Refocusing on
a Killer

By Paul E. Lemanski, MD, MS, FACP

Medicines are a mainstay of American life and the healthcare system not only because they are perceived to work by the individuals taking them, but also because their benefit may be shown by the objective assessment of scientific study. Clinical research trials have shown that some of the medicines of Western science may reduce the risk of heart attacks, strokes and cardiovascular death.

In the first 94 installments of the Non-Medicated Life, certain dietary practices and a healthy lifestyle have been shown to accomplish naturally for the majority of individuals most of the benefits of medications in the prevention and treatment of chronic medical conditions such as hypertension, high cholesterol, pre-diabetes, diabetes and heart disease.

Over the past two years, the majority of the attention of this column has been directed to lifestyle and public health strategies to combat the Covid-19 pandemic. With the virus hopefully entering an endemic stage, it is time to turn our attention back to a killer no less daunting than SARS-CoV-2 – I am speaking of cardiovascular disease. In the last two years, Covid-19 has killed one-million Americans. In that same period cardiovascular disease – primarily heart attacks and strokes – have killed more than 1.6-million Americans. It is, indeed, time to refocus on this killer and the lifestyle strategies that combat it, which can in some studies reduce cardiovascular death and non-fatal heart attack by 70%.

To start the refocus we must first ask, what is cardiovascular disease and what causes it? The most obvious manifestations of cardiovascular disease are heart attacks and strokes. Both of these are a consequence of the process of atherosclerosis or hardening of the arteries. Arteries harden when LDL or the bad cholesterol, that is present as spherical particles in the blood, occurs in excess amounts in the blood stream and then insinuates itself into the artery wall to form a collection or plaque. This plaque forms just beneath the endothelial cell layer, the inner most cell layer in contact with the blood flow. 

The LDL in the plaque becomes oxidized and initiates an immune inflammatory response involving white blood cells from the blood attacking the plaque, undermining its structural integrity, and causing a tear in the endothelial layer. This tear attracts platelets from the blood stream to form a clot above the plaque that can grow large enough to occlude the vessel and stop blood flow downstream. The loss of blood flow – and the oxygen and nutrients it contains – causes the death of cells downstream from the obstructing clot and occurring in the heart results in a heart attack and in the brain results in a stroke.

With this understanding of atherosclerosis, it becomes more apparent how lack of a healthy diet, daily exercise, and healthy lifestyle changes can increase the risk of disease. The strategy should reduce LDL cholesterol in the blood, reduce the penetration of LDL cholesterol particles into the artery wall, and reduce the inflammatory response.

You can reduce the formation of LDL cholesterol quite simply by eating less saturated fat. I recommend a diet with under 15 grams of saturated fat a day. What foods contain saturated fat? Marbled red meats, the skin of poultry, butter, ice cream, cheese, whole milk products, and coconut. This means eating these foods rarely, or at least within the 15 gram a day limit. Substituting filet mignon for porterhouse steak, chicken breast for wings, tub margarine for butter, frozen yogurt for ice cream, low-fat or no-fat cheese and milk products for whole milk products, and olive oil for coconut oil – these substitutions can help us achieve the 15 gram a day limit and lower the blood LDL cholesterol. 

Eating more plants and grains that have little to no saturated fat also will help. Avoiding fried foods and most prepared, processed foods can also help reduce saturated fat and lower LDL cholesterol in the blood. Moreover, with the appropriate medical indication, it is possible for your physician to order blood tests (standard lipid profile) that can measure LDL cholesterol in your blood and give you feedback on how your lifestyle efforts are succeeding.

How can you reduce the penetration of LDL cholesterol into the artery wall? First, reducing the concentration of LDL cholesterol in the blood, in the ways noted above, will reduce the penetration of LDL into the artery wall. Apart from this, modifying the size of LDL particles in the blood can reduce the penetration into the artery wall.

Small LDL particles more easily penetrate into the gaps between endothelial cells, the octagonal plate like cells, that line the inner wall of the arteries, much like bathroom tile lining the inner wall of a pipe. Larger LDL particles have a much more difficult time getting into the artery wall to form a plaque. 

How do you alter the size of your LDL particles to favor a predominance of larger particles? First, daily moderate exercise such as walking briskly for 30 minutes will favor the liver producing fewer, larger LDL particles rather than more numerous, smaller LDL particles from the saturated fat we eat. The second powerful way to alter LDL particle size is to lose weight, especially if you are overweight or obese. A loss of 5-10% of your bodyweight can start this process in a powerful way, especially when combined with exercise. Additionally, with the appropriate medical indication, it is possible for your physician to order blood tests (NMR LipoProfile) that can show the relative amounts of small and large LDL particles and give you feedback on how your lifestyle efforts are succeeding.

Finally, how can you reduce the inflammatory response? Reducing the LDL cholesterol concentration in the blood, and then reducing the penetration of the LDL by increasing the size of the particles will reduce the total amount of LDL in the artery wall, and directly decrease its ability to cause inflammation. 

But it is not simply the amount of LDL that determines the degree of inflammation, but also the amount of oxidized LDL. Reducing oxidation requires the consumption of natural anti-oxidants contained in plants and thus requires us to do as our mothers always told us and eat our vegetables- both varied in type and large in amount. By eating more vegetables, we also are eating lower caloric density foods and satisfying our appetites at a lower total caloric intake. This will aid in weight loss that by itself is probably the most powerful way to decrease the inflammatory response in the body. And again, with the appropriate medical indication, it is possible for your physician to order blood tests (high-sensitivity CRP) that can measure the level of inflammation in your blood and give you feedback on how your lifestyle efforts are succeeding.

Lowering LDL cholesterol, encouraging the production of fewer, larger LDL particles, and decreasing the inflammatory response is not as hard to do as it may sound. Indeed, it may be as simple as embracing a Mediterranean diet and active lifestyle. In the Lyon Diet Heart Study, a high Omega-3 Mediterranean diet, reduced the risk of fatal and nonfatal heart attack by 70%. This is especially impressive given that statins, one of the most powerful drug classes to reduce heart attacks and strokes, evidence a relative risk reduction of only 30-40%. Why not consider implementing just such a lifestyle change today and reduce your own risk?

In summary, cardiovascular disease, is the number one killer of men and women in the United States. In the last two years, cardiovascular disease has actually killed more Americans than Covid. It is time to refocus on this killer and implement a diet and lifestyle that has been proven to successfully combat it.

Paul E. Lemanski, MD, MS, FACP (plemanski3@gmail.com) is a board-certified internist practicing internal medicine and lifestyle medicine in Albany. Paul has a master’s degree in human nutrition, he’s an assistant clinical professor of medicine at Albany Medical College, and a fellow of the American College of Physicians.