Diet or Drugs to Prevent Heart Disease

The risk of heart disease has been associated with countless different things.

Smoking, diabetes, high blood pressure, overweight, obesity, sitting and watching TV, eating too much fat, eating too much sugar, not eating certain fats, eating meat, not eating fish, eating too much animal fat, eating cholesterol, eating saturated fat, eating trans fats, high blood cholesterol, high LDL-cholesterol, inflammation, family history of heart disease….

Diet or Drugs to Prevent Heart Disease

Is it really possible to avoid being hit by this dreadful disease, the most common cause of death and disability worldwide?Should we change our lifestyle? How can we improve our diet? Should we take drugs for prevention?

The risk of heart disease increases with age. So, if we become old enough, we will probably have heart disease sooner or later, and most likely die from it. But that is not necessarily a bad thing. We all have to die from something. Dying from something else is not a goal by itself.

So maybe we would be more accurate if, instead of aiming at preventing, our goal was to delay the onset of heart disease. However, defining our goal is probably less important than defining the methods to achieve it.

A huge number of healthy adults will have heart disease in the next ten years. Many will be treated with drugs, some will have angioplasty and stents, and some will have open heart surgery. Many will die from the disease. A substantial number will be left with severe disability. Many will not be able to work, and many will not enjoy the quality of life they had before the disease hit them. So, I presume we all agree that delaying the onset of heart disease is a worthwhile target.

Who should worry about getting heart disease? Probably everybody. But, who should worry the most? Who is most likely to be struck by heart disease in the next few years?

This is where it comes to the so-called risk factors. If you have many risk factors, the risk of having a heart attack or stroke becomes higher. The strongest risk factors are smoking, diabetes, high blood pressure, high levels of LDL-cholesterol, low levels of HDL-cholesterol, overweight or obesity, and family history of premature coronary artery disease. If you don’t have any risk factors, your aim should be to avoid them at all costs. But, if you have some of these risk factors, what can you do?

A Visit to Dr. Oxenhaler

Let’s assume you are a responsible person (you probably are by the way, because you are reading my blog), and you want to do everything you can to delay the onset of heart disease.

Maybe your father had a heart attack in his fifties. Maybe you have gained a bit of weight, and maybe your cholesterol level is a bit too high. So, you decide it’s time to have a chat with your general practitioner, Dr. Oxenhaler, the family doctor. Last year he put you on a drug to lower your blood pressure. This time, you are better prepared for your visit because you have been reading my blog.

You are sitting in front of Dr. Oxenhaler in his office. He just finished measuring your blood pressure, and now he is watching your blood work on his computer screen. This is how the conversation might evolve.

‘Is there a specific reason you decided to come to see me. Have you been having chest pain or discomfort of any kind?’
‘No Dr. Oxenhaler. I was just worried. I’ve been reading lots of stuff about heart disease on the internet. I was wondering what I should do to avoid having a heart attack.’
‘Well, I guess you should be a little bit worried, but I’m glad you care. That’s the first step. Your blood pressure is fine, thanks to the medication I prescribed for you last year. However, your cholesterol is 277 mg/dl (6.9 mmol/L), that’s  way too high.’
‘How about my LDL cholesterol?’

Diet or drugs to prevent heart disease. A vist to Doctor Oxenhaler.

Dr. Oxenhaler watches you carefully, his glasses sliding down on his nose. He takes a deep breath.

‘I see you’ve been reading. That’s good. Education is the key to better health. Your LDL cholesterol is 182 mg/dL (4.7 mmol/L), that’s also way too high. HDL-C, the good cholesterol is 40 mg/dL (1.0 mmol/L) which is too low. Considering your family history and your history of high blood pressure, the risk is quite high. By using the Framingham risk calculator, I can see that your risk of having a heart attack in the next ten years is about 17 percent.’

You feel a little numb like the blood is draining from your head. Dr. Oxenhaler notices your paleness and becomes a bit more sympathetic.

‘Don’t be scared though. We can take care of this. Treatment is available. By putting you on a cholesterol lowering drug, we can lower your risk substantially.  Your cholesterol will go down and so will LDL-cholesterol. Your risk of heart attack will be much less’.
‘But I read that the effect of statin drugs is very small when they’re used for prevention in people who don’t have heart disease’.
‘That’s a misinterpretation. The risk reduction in the clinical trials is about 30 percent among high-risk individuals, which in my mind is quite substantial.’
‘You’re talking about relative reduction then Dr. Oxenhaler, aren’t you?´

There is a momentary pause. You catch a glimpse of surprise in his eyes. He looks at his watch and then back at you, a faint smile on his lips.

‘Yes, relative reduction, that’s correct’, he says.
‘I’ve read that statins have lots of side effects as well.’
‘Side effects are very uncommon. A small number of people have muscle pain, but it’s rare. Most people do not have any problems with cholesterol-lowering drugs.’
‘I read that some people have memory loss.’

He looks surprised.

‘I don’t recall any of my patients complaining of memory loss from statins.’

Now you can’t help wondering whether Dr. Oxenhaler is taking statins. You dismiss the thought immediately. You have to keep focus.

‘I’ve heard there is  more risk of diabetes if you take statins,’ you say,

He loosens his tie a bit, and he has stopped smiling. You’re aware that you’re using up a lot of his time. There are more patients waiting for him.

‘Let me just tell you that the benefits of statins definitively outweigh the risks’, says Dr. Oxenhaler.

But you’re not giving up.

‘Isn’t there something I can do by myself, change may diet or exercise more?’, you ask.
‘Diet and exercise is fine. Cut down on fats, especially saturated fat and don’t eat too much cholesterol. That’s helpful. But it won’t replace statin treatment when it comes to reducing your risk.’
‘I heard about a study published recently in The New England Journal of Medicine showing that a Mediterranean diet could lower the risk of heart attack and stroke if you have risk factors like I do’
‘You’re right indeed, but the effect is very small. Besides, diets are usually hard to stick with.’
‘I read that the relative risk reduction was about 30 percent on the Mediterranean diet compared to a low-fat diet. Isn’t that about the same effect that statins have in a similar population?’ Could a Mediterranean diet be an alternative to statin therapy?

Dr. Oxenhaler does not answer right away. He stares at the computer screen.

‘Very well, why don’t you try the Mediterranean diet for six months and then come visit me again. We’ll measure your cholesterol and decide what to do. If it’s still high, I definitively recommend statin treatment to cut your risk’, he says eventually, still watching the computer screen.

‘Isn’t it possible that the diet is helpful, although my cholesterol stays the same?’

Now he is looking at you again, more seriously than before. You can’t really tell whether he is annoyed or not.

‘If we are to succeed in lowering your risk of heart disease, we must lower your LDL-cholesterol. That’s a fact.’
‘But, I just read about the Women’s Health Initiative showing that reducing the intake of fat lowered cholesterol, but did not cut the risk of heart disease’.

Now he is up on his feet and offering his hand. He shakes his head in disbelief, but he is smiling again.

‘Please come back to see me in six months. Good luck with the Mediterranean diet. Go easy on the wine though. And for God’s sake don’t believe everything you read on the internet….’

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bhrdoc
7 years ago

Excellent piece Axel. Would that all patients were this well informed. As we know from the Lyon Diet Heart study, even in people who have survived a heart attack, adhering to the Mediterranean Diet lowers risk of death, cardiac death and recurrent heart attack, by even greater margins than that found in the recent primary prevention PREDIMED study, and without any significant lowering of LDL-cholesterol.

davebrown9
7 years ago

The so-called Mediterranean diet is indeed healthy for the heart, but not for reasons most people visualize. Two studies suggest that inadvertently lowering omeg-6 is the key. Excerpts: The only striking difference between the two groups in the Lyon Diet Heart Study was the restriction of omega-6 fatty acids in the experimental group. You find omega-6 fatty acids in vegetable oils like corn, safflower, and sunflower oils. They accomplished this dietary change by giving the subjects in the experimental groups margarines rich in omega-3 fats and trans fats. Although there was a dramatic decrease in death between the two groups… Read more »

JeffryGerberMD
7 years ago

Axel – I think that you coached the patient! Well done.

Teitur Guðmundsson, MD

Very politically correct and fun to read. Sadly very few patients challenge their doctor in this way. The doctor on the other hand does not need to provide any details on his CME to his patient base. Therefore the patients will never really be able to know whether or not the MD is current (up to date) in his practice. Quite an interesting aspect of the very unbalanced relationship between a doctor and a patient indeed! Thank god for the internet. Good article!

Richard
Richard
7 years ago

Sorry, Axel. I don’t really get this. What was the point of this article? The WHI-trial showed that when people consume 3/4 of their protein from animals together with daily intake of 16 grams of fiber per day, there is no substantial benefit of attempting to cut down on fats. The intervention arm, the ones who received their 20 min of counselling, did not increase their intake of whole-grains, legumes, fruits or vegetables. They kept tinkering on fat within the context of a diet high in animal products. The intervention arm did not show any difference in LDL cholesterol next… Read more »

davebrown9
7 years ago

@ Richard,

Quote: Firstly, the idea that ‘lower is better’ has not been formally tested. It’s actually based on assumptions. And these assumptions come from studies that were never able to determine whether getting cholesterol levels down to a certain level is better for patients than other levels. In fact, it’s been previously noted in the scientific literature that the idea of treating people according to predetermined cholesterol levels is not founded in science at all. https://www.drbriffa.com/2013/02/28/are-we-soon-to-see-a-relaxing-in-cholesterol-guidelines/

Richard
Richard
7 years ago

^I feel I need to clarity myself. This was excellent piece and illustrated very well the new kind of problems doctors face with patients these days. But I wasn’t too enthusiastic about these little, subtle enunciations in the text in regards to statin therapy and dietary interventions.

Doc´s opinion
Admin
Doc´s opinion
7 years ago
Reply to  Richard

I get your point Richard. I wanted to reflect on the doctor-patient relationship in the age of information and internet. A doctor has to follow scientific results and clinical guidelines delivered to him by the medical and scientific community. By doing that he is practicing evidence base medicine which in my mind he definitively should. However, he also has to deal with pressure from other informative sources which are good or bad, true or false, or somewhere in between. This isn´t always an easy task. Therefore, I think we have to show Doctor Oxenhaler some sympathy. Another thing I wanted… Read more »

Ivor Goodbody
7 years ago
Reply to  Doc´s opinion

Dear Doc Sigurdsson At least one such study (actually, series of studies) IS available: the work by Dr David Jenkins on the Portfolio Diet compared to first-generation statins: Sample quote: “We conclude that acceptable diets of foods from supermarkets and health food stores that contain recognized cholesterol-lowering dietary components in combination (a dietary portfolio) may be as effective as the starting dose of older first-line drugs in managing hypercholesterolemia.” Some references (not exhaustive): A dietary portfolio approach to cholesterol reduction: Combined effects of plant sterols, vegetable proteins, and viscous fibers in hypercholesterolemia [vs control diet using lovastatin] https://www.metabolismjournal.com/article/S0026-0495%2802%2900166-X/abstract Direct comparison… Read more »

Richard
Richard
7 years ago

Yes, Doc. You are absolutely right. However, in regards to your last argument. The drug-free Ornish program is known to lead in ~40% reduction in LDL cholesterol in 12-weeks. This is equal to high-dose statin therapy and verified in multiple sites (more information, see Ornish’s own website) Ofcourse this kind of program is hard to replicate in hospitals and clinics which have not “installed” the Ornish program. However the large reduction in LDL ought to be mediated pretty much by the diet alone. I think patients should be informed about this kind of powerful, drug-free, evidenced based therapy. It has… Read more »

David Brown
7 years ago

Richard, I would encourage you to investigate the omega-6 hazard. Among the advantages of the Ornish program is that it drastically reduces over all fat intake inadvertently lowering omega-6 intake. Unfortunately, the low-fat approach is not appropriate for that portion of the population that is carbohydrate resistant(1). Dr. Barry Dears critiqued the PREDIMED study. His comment: In contrast to this poorly executed study, there exists a far more powerful study conducted nearly 20 years ago on the benefits of a stricter Mediterranean diet. This is was the Lyon Diet Heart Study. The primary clinical difference between this new study and… Read more »

Richard
Richard
7 years ago

David Brown, see the article by Pritikin. Pritikin refers to studies which have put diabetics in a diet where 80% of the calories have come in the form of pure table sugar. Such diets have improved the glucose tolerance of diabetics. No one is advocating sugar to diabetics but it ought to put things into perspective. Diabetics have got their diabetes thanks to high-fat diets, and studies show that diabetics are off the medicine in few weeks after adhering some exercise and complex carbohydrate feeding. Ornish diet works very well on diabetics. In fact, you can see it in Forks… Read more »

Mark
Mark
7 years ago
Reply to  Richard

A high fat, low carbo (Paleo) diet has virtually eliminated my diabetes, so not sure I follow. High sugar,high carbs and my readings are off the chart

David Brown
7 years ago

Richard, I’m reading the article. Quote from page 9: “Can a diet restricting fat to 10% produce deficiencies? The only fat the body cannot manufacture is lenoleic acid. Winitz(24) has shown the daily requirement for lenoleic acid to be only two grams. Recent findings by Press(27) demonstrate that only .1% of total calories as lenoleic acid as a therapeutic dose is required to correct essential fatty acid deficiency: that is only 1/300th of an ounce per day.” Seems like the Pritikin article supports my position. Omega-6s are a novel addition to the modern human dietary(1,2). Yet, there is very little… Read more »

Mie
Mie
7 years ago

“In fact, it’s been previously noted in the scientific literature that the idea of treating people according to predetermined cholesterol levels is not founded in science at all. https://www.drbriffa.com/2013/02/28/are-we-soon-to-see-a-relaxing-in-cholesterol-guidelines/” Briffa’s piece is based on a review by Hayward et al (2006) which is outdated. According to the recent Joint ESC Guidelines, more recent meta-analyses have examined the same issue and confirmed the treatment goals for high-risk patients: https://www.ncbi.nlm.nih.gov/pubmed/21067804 https://www.bmj.com/content/338/bmj.b2376 https://www.ncbi.nlm.nih.gov/pubmed/19022156 Concerning the “n-6 & inflammation” -case: much ado about nothing. According to NHANES 2009-10, a regular American gets about 6,5% of total energy intake from n-6 fatty acids. If we… Read more »

Mie
Mie
7 years ago

Richard stated:

“Pritikin refers to studies which have put diabetics in a diet where 80% of the calories have come in the form of pure table sugar. Such diets have improved the glucose tolerance of diabetics.”

As far as I can see, there is only one such study mentioned in the article you linked.

https://ajcn.nutrition.org/content/26/6/600.full.pdf+html

Both the glucose and the sucrose groups had significantly worse triglyseride values and the former gained weight (on a diet with the same energy intake as the control group!). Hurrah??

Richard
Richard
7 years ago

“Both the glucose and the sucrose groups had significantly worse triglyseride values and the former gained weight (on a diet with the same energy intake as the control group!). Hurrah??” Yes, this was the observed downside, and no one has insisted that sugar ought to fed to diabetics. Patients in Ornish’s (1990) intervention arm showed mild elevation in triglyceride levels as well, simultaneously as their plaques were regressing. Complex carbohydrate feeding usually result in lower triglycerides as multiple studies have indicated. Hence, I am entirely sure what happened with Ornish’s patients. Nevertheless, elevation of triglycerides, a second-tier risk-marker, was trivial… Read more »

David Brown
7 years ago

Excerpt: “Sugar feeding markedly exaggerated the hyperglyceridemia in all of the patients studied. Equicaloric substitution of starch for sugar in the diet resulted in lowering of the elevated serum lipids toward normal. It was necessary to raise the daily carbohydrate intake to 85-90% of the total daily caloric intake in order to induce hyperglyceridemia in normolipemic subjects.” https://ajcn.nutrition.org/content/20/2/116.abstract The lesson here is that people vary in their metabolic makeup which modulates their response to macronutrient configuration. Some do not tolerate high-fat intake well. Others thrive on high-fat. Ditto for carbohydrates. Richard says, “Complex carbohydrate feeding usually results in lower triglycerides… Read more »

Mark
Mark
7 years ago
Reply to  David Brown

Just take a look at Dr Bernstein’s success with low carbing and diabetes. This is pretty much a no-brainer for us diabetics.

Ivor Goodbody
7 years ago

“It would certainly be interesting if the effect of statin therapy for example was compared to lifestyle change or a diet intervention. Such studies, unfortunately are not available.” Oh yes they are! For the Portfolio Diet devised by Dr Jenkins. He’s done a whole series of studies. I’ll cite just two: Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin [lovastatin] in hypercholesterolemic participants https://ajcn.nutrition.org/content/81/2/380.full A Dietary portfolio: Maximal reduction of low-density lipoprotein cholesterol with diet https://link.springer.com/article/10.1007/s11883-004-0091-9 The catch: the diet is harder both to switch to and stick with for regular eaters than the Med Diet,… Read more »

Doc´s opinion
Admin
Doc´s opinion
7 years ago
Reply to  Ivor Goodbody

Thanks Ivor. I appreciate your comments. I agree with you on diets vs. drugs. It does not need to be either or, and it should’nt be. However, it is often easier for doctors, and other health professionals to prescribe a drug than to inform about lifestyle alternatives. My article was supposed to underscore the importance of lifestyle measures when it comes to cardiovascular prevention, and that they should not be ignored although we have drugs. I also wanted to highlight some of the issues that may surface regarding the doctor-patient relationship when dealing with these matters. The doctor’s and the… Read more »

Mie
Mie
7 years ago
Reply to  Ivor Goodbody

“The catch: the diet is harder both to switch to and stick with for regular eaters than the Med Diet, since it’s vegan.”

Indeed. And the results in triglyserides and HDL are less impressive than with statins. However, Portfolio does seem to beat regular low-fat diet hands down, so at the very least it seems a feasible (short-term) clinical solution in a situation where you need to address LDL levels quickly. In terms of regular diet and/or weight management: not so.

Doc´s opinion
Admin
Doc´s opinion
7 years ago
Reply to  Ivor Goodbody

Although we have studies comparing the effects on lipid parameters of diet vs. cholestereol lowering drugs, we still don’t haves any studies available comparing the effects of these two treatment options on clinical endpoints such as mortality and cardiovascular events.

Ivor Goodbody
7 years ago
Reply to  Doc´s opinion

As important (more important?) than the question of proven efficacy of statins vs diet may be the question: which are patients most likely to comply with enough to make a worthwhile difference? Here again, diet seems to be the clear winner on current evidence. https://ajcn.nutrition.org/content/83/3/582.full Jenkins found 79% of Portfolio Dieters in a 1-year study stuck successfully to almonds, and 67% to sterol-enriched margarine. By contrast, compliance for either viscous fibre or soy protein was little better than 50-50. Even so, overall 32% of subjects reduced LDL-C by >20%. Those higher figures – and the outcomes – look very much… Read more »

Mie
Mie
7 years ago
Reply to  Ivor Goodbody

Ivor, your reasoning here is flawed (and I wouldn’t let Jenkins et al. off the hook either…) First, this: “As important (more important?) than the question of proven efficacy of statins vs diet may be the question: which are patients most likely to comply with enough to make a worthwhile difference? Here again, diet seems to be the clear winner on current evidence. https://ajcn.nutrition.org/content/83/3/582.full” You cannot possibly compare a 12-month-long small RCT (55 participants completing the study) which didn’t even look at CV endpoints to large statin trials with a) tens of thousands of patients going on for b) several… Read more »

Ivor Goodbody
6 years ago
Reply to  Mie

1. “You cannot possibly compare a 12-month-long small RCT (55 participants completing the study) which didn’t even look at CV endpoints to large statin trials with a) tens of thousands of patients going on for b) several years and expect to be able to say anything on the efficacy of these two options that isn’t … well, pure speculation!!” I used the word “seems” advisedly. Of course the evidence as it currently stands isn’t anywhere near enough to prove the superiority of this (or any other) diet to statins. But the larger point is that it doesn’t matter how efficacious… Read more »

Mie
Mie
6 years ago

Ivor, “But the larger point is that it doesn’t matter how efficacious statins or any other drugs are in studies if you can’t get patients to take them in efficacious doses in the real world, or perhaps just can’t get patients to comply nearly as well with them as they might with some diet or food that is equally efficacious when consumed in the recommended amounts.” Perhaps. However, with the patients to whom statins are recommended from the start, there’s no evidence to suggest that the latter (lifestyle intervention getting better compliance than medication) is the case. Unfortunately so. It’d… Read more »

Ivor Goodbody
6 years ago

Only one point worth replying to explicitly, I think. I must confess I HAVEN’T heard of “plasebo” no 🙂 I HAVE heard of the placebo effect. But it’s a spurious reason for drawing a distinction between Jenkins’ trials and clinical studies of statins. Why? Because objective outcomes such as blood lipid levels have been used to measure efficacy in both cases. In general, placebos have been found to have “no significant effects on objective…outcomes [and only] possible small benefits in studies with continuous subjective outcomes” https://www.ncbi.nlm.nih.gov/pubmed/11372012 There is certainly an interesting philosophical debate to be had (and no, I am… Read more »

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