|
Conditions and Diseases
ATHEROSCLEROSIS
Atherosclerosis is the process of forming a plaque, or atheroma, in the wall of an artery. This is sometimes referred to as arteriosclerosis. The formation of this plaque results in a narrowing of the artery, reducing the blood flow to the organ or tissue that artery supplies. The primary health concerns of atherosclerosis are the development of ischemic heart disease, refereed to as coronary artery disease or CAD, and stroke, referred to as arteriosclerotic cerebrovascular disease or ASCVD. Atherosclerosis can also effect the arteries that supply the legs, and is known as peripheral vascular disease.
THE IMPACT OF ATHEROSCLEROSIS:
Atherosclerosis is the leading cause of death in the United States. Coronary artery disease is responsible for 36% of all deaths, and when combined with stroke, atherosclerosis accounts for 43% of all deaths in the United States. Peripheral vascular disease is the leading cause of non-traumatic amputations of the lower extremities. Needless to say, atherosclerosis takes a huge personal and societal toll in dollars and disability.
OUR APPROACH TO ATHEROSCLEROSIS AT NATURE’S HEALTHCARE
While there are genetic factors involved in the development of atherosclerosis, many of the causative factors of atherosclerosis are dietary and lifestyle in origin. As well, certain other diseases, such as diabetes and hypertension, can result in atherosclerosis, and they too have dietary and lifestyle issues as contributing factors. This makes atherosclerosis a prime target for treatment using methods other than drugs. This is not to say that drugs do not have a place. Rather, it suggests to us that using a drug to treat a disease of lifestyle seems misdirected, and that drug therapy alone seems incomplete. Indeed, in the Presidential Address to the American Heart Association in 1997, Martha Hill, Ph.D., RN, made the following statements: Individuals’ lifestyles significantly impact their health, with unhealthy habits accounting for 54% of known contributions to heart disease. Behavioral and biological interventions can reduce morbidity, mortality, disability, and death due to heart disease and stroke. She went on to describe a gap which exists between the effective behavioral and biological interventions and their implementation in practice, saying that formal integrated interdisciplinary teams are the exception, not the norm, in most inpatient and ambulatory care settings. It is our goal at Nature’s Healthcare to help close that gap. Our healthcare team consists of medical doctors, chiropractors, massage therapists, behavioral therapists, dietary and nutritional counselors, instructors in Yoga and Tai Chi, and a practitioner
of Traditional Chinese Medicine, Acupuncture, and Herbology. This healthcare
team was assembled to allow us to integrate into your treatment plan the nutritional, behavioral, and lifestyle issues which have been proven beneficial in the management of atherosclerosis.
WHO BENEFITS FROM INTERVENTIONS FOR ATHEROSCLEROSIS?
The answer is any one who wishes to reduce their risk of atherosclerosis and its complications. The greatest benefit would be derived by those in two groups, which would be:
(1.) Those who are considered to be at high risk of Coronary Artery Disease or Stroke, and who wish to prevent or reduce the chances of having these problems. This is referred to as Primary Prevention.
(2.) Those who have already
suffered a Cardiac Event, such as an MI, (myocardial infarction or heart attack), or a Stroke, and who wish to prevent the occurrence of another. This is referred to as Secondary Prevention.
The first step in planning an intervention for atherosclerosis is to assess the degree of risk for an atherosclerotic problem. The American Heart Association has developed criteria by which to judge the degree of risk.
The older classification system of the American Heart Association classifies risk factors into Major and Contributory. This system has been replaced by a newer, and to some a more cumbersome, classification system, but this older system is still in use.
MAJOR RISK FACTORS:
These are the risk factors known to be associated with a significant increase in heart disease and stroke. They are divided into those that are modifiable, and those that are not.
NON-MODIFIABLE:
Advanced age.
Male gender.
Heredity/Family History.
Race.
MODIFIABLE:
Smoking.
Elevated Cholesterol.
Elevated Blood Pressure.
Diabetes.
Physical Inactivity.
Obesity/Overweight.
CONTRIBUTORY RISK FACTORS:
These are risk factors that have
been associated with an increased risk of heart disease, but the significance
of that risk has not been determined yet.
Stress.
Elevated triglyceride.
More than moderate alcohol use.
Estrogen deficiency.
Syndrome X.
Syndrome X is used to describe a
particular group of risk factors which seem to cluster in certain groups of
people, and such people appear to be at an increased risk of heart disease and stroke. These characteristics include:
-Central Obesity.
-Glucose Intolerance.
-Hyperlipidemia, primarily high triglyceride and high LDL.
-High Blood Pressure.
The newer system of risk factors
devised by the American Heart Association takes into account new evidence showing additional factors associated with heart disease. This gives a more detailed, but also more involved, array of risk factors to consider. They are grouped into four categories:
(1.) CAUSATIVE RISK FACTORS:
-Advanced Age.
-Smoking.
-Elevated Blood Pressure.
-Elevated Cholesterol or LDL.
-Diabetes.
-Elevated ApoLipoprotein B.
-Low LDL.
(2.) CONDITIONAL RISK FACTORS:
-These are called conditional because
they are associated with an increased risk on the condition they are elevated:
-Elevated Triglyceride.
-Elevated Lipoprotein B.
-Elevated Homocysteine.
-Elevated Coagulation Factors.
-Elevations of:
-Fibrinogen.
-Plasminogen Activating
Factor I.
-C-Reactive Protein.
(3.) PREDISPOSING FACTORS:
These factors contribute to the development of causal and conditional factors.
-Overweight/Obesity.
-Physical Inactivity.
-Male Gender.
-Family History of a premature
cardiac event.
-Low Socioeconomic Status.
-Behavioral Factors such as Depression.
-Insulin Resistance.
(4.) EKG FINDINGS:
There are two EKG findings which, if present, are considered risk factors:
(1.) Non-specific ST-T changes: This is considered to be a causative factor.
(2.) Evidence of left Ventricular Hypertrophy: This is called a Susceptibility Factor.
PRIMARY PREVENTION
The goal of primary prevention is the evaluation of risk factors for atherosclerosis and the development of a prevention strategy for a patient without established Coronary Artery Disease. The evaluation of risk allows for placement of a patient into one of three categories: Low Risk, Intermediate Risk, and High Risk. The intensity of the risk factor management can then be adjusted based on the severity of the risk, to include drug therapy where clinical judgement deems that to be appropriate.
Intervention is recommended when any causative risk factor reaches a certain categorical level. Those categorical levels would be:
-Cigarette Smoking: any current smoking.
-Blood Pressure: greater than 140/90.
-Elevated LDL Cholesterol: greater than 160.
-Low LDL Cholesterol: less than 35.
-Diabetes: blood sugar greater
than 126.
The gist of treatment recommendations for low risk patients would be for them to observe healthy dietary, behavioral, and lifestyle choices, which will be outlined in our treatment section. Similar advice is given for patients at high risk, but they also enter into a more aggressive treatment plan to include drug therapy where needed. Patients at intermediate risk are advised to consider testing aimed at evaluating the presence of atherosclerosis through non-invasive means. This is intended to further evaluate their risk, which then allows treatment advice.
The therapeutic regimens will be detailed in our section regarding treatment.
SECONDARY PREVENTION
Secondary prevention is the treatment of patients with established cardiovascular disease and those who have had a cardiovascular event (such as a heart attack) or a stroke. The goal is to prevent or slow the development of, and in some cases to reverse, the changes of atherosclerosis, and to prevent another heart attack or stroke. Comprehensive risk factor interventions in such patients have been shown to extend overall survival, improve the quality of life, decrease the need for interventional procedures such as bypass, and to decrease the chance of another heart attack.
SCREENING FOR CHOLESTEROL AND OTHER BLOOD LIPIDS:
First, some definitions.
CHOLESTEROL AND LIPOPROTEINS:
Cholesterol is one of the fatty components of our blood. Its importance is that it is used to form cell membranes and some hormones. An elevated level of cholesterol has been shown to be a major risk factor for the development of atherosclerosis. In order for cholesterol to be used, and, more importantly, metabolized, it must be transported in the blood to the cells by chemicals which are specialized carriers of both lipids and proteins, which are called lipoproteins. There are two types of lipoproteins called Low-Density Lipoprotein, or LDL, and High-Density Lipoprotein, or HDL.
LDL:
LDL is the primary lipoprotein that transports cholesterol. An elevated level of LDL is known to increase the risk of atherosclerosis by depositing within the wall of an artery in the process of forming a plaque. As mentioned, this reduces the amount of blood flowing through the artery and can result in tissue damage leading to a heart attack or stroke. This is why you will hear LDL referred to as bad cholesterol.
HDL:
HDL is less prevalent than LDL,
but its importance is in its ability to carry cholesterol away from the arteries and to the liver where it is metabolized and eliminated from the body. As such, the less HDL that is available, the less cholesterol is removed from arteries and eliminated, and more is available to deposit in arterial walls.
TRIGLYCERIDES:
Triglycerides are the form in which most fats exist in food and in the body. Cholesterol and triglycerides together comprise the lipids (fats) present in the plasma (blood stream). While cholesterol is used as a component of cell walls and in the production of certain hormones, triglycerides are primarily used as sources of metabolic energy (calories).
Triglycerides in the blood come from two sources. One, they are present in the foods we eat. Two, other foods, such as carbohydrates, which also serve as sources of metabolic energy, are converted to triglycerides and stored as fat if not used for metabolic energy.
Triglycerides have been linked to an increased risk of cardiovascular disease and stroke.
HYPERLIPIDEMIA:
Hyperlipidemia is where fats (lipids) are present in increased amounts in the blood stream. An elevation of cholesterol is called hypercholesterolemia. An elevation of triglycerides is called hypertriglyceridemia. An elevation of lipoproteins such as LDL and HDL is called hyperlipoproteinemia.
NORMAL VALUES:
Cholesterol:
-A cholesterol level below 200
is considered NORMAL.
-A cholesterol level between 200 and 240 is considered BORDERLINE.
-A cholesterol level above 240 is considered ELEVATED.
HDL:
-An HDL above 35 is considered
NORMAL.
-An HDL below 35 is considered
LOW. This is also considered an independent risk factor for heart disease. An HDL greater than 60, however, counts as a negative risk factor, indicating
that it is protective.
LDL:
-An LDL below 160 is considered
NORMAL.
-An LDL above 160 is considered
HIGH.
TRIGLYCERIDE:
-A triglyceride level below 200 is considered NORMAL.
-A triglyceride level between 200 and 400 is considered BOEDERLINE.
-A triglyceride level between 400 and 1000 is considered HIGH.
-A triglyceride above 1000 is considered VERY HIGH.
APOLIPOPROTEIN A-1:
This is the major constituent of HDL. The higher the level of Apolipoprotein-A1, the greater the degree of protection from developing cardiovascular disease and stroke. This substance seems to be the best predictor of premature coronary event in patients who have a family history of cardiovascular disease.
APOLIPOPROTEIN B:
This is the major constituent of LDL. The higher the level, the greater the risk of developing cardiovascular disease and stroke. Along with Apolipoprotein-A1, this is also an excellent predictor of developing a premature cardiovascular event.
OTHER LAB TESTS USED FOR RISK ASSESSMENT:
There are a number of other substances, besides these lipids, which have also been found to be associated with the development of cardiovascular disease and stroke. This appears to be due to their involvement in the development of an atherosclerotic plaque.
HOMOCYSTEINE:
It is being increasingly recognized that Homocysteine plays a role in the development of an atherosclerotic plaque, thereby increasing the risk of cardiovascular disease. Its role in plaque formation seems to be by acting as a type of molecular abrasive, causing damage to the endothelium of the arteries in the heart, and stimulating the deposition of platelets and other clotting factors involved in the formation of a plaque.
Homocysteine is a precursor in the production of methionine through an intermediate called cystathionine. This process requires folic acid, Vitamin B12, and Vitamin B6. A deficiency of these vitamins can lead to increased levels of homocysteine, and as a result, an increased risk of cardiovascular disease and stroke.
Men with very high levels of homocysteine have been found to have a risk of heart disease three times normal. This risk is independent of any of the lipid-related risk factors.
C-REACTIVE PROTEIN:
Inflammation is a complex process, involving a number of substances and occurring for a number of different reasons. Cardiovascular disease is being increasingly recognized as having an inflammatory component. C-Reactive Protein, or CRP, is a marker of the inflammatory process, associated with the production of inflammatory cytokines. CRP is now recognized as a predictor of developing cardiovascular disease, and, according to an article in the New England Journal of Medicine, this association is independent of lipid and non-lipid risk factors.
There also seems to be an association between an elevated level of CRP and previous infection with the genital bacterium Chlamydia and the ulcer-causing bacterium Helicobacter Pylori.
FIBRINOGEN:
Fibrinogen is one of the many factors involved in the formation of a clot, or thrombus, and is elevated in a variety of infectious, inflammatory, and traumatic conditions. Its role in the formation of a plaque, and in the formation of a clot within a plaque, is by promoting platelet aggregation and injury to the vascular endothelium. The higher the level of fibrinogen, the higher the risk of cardiovascular disease. Fibrinogen is known to be increased by smoking, obesity, inflammation, stress, birth control pills, and aging.
BODY COMPOSITION ANALYSIS:
Body composition analysis is one of the measurements of overall physical fitness. Determination of Body composition allows for the determination of obesity and overweight. Obesity, as mentioned above, is considered a major risk factor for cardiovascular disease.
The two primary methods of determination of Body composition are the Body Mass Index (BMI) and the determination of the percent body fat. An older method of determination was the waist-to-hip ratio (WHR), but this is no longer recommended by the American Heart Association.
-BODY MASS INDEX (BMI):
The BMI is the expression of the amount of body weigh relative to height. At Nature’s Healthcare, we have charts that can be used to determine your BMI. You can compute your BMI with the following formula:
-Multiply your weight in lbs. by 705.
-Divide this by your height in inches.
-Then again, divide this by your height in inches.
A BMI between 25 and 30 is considered OVERWEIGHT.
A BMI over 30 is considered OBESE.
A BMI over 40 is considered EXTREME OBESITY.
-BODY FAT DETERMINATION:
By using an infrared sensor, a
measurement can be made allowing determination of the percent body fat, which
also allows for the determination of obesity. At Nature’s Healthcare, we can
measure for you your percent body fat.
WHO SHOULD BE SCREENED OR TESTED?
The guidelines below are those put forth by the National Cholesterol Education Project (NCEP), which are supported by the American Heart Association. The recommendations for testing are:
-For all adults 20 years of age
and older: Measure total cholesterol and HDL with risk factor assessment every five years.
-Measure LDL if:
-Total cholesterol is greater than 240.
-Total cholesterol is greater than 200 with 2 or more risk factors.
-HDL is less than 35.
Periodic screening is recommended through age 75. After age 75, testing is individualized based on assessment of risk factors. At this age, the benefits of routine testing become less clear.
More frequent testing than every 5 years would be recommended for patients who:
-Have more than 2 non-lipid risk factors (smoking, elevated CRP, etc.).
-Are at low risk, but have potentially changing cholesterol levels, such as perimenopausal women, or patients with significant changes in body weight, life-style, etc.
-Have a cholesterol that is near a treatment threshold, which might change sooner than 5 years.
Triglyceride testing: triglycerides are not generally measured in screening, as an isolation elevation of triglycerides does not seem to be an independent risk factor for cardiovascular disease. As well, such an isolated elevation is uncommon, except in patients with an inherited metabolic abnormality such as familial hypertriglyceridemia, where triglycerides are found to be very high. Triglyceride testing is generally done when cholesterol-lowering drug therapy is being considered, as the triglyceride level is used in the drug selection process.
The non-lipid factors such a CRP, homocysteine, and fibrinogen can be tested for on an individual basis on the basis of other risk factors and family history.
If the results of testing are abnormal, intervals for subsequent testing are individualized, and are timed so as to re-evaluate the success of intervention and treatment strategies.
GOAL OF INTERVENTION EFFORTS:
The goal of therapeutic intervention is the prevention of cardiovascular disease and stroke. Primary prevention is the term used to describe intervention efforts in patient who have no demonstrated cardiovascular disease, where the goal is the prevention of disease. Secondary prevention is the term used to describe intervention in patients with demonstrated disease, where the goal is to prevent the progression of disease and possibly a reversal of existing disease.
Patients who would benefit from
intervention efforts would be the following:
(1.) Patients with cardiovascular disease.
(2.) Patients who have no cardiovascular disease but are at risk
(3.) Everybody else.
What we’re saying is that everybody can benefit to some degree by implementing intervention strategies appropriate to their situation.
INTERVENTION STRATEGIES FOR HEART DISEASE EVERYONE SHOULD OBSERVE
Intervention strategies everyone should observe fall into three categories:
1.) Dietary.
2.) Lifestyle.
3.) Risk Factor Assessment.
DIETARY STRATEGIES
To reduce the risk of heart disease in patients with normal cholesterol and without demonstrated heart disease, the American Heart Association recommends what they refer to as the Step I Diet.
THE STEP I DIET CONSISTS OF THE
FOLLOWING: RECOMMENDATIONS:
1.) TOTAL FAT INTAKE: It is recommended that the calories obtained from fat should be no more than 30% of total calories.
2.) SATURATED FAT: Calories from saturated fat (sat fat) should be limited to 8-10% of total calories.
3.) POLYUNSATURATED FAT: Calories from Polyunsaturated fat can account for up to 10% of total calories.
4.) MONOUNSATURATED FAT: Calories from monounsaturated fat can be up to 15% of total calories.
5.) CARBOHYDRATES: Calories from carbohydrates should be 55% or more of total calories.
6.) PROTEIN: Calories from protein should be approximately 15% of total calories.
7.) CHOLESTEROL: Cholesterol intake should be limited to 300 mg per day.
8.) TOTAL CALORIES: Total calories should be the number of calories that would allow you to achieve and maintain a desired weight.
The following chart will allow you to estimate fat intake at selected levels of total calorie intake according to the Step I Diet:
|
TOTAL CALORIES
|
TOTAL FAT (grams)
|
SATURATED FAT (gm)
|
|
1200
|
40 or less
|
11-13
|
|
1500
|
50 or less
|
13-17
|
|
1800
|
60 or less
|
16-20
|
|
2000
|
67 or less
|
18-22
|
|
2200
|
73 or less
|
20-24
|
|
2500
|
83 or less
|
22-28
|
|
3000
|
100 or less
|
27-33
|
LIFESTYLE ISSUES
Appropriate lifestyle modification should occur, and should address the following areas:
1.) SMOKING: The
goal should be complete cessation of smoking. A smoking cessation program should be discussed, to include cessation strategies and pharmacological therapy where appropriate.
2.) EXERCISE: A
goal should be set for physical activity to include 30 minutes of vigorous exercise 3 to 4 times per week. Daily activities should be modified so as to increase the amount of walking, such as parking farther from the store or office, taking stairs instead of elevators, etc.
3.) ALCOHOL INTAKE:
Alcohol should be consumed in moderation, as excessive alcohol consumption has been linked to an increased risk of heart disease. Moderation is defined as no more than 2 alcohol containing beverages per day. Red Wine consumption, at no more than 2 glasses per day, has been shown to be associated with a reduced risk of cardiovascular disease. This is thought to be due to its content of tannins and isoflavones, which function as anti-oxidants.
4.) STRESS MANAGEMENT: Stress, and how we deal with it, is known to contribute to the development of cardiovascular disease. Life stressors should be examined, and an appropriate strategy to better deal with stress should be undertaken, to include the use of behavioral therapists or other treatment modalities, such as biofeedback, Yoga, meditation, and acupuncture.
PERIODIC RISK FACTOR ASSESSMENT:
Risk factors for cardiac disease should be assessed periodically by your primary care physician. These should include:
-Lipid Screening: to include measuring total cholesterol, LDL, and triglycerides.
-Blood Pressure Screening.
-Monitoring Weight.
-Assessment of estrogen status.
When assessment of these risk factors shows the need, intervention strategies should be implemented as appropriate.
INTERVENTION STRATEGIES FOR PATIENTS WITH RISK FACTORS OR WITH ESTABLISHED HEART DISEASE
Patients who have risk factors for heart disease, or those who have established atherosclerosis as demonstrated by a heart attack or stroke, should follow all of the above advice, but with two modifications:
1.) Patients with established vascular disease, or those high-risk patients with elevations
of blood lipids are advised to follow what is referred to as the Step II Diet.
2.) The addition
of cholesterol lowering drugs should be considered.
As well, there are a number of Complementary and Alternative therapies that can be of benefit. These modifications, and the Complementary and Alternative Approaches will be addressed separately.
THE STEP II DIET
The Step II Diet is recommended
for anyone who has had a heart attack or stroke, and for patients with elevations of cholesterol. As discussed above in the section on cholesterol screening, total cholesterol should be measured periodically. An LDL cholesterol is measured if:
-Total cholesterol is greater than 240, or
-Total cholesterol is greater than 200 in the presence of 2 or more risk factors.
Based on the LDL, then, the Step II Diet is advised if:
-The LDL is greater than 160, or
-The LDL is greater than 130 in the presence of 2 or more risk factors.
THE STEP II DIET CONSISTS OF THE FOLLOWING RECOMMENDATIONS:
1.) TOTAL FAT: Calories from fat should account for no more than 30% of total calories.
2.) SATURATED FATS: Calories from Sat Fat should account for no more than 7% of total calories.
3.) POLYUNSATURATED FATS: Should account for no more than 10% of total calories.
4.) MONOUNSATURATED FATS: Can account for up to 15% of total calories.
5.) CARBOHYDRATES: Should account for 55% or more of total calories.
6.) PROTEIN: Should account for approximately 15% of total calories.
7.) CHOLESTEROL: Cholesterol intake should be limited to 200 mg per day.
8.) TOTAL CALORIES: Should be adjusted to allow you to achieve and maintain a desired weight.
The following table will allow you to estimate fat intake at selected levels of calorie intake according to the Step II Diet:
|
CALORIE INTAKE
|
TOTAL FAT (IN gm.)
|
SAT. FAT (IN gm.)
|
|
1200
|
40 OR LESS
|
LESS THAN 9
|
|
1500
|
50 OR LESS
|
LESS THAN 12
|
|
1800
|
60 OR LESS
|
LESS THAN 14
|
|
2000
|
67 OR LESS
|
LESS THAN 16
|
|
2200
|
73 OR LESS
|
LESS THAN 17
|
|
2500
|
83 OR LESS
|
LESS THAN 19
|
|
3000
|
100 OR LESS
|
LESS THAN 23
|
THE GOAL OF THE STEP II DIET
The primary goal of the Step II Diet is to achieve an LDL less than 100.
The secondary goals of the Step
II Diet are to achieve an HDL greater than 35, and a triglyceride less than 200.
It must be emphasized at this point that the Step II Diet should be followed along with attention to appropriate lifestyle issues and on-going risk factor assessment.
If the Step II Diet does not bring the LDL below 100, or, if the LDL remains above 130, consideration should be given to cholesterol lowering drug therapy.
CHOLESTEROL LOWERING DRUG THERAPY
Cholesterol lowering drug therapy should be considered for the following groups:
1.) Anyone who has been placed on the Step II Diet, but did not achieve the desired goal
of an LDL less than 100.
2.) Anyone with heart disease and an LDL greater than 130.
3.) Anyone without heart disease and an LDL greater than 160 in the presence of 2 or more risk factors.
4.) Anyone without
heart disease and an LDL greater than 190 with fewer than 2 risk factors.
The decision to initiate and monitor cholesterol lowering drug therapy should be made by you and your primary care physician or cardiologist. At Nature’s Healthcare, we consider our role to be advising you on which Complementary and Alternative methods of treatment show promise in further reducing your risk of atherosclerosis. As such, we prefer to avoid a detailed discussion of cholesterol lowering drugs so that we can focus on these methods of treatment.
ASPIRIN THERAPY
Aspirin is now widely used in the prevention of heart disease. The question is, what is its’ role? Aspirin acts to inhibit platelet aggregation. Platelet aggregation is one of many factors involved in the formation of a clot within an atherosclerotic plaque. The formation of such a clot is often the trigger for a heart attack or stroke, and is refereed to as an occlusive vascular event. The evidence is clear with regards to secondary prevention. Aspirin reduces by approximately 25% the risk of developing a heart attack or stroke, when taken by patients with a prior heart attack, stroke, or other evidence of existing cardiovascular or peripheral vascular disease.The dose of aspirin in the study group ranged from 75 mg to 325 mg per day. Higher doses did not appear to be more effective.
With primary prevention, the evidence is less clear. The two large trials done using aspirin in patients with no evidence of existing heart disease showed results that were called inconclusive. That is, the findings did not allow a recommendation for or against the routine use of aspirin for primary prevention of a first heart attack or stroke. The decision to recommend aspirin in such patients is made on an individual basis, taking into account the patient’s individual risk profile and comparing it to the as yet unknown risks of such long term therapy. Studies are on going to elucidate further the use of aspirin in primary prevention.
COMPLEMENTARY
AND ALTERNATIVE
TREATMENT OPTIONS
FOR ATHEROSCLEROSIS
DIETARY CONSIDERATIONS:
There is more to the dietary approach to atherosclerosis than eliminating fat from the diet. Fat restriction is important, but there are other dietary strategies that can be used to help lower cholesterol. As well, there are a variety of vitamins, nutrients, and micronutrients that can lower the risk of heart disease when consumed as part of a fat-restricted diet. We have placed our dietary recommendations under Complementary and Alternative approaches to treatment not because they are not considered mainstream, but because the level of detail we provide is not the level of detail provided by most mainstream practitioners. Dietary changes such as we describe should certainly be considered a critical, and mainstream, part of your approach to cardiac risk
reduction, and should be implemented along with either the Step I or Step II
Diet.
HIGH FIBER DIET:
A diet high in fiber has been shown to be very beneficial in lowering total serum cholesterol. The goal for fiber intake is 35 grams per day. See the section on dietary fiber in our handout entitled Health and Wellness Through Nutrition for a list of food items and their fiber content.
PHYTOCHEMICALS AND MICRONUTRIENTS:
There are a number of substances contained in plants, which are called phytochemicals, and substances in some fish, that have been shown to lower cholesterol, in some cases blood pressure, and can lower the risk of developing atherosclerosis. The American Heart Association endorses dietary strategies that promote increased consumption of the plants and fish containing these substances. Those substances include the following:
OMEGA-3 FATTY ACIDS: Omega-3 fatty acids are substances found in cold water fish to include: ocean-raised salmon, mackerel, herring, halibut, and albacore tuna. Omega-3 fatty acids have not been shown to lower cholesterol or to reduce the risk of developing heart disease, but they have been shown to lower blood pressure. To achieve the beneficial effects of Omega-3 fatty acids, one needs only to consume 2 servings of fish per week. There are beneficial effects other than lowering blood pressure which may lead us to recommend a fish oil supplement (which contains Omega-3 fatty acids). And, if your diet does not include 2 servings per week of cold water fish, supplementation should be considered.
STEROLS: A small number of plants contain chemicals known as sterols, which have been shown to lower serum cholesterol by 7-10 percent. A reduction in cholesterol of 1% reduces the risk of heart disease by 2%. The products that contain these sterols include: monounsaturated and polyunsaturated vegetable oils such as olive oil, and a little-used oil known as rice bran oil.
FLAVONOIDS: Flavonoids are chemicals that are known to have antioxidant properties. As such, they have an important impact on our health by effecting a number of organ systems and conditions. With regard to heart disease, flavonoids have been shown to be protective against heart disease without question by protecting the arterial lining from free-radical damage. Flavonoids also inhibit platelet aggregation and oxidation of LDL, both of which are involved in the development of an atherosclerotic plaque. Flavonoids are found in tea, particularly green tea, and in soy, onions, and wine.
SULFUR-CONTAINING COMPOUNDS: This group includes garlic, onions and leeks, which are included in what is known as the Allium family of plants. They have been shown to lower cholesterol by approximately 9 percent, which translates into a reduction of heart disease risk of 18 percent. Garlic is also known to lower blood pressure.
The amount of garlic required to produce this 9 percent reduction is 4000 mg per day, or approximately 1-4 cloves of garlic per day.
ANTIOXIDANTS: There is no question regarding the research involving heart disease and the consumption of antioxidant-containing foods. Such foods significantly lower the risk of heart disease by protecting the arterial lining from damage by free radicals. We strongly encourage you to focus on dietary consumption of antioxidant-containing foods, which include:
-Green leafy vegetables
-Yellow and Orange vegetables and fruits such as carrots, mangoes, squash, apricots, and yams.
-Legumes (peanuts, beans), grains, and seeds.
FUNCTIONAL FOODS:
The FDA has recently endorsed the idea of calling certain foods Functional Foods. Functional Foods are those foods that contain ingredients in amounts that have been shown to lower the risk of developing certain conditions, most commonly heart disease and cancer. In addition to containing ingredients thought to be beneficial, in order to be approved as a Functional Food, they must not contain ingredients in amounts thought to be harmful, such as excess sodium or fat, for example. Once a food is granted status as a functional food, the producer of that food is allowed to sell and advertise that food item with the claim of its’ beneficial effect, and you will see advertising and product labeling with these claims.
Those foods which have been shown to reduce the risk of heart disease, in addition to the above, and which have been approved as functional foods include oat bran and oatmeal.
REFINED SUGARS AND SIMPLE CARBOHYDRATES:
Consumption of refined sugars and simple carbohydrates have been associated with an increased risk of developing atherosclerosis by contributing to increased insulin levels. Our advice is to limit your consumption of refined sugars and simple carbohydrates. See our handout on Health and Wellness Through Nutrition for a listing of items considered as refined sugars or simple carbohydrates
THE IMPORTANCE OF BREAKFAST:
A study known as the National Health and Nutrition Examination Survey II found that the group of people with the lowest cholesterol was the group that ate whole grain cereal for breakfast. The group with the highest cholesterol was found to be the group that skipped breakfast entirely. We suggest you consider implementing this simple dietary change as a way of lowering your cholesterol and reducing your risk of atherosclerosis.
DIETARY SUPPLEMENTS AND ATHEROSCLEROSIS
Before we give you advice on dietary supplements in the prevention of atherosclerosis, we want you to know the following information. The American Heart Association has taken the position that there is insufficient scientific evidence to recommend routinely taking dietary supplements for the prevention of atherosclerosis. Their advice is to obtain adequate amounts of vitamins and nutrients from foods eaten in variety and moderation.
While we support this advice regarding obtaining adequate nutrients from your diet, we would like to explain how it is they came to their position on supplements, and to expand on it.
The first thing you should consider in making your decision to take dietary supplements is whether or not you, personally, can achieve sufficient amounts of these nutrients from dietary sources. That is, whether or not a diet such as this is realistic for you.
Regarding the AHA’s position on
dietary supplements, they arrived at it by looking at the scientific evidence
that is available. There is overwhelming and convincing evidence that providing certain nutrients from dietary sources is associated with a reduction in the risk of atherosclerosis. There is also evidence from what are called observational studies that those who take certain dietary supplements, such as antioxidants, for example, have lower rates of cardiovascular disease. The concern they have about these observational studies is that observational studies look at groups of people who do or do not take certain things and then analyze the groups for differences in disease rates. What is lacking here is the control over other variables in these groups. The AHA says, for example, that people who take supplements
may have lower rates of heart disease not because of the supplements but because they may be generally healthier, that is, more active, less overweight, etc. The type of study the AHA and the general medical community accepts as the gold standard is the prospective, case-controlled study. This type of study, in essence, matches people who are otherwise alike, that is, in this case, patients of similar weight, similar levels of physical activity, etc, and then compares the group who took a supplement to those who did not. The AHA’s position on supplements stems from the fact that studies of this type have not been done.
The AHA also mentions the concern that it may not be the nutrients themselves that lower the rate of cardiovascular disease, but a combination of or interaction of other plant ingredients that are responsible. However, there are literally hundreds of scientific studies that measure blood levels of things like vitamin C, folic acid, and B12, among others, that show a statistically significant reduction in heart disease at higher levels of these nutrients.
Our advice regarding your decision to take dietary supplements is to make your decision based on your cardiovascular risk, your level of concern about cardiovascular disease, and your feeling about the adequacy of your diet to provide the desired nutrients. We believe that the direction the research is going in this area will eventually lead to the kinds of studies that will win over even the American Heart Association to endorse the use of dietary supplements for the prevention of heart disease. This is, we emphasize, just our opinion. However, if this research does pan out, you will then find yourself saying one of two things. The first would be I’m sure glad I’ve been taking those supplements. The second would be I sure wish I had been taking those supplements.
Having said that, we will now outline for you those supplements that have been studied in the prevention of atherosclerosis, and have been found to be helpful.
NIACIN:
You may also see niacin referred to as INOSITOL, as the form of niacin that is tolerated the best is Inositol Hexaniacinate. The scientific evidence is clear. Niacin is effective in lowering total cholesterol, LDL cholesterol, Lp(a) (lipoprotein a), triglycerides, and fibrinogen. It also raises HDL. In short, it has a positive effect on all of the lipids involved in the formation of an atherosclerotic plaque.
Studies have been done comparing niacin to the newer cholesterol lowering drugs, such as the statins, as well as to the bile-sequestering agents, such as cholestyramine, and to clofibrate and gemfibrizol. In short, niacin favorably effects blood lipids as well as or better than the more expensive and more commonly prescribed drugs. As well, the effects of niacin appear to last for years even after therapy with niacin is discontinued.
A very important finding appeared in what is known as the Coronary Drug Project, a widely respected and often quoted study on the treatment of atherosclerosis. They found that niacin was the only lipid lowering agent to show a reduction in overall mortality, that is, the mortality rate from all causes combined, not just from heart disease. The explanation appeared to be that patients taking cholestyramine and clofibrate in this study had an increased risk of dying prematurely from cancer, gall bladder disease, and other conditions.
It is for these reasons that many people believe Niacin should be the cholesterol-lowering agent of first choice. It can be combined with other cholesterol-lowering drugs, and the AHA has guidelines including the use of niacin in selected patients. The main drawback of niacin is its’ side-effects, most prominent of which is facial flushing. Other side effects include stomach irritation and nausea. These problems can be minimized by using the form of niacin known as inositol hexaniacinate, by using a gradual increase in dosage, and by taking it with meals. The dosing schedule is to start at a dose of 500 mg of inositol hexaniacinate three times a day for 2 weeks, then increasing to 1000 mg three times a day.
PANTETHINE:
Pantethine is involved in the metabolism of fat into energy. It has been shown to lower total cholesterol, LDL, and triglycerides, and to raise HDL. There appears to be no known toxicity or side effects from pantethine. The dose is 300 mg three times a day.
ANTIOXIDANTS:
The subject of antioxidants in the treatment and prevention of atherosclerosis could be an entire handout by itself. We want to remind you of the AHA’s position on antioxidant supplementation as discussed above. We also want to emphasize that dietary sources of antioxidants are best, and no supplement can replace a diet of nutritious foods eaten in variety and moderation. Rather than detail for you the numerous studies outlining the effectiveness of antioxidant supplementation, we would be happy to provide you a list of reference that we and much of the scientific community believe support the use of antioxidants in the prevention of atherosclerosis.
The basic function of antioxidants is to prevent damage to tissues from free radicals. Free radicals are chemical substances that are normally produced by the body in the utilization of oxygen for the production of metabolic energy. If there is not a sufficient supply of antioxidants, free radicals are left unchecked and are felt to be involved in a number of disease processes including atherosclerosis.
When taking antioxidants as nutritional supplements, it is important to take a combination of antioxidants rather than a single antioxidant. The carotenoids, for example, have been shown to actually increase the risk of certain cancers when taken alone without other antioxidants. At a minimum, we believe your choice of antioxidants should contain the following:
-Vitamin E.
-Vitamin C.
-Co-Enzyme Q10.
-L-Carnitine.
-Mixed Carotenoids.
You will find some products referred to as a Heart Support Formula, or ones that promote Cardiac Health. These are generally combination of antioxidants such as those listed above combined with other nutritional supplements shown to have beneficial effects on the heart. Those other supplements would include:
- MAGNESIUM: Magnesium has been shown to be especially beneficial for those patients with established Coronary Artery Disease, where the goal would be secondary prevention. Magnesium is known to inhibit the aggregation of platelets, known to be involved in the formation of an atherosclerotic plaque. It also influences coronary vascular tone and reactivity, that is, the regulation of how open or closed the coronary arteries become. The dose of magnesium that can be safely taken is 400-800 mg per day.
-B VITAMINS: The role of B Vitamins in the prevention of atherosclerosis is in the reduction of elevated levels of homocysteine, which is now accepted as an independent risk factor for heart disease. The B Vitamins, especially folic acid, are required for the metabolism of homocysteine, so that a deficiency of folic acid results in elevated levels of homocysteine. Because supplementation with folic acid can mask a deficiency of B12, it is recommended that folic acid be given along with B12. The dose for folic acid supplemenetation is 400 micrograms (mcg) per day, and should be part of a B-Complex supplement,
There are two other groups of substances that should be given strong consideration for supplementation; that would be the Flavonoids and the Essential Fatty Acids. These two groups are discussed above under dietary recommendations. We emphasize again that focusing on dietary sources of these nutrients is best. However, if supplements are considered, the following sources are available:
-ESSENTIAL FATTY ACIDS: Available sources include fish oil, flaxseed oil, and evening primrose oil. It is our opinion that the preferred source is fish oil.
-FLAVONOIDS: Available sources include grape seed extracts, pine bark extracts, green tea, and Ginkgo biloba extract. There are over 500 naturally occurring flavonoids, but some of the more common flavonoids you will see listed in supplements include: quercetin, hesperidin, and rutin.
In addition to the above, we believe everyone should take a high-potency multivitamin and mineral supplement.
BOTANICAL MEDICINES IN THE PREVENTION OF ATHEROSCLEROSIS
There are two types of Herbal Remedies available. One would be what we have come to call Western Herbs, the other would be Chinese Herbs. With Western Herbs, we generally understand the mechanism of action of the Herb. That is, we know what cellular function or metabolic process those Herbs effect, much like we understand the mechanism of action of prescription drugs. Unlike most prescription drugs, however, many Herbs effect cellular functions in more than one place or in more than one tissue, so they can be used for more than one symptom or condition. Chinese Herbs, on the other hand, are not directed at a particular cellular function or metabolic process. Rather, they are used in combinations, and are directed at symptoms or conditions that are felt to arise from an improper flow of energy, or Qi (pronounced chee), through the body.
If you decide to use Chinese Herbs, the combination of herbs given to you will be decided by our practitioner of Traditional Chinese Medicine based on her evaluation of you. If you decide to use Western Herbs, there are several herbal remedies that can be used in your case:
GARLIC (Allium sativum) AND ONION (Allium cepa bulbous)
Garlic is effective at lowering
the risk of atherosclerosis by lowering total cholesterol, LDL, and triglycerides, and by elevating HDL. The component of garlic responsible for the cholesterol-lowering properties is allicin, which is also responsible for the odor. An oderless form of garlic is available that contains allin, which is converted to allicin in the GI tract. It is available as a time-release preparation, and a dose of 10 mg of allin allows for the cholesterol-lowering effect to occur without the odor. The German Commission E, the world’s authority on herbal medicines, has approved Garlic for use in lowering cholesterol, and recommends a dose of 4000 mg per day of fresh garlic, equivalent to about one clove.
Patients taken anticoagulants, such as coumadin or warfarin, should be aware that garlic can add to the anticoagulant effect of these drugs. As well, patients taking aspirin as secondary prevention may also experience a prolongation of the bloods’ ability to clot.
Onion is also effective at lowering blood lipids and prevents plaque formation by inhibiting platelet aggregation. The dose of onion to achieve these therapeutic benefits is 50 GM per day of fresh, cut onion or 20 GM per day of the dried preparation.
SOY LECITHIN AND SOY PHOSPHOLIPID:
These soy preparations have been shown to be effective in lowering blood lipids. The German Commission E indicates their use to be primarily in patients with mild elevations of lipids who have not responded to dietary interventions or other non-medical strategies such as exercise and weight loss. The dosage is guided by the phospholipid content. For soy lecithin, the dose corresponds to 3.5 GM per day of 3-sn-phosphtidylcholine, as a preparation made from soybeans for natural intake. For soy phospholipid, the dose is 1.5-2.7 GM of phospholipids from soybeans with 73-79 percent 3-sn-phosphatidylcholine in a single dose. There are no side effects or drug interactions.
GUGULIPID:
Gugulipid is the standardized extract of the mukul myrrh tree (Commiphora mukul). It has been shown to lower total cholesterol, LDL, and triglyceride, and to raise HDL. It works by delivering more cholesterol to the liver and then facilitating its metabolic breakdown. It also inhibits platelet aggregation. The dosing is based on the content of what is called guggulosterone content. The dose is a standardized extract containing 25 mg of guggulosterone per 500 mg tablet, given tree times a day. Gugulipid is without side-effects.
There is a growing body of evidence connecting emotions and behavior with cardiovascular risk. There is now an accepted link between such things as depression and anger with an increased risk of cardiovascular disease and death. Pioneering research done in the 60’s by Dr. Meyer Friedman showed an increased risk of heart disease in men with the so-called Type A Personality. More importantly, he showed that patients with a Type A Personality who have experienced a heart attack can reduce their risk of a subsequent heart attack by psychotherapeutic interventions that address the Type A behavior. If you believe that you have a Type A Personality, or if the way you express anger is a worrisome to you, you should consider psychotherapy in a group or individual setting. At Nature’s Healthcare, we have a network of behavioral therapists to whom we could refer you for such treatment. If you believe you experience episodes of depression, that can be addressed in a number of ways, including psychotherapy and medication, or through the use of a variety of herbal remedies.
Stress is also being looked at as a risk factor for heart disease. We know it plays a part, but we are still trying to determine if it is an independent risk factor, such as high cholesterol or high blood pressure. It is well accepted that patients experiencing stress can lower their risk of heart disease by adopting certain stress management techniques. Stress management can be facilitated through consultation with a behavioral therapist. There are also a number of stress management strategies which can be self-taught and implemented. We will touch on some of these techniques below.
TECHNIQUES FOR MANAGING STRESS
This can become an entire treatment program in itself. There are many stress reduction strategies which can be utilized to minimize the impact stress has on us. We will only be hitting the highlights here, and we encourage you to select one or more of these areas for more in-depth study and practice. Numerous self-help books are available on these subjects, and we encourage you to seek them out.
ELIMINATING THE SOURCES OF STRESS:
We encourage you to look at those areas of your life that seem to be the sources of stress. Many times, our stress stems from activities or responsibilities we have taken on voluntarily. Or from activities we participate in, but which could be done less often. An example would be someone who relates experiencing stress when visiting her mother in law. One strategy for managing that stress would be not to visit your mother in law as often, if at all. When stress gets to the point where it is effecting your emotional or physical health, it is time to re-evaluate your involvement in those activities causing the stress.
TIME MANAGEMENT SKILLS:
At times, stress is experienced not because we are doing too much, but because we are not doing it efficiently. Various time management principles are available to help us accomplish our tasks without experiencing stress as a result. An important part of time management is the setting of priorities, which allows us the opportunity to decide what’s important. We can then focus on those things we feel have to be done, and it gives us the opportunity to decide, more importantly, what does not need to be done.
RELATIONSHIPS:
The area of our life that seems to contribute the most to stress is our relationships. Those relationships would be our marital relationship, our family relationships, and our relationships at work. An important aspect of dealing with all these areas is utilizing effective communication skills. Again, resources are available to assist in the development of effective communication skills.
MIND/BODY TECHNIQUES:
A critical component in managing
the emotional and physical impact stress has on us is the implementation of
relaxation techniques. There are a number of relaxation techniques available
to include:
-Meditation and Yoga.
-Relaxation Breathing.
-Progressive Relaxation.
These techniques have been shown
to assist in stress management as well as in lowering blood pressure. We encourage you to choose one of these methods that you believe would work for you, and make it a part of your daily routine.
The National Institutes of Health (NIH) has established the Committee for Complementary and Alternative Medicine (CCAM), and has accumulated a large database of research published on Complementary and Alternative Therapies. In the December 1998 issue of the Journal of the American Medical Association, an article was published indicating the effectiveness of acupuncture in a wide variety of conditions. And, in many conditions for which acupuncture is not an effective primary treatment, it has been shown to be effective adjunctive therapy. Acupuncture is often used in combination with Chinese Herbal Therapy to reestablish proper flow of Qi through the meridians, or channels of energy.
With regards to atherosclerosis, acupuncture is helpful in those patients who may benefit from a stress management program. It is highly effective in assisting patients who are stressed achieve a sense of calm and balance. It has also been shown to be effective in lowering blood pressure. If stress is a concern of yours, or if you have hypertension, we strongly suggest you consider acupuncture as part of your treatment program.
SELF:
At Nature’s Healthcare, we believe it is important to focus on achieving a sense of balance, including devoting the proper time and attention to the maintenance of ones’ spiritual and emotional health. This involves the setting of priorities and efficient time management in order to balance the time you spend on your occupation, your family, and yourself. Time for yourself includes not only time spent on your physical health, but also time spent on your spiritual growth, your personal growth, personal reflection and fulfillment.
We are glad you have chosen us at Nature’s Healthcare to be your partner in pursuing your goal of improved heath and wellness. We will be happy to interact with your other treating physicians in order to foster communication among your providers of care. As always, we are available for your question at 306-0212.
Return To Top
|
