressure levels. This should be defined as a level < 115/75 (or at least reduce your systolic blood pressure by at least 20 points). You should start with an ACE inhibitor. However, my strategy for selecting an additional medication, should it be required, depends upon whether you are actively losing weight, since moderator high-dose beta-blocker therapy can reduce your metabolic rate (making it tougher to lose weight).
In such a case the second step should utilize a diuretic instead of a beta-blocker. If your blood pressure remains above 115/75 after use of an ACE inhibitor and a diuretic, the angiotensin receptor blocker candesartan or the calcium blocker amlodipine are effective and have been studied extensively, assuring their safety. I cannot say the same for other calcium blockers. If your blood pressure were extreme, above 150/100, then even if you were trying to lose weight, I would use beta-blocker therapy as well.
If you were not actively losing weight (and you need to be honest with yourself here), a beta-blocker would be the recommendation after an ACE inhibitor and a diuretic, rather than candesartan or amlodipine.
Protect your vascular system with aspirin (after discussing it with your doctor). Aspirin should be utilized at a dose of 81 mg once daily if you are over 50 or post-menopausal, as long as your blood pressure is satisfactory. Studies have shown that the risks of bleeding with aspirin are lower when you take a lower dose (81 mg, not 325 mg) and when your blood pressure is controlled. Risks can increase when systolic blood pressure is above 180, so try to get your pressure down to at least the 140s before starting the aspirin. If your BMI is greater than 30, aspirin therapy should be started in your 40s. If you are diabetic and your BMI is greater than 30, aspirin should be started in your 30s. If you have any signs or a history of vascular disease, or have a history of heart attacks, strokes or high blood pressure in your family, then you should start in your 30s.
Whether you are obese or merely 10 to 15 pounds overweight, if your blood pressure is less than 115/75 and your LDL is less than 100, your doctor may tell you that you don't need to worry. Even in that case, if you are 50 or post-menopausal or your BMI is above 30, you should ask your doctor about low-dose aspirin therapy. Even low-dose ACE inhibitor and statin therapies can reduce your risk further.
Plaque Problem: Different in Women
Heart attacks are caused by two distinct mechanisms, both of which lead to reduced blood flow to the heart muscle. Part of the reason that the symptoms of heart disease may be different than for men is that women can suffer heart attacks caused by a different mechanism.
The first and most commonly described cause of a heart attack (and the one that occurs primarily in males) happens as a result of a break in the thin lining that covers a fatty plaque (made up of cholesterol) in the artery wall. Initially, a small break may heal and not be noticed externally, but it may cause a slight disturbance in the blood flow, much as a large rock in a stream might slightly divert the water flow while still letting the water get by. However, some plaques may be inflamed and filled with cholesterol. When these plaques rupture, the material within the plaque causes a dense blood clot, which can completely block the blood flow in the artery, like a large boulder in a small stream blocking the flow totally. A complete and abrupt obstruction in your coronary arteries will lead to a heart attack and potentially an arrhythmia that could be instantly fatal.
If the first plaque rupture is not fatal, then more and more small ruptures may occur, leading to severe blockages. Eventually blood flow will be affected and symptoms will develop. At this advanced stage, any stress test will detect these severe blockages.
Are you a candidate for the Before It Happens Plan?
Ana is 48. She stays in shape, is not overweight and doesn't smoke. Her blood pressure is ideal, but her cholesterol level isn't quite optimal: Ana's risk is high because she is about to enter, menopause and because of her family history. Ana's dad died from a heart attack at 42. Taking an aspirin and a statin will cut her risk almost in half.
The Plan for Women
*Your LQL needs to be < 100:
*Your blood pressure needs to be '< 115/75 (both numbers).
*You need an ACE inhibitor to protect your blood vessels once you
reach menopause.
*You need to take an aspirin (81 mg) each day once you reach menopause.
*You need your HDL > 50.
If you have diabetes, you need your HgAlc to be < 6%.
The two medicines that are first choices are ACE inhibitors and beta-blockers, because each reduces your risk more than just by lowering blood pressure (ARB may be substituted for ACE inhibitors if you can't tolerate them). The next choice should be a diuretic.
Critics might blame the predominantly male medical profession for gender bias in treatment; however, I don't think that doctors set out to deal with women differently. If you look closely at the data, it becomes clear that the differences are due largely to the fact that heart disease presents differently in women. If there is blame to be laid, it might well have to do with the fact that more studies have been conducted on men than on women, so that we better understand how cardiovascular disease evolves and causes symptoms in men. Women present with symptoms that are less likely to be recognized for the warning signs that they are. You need to take charge and make sure that your doctor understands you and your symptoms.
This book is your call to action. If you understand your own gender-specific warning signs, you will be better prepared to advocate for yourself.
