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Opening the Heart and Opening the Arteries


Opening the Heart and Opening the Arteries Cardiovascular Disease A Holistic Approach to Reducing the Risk The typical talk on this subject: Cardiovascular ... – PowerPoint PPT presentation

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Title: Opening the Heart and Opening the Arteries

Opening the Heart and Opening the Arteries
  • Cardiovascular Disease A Holistic Approach to
    Reducing the Risk

The typical talk on this subject
  • Cardiovascular Disease Prevention Risk Factor
  • Tobacco
  • Lipids diet for a 15 drop, drugs for more,
    statins, fibrates, etc.
  • CRP statins?
  • Aspirin, plavix, aggrenox, etc.
  • ACEIs
  • Exercise

The Green Medicine talk on this subject
  • Cardiovascular Disease Prevention Risk Factor
  • Tobacco
  • Lipids add in red yeast rice extract, CoQ10
    with statins, etc.
  • CRP some herbal anti-inflammatory combos
  • Other blood thinners (garlic, vitamin E, fish
    oil, etc.)
  • Exercise

This talk
  • A Whole Person talk on Heart Disease primary and
    secondary prevention
  • Mind-body Medicine and Heart Disease
  • Diet and Exercise changes
  • If time allows, the subject matter of the green
    medicine talk natural medicines for treatment
    of specific risk factors

Basic Principles of Holistic Medicine
  • The Body is a Self-Healing Organism
  • If we remove toxic influences and provide basic
    needs, people will often get better
  • Unconditional Love is Lifes Most Powerful Healer
  • Do not underestimate the power of this factor
    (data to follow)
  • People behave as they do for good reasons
  • Self-destructive behaviors are often coping
    mechanisms that have become meladaptive
  • Even when looking at more concrete risk factors
    (diet, exercise), we find that in order to help
    patients adopt the lifestyle measures that
    provide for health of the body, we need to be
    watching out for the health of the mind and spirit

A Broader Approach to Cardiovascular Disease
Prevention Risk Factor Modification
  • Relaxation/Stress Reduction
  • Social Connection/Intimacy
  • Tobacco
  • Exercise
  • Diet
  • Lipids
  • Homocysteine and CRP
  • Fish oil


Causes of Death
Causes of death Trauma is 1 age 1-44
Cardiovascular leads cancer
Causes of Death
Mortality Rates, 1995 and 2001rates per 100,000 Mortality Rates, 1995 and 2001rates per 100,000 Mortality Rates, 1995 and 2001rates per 100,000 Mortality Rates, 1995 and 2001rates per 100,000 Mortality Rates, 1995 and 2001rates per 100,000
  United States United States Washington Washington
  1995 2001 1995 2001
Heart Disease 280.7 245.8 208.6 188.2
Stroke 60.1 57.4 60.7 62.8
All cancers 204.9 194.4 183.0 180.2
Source National Center for Health Statistics, 2003 Source National Center for Health Statistics, 2003 Source National Center for Health Statistics, 2003 Source National Center for Health Statistics, 2003 Source National Center for Health Statistics, 2003
Actual Causes of Death
Source McGinnis JM, Foege WH. Actual causes of
death in the United States. JAMA 1993
270220712. (1990 data). Note The percentages
used in the figure are composite approximations
derived from published scientific studies that
attributed death to these causes.
Actual Causes of Death
  • Physical inactivity and unhealthy eating are
    responsible for at least 300,000 preventable
    deaths each year.
  • Only tobacco use causes more preventable deaths
    in the United States.

The Rules of Tacks
  • 1. If you are sitting on a tack, it takes a lot
    of aspirin to make the pain go away.
  • 2. If you are sitting on 2 tacks, removing one
    does not result in a 50 improvement in symptoms.
    (It still hurts to sit down.)

Healing the HeartFurther Broadening the
  • The heart is a metaphorically important organ as
    well as physiologically important
  • Interestingly, science is showing that caring for
    our metaphorical heart is important for the
    health of the physical one
  • stress and isolation might be added to
    inactivity, poor diet, and tobacco as actual
    causes of this illness

The Essential 8
  • Air and Breathing
  • Water and Moisture
  • Food and Supplements
  • Exercise and Rest
  • Play/Passion/Purpose
  • Gratitude/Prayer/Meditation
  • Intimacy Connection
  • Forgiveness

Mind and Spirit
  • The role of stress in heart disease
  • In 683 patients, there was a significant
  • non-uniformity to the distribution of
  • threatening arrhythmias, sudden death,
  • and MIs, with the major peak on
  • Mondays (plt.001)
  • Peters RW et al. Circulation 1996 941346

  • A Definition

  • Homeostasis based definition stress is the
    compromise of homeostasis an imbalance that can
    lead to changes over time (as the physiological
    adaptation occurs) or dysfunction.
  • Adrenal-based definition. The state of adrenal
    activation stimulated by the influence or
    detection of an environmental challenge to the
    body's homeostatic mechanisms that cannot be
    accommodated within the normal metabolic scope of
    the animal. Rooted in the observations of
    adrenal hypertrophy (due to overactivity)
    in chronically stressed animals.

General Adaptation Syndrome (GAS)
  • The Response to Stress, in 3 Phases
  • Alarm Reaction
  • Stage of Resistance
  • Stage of Exhaustion

Alarm Reaction Fight-or-Flight
  • Evolutionary Role escape from predator or acute
    physical danger

Alarm Reaction
  • Physiological changes Adrenal hormones
    adrenaline (epinephrine) and norepinephrine
  • Metabolism increases
  • Heart rate increases
  • Blood Pressure increases
  • Breathing Rate increases
  • Muscle Tension increases

General Adaptation Syndrome (GAS)
  • The Response to Stress, in 3 Phases
  • Alarm Reaction
  • Stage of Resistance
  • Stage of Exhaustion

Stage of Resistance
  • HPA (hypothalamo-pituitary-adrenal axis Cortisol
    increases when stress becomes chronic
  • Block energy storage and help mobilize energy
    from storage sites
  • Increase cardiovascular tone
  • Inhibit anabolic processes such as growth,
    repair, reproduction and immunity

General Adaptation Syndrome (GAS)
  • The Response to Stress, in 3 Phases
  • Alarm Reaction
  • Stage of Resistance
  • Stage of Exhaustion

Adrenal Exhaustion
  • Coping responses cannot sustain their response if
    stressor is sufficiently severe and prolonged
  • Diseases of adaptation" may arise
  • Hypertension
  • Ulcers
  • Heart disease
  • Symptoms that disappeared during the stage of
    resistance may reappear
  • Death possible

Physical and Psychological Side Effects of Stress
  • The body cannot distinguish physical danger from
    psychological threat
  • For most modern stressors, the value of
    increased heart rate, increased muscle tone, etc.
    is less, and those changes are not utilized for
    physical exertion, leaving the organism aroused
    without a release
  • (one part of the solution is cognitive therapy)

Maladaptive Symptoms with Acute Stress Hormones
  • Cold Hands and Feet
  • Palpitations
  • Diarrhea or Constipation
  • Decreased sleep

Maladaptive Changes with Chronic Stress
  • Worsened blood sugar control/increased insulin
  • Increased visceral fat deposition (apple-shaped
    weight gain)
  • Increased inflammation
  • Decreased immunity

Documented Relationship of Illness to Chronic
  • Susceptibility to the common cold correlates with
    psychological stress
  • Psychological stress and susceptibility to the
    common cold S Cohen, DA Tyrrell, and AP Smith
    NEJM Volume 325606-612 August 29, 1991. Number 9
  • Several potential stress-illness mediators,
    including smoking, alcohol consumption, exercise,
    diet, quality of sleep, white-cell counts, and
    total immunoglobulin levels, did not explain the
    association between stress and illness. Controls
    for personality variables (self-esteem, personal
    control, and introversion-extraversion) failed to
    alter findings.
  • Timing of heart attacks as previously mentioned
  • Many studies have shown an excess of
    cardiovascular events on Mondays. A relative
    trough has been seen on Saturdays and Sundays
    compared with the expected number of cases.
    Highest incidence is within the first three hours
    of waking on Monday morning.
  • New Insights into the Mechanisms of Temporal
    Variation in the Incidence of Acute Coronary
    Syndromes Strike PC, Steptoe A, Clin. Cardiol.
    26, 495499 (2003)

Blaming or Taking Responsibility
  • Understanding the importance of stress in our
    medical conditions gives us the power to use
    stress management to decrease illness and change
    our experience of it
  • This concept should not be used to blame people
    for their illnesses

Mind-Body and Body-Mind Interactions in Chronic

How Emotions and Stress Affect Disease Risk
  • Hormonal Effects as described for cortisol
  • Vasoreactive effects with adrenaline
  • Sleep disruption causes multiple physiological
  • (Shift work increases the risk of CHD by up to
    50. Scand J Work Environ Health. 1997

How the Body Affects Emotions and Stress
  • Body tension is perceived as emotional by the
  • Pen demonstration
  • I have so much to do
  • Therefore, some simple physical relaxation
    techniques can help to alleviate mental/emotional
  • Abdominal Breathing

The Relaxation Response
  • Counterbalancing mechanism to the Fight-or-Flight
  • Metabolism decreases
  • Heart rate decreases
  • Blood Pressure decreases
  • Breathing Rate decreases
  • Muscle Tension decreases
  • May be consciously elicited
  • Generally needs to be practiced

Techniques Which Can Elicit the Relaxation
  • Diaphragmatic Breathing
  • Meditation
  • Body Scan
  • Mindfulness
  • Repetitive exercise
  • Repetitive prayer
  • Progressive muscle relaxation
  • Yoga Stretching
  • Imagery
  • (Music)

Common Elements of Techniques Used to Elicit the
Relaxation Response
  • Focusing of attention through repetition of words
    or physical activity
  • Passive disregard of everyday thoughts when they
    occur, and return to the repetition

Benefits of the Relaxation Response
  • Immediate
  • Getting through procedures and short-term stress
  • Long-term
  • Used consistently, there are carry-over effects

  • Meditation/Prayer/Gratitude
  • Intimacy and Connection
  • Forgiveness

Relaxation Practice and the Mind-Body - heart
  • In 107 patients with ischemic heart
  • disease, 38-month risk for cardiac
  • events was 0.26 in those who had
  • undergone sixteen 1.5-hour sessions of
  • stress management cognitive education
  • and relaxation training (p.04) v.
  • conventionally treated controls
  • Blumenthal JA et al. Arch Intern Med 1997

Just for Comparison
  • 4S trial RR 0.67 after 5.4 years treatment with
    simvastatin Circulation. 1998971453-1460
  •  MIRACL Trial (higher risk patients, like the
    relaxation trial) RR 0.84 in 16 weeks on
    atorvastatin 80 mg vs. placebo JAMA. 20012851711
  • LIPS RR 0.78 after 3-4 years post PCI on
    fluvastatin 80 mg vs. placebo JAMA Vol. 287 No.
    24, June 26, 2002
  • EUROPA and HOPE trials show approximately 20
    reduction in risk of events over 4 to 5 years of
    treatment with an ACEI Lancet 2003 Sep 6 Vol.
    362 (9386), pp. 755-7

Religious Expression
  • Mortality
  • 39/52 studies religious persons lived longer
  • 12/13 more recent (and more rigorous) studies
    found significantly longer survival, especially
    among those who were active in the religious

  • Meditation/Prayer/Gratitude
  • Intimacy and Connection
  • Forgiveness

Connection with Parents
  • The Harvard Mastery of Stress Study
  • 126 male Harvard students were asked questions
    regarding their relationship with their mothers
    and fathers. They were then followed for 35 years
    regarding their own development of health risks
    and illness. The key question was
  • Would you describe your relationship with your
    mother and father as
  • Very close
  • Warm and friendly
  • Tolerant
  • Strained and cold

  • On follow up, 35 years later, the outcomes were
    as follows
  • If relationship with Mother was
  • Tolerant or strained - 91 had significant health
  • Close and Warm - 45 had significant health issue
  • If relationship with Father was
  • Tolerant or strained - 82 had significant health
  • Warm and close - 50
  • If relationship with both parents was
  • Strained - 100 incidence of significant health
  • Warm and close - 47 had a significant health

Connection in Marriage
  • Angina pectoris among 10,000 men II. Psychosocial
    and other risk factors as evidenced by a
    multivariate analysis of a five-year incidence
    study. Medalie, JH and U. Goldbourt, Am. J of
    Medicine, 1976, 60(6) 910-21
  • 10,000 men were surveyed and followed for 5
    years. The key outcome was the development of
    angina. Men with substantial risk factors for CAD
    (elevated cholesterol, age gt 45, HTN, diabetes,
    EKG abnormalities) were 20 times more likely to
    develop angina than men without those risks. When
    asked, "Does your wife show you her love? men
    within the high-risk group who said, "Yes" had
    half the development of angina.

Social Connection
  • The Alameda County Study LF Berkman, LS Syme,
    L Breslow multiple publications.
  • 6,900 participants were surveyed and followed for
    17 years. Key issues were contact with friends
    and relatives, church membership, membership in
    clubs or groups, and marriage. Those without
    close ties or frequent social contact had an
    overall death rate 3.1 times higher than those
    who did have these contacts.
  • Social and community ties were more predictive
    than smoking (1.8), overeating, physical
    activity, etc. This has been confirmed in
    Sweden, Finland, Evans County Georgia and many
    other communities

Social Connection Altruism
  • Tecumseh Community Health Study
  • Some social activities were more protective than
    others. Those who volunteered to help others at
    least once a week were 2 ½ times less likely to
    die during the 9-12 year study than those who
    never volunteered
  • Science 1988, 241540-45

Social Connection Altruism
  • Study of women with children
  • Major illness developed over a 30 year period in
  • 36 of women who were members of volunteer
  • 52 of women who were not members of volunteer
  • Successful Aging, American Journal of Sociology,
    1993, 971612

Connection Heart Surgery Outcome
  • U Texas study on people having heart surgery
  • Do you participate
  • in organized social groups? Yes No Yes No
  • Do you draw strength from
  • your religious or spiritual faith?
    Yes Yes No No
  • Risk of dying 6 months later 3 9 8 22

  • Into-Me-See
  • An element of disclosure/trust
  • Social support simple ratings of feeling loved
    are more important than number and size of
  • Someone special, whom you can lean on, to
    share feelings with, to confide in, to hold and
    comfort you

  • Having a pet CAST trial which looked at
    flecainide and encainide
  • Death rate 1.1 of people who owned dogs
    6.7 of people who did not own dogs
  • In one study, the effect of a dog on lowering
    blood pressure reactivity was greater than the
    presence of a good friend, since the friend was
    often perceived as being judgmental whereas the
    dog was not

Touch - Physical Intimacy
  • Humans need to touch and be touched, just as we
    need food and water
  • Saul Schanberg, M.D., Ph.D.
  • Half of 40 preemies were gently stroked 45
    min/day half were not
  • All were fed the same amount of calories
  • After 10 days, stroked babies were 47 heavier
    than unstroked, and were more active, more alert
    and more responsive to social stimulation
    Confirmed in Ind. J. Pediatrics Volume 68, Number
    11 / November, 2001

  • Even rabbits are more resilient to the effects of
    a high fat diet when stroked and handled
  • Significantly fewer arrhythmias were found in one
    study when the nurse or doctor took the pulse in
    the ICU Psychosomatic Medicine, Vol 39, Issue 3
    188-192, 1977

  • Meditation/Prayer/Gratitude
  • Intimacy and Connection
  • Forgiveness

Health Benefits of Forgiveness
  • U of Tenn forgivers had decreased blood
    pressure, muscle tension, and heart rates.
  • U of Wisconsin positive correlation between
    forgiving and having fewer illnesses and fewer
    chronic conditions.
  • Stanford those who forgave had lower scores on
    scales for stress and anger and higher optimism.
    Forgivers reported feeling healthier at the end
    of the experiment.
  • People who even think about forgiving have
    improved functioning in their cardiovascular and
    nervous systems.

Forgiveness a Definition
  • The feeling of peace that emerges as you
  • (1) take a hurt less personally
  • (2) take responsibility for how you feel
  • (3) become a hero instead of a victim in the
    story you tell
  • Dr. Fred Luskin of the Stanford Project

Type A Intervention
  • Type A intervention (followed 4 1/2 years after
    a heart attack)
  • Heart attack Recurrence
  • No intervention 28.2
  • Information/advice 21.2
  • Support group 12.9
  • It turns out hostility, cynicism, suspicion are
    more important than multitasking , time urgency,

Some Resources for Patients
  • Center for Attitudinal Healing
  • Multiple religious organizations and volunteer
  • Bibliotherapy
  • Love and Survival, Dean Ornish, M.D.
  • Forgive for Good, Fred Luskin PhD
  • The Feeling Good Handbook, David Burns,MD
  • The Wellness Book, Benson et. al.
  • Many others


Health of the Body
  • Air and Breathing
  • Water and Moisture
  • Exercise and Rest
  • Food and Supplements

  • Cigarette smoke second hand smoke exposure
    (living with a smoker) increases the risk of
    heart attack by 30 at age 65.
  • Smoking 20 cigarettes per day increases the risk
    of ischemic heart disease by 80

Tobacco Cessation
  • The subject of another talk, but I would note
    that coping skills for emotional issues are
    helpful with any addiction needing treatment
  • Chantix has worked wonderfully in some of my
    patients who failed everything else

Health of the Body
  • Air and Breathing
  • Water and Moisture
  • Exercise and Rest
  • Food and Supplements

  • Scientists are finding in ground wateralong with
    industrial pollutantsminute amounts of
    pesticides, estradiol, acetaminophen, herbicides,
    codeine and caffeine.
  • Water pollution attributable to US agriculture,
    including runoff of soil, pesticides and manure
    Greater than all municipal and industrial sources
    combined. There is a link between chemical
    exposure and diabetes (though causality is not
    yet proven) Diabetes Care 251487-1488, 2002
  • Lead and other toxic minerals can enter drinking
    water AFTER it leaves the treatment plant
    (lead-soldered copper pipes, PVC pipes dioxin).
    Heavy metals are also implicated in
    cardiovascular disease. http//
  • If you arent drinking filtered water, your body
    becomes the filter.

Health of the Body
  • Air and Breathing
  • Water and Moisture
  • Exercise and Rest
  • Food and Supplements

  • Reduces the risk of dying from or developing
  • Coronary heart disease 3x decrease in risk of
    death from heart disease if able to go 4.4
    minutes longer on the treadmill
  • High blood pressure
  • Colon cancer
  • Breast cancer
  • Diabetes.
  • Helps maintain healthy bones, muscles, and
  • Helps control weight, build lean muscle, and
    reduce body fat.

Fitness in Perspective
  • In one study, low fitness was an independent risk
    factor of as much importance as diabetes,
    hypertension and smoking (each with RR of 3-5 in
    obese men, after controlling for other risk
    factors present).
  • Relationship Between Low Cardiorespiratory
    Fitness and Mortality in Normal-Weight,
    Overweight, and Obese Men Ming Wei, MD, MPH
    James B. Kampert, PhD Carolyn E. Barlow, MS
    Milton Z. Nichaman, MD, ScD Larry W. Gibbons,
    MD, MPH Ralph S. Paffenbarger, Jr, MD, DrPH
    Steven N. Blair, PEDJAMA. 19992821547-1553

But still. . .
  • More than 60 of American adults do not engage in
    levels of physical activity necessary to provide
    health benefits.
  • More than one-fourth are not active at all in
    their leisure time.
  • Activity decreases with age and is less common
    among women than men and among those with lower
    income and less education.

Bottom Line for Exercise
  • Physical activity need not be strenuous to
    achieve health benefits.
  • The same moderate amount of activity can be
    obtained in longer sessions of moderately intense
    activities (such as 30 minutes of brisk walking)
    as in shorter sessions of more strenuous
    activities (such as 1520 minutes of jogging).
  • Additional health benefits can be gained through
    greater amounts of physical activity.

Start Low, Go Slow
  • Start with short intervals (510 minutes) of
    physical activity and gradually build up to the
    desired level of activity.
  • Swimming, Elliptical trainers, and Ski machines
    have the least impact for those with joint, back,
    or neck pain

  • Intrinsic
  • Energy level improves
  • Chronic pain improves
  • Social support from family and friends has been
    consistently and positively related to regular
    physical activity.
  • Altruism find someone else who needs to get out
    for walks and make them your project

Motivation and Adherence
  • Solitary vs. Group vs. Buddy
  • Keeping it interesting
  • Conversation
  • Books on tape
  • Moving meditation
  • Exercise equipment and television/VCR

  • Insomnia affects 30 of people over a year
  • Our lifestyle encourages sleep deprivation as a
    tool for doing too much
  • . . . The subject of another talk

Health of the Body
  • Air and Breathing
  • Water and Moisture
  • Exercise and Rest
  • Food and Supplements

Modifiable, Measurable Biochemical Risk Factors
  • Cholesterol, esp. LDL cholesterol
  • LDL deposits in artery walls when oxidized
  • Homocysteine a pro-oxidant
  • CRP a marker for inflammation
  • And, fibrinogen, LpA, etc. . .
  • Inflammation and Oxidation are central to
    Atherogenesis, and may explain the results of
    dietary intervention trials

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  • Homocysteine is an amino acid for which higher
    levels are associated with
  • Stroke
  • Heart attack
  • Dementia
  • Effects of homocysteine on endothelial cells
  • reduce nitric oxide
  • Reduce prostacyclin synthesis and activity
  • endothelial dysfunction through oxidative damage
  • increased oxidation of low-density lipoprotein
  • stimulation of smooth muscle cell proliferation,
    prothrombotic effects, and impaired thrombolysis

Homocysteine as Predictor of Risk
Nygård O, Nordrehaug JE, Refsum H, Ueland PM,
Farstad M, Vollset SE. Plasma homocysteine levels
and mortality in patients with coronary artery
disease. N Engl J Med 19973372306
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Homocysteine Metabolism
  • Breakdown of homocysteine requires
  • B6 (Pyridoxine)
  • Folic acid
  • B12
  • And sometimes betaine is helpful

Homocysteine-Lowering Vitamins and Clinical
  • Treatment with a combination of folic acid,
    vitamin B12, and pyridoxine significantly reduces
    homocysteine levels and decreases the rate of
    restenosis and the need for revascularization of
    the target lesion after coronary angioplasty.
  • Decreased rate of coronary restenosis after
    lowering of plasma homocysteine levels. Schnyder
    G - N Engl J Med - 29-NOV-2001 345(22) 1593-600

Homocysteine and Carotid Plaque
  • Vitamin therapy regresses carotid plaque in
    patients with H(e) levels both above and below 14
  • What level of plasma homocyst(e)ine should be
    treated? Effects of vitamin therapy on
    progression of carotid atherosclerosis in
    patients with homocyst(e)ine levels above and
    below 14 micromol/L.
  • Hackam DG - Am J Hypertens - 01-JAN-2000 13(1 Pt
    1) 105-10

Before vitamin treatment After B6,folate, B12
HCYgt14 0.21 /- 0.41 cm2/year -0.049 /- 0.24 cm2/year Plt0.001
HCY lt14 0.13 /- 0.24 cm2/year -0.024 /- 0.29 cm2/year P0.022
On the other hand. . . .
  • Supplementing B vitamins to lower homocysteine
    does not decrease cardiac events in studies to
    date, though it may decrease stroke risk
  • Current Opinion in Clinical Nutrition Metabolic
    Care. 10(1)32-39, January 2007
  • (an aside on primary vs. secondary endpoints in

Homocysteine and Lifestyle
  • Exercise decreases plasma total homocysteine in
    overweight young women with polycystic ovary
  • Randeva HS - J Clin Endocrinol Metab -
    01-OCT-2002 87(10) 4496-501
  • Higher fruit and vegetable intake is associated
    with lower homocysteine. Public Health Nutrition
    (2007), 10266-272

  • 1.0 to 3.0 mg/L moderate risk of cardiovascular
  • gt3.0 mg/L high risk of cardiovascular disease
  • Subjects in the upper third of C-reactive
    protein levels have about twice the risk (odds
    ratio 2.0 95 confidence interval 1.6 to 2.3)
    of major coronary events

CRP vs. Cholesterol as a Risk Factor
  • 77 of all future cardiovascular events occurred
    in women with LDL cholesterol lt160 mg/dL (lt4.1
    mmol/L) and 45 occurred in those with LDL
    cholesterol lt130 mg/dL (lt3.4 mmol/L).
  • hs-CRP proved to be a stronger predictor than
    LDL cholesterol
  • hs-CRP and LDL cholesterol tended to identify
    different high-risk groups, and measurement of
    both provided better prognostic information than
    did measurement of either alone
  • Ridker PM, Rifai N, Rose L, et al. Comparison of
    C-reactive protein and low-density lipoprotein
    cholesterol levels in the prediction of first
    cardiovascular events. N Engl J Med

CRP Lowering with Multivitamin
  • Mean change in C-reactive protein levels after 6
    months of intervention in the placebo and
    multivitamin groups, by baseline C-reactive
    protein level, after adjustment for baseline
    C-reactive protein level, age, body mass index,
    sex, hormone replacement therapy, and statin use.
    Error bars represent 95 confidence intervals.
  • Reduction of C-reactive protein levels through
    use of a multivitamin Timothy S. Church, MD,
    MPH, PhD, Conrad P. Earnest, PhD, Kherrin A.
    Wood, MS, James B. Kampert, PhD a American
    Journal of Medicine Volume 115 Number 9
    December 15, 2003

Inflammation Benefits of Aerobic Exercise
  • Regular aerobic exercise can decrease risk of
    having elevated CRP.
  • Most significant drop in CRP is when sedentary
    adults move from sedentary lifestyle to regular,
    low to moderate intensity exercise program.
  • As exercise intensity, frequency, and duration
    increase, the CRP continues to drop.
  • Anaerobic high intensity training (interval
    training) may elevate CRP temporarily.
  • Colbert LH et al J Am Geriatr Soc. 2004
  • Tomaszewski M et al Arterioscler Thromb Vasc
    Biol. 2003 Sep 123(9)1640-4.

Lowering CRP
  • Diet-induced weight loss
  • Adipocytes synthesize interleukin 6, the
    principal activator of C-reactive protein
  • Low Glycemic Index Diet
  • Insulin resistance, which is common in obese
    patients, is also associated with elevated
    C-reactive protein levels
  • Omega-3 fatty acids studies are mixed
  • Diets high in plant sterols, soy protein, viscous
    fiber, and almonds
  • Exercise
  • Statins 15 lowering
  • Fibric acid derivatives
  • Multivitamins

Is a theme emerging?
  • Rather than a pill for each risk factor, what if
    there were one general intervention that could
    lower many of them?

Diet Interventions after MIDART
  • DART 1989 Diet and Reinfarction Trial
  • 2033 men post MI Duration 2 years Randomized
  • 1. Eat fatty fish 2-3 x per week
  • 2. Increase cereal fiber
  • 3. Decrease total fat, increase polyunsaturated
  • No change in fat advice or fiber advice groups
  • 29 reduction in all-cause mortality in fish group

Diet Interventions Post-MICardioprotective Diet
  • 505 subjects with suspected AMI. Randomized,
    single-blind both groups on a low fat diet. The
    intervention group (Group A) was advised to eat
    more fruit, vegetables, nuts, and grain products
  • Cholesterol fell by 0.74 mmol/L in group A versus
    0.32 mmol/L in group B
  • Weight fell by 7.1 versus 3.0 kg, (CI 95,
  • Cardiac events lower in group A than group B (50
    versus 82 patients, Plt0.001)
  • Lower total mortality (21 versus 38 died, Plt0.01)
    in group A than group B
  • Cardioprotective Diet Trial 1992 BMJ. 1992 Apr

Angiographic Trials
  • Lifestyle Heart
  • 28 men and women duration 1 year
  • Randomized Very low fat (lt10) vegetarian diet,
    exercise, stress management, smoking cessation
    Significant weight reduction along with 37
    decline in LDL-C and 3 decline in HDL-C
    Progression in 53 of controls, 18 of treatment
    group regression in 82 of treatment group

Diet Post-MI - Mediterranean DietLyon Diet Heart
  • 605 men and women post myocardial infarction
    Duration 27 mo. Also follow-up report with mean
    46 months per patient
  • Randomized, single-blind dietary habits of
    controls not investigated and recorded at start
    of study
  • Canola oil margarine enriched in linolenic acid
    fewer fat calories, more fiber, monounsaturated
    fatty acids less saturated fat and dietary
  • Intervention group had increased n-3 fatty acids
    in blood. There was reduction in CHD death and
    nonfatal myocardial infarction as well as above
    plus major secondary end points
  • 76 reduction in rate of fatal and nonfatal CHD
    at end of 27 months
  • Lyon Diet Heart Study Circulation 199999779-85

Diet Interventions after Heart AttackMediterranea
n Diet
  • After first heart attack Overall mortality was
    20 in the control, 8 in the experimental group,
    an adjusted risk ratio of 0.30 for those placed
    on a Mediterranean diet vs. traditional AHA diet.
    Serum lipids, blood pressure, and body mass index
    remained similar in the 2 groups.
  • Lancet. 1994 Jun 11343(8911)1454-9

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Dietary Intervention - Fleming
Weight TC LDL-C HDL-C Homocysteine Lipoprotein(a) Fibrinogen
LF 18.4 39.1 52 h9 13.6 7.4 11.0
Phase II 12.6 30.4 38.8 h3.6 14.6 10 6.3
MF 2.6 NS 5 6.1 1.5 h9.7 h4.7 0.6
HF 13.7 h4.3 h6 5.8 h12.4 h31. h11.9
MF- moderate fat without calorie restriction LF -
low-fat (LF) diet (phase I) Phase II moderate
fat with caloric restriction HF high-fat diet
Fleming RM - Prev Cardiol -
01-JUL-2002 5(3) 110-8
Vegetarian Diet and Mortality
  • 11- year OR for mortality in strict German
    vegetarians was .66 v. the general population
  • OR for those engaging in moderate/high v. low
    physical activity was .47 (p.004)
  • Chang-Claude J et al. Int J Epidemiol 1993

Vegetarian Diet and CAD
  • Meta-analysis of 5 studies and 76,000 subjects,
    11-year OR for mortality from CAD was 24 lower
    in vegetarians than in nonvegetarians (plt.01)
  • Best off were fish eaters and lacto-ovovegetarians
  • Key TJ et al. Am J Clin Nutr 1999516S

The optimal diet Low-fat or Mediterranean?A
  • Randomized, controlled clinical trial , compares
    dietary intervention per se with usual care in a
    case-control analysis. First MI survivors were
    randomized to a low-fat or Mediterranean-style
    diet. Individual dietary counseling sessions, 2
    within the first month and again at 3, 6, 12, 18,
    and 24 months, along with 6 group sessions.
  • Primary-outcome-free survival did not differ
    between low-fat (42 of 50) and Mediterranean-style
    (43 of 51) diet groups over a median follow-up
    period of 46 months (range 18 to 72 log-rank p
  • Patients receiving dietary intervention had
    better primary-outcome-free survival (85 of 101)
    than usual-care controls (61 of 101) (log-rank p
    lt0.001), with unadjusted and adjusted odds ratios
    of 0.33 (95 confidence interval 0.18 to 0.60, p
    lt0.001) and 0.28 (95 confidence interval 0.13 to
    0.63, p 0.002), respectively.
  • The American Journal of Cardiology - Volume 101,
    Issue 11 (June 2008)

The Polymeal
Effect of ingredients of Polymeal in reducing
risk of cardiovascular disease
Ingredients Percentage reduction (95 CI) in risk of CVD Source
Wine (150 ml/day) 32 (23 to 41) Di Castelnuovo et al (MA)6
Fish (114 g four times/week) 14 (8 to 19) Whelton et al (MA)7
Dark chocolate (100 g/day) 21 (14 to 27) Taubert et al (RCT)8
Fruit and vegetables (400 g/day) 21 (14 to 27) John et al (RCT)10
Garlic (2.7 g/day) 25 (21 to 27) Ackermann et al (MA)11
Almonds (68 g/day) 12.5 (10.5 to 13.5) Jenkins et al (RCT),15 Sabate et al (RCT)16
Combined effect 76 (63 to 84)
BMJ. 2004 December 18 329(7480) 14471450.
Optimal Diet
  • Primitive use the fuel for which the machinery
    was designed
  • Emphasize Fruits Vegetables and Nuts
  • Very Limited or No Meat
  • Fish in moderation

Not Atkins
  • Volunteers on an Atkins-type high fat diet
  • experienced an increase in LDL-C of 7
  • after six months
  • Westman EC et al. Am J Med 200211330

Not Atkins
  • In 100 people assigned to different
  • diets for a year, weight loss was one
  • pound/week on a 10 fat diet vs. 0.6
  • pounds/week on an Atkins diet LDLC
  • fell 52 vs. an increase of 6,
  • respectively
  • Fleming RM. Prev Cardiol 2002 5110

Features of the Optimal Diet
  • 5-9 or more servings of Fruits and Veggies per
  • High fiber
  • Low Glycemic Index
  • Low Fat Omega-3 fats emphasized

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Why a Campaign?
  • Only 27 of women and 19 of men eat the
    recommended five or more servings of fruits and
    vegetables each day.
  • Of young people, less than 30 eat sufficient

5-9 Servings of Fruits and Veggies Per Day
  • Recommended by the NCI to help prevent lung,
    breast, colon and prostate cancers by 50 or more
    (As long as we are taking a holistic view)
  • Recommended by the AHA to prevent heart disease
    and stroke

Fruits, Veggies and Cancer
  • RRs in the upper tertile of vegetable intake
    ranging from 0.2 for esophagus, liver and larynx
    to 0.7 for breast cancer
  • RRs in the upper tertile of fruit intake were
    between 0.2 and 0.3 for oral cavity and pharynx,
    oesophagus and larynx relative to the lowest
  • Significant inverse relationships were observed
    for liver, pancreas, prostate and urinary sites

How They Work
  • A large number of potentially anticarcinogenic
    agents as well as anti-inflammatory agents are
    found in these food sources
  • Carotenoids - Selenium - Dietary fiber
  • Dithiolthiones - Glucosinolates - Indoles
  • Isothiocyanates- Flavonoids - Phenols
  • Limonene - Protease inhibitors - Plant sterols
  • Allium compounds

  • Complementary and overlapping mechanisms of
  • Induction of detoxification enzymes
  • Inhibition of nitrosamine formation
  • Provision of substrate for formation of
    antineoplastic agents
  • Dilution and binding of carcinogens in the
    digestive tract
  • Alteration of hormone metabolism
  • Antioxidant effects
  • Others.

Why Not Just Take a Vitamin?
  • Lung Cancer and b Carotene the Finnish study
  • Cervical Dysplasia and Folic acid
  • A long series of disappointing clinical trials in
    heart disease with antioxidants-in-a-pill

5-9 Servings of Fruits and Veggies Per Day
  • Recommended by the NCI to help prevent lung,
    breast, colon and prostate cancers by 50 or more
  • Recommended by the AHA to prevent heart disease
    and stroke

Veggies and Stroke
  • In 832 healthy Framingham men, 20- year RR for
    all types of strokes was progressively lower for
    each quintile of increased intake of fruits and
    vegetables established by 24- hour nutritional
    recall at baseline (p.01)
  • Gillman MW et al. JAMA 1995 2731113

Fruits, Veggies, and Cardiovascular Morbidity and
  • Consuming fruit and vegetables 3 times/d
    compared with lt1 time/d was associated with
  • 27 lower stroke incidence
  • 42 lower stroke mortality
  • 24 lower ischemic heart disease mortality
  • 27 lower cardiovascular disease mortality
  • 15 lower all-cause mortality
  • after adjustment for established cardiovascular
    disease risk factors
  • American Journal of Clinical Nutrition, Vol. 76,
    No. 1, 93-99, July 2002

Why More Fruits Veggies?
  • Fiber
  • Antioxidants

  • Filling
  • replaces higher caloric density foods
  • Maintains normal colonic flora
  • Glycemic Index (more later)
  • Binds things
  • Enterohepatic Circulation of Cholesterol
  • Toxins produced by bacterial fermentation

  • In 25 hyperlipidemic volunteers, LDL-C fell
  • 29 (plt.001) in those randomized to a diet
  • high in plant sterols, soluble fiber and
  • vegetable protein (soy, almonds, okra,
  • eggplant, metamucil, oats, barley, legumes)
  • v. an LDL-C fall of 12 in those on a low
  • fat, low cholesterol diet
  • Jenkins DJ et al. Metabolism 2002 511596

Oxidation a byproduct of metabolism
  • Damages DNA
  • Cancer genesis
  • mutations that activate oncogenes
  • Damages Fats and Membranes
  • CAD
  • LDL-C must be oxidized to deposit in arterial
  • Dementia
  • Damages Structural Components
  • Arthritis
  • Damage to joint components

  • Protect our cells from oxidation by accepting
    free radicals
  • Work in groups
  • Chain of acceptance of free radicals
  • Implications single vitamins may be
  • Glutathione

Antioxidant Strategies
  • 5-9 Fruits and veggies
  • Supplements Made from Whole Foods
  • Food For Life
  • Juice Plus
  • Decreases oxidation of LDL
  • Decreases homocysteine
  • Decreases lipid peroxides in the urine
  • Decreases DNA Damage in circulating lymphocytes

Antioxidant Strategies
  • 5-9 Fruits and veggies
  • Supplements Made from Whole Foods
  • Food For Life
  • Juice Plus
  • Decreases oxidation of LDL
  • Decreases homocysteine
  • Decreases lipid peroxides in the urine
  • Decreases DNA Damage in circulating lymphocytes
  • Herbals
  • Grape seed extract, pycnogenol
  • Ginkgo biloba
  • Etc.

Features of Optimal Diet
  • 5-9 Servings Fruits and Veggies per Day
  • High fiber
  • Low Glycemic Index
  • Low Fat Omega-3 fats emphasized

Not All Carbs are Created Equal
  • The insulin mobilized over two hours by 10
  • healthy volunteers after consuming a snack
  • of cola and chips was 75 GREATER than
  • that after ingesting an isocaloric amount of
  • sugar from raisins and peanuts (2plt.001)
  • Oettle GJ et al. Am J Clin Nutr 1987 4586

Glycemic Index Not All Carbs Are Created
  • Yogurt, lowfat, 14
  • unsweetened, plain
  • Lentils 29
  • Apple 36
  • Spaghetti, ww 37
  • Tortilla, corn 38
  • All-bran cereal 42
  • Orange 43
  • Think Primitive!
  • Corn 49
  • Spaghetti, durum 55
  • Rice, white 59
  • Ice Cream 61
  • Macaroni and cheese 64
  • Grape-nuts cereal 67
  • French baguette 95

Glycemic Index and Snacking
  • Voluntary snack intake in a 5- hour period
  • after a high- glycemic index meal was 81
  • greater than after an equicaloric low- GI meal
  • Ludwig DS et al. Pediatrics 1999 103E26

Bottom Line on Glycemic Index
  • Low Glycemic Index Diet can assist weight loss by
    lowering insulin levels and decreasing the
    impulse to snack
  • Low Glycemic Index Diet can decrease the lifetime
    risk of developing diabetes

Features of Optimal Diet
  • 5-9 Servings Fruits and Veggies per Day
  • High fiber
  • Low Glycemic Index
  • Low Fat Omega-3 fats emphasized

Functions of Fats
  • Energy Storage
  • Membrane components
  • Precursors to prostaglandins and other
    hormones/messenger molecules
  • Latter two are affected by types of fats consumed

Omega 3 Fats fish, walnuts, flax
  • Omega 3 fats are
  • Anti-inflammatory
  • Anti-thrombotic
  • Anti-arrhythmic

Fish Oil Effects on Cardiovascular Disease
  • At higher doses (3-5 grams per day)
  • BP-lowering effect
  • Improve the lipid profile decreasing
    triglycerides and very-low-density lipoproteins
    and slightly raising the cardioprotective
    high-density lipoprotein cholesterol
  • Alter prostaglandin metabolism by inhibiting the
    production of thromboxane A2 and inflammatory
    cytokines, reducing the likelihood of acute
    coronary thrombosis
  • At dietary doses
  • Decrease arrhythmias

Fish Oil and Arrhythmia
  • Sudden death caused by sustained ventricular
    arrhythmias accounts for 50 to 60 of all deaths
    in persons with CHD
  • GISSI-Prevenzione Trial 11,324 patients with
    known CHD who were randomized to receive either
    300 mg of vitamin E, 850 mg of omega-3 FA, both,
    or neither. After 3.5 years, the group receiving
    omega-3 FA alone had a 45 reduction in sudden
    death and a 20 reduction in all-cause mortality.
  • United States Physician's Health Study 20,551
  • One serving of fish per week resulted in 52
    decrease in sudden cardiac death

Omega 3 Bottom Line
  • Fish oil is most certain source
  • Increasing omega-3s can improve
  • Memory
  • Mood
  • Heart disease
  • Eating fish once a week cuts risk of sudden death
    from heart attack by 50
  • Cancer risk
  • Inflammation/Auto-immune disease

Supporting People in Dietary Change
  • Information
  • Change Theory

Stages of Change
  • Stages of Change Big lifestyle changes like a
    change in the diet require preparation, emotional
    as well as logistical

Contemplation - Obstacles to Change
  • Cost
  • Willpower Emotional decisions about what to
    eat, when, and how much
  • Digestive Problems
  • Knowledge
  • Knowing what to eat
  • Knowing how to prepare healthy food

  • Cost per calorie is lower for processed foods and
    foods high in sugar, however in this country few
    people are truly lacking in calories.
  • Beans and grains are low cost, however
  • Black beans are 69-99 cents/lb dry(about 10
  • 0.16/serving 140 calories, 0 fat, 18g protein,
    30 g fiber
  • Extra lean ground beef 2.49/lb,
  • 0.62/serving (4 oz) 256 calories, 19g fat, 21
    g protein, 0 fiber

Obstacles to Change
  • Cost
  • Willpower Emotional decisions about what to
    eat, when, and how much
  • Digestive Problems
  • Knowledge
  • Knowing what to eat
  • Knowing how to prepare healthy food

Motivation(Contemplation and Pre-Contemplation)
  • For those who will not change what they eat for
    health reasons, weight loss can be a motivator
  • Eat to Live by Joel Fuhrman is a great resource
  • Sense of well-being
  • Ornishs program starts in a hotel most people
    continue to adhere after leaving because they
    feel better try to get a 1-week commitment from
    patients and have them notice how they feel

Emotional Choices About What to Eat
  • There is a difference between wanting food and
    being hungry
  • Mindfulness when hungry/reaching for food can be
    very illustrative
  • Meet needs that are being met by food with other
    means (and first, figure out what those needs
  • The Solution, by Laurel Mellin, is a great
  • Deep Healing, by Emmett Miller, also addresses
    these issues

Obstacles to Change
  • Cost
  • Willpower Emotional decisions about what to
    eat, when, and how much
  • Digestive Problems
  • Knowledge
  • Knowing what to eat
  • Knowing how to prepare healthy food

  • Chewing dental health and taking time
  • Digestion stomach acid, enzymes, bean-o
  • Elimination constipation, related to
    medications or other issues, can be treated with
    magnesium or try flax pudding
  • Soak 2 tablespoons of flax seeds overnight in
  • in the morning, add an equal amount of yogurt (or
    Cool Whip, in the original recipe) and dried
    fruit (apricots, prunes, etc.) and mix in the
    blender. (Can make up for several days and keep
    in the fridge)

Obstacles to Change
  • Cost
  • Willpower Emotional decisions about what to
    eat, when, and how much
  • Digestive Problems
  • Knowledge
  • Knowing what to eat
  • Knowing how to prepare healthy food

Tips to Increase Fruits Veggies
  • Pre-cut vegetables and salad mixes, even fruit
  • Add fresh fruit and vegetables to foods you
    already eat - like berries and bananas to yogurt
    and cereal vegetables to pasta and pizza and
    lettuce, tomato and onion to sandwiches
  • When its snack time, grab an apple or orange, or
    make a ready-to-eat bag of sweet cherries.

More Tips
  • Make a quick smoothie in the blender by puréeing
    peaches and/or nectarines, a touch of your
    favorite fruit juice, crushed ice, and a light
    sprinkling of nutmeg.
  • Use sauces to improve palatability for veggies
    you do not like
  • Try stir-fries and stews using lots of veggies
    and meat as a condiment

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  • Changing behavior

Logistics/Planning for Good Nutrition
  • It is generally easier to add good foods than
    to eliminate the bad ones we crave
  • Stock easy healthy foods, do not keep junk food
    in your home
  • Cook ahead
  • Use appliances (cuisinart)
  • Make trades

Some Food Preparation Ideas
  • Sautés/Steams with varying flavors
  • Assorted veggies (onions, garlic, ginger, yams,
    broccoli, carrots, zucchini, snow peas, etc.) can
    be prepared with tofu or skinless chicken breasts
  • Soy sauce/sesame oil/
  • Thai curry paste with low fat coconut milk
  • Diced tomatoes with Italian seasoning blend or
    rosemary (no ginger)
  • Soup recipes
  • Steamed Greens
  • Salads with low-fat dressing

  • Continuing the changed behavior and preventing
  • Make note of how your body feels when you eat
    more healthfully, and remind yourself of this
    when you feel drawn to other foods. Note the
    effects on your symptoms when you fall off the

Hypertension JNC-7
  • In persons older than 50 years, systolic blood
    pressure greater than 140 mmHg is a much more
    important cardio-vascular disease (CVD) risk
    factor than diastolic blood pressure.
  • The risk of CVD beginning at 115/75 mmHg doubles
    with each increment of 20/10 mmHg

Hypertension and Pre-hypertension
  • People who are normotensive at age 55 have a 90
    percent lifetime risk for developing
  • People with a systolic blood pressure of 120139
    mmHg or a diastolic blood pressure of 8089 mmHg
    should be considered as prehypertensive and
    require health-promoting lifestyle modifications
    to prevent CVD.

Remember the Rules of Tacks
Identifiable causes of Hypertension
Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing's syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease
Drugs Contributing to Hypertension
  •   Nonsteroidal anti-inflammatory drugs
    cyclooxygenase 2 inhibitors
  •   Cocaine, amphetamines, other illicit drugs
  •   Sympathomimetics (decongestants, anorectics)
  •   Oral contraceptives
  •   Adrenal steroids
  •   Cyclosporine and tacrolimus
  •   Erythropoietin
  •   Licorice (including some chewing tobacco)
  •   Selected over-the-counter dietary supplements
    and medicines (e.g., ephedra, ma haung, bitter

Lifestyle Modifications to Control Hypertension
Weight reduction Maintain normal body weight 520 mmHg/10 kg weight loss
Adopt DASH eating plan Consume a diet rich in fruits, vegetables, and lowfat dairy products with a reduced content of saturated and total fat. 814 mmHg
Dietary sodium reduction Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). 28 mmHg
Lifestyle Modifications to Control Hypertension
Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week). 49 mmHg
Moderation of alcohol Limit consumption to no more than consumption 2 drinks (1 oz or 30 mL ethanol e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter weight persons. 24 mmHg
Natural Medicine for Hypertension
  • Hawthorn extract must include the leaf
  • Magnesium especially if diabetic or treated
    with diuretics
  • Meditation
  • Others
  • Olive leaf extract
  • Linden and others

Meds for Lowering Cholesterol
  • Statins beware, these can lower coenzyme Q10
    (and supplementing it can decrease muscle pain,
    fatigue associated with their use).
  • Others less data suggesting they prolong life

Natural Substances for Lowering Cholesterol
  • LDL 7-10 drop in LDL with taking psyllium
    before meals Am J Clin Nutr. 2000 Feb71(2)472-9
  • Hypertension, weight Clin Exp Hypertens. 2007
  • Glycemic control Lowered glucose and HgbA1C in
    diabetic outpatients J Ethnopharmacol. 2005 Nov
    14102(2)202-7. Epub 2005 Sep 8.
  • Avoid using this with your fish oil, may
    interfere with absorption of some other meds and

  • Niacin lowers triglycerides, raises HDL, lowers
    LDL, is also anti-inflammatory Med Hypotheses.
  • Lowers atherosclerotic complications and total
    mortality in trials Curr Cardiol Rep. 2003
  • Do not use time-release niacin can cause liver
  • Causes flushing aspirin before dose reduces
    this, and tolerance to flushing develops
  • May worsen blood sugar control

Plant Sterols (Phytosterols)
  • 2g/d provides 10 reduction in total cholesterol
    and 13 reduction in LDL cholesterol levels Am J
    Med. 1999 Dec107(6)588-94
  • Eating foods low in saturated fat cholesterol
    and high in stanols or sterols can reduce LDL by
  • Adding sterols or stanols to statin medication is
    more effective than doubling the statin dose.
    Mayo Clin Proc. 200378965-978

Red Yeast Rice Extract
  • Red Yeast Rice Extract similar to statins, but
    a mixture of compounds and lower potency results
    in fewer side effects. I still monitor LFTs. Can
    produce 25-30 lowering in LDL.

Garlic (Allium Sativum)
  • Garlic (Allium sativum) 10-15 drop in LDL, 1
    clove per day or 4000 mg fresh garlic or 10 mg
    alliin or 4000 mcg total allicin potential
    lowers platelet aggregation, increases
    fibrinolytic activity, prevents LDL oxidation and
    may lower blood pressure as well, improved
    elasticity of the aorta in one trial
  • Form cooked garlic, powder (most research) or
    aged garlic extracts (odourless) oil is not as
  • Note blood thinning properties changes platelet
    membrane structure, lowers thromboxane, increases
    fibrinolytic activity should be stopped prior to
    elective surgery

Probably not worth using
  • Policosanol mixed clinical trials, and I have
    had no success with this from a reputable company
  • Guggul (Commiphora mukkul) 12 drop in
    cholesterol and LDL in some studies, but 2003
    study showed it raised cholesterol rash, gi side
    effects mechanism is antagonism of farnesoid X

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Poly-portfolio for Prevention
TABLE 2 . Estimated Reductions in the Risk of Major Coronary Heart Disease (CHD) Events and Stroke in Patients With Any CHD, Post-myocardial Infarction (MI),
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