Professional Documents
Culture Documents
1
Chapter 3: Addressing the Principal Issues 71
Is Cholesterol Theory of Cardiovascular Disease Correct? 72
Pivotal Studies Linking Cholesterol and Coronary
Artery Disease 75
Challenging the Cholesterol Hypothesis 76
Beyond Cholesterol as the Cause 83
Oxidative Injury & Coronary Artery Disease 85
Facts About Heart Attack 88
The Scary Environments of Hospitals 90
What Kinds of Risks Lurk in the CCU 93
Expensive and Dangerous Urination in the Acute Care
Setting 94
Tubes and Needles 96
Cost-Effective Cardiac Testing and Treatment 97
Escape From the Coronary Care Unit 100
Returning to Normal Life Following a Heart Attack 104
Sex After Heart Attack 109
Do Not Forget the Mind 110
The Benefits of Bypass Surgery: Unresolved 112
What Happens to Patients Undergoing Bypass Surgery 119
Avoiding Revascularization (Bypass and Angioplasty)
Procedures 121
A Word About Chelation Therapy 123
Doctor Watchers: A Necessary Evil 124
Sudden Cardiac Death 127
CPR: A Practical Skill 130
The Dangers of Diabetes Mellitus 132
Exercise & Coronary Risks 133
An Aspirin a Day Keeps the Heart Attack Away 134
Radical Arguments From Free-Radical Proponents 135
Smoker’s Heart Attack 136
Risk Factors for Hypertension 137
The Silent Killer is Often Mild 139
Good Trends Hide Bad Situations 143
Lowering Blood Pressure Without Drugs 151
Evidence That Good Habits Lower Blood Pressure 155
Substance Abuse and High Blood Pressure 158
Simple Dietary Switches With Big Effects 161
Miscellaneous Natural Options 162
Dietary Supplements Emerge as an Option 162
2
Summarizing Natural Approaches to Blood Pressure
Reduction 163
Chapter 4: Lifestyle Approaches 166
Lifestyle Change: Plans Not Diets 167
Smoking 168
Stress 169
The Lifestyle Concept 172
The Ten Lifestyle Commandments 175
Self-Identification and Self-Intervention 176
Changing Behavior 181
Excessive Drinking 183
What is Sensible Drinking? 186
Prevention of Alcohol Problems 188
Alcohol and Heart Disease 190
Drinking Doctors and Cardiovascular Risks 191
Substance Abuse 194
Smoking 195
Prescription Drug Abuse 196
Exercise 198
Psychological Well-Being 201
Depression 201
Self-Help Techniques for Elevating Mood 203
Behavior That Will Get You in the End 203
Type A Behavior and Cardiovascular Disease 204
The Irritable Bowel Syndrome 207
The Mind Minds the Heart 209
The Body’s Innate Ability to Heal 211
Spiritual Connection 212
Mind Body Prescription for the Heart 214
Social Aspects of Cardiovascular Wellness
218
Stress Reduction and Relaxation Programs 219
Remember the Bouquet of Barbed Wire 223
Chapter 5: Dietary Adjustments 224
Reversing Atheroma? 225
Drs. Pritikin and Ornish Speak! 228
Who Missed the Boat? 234
Dr. Fredericks Got it Right! 235
Diets at the Crossroads 237
The Missing Links are Discovered? 238
3
Soy Essential Fatty Acids and Fiber Prevail 241
Chapter 6: Nutritional Influences on Cardiovascular Disease 242
Nutritional Therapy of Lower Lipid: The Dietary
Supplement 243
Some Important Dietary Details 244
Fussing About Fat 246
Bad Eggs, Good Eggs? 247
Rotten Egg Ratios 248
Selecting Foods 249
Dietary Fiber 251
Focus on Fiber 253
The Fiber Hypothesis 254
Irritable Bowel Syndrome 256
Increasing Dietary Fiber Intake 257
Fiber in Soya 258
Fiber and Longevity 263
Benefits of Eating Fiber 264
How Much Fiber? 265
Different Fibers Cause Much Confusion 266
Soya Fiber Lowers Cholesterol 267
Diabetes mellitus a Cardiovascular Killer 269
Get the Right Type of Carbohydrates 270
Alcohol and Coffee Consumption 271
Vitamins 273
Minerals 274
Miscellaneous Nutritional Factors 277
Chapter 7: Soy and Cardiovascular Health 279
Overlooking Diet as the Key to Cardiovascular Health 280
Premature Prescription Practice? 280
Soya Protein Isolates are Effective at Lowering Cholesterol 282
Is Soy Rabbit Food? 287
How Does Soy Lower Cholesterol? 288
How Does Soy Promote Cardiovascular Wellness? 293
What is in a Soyabean? 295
What Other Cardiovascular Benefits are Present in Soy? 295
Summing Up on Soy 300
Can Soy Milk Replace Cow’s Milk 303
Is Soy Milk Dangerous in Infancy? 306
Chapter 8: The Omega Factors 307
Do Not Skip This Chapter! 308
4
Not All Fats are Bad 309
Understanding the Chemistry of Essential Fatty Acids 311
Oils Produced by Bad Processes 313
What do Fatty Acids Do? 315
The Essential Nature of the Essential Fatty Acids 316
Sources of Essential Fatty Acids 319
Tracing the Origin of the Health Benefits of Fish Oils 321
The Health Benefits of Fish Oil 322
The Importance of EPA & DHA 325
A Brief Overview of Essential Fatty Acids 327
Putting Essential Fatty Acids in Pathways 331
Good and Bad Oils from Fish 337
How Much Fish Oil per Day? 339
Essential Fatty Acids Need Co-Factors 340
Ideal Intakes? 341
Delayed-Release Fish Oil Supplements Are Desirable 343
A Word of Caution 345
Frying or Heating Dietary Fat
346
Fish Oil is Essential 348
The Omega 6 and 3 Balance 348
Visiting the Omega 3 Factor 350
Essential Fatty Acids and Prostaglandins: The Important
Health Link 353
Fish Oil Shifts Away From Leukotrienes 357
Fish Oil and the Generation of Prostaglandins 358
Series 1 Prostaglandins 359
Type 3 Prostaglandins Preferred Over Type 2 360
Retiring Type 2 and Emerging Type 1 and 3 360
Type 1, 2, and 3 Prostaglandins Understood by
Remembering 3 361
Dangerous Animal Protein Diets and Prostaglandins 362
Fish Oil Lowers Cholesterol 364
Dr. Phillipson’s Pivotal Study on Fish Oil 364
The Eskimo Research Project 366
Both levels of Blood Cholesterol and Amounts of Fish
Oil are Important 368
Preventing Atheroma and thrombosis 369
Lowering Blood Pressure 370
Fish Oil for Bypass Surgery 371
5
Fish Oil and Angina 372
Eicosopentanoic Acid in Focus 372
Fish Oil Supplements 376
Conclusion 379
Chapter 9: Botanical Influences on Cardiovascular Disease 380
Botanical Influences or Cardiovascular Diseases 381
A Warning About Botanicals 383
Garlic 386
Versatile Effects of Garlic 386
Focus on Garlic and Cardiovascular health 393
Garlic: How Much? What Type? 393
Procyanidolic Oligomers 396
Plant Constituents: Polyphenols & Bioflavonoids
396
Free-Radical Damage to the Cardiovascular System 413
Antioxidant Effects of Co-Enzyme Q10 415
Ginger 417
Ginseng 418
Guggul 424
Fo-ti 425
Some Natural Blood Pressure Lowering Agents 426
“Salt” by Other Names and Types 426
A “Salty” Education 428
Celery May Lower Blood Pressure 431
Combination Remedies in Dietary Supplements:
Mixed Blessing 432
Chapter 10: General Dietary Factors 435
Optimal Nutrition
436
A Reasonable Composite Diet 437
A Primer of Digestion and Nutrition
439
From Mouth to Anus 442
Main Dietary Constituents in Simple Focus 446
Understanding Vitamins 447
Some Alarming Facts About Children 451
Dr. Attwood’s Twelve Common Myths 453
Special Consideration: The Young and The Elderly 459
Examining Aspects of Popular Childhood Diets 463
Childhood Nutrition and Cardiovascular Risk 464
6
Dietary Supplements Present Options 469
Diet in the Mature Female 470
Simple Facts About Menopause 471
Difficult Decisions for the Mature Female 472
Simple Observations in the Climacteric 473
Biopharmaceutical Complexity of Isoflavones 475
Where Do Isoflavones Act in the Body? 481
Estrogenic Activities of Isoflavones 482
The Potential Significance of the Estrogenic Effect of Soy
Isoflavones 484
A Miracle of Menopause 485
The Downside of Female Maternity 486
Soy Isoflavones and Menopausal Symptoms 487
Double-Blind Controlled Trials Show the Benefit of Soy
Isoflavones in Menopausal Women 488
Can Soy Isoflavones by Used as Natural HRT? 491
Words of Caution About Isoflavone Dosage 493
Doses of Isoflavones for Health Benefits? 494
Focus on Soy and Cardiovascular Disease in the Mature
Female 495
Other Benefits of Soy in the Post-Menopausal State 497
Are Phytoestrogens Safe? 498
Summing Up Soy Isoflavones 499
Carnitine: Not Just for the Body-Builder 501
Chromium 503
Cardiovascular Function Fights Father Time 505
Diets for the Elderly at Risk of Cardiovascular Disease 507
Looking at Food: How to Eat? 509
Chapter 11: Weight Control 516
Caution for the Dieter 517
Eating Disorders May be Forgotten 517
Dispelling the Fads: Looking at Diets 520
Chapter 12: Obesity 527
Overview of Obesity 528
Measuring Weight Status 530
The Confused Healthcare Giver 533
The Importance of Body Fat Distribution 533
Killer Types of Obesity 534
Population Studies Define Risks 535
“Tailor Made” Diets 537
7
Critical Elements of Diets 539
Different Direction With Diets 540
Obesity Defined and Re-Defined 541
The Significance of Being Fat 544
What Causes Obesity? 544
Chapter 13: Making Recommendations 549
Pulling it All Together 550
The Author’s Recommendation on Diet Plans 551
Special Diets for Special People 557
Natural Substances for the CardioPlan 561
8
FORWARD
The concepts that Dr. Holt presents as “The Cholesterol Time Bomb”
subscribe to the notion that cardiovascular risk factors are interwoven to
form a pernicious web of danger. Although the evidence for the role of
cholesterol and blood lipid abnormalities as a pivotal cause of
atheriosclerosis is unquestionable, Dr. Holt points out that they are only part
of the overall puzzle of cardiovascular disorders. Dr. Holt goes beyond our
knowledge of the pathophysiology of atherosclerotic cardiovascular disease
and discusses the poorly applied link of psychosocial factors and
9
cardiovascular wellness.
The most striking feature of this book is the validity of its discussion
about natural medicine. This discussion is supported by an expert appraisal
of contemporary scientific literature. Dr. Holt has produced a readable book
that will not bore even the most informed. Individuals interested in
cardiovascular health from a personal or professional basis stand to gain
much applicable knowledge from this work. There is an up to date account
of the scientific basis or rationale for the use of several macro- or
micronutrients to promote cardiac health. This book proposes non-invasive
and potentially cost-effective approach to cardiovascular wellness in a
commendable manner and it is recommended as timely in the face of
escalating costs of healthcare.
Not only does this book examine natural options for the person with
established coronary heart disease, it provides common-sense tactics for
cardiovascular disease prevention. The concept of combining diet and
lifestyle with the appropriate selection of conventional or alternative medical
options makes this book a unique contribution to healthcare. Dr. Holt
pioneers the expansion of pluralistic medicine in tackling atherosclerosis
which is humankind’s number one killer disorder. The contribution of this
book in the war against cardiovascular disease will be easily recognized.
10
PREFACE
Real progress most often occurs at that cutting edge that separate
disciplines. Many people are disenchanted with both conventional and
alternative medicine. The constant dog-fights between the conventional and
alternative practitioners of medicine leave us wondering about the
competence of both. Every healthcare consumer should have the right to
receive the best treatment and the best preventive care. Anyone who truly
needs cardiac bypass surgery should have it and not have to resort to untried
or tested interventions. However, if the best approach may is to put the
cardiac surgeon out of business by preventing coronary atherosclerosis
through an alternative approach, then this option should be available.
13
CHAPTER 1
THE BOMB
14
What is the Cholesterol Time Bomb?
At this stage, anyone who questions the role of hypercholesterolemia
in the causation of coronary heart should probably join “the flat earth
society”. However, high blood cholesterol is not the only issue relevant to
cardiovascular wellness, and this is why the author has coined the collective
term “Cholesterol Time Bomb”. Time bombs usually tick and provide some
warning before they go off. Unfortunately, the “Cholesterol Time Bomb”
has no tick, but it can be spotted before detonation.
Factor Significance
15
Blood Pressure Risk is directly proportionate to the increase of systolic
or diastolic blood pressure.
Diabetes Mellitus Risk is two times control in diabetic men, three times
control in diabetic women.
Obesity Fat people have more coronary artery disease than those
of normal body habitus.
Table 1: Risk Factors for Coronary Artery Disease. Although alcohol and
caffeine have been claimed by some to be independent risk factors, they
have not been established to be clear risks. However, obesity acts by
increasing the severity of hypertension, hyperlipidemia, and diabetes
mellitus and it has an important influence on the development of coronary
artery disease.
16
of the adverse lifestyle often determines the risk. The earlier the
intervention, the better the prognosis in most disease states.
The major reason is that adverse lifestyle is pleasurable for many and
it is often subject to denial, projection or rationalization: “If my friends did
not smoke, I would not smoke.” “The occasional six pack of beer (on a
daily basis) does not hurt. Did you know they brew the beer with spring
water and organic hops……?” There is a large body of scientific evidence
to support the notion that most people minimize their indulgence in adverse
lifestyles. The person who has an eating disorder at the root of his or her
problem of obesity and hypercholesterolemia is highly likely to
underestimate the quantity and quality of food consumed on a daily basis.
Fast food has become a staple diet for many but it is often loaded with
unhealthy types of fat and it is cholesterol rich. It is a normal human
reaction to suppress the significance of a risk, especially if maintaining the
risk is pleasurable.
18
Lifestyle Approach
to Poor Health Comments
Drink Alcohol If you do not die of liver disease you will succumb
to
Excessively trauma usually after very painful social isolation.
Do Not Exercise This assures many health problems and a lack of well-
being.
Stress Yourself You may become distraught, mentally or physically ill and
Constantly persecute others.
Eat a Lousy Diet A good way to make almost every organ in the body fail.
Distain Nutritionally He or she has a lot to offer and can enhance the quality of
Orientated Physicians your life.
Do Not Have Periodic You will never know much about your risks of illness or
Health Checks death. You will suffer or die in ignorance.
Take Excessive Quantities You can ruin your health with excessive vitamin intake.
of “Health Foods”, Dietary Many dietary supplements have “purposely” misleading
Supplements or “way-out” health claims. Some herbs are great poisons.
Herbal Cures
Make Your Own Diagnosis There are many serious diseases that can kill you slowly.
and Ignore Prolonged or Several are amenable to cure. Self-medication or diagnosis
Serious Symptoms is a great way of denying yourself a good health outcome.
Engage in Risk Lifestyles It may be pleasurable to put your life at risk and it is easy
to die prematurely.
19
Table 2: Some sure tactics for poor health. NOTE: These are not recommendations
for anyone to follow. They are written and expressed in a manner that is designed to
stimulate thoughts about lifestyle change that could accrue to an individual’s benefit.
20
Whopper Burger 36
Burrito Supreme 22
Deluxe Hamburger 21
Sausage Biscuit with Egg 33
Popcorn Chicken 45
Quarter Pounder with Cheese 28
Table 3: The approximate fat content of single servings of some of the most
popular fast food items. The fat is largely of the saturated type and the food
contains a relatively large amount of trans-fatty acids that may be dangerous
to health. These fast food items are not much different than many processed
animal protein products that are found in all stores. Compositions of food
vary with time and salad bars have emerged in fast food restaurants as this
industry responds to demands for better nutrition.
21
campaigns to attract clients. However, very few managed care organizations
will foot the bill or pay directly for preventive medicine. The “new”
physician may often have a “no talk, hands off, investigational-intense”
attitude. This attitude is often combined with a quick reach for a
prescription pad. When did a physician in the United States last make a
“house call”? It is understood that Dr. Jack Kevorkian makes regular house
calls in Michigan and his practices reflect our general social endorsement of
slow suicide by continued adverse lifestyle. The sardonic nature of this
dialogue is to reinforce the complacency that exists. This complacency is
difficult to overcome.
The author would like to emphasize that he does not believe that the
lowering of blood cholesterol is an unnecessary pastime, however, this
intervention must be undertaken with that a multi-pronged approach to
24
disease prevention by addressing all risk factors in a simultaneous manner.
Opinions that blood cholesterol are not part of the cause of cardiovascular
problems should be rejected with the added caveat that it is only one of
several major components of cardiovascular risk factors.
↓
Optimal LDL Cholesterol → -Individualize Instruction on
Diet and
≥100 mg/dL (2.6 mmol/L) Physical Activity Level
-Repeat Lipoprotein Analysis
annually
↓
Higher Than Optimal LDL → - Do Clinical Evaluation (History,
27
Cholesterol Physical Examination, and Labora-
>100 mg/dL (2.6 mmol/L) tory Tests)
- Evaluate for Secondary Causes
(When Indicated)
- Evaluate for Familial Disorders
(When Indicated)
- Consider Influences of Age, Sex,
and
Other CHD Risk Factors
↓
Initiate Therapy
28
The recommendations of the second report of the National Cholesterol
Education Program expert panel to treat blood lipids abnormalities are
summarized in Table 5. These recommendations were published in the
Journal of the American Medical Association in 1993 and have been
considered by some individuals to be quite aggressive in their approach.
The recommendations are somewhat incomplete because they do not include
any recognition of the many options to lower blood cholesterol other than
specific dietary or drug therapy. The recommendations have a surprisingly
low threshold for recommending the prescription of lipid lowering drugs,
probably because of the political lobby of the multinational pharmaceutical
industry.
29
Treating High-Density Lipoprotein Cholesterol (Less Than 35 mg%)
Although one could not argue with the advisability of the thresholds of
blood cholesterol levels that have been chosen to initiate treatment, there is a
risk that these recommendations may tend to spur healthcare givers into a
premature prescription of lipid lowering drug therapy (Table 5).
There are several readily identifiable risk factors that can be changed
and most bear some relationship to cholesterol (Table 6). Equally, there are
several simple goals that underlie such changes (Table 6). Do not feel
unique in facing the challenges presented by Table 6, you have many peers
in the same boat!
31
Defusing the Bomb
This book promises nothing and it is not written primarily to proffer
medical advice. Your healthcare giver is the person with whom you should
consult in a quest for health. The author trusts that the content of this book
will stimulate lifestyle change that will promote cardiovascular wellness. Its
purpose is to provide a summary of contemporary thought on more natural
ways to achieve cardiovascular health. Understanding the principles of a
natural path to health may permit an individual to make a wiser consumer
choice of healthcare services. The term healthcare services is used to
embrace everything from the use of a slimming clinic to the receipt of
advanced cardiac life support. If this book pushes the “at risk” individual
towards a healthcare giver who can steer the person away from risk, it will
have achieved its objective.
Table 6: Cardiovascular risk factors that are readily changed and simple
approaches to reducing risks.
33
CHAPTER 2
34
Don’t Just Lower Cholesterol
Targeted therapy to just lower blood cholesterol in isolation may be
short-sighted or even foolish medicine. Cholesterol reduction that is induced
by the dietary exclusion of cholesterol and synthetic lipid lowering drugs, in
the absence of a nutritional program to improve general health, is not always
safe and it is not cost-effective. The ability of cholesterol lowering drugs to
reduce cholesterol the “easy way” has overshadowed the importance of their
side effect profile. Side effects of some of these lipid lowering drugs are
sometimes serious and such drugs are expensive (Table 7). These are
overriding reasons to seek safer, natural options to lower cholesterol,
normalize blood lipids and promote general wellness.
Probucol Benzphetamine *
35
Gemfibrizol Diethylprotion
Phenylpropanolamine
Table 7: Drugs that are commonly used to lower cholesterol and treat
obesity. The asterisks (*) denote amphetamine-like compounds which
should not, in the author’s opinion, be used for obesity management. Many
of the drugs listed for obesity management are controlled substances and
they have adverse effects on cardiovascular function.
At the same time that the public awareness was increasing in blood
cholesterol elevations and heart disease, a few farsighted individuals
attempted to promote what they termed life extension programs. The idea of
life extension is neither novel nor new, since it has been an unfulfilled
ambition of humankind from early civilizations to the present. However, the
real importance of life extension philosophies is that they broaden ideas to
the concept of general wellness promotion rather than a fixation on only one
part of the health puzzle. It is the author’s thesis that the focus on
cholesterol and cardiovascular risk has led to an unhealthy preoccupation of
reducing one risk factor for premature mortality at the expense of the
individual’s consideration of more general health promotion.
The latter half of the 20th century has seen an ever-increasing number
of scientific articles that clearly document the relationship between high
blood cholesterol and heart disease, and contemporary research has shown
that cholesterol is not the only blood lipid to consider. There are many
lipoprotein fractions in the blood as summarized in Table 9. Prevention of
coronary artery disease is possible with interventions that lower blood lipids.
Overall, it is believed that a high total blood cholesterol, a high low-density
lipoprotein (LDL), a high very low-density lipoprotein level (VLDL), a high
triglyceride level (TG), and a low high-density cholesterol level (HDL) are
all deleterious to health. In simple terms, low-density cholesterol (LDL) is
the “bad type” of cholesterol and high-density cholesterol (HDL) is the
“good type” of cholesterol.
44
Lipoprotein Fractions
Chylomicron
Very low density lipoprotein (VLDL)
-very low density lipoprotein ( -VLDL or VLDL2)
Intermediate density or remnant lipoprotein (IDL)
Low density lipoprotein (LDL)
High density (HDL)
45
Severe Problem ≥300 mg/dl ≥210 mg/dl
46
only “good type of cholesterol”, the rest are bad!
Bad Cholesterol
Cholesterol is only one of several lipids with variable functions that
are found in the blood and tissues. Some understanding of the components
of
blood lipids is required in order to interpret abnormalities. Low density
lipoproteins (LDL) are believed to be the major problem in determining
atheroma (a process of blocking and “hardening” of the arteries) and, in
particular, coronary artery disease. In general, the higher the LDL the
greater the risk of occurrence of coronary artery disease.
Good Cholesterol
In contrast to the characterization of LDL and VLDL as “bad types”
47
of cholesterol, high density lipoprotein cholesterol (HDL) is considered a
“good type” of cholesterol. In simple terms, HDL exerts an effect of
drawing cholesterol into the circulating blood away from its site of
deposition in arterial blood vessel walls (anti-atherogenic). High density
lipoprotein has a complex function. It is responsible to some degree for
returning cholesterol to the liver and it directly protects the lining of blood
vessels from smaller remnants of fat that have been enzymatically digested
in the blood stream.
49
Cigarettes Exercise
Table 11: Conditions or agents that alter high density lipoprotein (HDL)
Cholesterol Levels (good cholesterol). Note low overall fat intake as occurs
in the presence of a strict vegan diet lowers all types of blood lipids,
including HDL. This has been used as an argument against the proposed
healthfulness of the strict vegan diet.
51
Table 12: A Guide to the Levels of Blood Lipids
52
Desirable: Less than 200 mg/dl Less than 130 mg/dl
Borderline
High Risk: 200 - 239 mg/dl 130 - 159 mg/dl
High Risk: Greater than 240 mg/dl Greater than 160 mg/dl
53
There is much concern about the management of coronary artery disease in
women because evidence has emerged that it may be often under-diagnosed
in the female and managed in a much less assertive manner, than it may be
managed in a male.
Smoking Age
Elevated Blood Pressure Male Sex
Blood Lipid Disorders Family History
Diabetes Mellitus * Post-menopausal Female
Clotting Disorders
Behavioral Issues
Lack of Exercise
Being Fat
Deficiency of Essential Fatty Acids
Lack of Other Nutrients?
54
Table 14: An expanded list of ‘risk’ factors for coronary heart disease.
Arguments prevail about the true role of some of these items in the risk of
cardiovascular disease. * The post-menopausal risk is forgotten by many
but it may be amenable to modification by isoflavones or hormone
replacement therapy.
55
continues about the risk of hypertriglyceridemia alone as an independent risk
factor for coronary artery disease. The author believes that
hypertriglyceridemia alone is a risk factor, but most current treatment
recommendations suggest to manage this condition specifically only if there
is a marked elevation of triglycerides to levels of greater than 500 mg/dL or
higher.
58
20-24 105 55 160
25-34 110 70 160
35-39 120 75 170
40-44 125 75 175
45-49 130 80 185
50-54 140 90 200
55+ 150 95 215
Table 15: Total Blood Cholesterol and LDL vary by age and sex (modified
from Kowalski, 1989). 5% and 95% are percentiles. The risk of heart
disease relates to values above the 50th percentile.
Age Average 5% 95%
HDL: Male 5-14 55 35 75
15-19 45 30 65
20-24 45 30 65
25-29 45 30 65
30-34 45 30 65
35-39 45 30 60
40-44 45 25 65
45-69 50 30 70
70+ 50 30 75
Female 5-19 55 25 70
20-24 55 35 80
25-34 55 35 80
35-39 55 35 80
40-44 60 35 90
45-49 60 35 85
50-54 60 35 90
55+ 60 35 95
Triglyceride: Male 0-9 55 30 100
10-14 65 30 125
15-19 80 35 150
20-24 100 45 200
25-29 115 45 250
30-34 130 50 265
35-39 145 55 320
40-54 150 55 320
55-64 140 60 290
65+ 135 55 260
Female 0-9 60 35 110
59
10-19 75 40 130
20-34 90 40 170
35-39 95 40 195
40-44 105 45 210
45-49 110 45 230
50-54 120 55 240
55-64 125 55 250
65+ 130 60 240
Table 16: Blood HDL and Triglycerides vary by age and sex (modified
from Kowalski, 1989). 5% and 95% are percentiles.
60
achievement of a blood cholesterol of this level is often quite difficult for
individuals in Western society. The author does not believe that there is
clear cut evidence that reduction of blood cholesterol to this level is
necessarily advisable but would recommend that blood cholesterol be
lowered to less than 160 mg/dL in the presence of cardiovascular risk factors
in addition to elevated blood cholesterol. The authors advice is contrary to
some accepted guidelines and may be regarded by some as too lax.
Angina pectoris is chest pain derived from lack of blood supply to the
heart. The heart essentially “screams out” in pain in this situation, especially
if exercise or physiological stresses place a demand for increased blood
supply to the heart which cannot occur because of the reduction of diameter
and relaxability of the arteries that is caused by atheroma. Angina can be
stable or unstable when the risk of heart attack may be imminent (Table 17).
Table 17: Coronary heart disease: clinical manifestations are related to the
anatomical changes that occur in arteries that supply the heart.
64
Stressors That Determine Regulators of Oxygen
Oxygen Demand of the Heart Supply to Heart
Table 18: Factors that stress the heart and result in increased oxygen
demand can precipitate angina. Several factors regulate oxygen supply to
the heart, including flow of blood through the coronary arteries and the
status of oxygenation of the blood. For example, cigarette smoking may
decrease blood oxygenation and precipitate angina in the susceptible
individual with narrowing of the coronary arteries by atheroma.
Intense emotions
Physical exertion, especially if “unconditioned”
65
Exposure to excessive cold or heat
Vivid dreams (nocturnal angina)
Lying flat (decubitus angina)
Exaggerated “fright and flight” reactions
Heavy metal exposures
Smoking cigarette or marijuana
Stimulant drugs
Concomitant illness, e.g., retching, vomiting, excessive defecation
Table 19: Circumstances that can cause the onset of angina pectoris or
precipitate a heart attack.
person coronary artery disease these circumstances can herald the onset of a
heart attack (acute myocardial infarction, coronary thrombosis). People with
angina learn to avoid events that cause angina and this results in a crippling
existence for some individuals.
Summing Up
Understanding the importance of the effects of various risk factors on
the genesis of coronary artery disease is very important for the individual
who is determined to lower their risk of cardiovascular illness. The simplest
advice to enhance cardiovascular well-being include: smoking cessation,
regular exercise, weight control, good nutrition without more than 30% of
the energy derived in the diet from fat. Sounds simple but the “plot
thickens”.
67
68
CHAPTER 3
69
Is The Cholesterol Theory of Cardiovascular Disease Correct?
Several, well-ontrolled, scientific studies demonstrate unequivocally
that individuals who are able to reduce blood cholesterol levels experience
less heart disease. In addition, the converse is true! Individuals who do not
lower their blood cholesterol will tend overall to have more heart disease.
The data derived from such studies show that reducing total blood
cholesterol levels by a factor of one-third, or more, reduces the risk of
coronary artery disease by about 50%. Animal experiments indicate that
atherosclerosis will not occur in the absence of high blood cholesterol.
Extensive studies, such as the Lipid Research Clinics Coronary Primary
Prevention Trial, have indicated that males who lower blood cholesterol with
diet and cholesterol-lowering drugs suffer fewer heart attacks than those in
whom blood cholesterol remains elevated.
There has been a pernicious outcome of the studies that showed that
lowering cholesterol with synthetic drugs reduced cardiovascular risk. The
pernicious outcome is the premature prescription of the lipid-lowering drug.
70
The effectiveness of these drugs led several authors to recommend diet with
cholesterol-lowering drugs as the secondary (but early) intervention to
normalize blood lipids. These recommendations of adjunctive drug therapy
have become engraved in the memory of the medical profession because
very few natural options were tried prior to drug intervention. Furthermore,
much, if not most, of the research on blood lipids and cardiovascular
research has been funded by multinational pharmaceutical companies who
are in the business of the purveyance of the synthetic, pharmaceutical
approach.
The Oslo Study, in Norway, examined 1,234 mature males who were
split into two groups. One group modified its diet and adverse lifestyle with
an emphasis on lowering blood cholesterol, whereas the other group formed
a control group and received no such interventions. After five years, the
incidence of heart attacks was 47% lower in the group with the lifestyle and
dietary interventions compared with the control group.
Adult smokers
Women experiencing the climacteric (menopause)
Hypertensive females or males, especially over the age of 30
(BP > 140/80mmHg)
Mature men and women over the age of 50 years
Individuals who are more than fifteen pounds above average body weight
Hypercholesterolemia in the adult, especially if greater than 180 mg% over
the age of 35 years
74
Table 14: Characteristics of individuals who are advised to consider early
measures to reduce cardiovascular risks. This list is not complete.
other health benefits. However, before any decision can be made on the
selection of a nutritional program, other theories of the links between
cardiovascular disease and diet require exploration. The principal
hypotheses of the nutritional causes of cardiovascular disease are
summarized in Table 15.
78
Beyond Cholesterol as the Cause
Information that questions a conventional interpretation of the
Cholesterol Theory emerges from certain epidemiological studies that look
at ethnic and/or geographic differences in the incidence of coronary artery
disease. The prevalence of observations coronary artery disease is lower in
Japan than in the United States or Western Europe. Studies of Seventh Day
Adventists show lower cardiovascular mortality among this religious group.
Multiple observations of the cardiovascular disease profile of the Inuit or
Eskimo, who eat a traditional diet, show a lower incidence of arteriosclerotic
disease than that encountered in Westerners.
The Seventh Day Adventist has a vegetarian diet that is not strictly
vegan. These individuals are lacto-vegetarians and they may relatively
ingest relatively large amounts of cholesterol-containing dairy products,
such as milk and cheese. In this religious group, a higher dietary quantity of
79
essential fatty acids of the omega 3 and the omega 6 series of vegetable
origin may be protecting against cardiovascular disease. Whilst genetic
predisposition may play a role in the lower incidence of cardiovascular
disease in some ethnic groups, it is dietary complexities that most likely
account for many of the observed differences in disease profile.
Table 16: A summary of the types of damages to cells and molecules that
81
can be produced by free radicals.
There are elaborate plans that have been presented in the medical
literature that provide advice for managing the patient with a myocardial
84
infarction at home. These plans usually focus upon issues such as
cardiovascular conditioning, planned medical interventions with drugs and
supervised exercise programs.
The author wishes to stress that problems of test specificity are not
only encountered in cardiac investigations. The same problems apply with
tests performed in the investigation of many different types of diseases
affecting many different organs in the body. Of course, all tests must have
some drawbacks and these limitations or disadvantages are overcome with
advances in knowledge of the sensitivity and specificity of diagnostic tests
or the development of new tests or new technology to enhance the accuracy
of diagnosis.
90
Escape From the Coronary Care Unit?
The first time that most individuals will experience coronary care unit
is when they get “wheeled through the door” following a heart attack. The
human body has ways of responding and adapting to the external pressures
placed upon it. This is the root of stress. Coronary care unit has certain
characteristics that place significant demands on a patient who is already
stressed as a consequence of a serious illness.
Several studies have indicated that most of the abnormal rhythms that
are precipitated by acute myocardial infarction are benign and subject to
self-correction. However, this finding is diminished by recent research that
shows that specific types of cardiac arrhythmia with serious important are
amenable to correction with appropriate drug selection. The occurrence of
life threatening cardiac arrhythmias may be unpredictable.
Some of the most conflicting data about the benefits, or lack thereof,
of coronary care units in cardiovascular treatment come from studies that are
quite contradictory in their outcome. Some early studies of mortality and
effectiveness of coronary care units were performed in England in the
1960’s. Such studies included triage of patients to a coronary care unit or to
ordinary wards of the hospital and in one study patients were triaged to stay
at home. It is striking that in this particular study discussed by Dr. Robin, in
his book, the patients that were triaged to stay at home had the lowest death
rates. A reason proposed for this observation is that over-diagnosis and
over-treatment with its attendant risks is more likely in a coronary care unit.
95
process should be established prior to hospital discharge. However, the
process must continue in the early convalescent phase. Specific counseling
may be required and management plans for the survivor of a heart attack
should be tailored to the individual patient. The patient must be
knowledgeable about any further medical appointments or specific testing
that may be required to assess prognosis, further change of treatment or
other medical intervention.
There is a popular notion that people can drop dead during sexual
intercourse. Fortunately, this common fear is not justified. Studies of the
influence of sexual intercourse on sudden cardiac death seem to imply that
less than one percent of all such deaths occur during sexual intercourse and
97
when they do occur they most often occur as a consequence of extra-martial
affairs in which the male partner is usually a lot older than the female
partner. A light note could be applied to a serious circumstance by saying
that “sudden death during sexual intercourse is often a wage of sin”.
The reader should note that statistics on mortality and morbidity from
surgery can sometimes be related to the criteria that were used to select the
individuals who undergo the surgery. In some studies, people with less
severe forms of heart disease who are younger and in more robust health will
tend to have a better outcome than those with more severe disease.
Furthermore, there have been some frightening allegations that there have
been a substantial number of cardiac bypass operations performed that are
unnecessary.
The initial event in CPR is usually to strike the sternum (breast bone)
with moderate force and to apply mouth-to-mouth or mouth-to-nose assisted
breathing. The final component of the initial stages of CPR involves the
establishment of some form of circulation in the individual by the
intermittent application of mouth-to-mouth or mouth-to-nose breathing with
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repetitive pressure on the front of the chest wall to apply a pumping force to
the heart.
On the other hand, high levels of circulating insulin may tend to cause
atheroma in blood vessels. The benefit of precise control of blood glucose
in the reduction of arteriosclerosis effecting large arterial vessels, such as the
aorta, is not clear. The diabetic individual usually has multiple risk factors,
including abnormalities of blood lipids and high blood pressure. Aggressive
control of all risk factors is very important in the management of diabetes
mellitus because patients are at special risk of cardiovascular disease.
Aspirin is not without side effects and even in small doses it can cause
gastrointestinal irritation and occasionally bleeding from the gastrointestinal
tract. The evidence that aspirin can result in a lower death rate from
coronary artery disease is not clear in all studies and there are some
indications that aspirin ingestion may contribute to stroke due to hemorrhage
into the brain. However, this observed increase in stroke rate appears to be
quite small. Overall, low dose aspirin appears to be very beneficial in most
males over the age of 50 years who have coronary artery disease. Some
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healthcare givers have even extended the recommendation to take aspirin if
an individual over the age of 50 has multiple cardiovascular risk factors.
Aspirin is to be avoided by persons with bleeding tendencies or those who
have known gastrointestinal disease that may bleed as a consequence of the
administration of aspirin.
Table 18: Systolic and Diastolic elevations of blood pressure are more
common in the groups listed above.
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The author believes that overall, there has been a tendency in medical
practice to use drug therapy to treat mild hypertension at the expense of
considering more natural options to control blood pressure. It is recognized
that about 60 million Americans may have hypertension of variable severity.
As a consequence, many healthcare agencies and government institutions
have promoted programs for screening for high blood pressure and political
initiatives have proposed projects such as the National High Blood Pressure
Education Program. This widespread level of interest has resulted in
improvements in the management of hypertension but it may have also
resulted in the widespread use of drug therapy to lower blood pressure when
more natural methods of blood pressure reduction may have been equally
effective.
The author is not rejecting the opinion that many of these people with
high blood pressure require medical treatment but he does question whether
or not there exists among these people a large group of individuals who are
receiving drug therapy for hypertension who could have managed their
disease by more natural options. The application of natural options could
potentially obviate the need for the prescription of blood pressure medicines
in some individuals.
The effective healthcare giver will discuss freely any side effects that
an individual is having to an anti-hypertensive remedy. It is alarming to
note that up to one in five people receiving anti-hypertensive therapy may
well cease taking medication because of side effects. One important issue is
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that lowering blood pressure should not significantly interfere with quality
of life and, fortunately, newer drugs have been developed with more
acceptable side effect profiles. Despite this, some physicians are still using
obsolete and in some circumstances dangerous anti-hypertensive
medications. Anti-hypertensive drugs which have acceptable side effect
profiles include several gentle acting diuretics, a class of compounds called
angiotensin converting enzyme inhibitors, known commonly as ACE
inhibitors, drugs that block calcium channels and perhaps beta-blocking
drugs. Anti-hypertensive drugs that tend to result in orthostatic hypotension
(profound fall in blood pressure when changing posture) are best avoided,
especially in the elderly.
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An important consideration in the assessment of the efficacy of any
intervention for the treatment of high blood pressure is the recognition that
there are many circumstances that can interfere with the many interventions
that are used to lower blood pressure. An individual with high blood
pressure that wishes to self-medicate should be aware of drug interactions
with blood pressure. There are many over-the-counter medications or
dietary supplements that should be avoided in the person with elevated blood
pressure because these agents may promote high blood pressure or can
interfere with anti-hypertensive drugs. Table 20 gives a list of
circumstances that may interfere with interventions, natural or otherwise, to
lower blood pressure.
Table 20: Circumstances that may interfere with natural options or drug
therapy to control blood pressure. Note some of the problems occur as a
result of the injudicious use of natural options.
Weight reduction
Restriction of sodium in the diet
Physical exercise
Stress reduction
Dietary modification and use of dietary supplements
Specific pharmaceutical options, e.g., calcium, fish oil, magnesium and
potassium intake
There are studies that have shown that the restriction of salt alone can
reduce blood pressure. Fortunately, regulatory agencies are demanding
increasingly that food or health supplement manufacturers list the salt
content of prepared foods or dietary supplements. An individual can now
select from a number of “—substitute” types of salt condiments that can
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make food quite tasty without the need to lace it with table salt. However,
there are some unforeseen problems with salt substitutes. Some allegedly
“low salt” or “no salt” products are made from combinations of sodium and
potassium. This can be quite misleading because these products are not free
of salt and excessive use of condiments that are presumed to be low in
sodium can still deliver a significant sodium intake. These products contain
about half the amount of salt as regular table salt and using twice as much is
obviously the same as using too much salt.
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LIFESTYLE MODIFICATIONS:
Control weight
Elimination of substance abuse
Exercise
Dietary change
Smoking cessation
_ _
No Response Good response requires program and follow-
up to reinforce the change in behaviors
↓
Assess whether or not there
has been a change in lifestyle
and compliance with advice.
_ _
No compliance Repeat lifestyle advice and intervention
↓
Go do drugs
Instructions about arrows and directions or placement of arrows was too
ambiguous and confusing. (Can I see table from original book reference?)
Table 22: This table summarizes a treatment approach to hypertension. Most cases of
newly diagnosed hypertension are mild and the emphasis is placed upon natural options.
Drug therapy of increasing intensity and variety is to be reserved for more severe forms
of hypertension that are recalcitrant to simple interventions.
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CHAPTER 4
LIFESTYLE APPROACHES
139
Lifestyle Change: Plans Not Diets
The reader may be becoming receptive to the notion that the solution
to promoting cardiovascular wellness rests with interventions that involve
more than lowering blood cholesterol in isolation. The risk factors of
cardiovascular disease seldom occur in isolation and need to be tackled
together. Such risk factors include: obesity, high blood pressure, smoking,
lack of exercise, poor diet and stress, together with complex behavioral
issues. The bouquet of barbed wire needs work in many directions before it
will disentangle.
Whilst the reader may be saying to herself or himself, “It’s easier said
than done,” it is possible to tackle each problem in a systematic manner.
The logical approach is to take the easiest risk factor to change, or the risk
factor that when changed gives the most benefit to the individual. The
author accepts that the degree of difficulty encountered in changing each risk
factor may be different from one person to the other, but a common thread of
difficulty is shared by all. Individuals with cardiovascular risk do not walk
alone.
Smoking
The cardiovascular risk factor that stands out above the rest is
cigarette smoking. Smokers should be counseled that the primary issue is to
quit smoking. The health benefits of smoking cessation require no
discussion. Quitting smoking is very tough and only possible with intense
willpower and behavior modification. Adjuncts to smoking cessation are
“Band-Aids”, just like slimming drugs are “short-term crutches” for weight
loss. Short-term smoking cessation is one thing but relapse is another. The
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YoYo phenomenon operates with greater speed in the smoker than in the
would-be slimmer, because of the power of the smoking addiction. In
addition to commitment to quit, a plan of action is required.
Stress
Stress and lack of exercise are two important factors that are
frequently underestimated in terms of their importance as cardiovascular risk
factors. Both factors can independently cause a rise in blood pressure or
blood lipids or both, to some degree. Relaxation, positive thinking and
varying degrees of well-planned aerobic exercise may go a long way to the
promotion of general well-being. However, anyone who is completely free
from anxiety, worry and periodic blues is not alive, or may be psychopathic.
Many attempts have been made to measure or check lifestyle but the
best method involves the comparison of an individual’s components of life
with those of the general population. This measurement technique has the
advantage of showing us that there are degrees of poor lifestyle. This
process of comparison should not be perceived as an “all or nothing”
phenomenon.
Clearly, the more areas of an individual’s lifestyle that are under the
influence of positive action, the better off an individual will be or feel!
Alcohol Consumption
Psychological Well-Being
Substance Abuse
Nutrition/Eating
Sexual Activity
Physical Activity/Exercise
147
Lifestyle Problem Sample of Behavior
Alcohol Misuse Quantity, Frequency, Duration and
Selection of Alcoholic Beverage
148
three areas, including: A, which stands for Antecedent Cues, B, which
focuses on the Behavior itself, and C, which are the Consequences of the
habit or behavior that may diminish or enhance the behavior.
Changing Behavior
The mechanism of habit reinforcement permits the development of an
action plan to fight the habit, compulsion, dependent behavior or frank
addiction. Action plans have to be tailored to an understanding of the cues
that precipitate the behavior that results in the consequence. This process is
designed to allow self-intervention after self-identification of a problem with
a logical improvement in an individual’s self-control.
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The ABC Approach Reinforcement of Behavior
Antecedent Cues Short-term gratification - Reward now
Table 26: Hodgson and Miller (1982) propose that cues lead to behavior
with consequences (ABC Approach) and that the behavior is reinforced by
short-term, intermittent or relative elements.
Excessive Drinking
Most people assume that they would know if they are drinking
hazardous amounts of alcohol. However, this is a big misconception! As
with all forms of adverse lifestyle, drinking occurs in degrees of severity.
The chronic “alcoholic” is at one end of the drinking spectrum and the
abstainer or “teetotaller” is at the other. Like other lifestyle domains, one
cannot use the “all or nothing” approach when considering drinking habits.
There is a spectrum of drinking habits, i.e., shades of grey occur. First, we
need to examine the spectrum of alcohol drinking habits and see where we
fit in
152
Prevent Relapse The individual must anticipate
tempta-
tion and develop coping techniques.
(Figure 1). This will help us with the first key step of IDENTIFICATION of
a drinking problem.
From time to time all individuals who consume alcohol should take a
close look at their drinking habits. It is not possible to set rigid guidelines as
to what constitutes “sensible drinking” versus “risk drinking”. Tolerance to
alcohol varies and it is recognized that females may be more vulnerable to
154
develop some of the alcohol-related illnesses, such as liver disease,
compared with men for the same amount of alcohol intake. This known
increase in susceptibility of women to the adverse effects of drinking
compared with men has been ascribed in part to the amount of a protective
enzyme (gastric alcohol dehydrogenase, gastric ADH) present in the
stomach wall. There is a wide variability in people’s tendency to develop
drinking-related illnesses and this variability is not well understood.
Substance Abuse
Is it legal or illegal? Legalities and morals may matter less than slow
death or serious impairment of day-to-day life. Everybody has the potential
to become addicted to a drug. Any kind of addiction is self-defeating and
dangerous to well-being and happiness. Drug addiction is one of the biggest
problems facing mankind and it is responsible for much privation, premature
death and social misery.
Smoking
If you ask a heroin addict what he or she would take to the moon if
only one choice was available, he or she would answer cigarettes before
answering heroin. Smoking cigarettes is a very powerful and very unhealthy
addiction. There is perhaps little one needs to know about the adverse
160
consequences of smoking because the advertising media now has to disclose
health problems related to smoking as a means of promoting tobacco
products. Why do we not think about this modern day insanity? The
advertisement that lures an individual to smoke carries a clear message that
he or she may die or suffer a damnable consequence. This is the strength of
this enduring habit. There are many incentives for giving up smoking, such
as saving money, better health, better breath, whiter teeth, etc., but very few
disincentives except the power of the addiction. Remember, it is apparent
that the smokers may be doing as much harm to the health of other people in
the environment as they are to their own health.
The prescription drugs that are most likely to be abused are those that
have psychoactive properties (effects on the mind) such as sleeping tablets
(hypnotics) and tranquilizers. So-called minor tranquilizers are among the
most abused of all drugs. Such drugs include a group referred to as
benzodiazepines of which diazepam (Valium), chlordiazepoxide (Librium)
and lorezepam (Ativan) are common examples. Although these tranquilizers
are safe and effective in short-term treatment, they have a propensity for
being drugs of dependence. Dependence (addiction or habituation) probably
has at least two components. The first is the psychological component
where the individual becomes addicted to the complex effect of the drug on
the mind. This can range from a sensation experienced as a consequence of
the active tranquilizing effect or a more nebulous dependence, such as the
mere act of taking the drug. The second component of dependence (or
addiction) is the physical (or pharmacological) component which is a result
of chemical changes that occur in body tissue, such that they almost need the
162
drug before they function. Scientists are only just beginning to understand
the complex components of addiction, habituation or dependence.
Exercise
Exercise can make important contributions to physical and mental
well-being. Before commencing an exercise program, it is important that the
individual checks with his or her physician. A physician will be able to give
some advice about the type and amount of exercise that is ideal. There are
some misconceptions about the role of exercise in lifestyle. An individual
may set an expectation that is too great and it is known that an individual’s
ability to undertake an exercise depends on his or her physical condition, age
and general health. Unlike sportsmen or women who need to train very
arduously, most individuals will not have to prepare themselves for
competitive events.
Psychological Well-Being
The mind controls the body. In fact, the mind can make the body do
almost anything. Psychological well-being for most people implies a state
of happiness and moderate contentment. However, much of the time life is
not perfect. It is normal to perceive life as experiencing some ups and
downs. The negative effect of anxiety, stress and depression has become
clear. The idea of the broken heart as a consequence of emotional or
psychological problems transmits into a break in a cardiac health.
Depression
Although depression has been regarded as the “common cold” of
psychiatry, it is often vicious in its effects. Depression can cause unlimited
human suffering. Many sufferers are fooled by depression. An individual
may not be in touch with his or her mood and it may cause a spectrum of
problems from mild unhappiness to complete immobilization associated
with an overwhelming sense of despair. Understanding depression is a good
way to battle against it. Unlike stressful and upsetting life experiences, such
as
loss of a person or love, depression is always unreal, miserable, persistent
and frequently incapacitating. The author believes that depression is a clear
165
risk factor in cardiovascular disease.
You could select a specific exercise and see how long you need to do the exercise to burn
off certain items of food.
Table 28: Exercise Table. Duration of exercise required to burn off each
food item.
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Self-Help Techniques for Elevating Mood
People have vastly different coping techniques. There may be a
precipitating event that sends you into a tailspin, such as a death in the
family, a major financial loss, or loss of a job. In contrast, an individual may
not be able to easily identify a casual event. Some people may be so
depressed that they think they can never feel any other way or they may
have already decided to give up because they are so consumed and
preoccupied with sadness, worry or grief.
167
Type A personality in the causation of cardiac disease or the precipitation of
heart attack is well-charted territory.
In the same way that the author attempted to point out the sure ways
of detonation of the Cholesterol Time Bomb in Chapter 1, a study of the
opposite type of behavior to Type A behavior may be a good way of
identifying and correcting the adverse traits. The opposite type of behavior
has been termed Type B and it has been recognized that Type B personality
is
168
much less likely to get coronary heat disease than the Type A individual
even in the face of similar risk factors.
Feature Comment
Time urgency This is regarded as the key aspect of Type A
behavior. Not enough seconds in a minute!
Accentuation of words Typically hurries to finish a sentence
in speaking
Overt impatience Want people to get on with what they are saying or doing
Doing or thinking more The individual contaminates leisure time with thoughts of
than one thing at once work or problems.
Cannot smell the “roses” The individual must have things here and now
The face that makes people The Type A person is challenging and does not engender
feel like punching it! sympathy for his or her own affliction
Tics and Gestures Finger pointing, table thumping and jaw protrusion
are examples of the innate aggression
Belief that speed gives The Type A person has to move quicker than
anyone
an edge
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Measuring others deeds The Type A person may apply numbers to activities,
or actions thoughts or deeds
Type A plus Type A The Type A is rapidly engaged by his fellow Type A
make sparks
Table 29: Main features of Type A behavior that are modified from Friedman and
Rosenman (1974). The comments provide examples of the behavior.
not obsessed with the “here and now” and does not engage in the activity of
doing ever-increasing numbers of things in ever-decreasing amounts of time.
Switching from Type A to Type B behavior is the ideal but taking the edge
off the Type A tendency is probably all that is required. Friedman and
Rosenman (1974) have aided in the understanding of the desirable Type B
personality that is summarized in Table 30. Which type are you? - bearing
in mind that 10-20% of the population have an intricate mixture of Type A
and Type B tendencies and neither pattern may breed true entirely.
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The Type B trait is free of Type A habits and activities
No sense of time urgency
Does not experience free floating hostility
Does not need to keep discussing victories or topics of self-interest
No need to portray themselves as superior
Relaxes without guilt
Works efficiently but steadily
Not necessarily docile or “brain dead”
Table 30: The Type B behavior pattern as modified from Freidman and
Rosenman (1974).
Does such a disease entity exist? The heart has an autonomic nervous
system that is even more well developed than that supplying the gut.
Cardiac symptoms can occur in the absence of organic heart disease which is
the hallmark of the presence of functional disease. The irritable heart
syndrome is a likely entity which may occur with a heterogeneous symptom
expression in isolation or in association with underlying cardiovascular
disease. The author proposes this new syndrome to highlight the importance
of behavioral interventions in the promotion of cardiovascular wellness.
Dr. Weil shares the opinion of many antecedent researchers about the
importance of self-identification and self-intervention but extends these to
self-healing. There appears to be seven distinct strategies that an individual
can apply to promote self-healing (Table 31).
Spiritual Connection
The role of love and prayer in healing and wellness is a developing
173
science. According to Dr. Larry Dossey, “Love makes it possible for the
mind to transcend the limitations of the body.” Dr. Dossey is the author of
the book titled, “The Power of Prayer and the Practice of Medicine” (1993)
and was the Chairman of the National Institutes of Health Office Panel on
Mind-Body Interventions. Dr. Dossey believes in the power of love to
create health. He draws attention to the finding that in a study of 10,000
males with cardiac disease there was a 50 percent observed reduction in the
frequency of anginal chest pain in men who recognized their spouses as
loving and supportive. The importance of this observation is well illustrated
in the book titled, “Heartmates, A Survival Guide for the Cardiac Spouse”
by Rhoda F. Levin.
Strategy Comment
Not taking “No” When a patient is told or feels that nothing can be done
for an answer for his or her disease, he or she should not give up
Find others who The interaction of individuals with others who have had
have healed success in overcoming a similar disease may have a
positive outcome
Form good part- This is limited to finding the right healthcare professional
nerships with to work with. For example, a psychiatrist who possesses
healthcare givers moral judgment can rarely provide the right support
174
Make life Changing adverse lifestyle is the key
changes
Table 31: These strategies are proposed by Andrew Weil, M.D. in his book
titled “Spontaneous Healing” as a route to increase spontaneous healing
events.
Dr. Sinatra has explored the health effects of love and intimacy on
well-being with a focus on heart disease. This consideration has stimulated
several questions that he has attempted to answer (Table 32). This work is
important in our attempts to understand the many ways in which mind, body
and spirit work together to prevent or promote coronary heart disease. Dr.
Sinatra subscribes to the hypothesis that “heartbreak” of many kinds,
involving disappointments, bereavements, and other negative emotional
circumstances, can result in heart disease. The concept that detachment or
loss can precipitate heart disease or sudden death from a cardiac cause is
well illustrated in the theories of mind-body medicine. With this in mind,
the understanding of irritable heart syndrome becomes clearer, and easier to
mind.
To what extent do emotional factors and one’s own intrinsic personality play
a part in heart disease?
176
Are suppressed feelings and emotions significant?
Do negative feelings such as abandonment, heartbreak, betrayal or
humiliation create conditions that invite death?
What part do positive emotions such as love, faith and good humor play in
the process of healing and staying well?
What is the significance of the way we breathe?
There are many approaches to mind/body therapy but the overall goal
is to use psychotherapy, relaxation, counseling and spiritual methods to
protect the heart by releasing repressed emotions and resolving conflict. The
use of psychospiritual interventions, breathing exercises, sharing, love,
intimacy, prayer, visualization and meditation are all examples of techniques
that may exert powerful “healing” effects on the heart. This exciting and
177
novel approach to cardiovascular wellness can be considered a sophisticated
extension of stress reduction and behavioral therapy but it is in itself a
complete treatment approach. One of the perceived revolutionary aspects of
the Ornish program for cardiovascular wellness applies some principles of
mind-body medicine. At the very least, it provides an excellent adjunct to
conventional or alternative medical practices.
Few people doubt the power of this approach to healing because the
basis of mindful meditation is to relieve pain, illness, and lack of emotional
Stress
179
The applications: taking on the full catastrophe
Table 33: The five sections of the program for stress reduction and
relaxation proposed by Dr. Jon Kabat-Zinn.
Breakdown of Biological
Systems
↓
Illness: e.g., exhaustion, depression, coronary heart disease, cancer, bone
and joint disease, etc.
All of this sounds simple but several traps exist. Quitting smoking
often leads to weight gain. Exercise increases appetite and some diets that
are designed for weight loss result in rebound weight gain. Unfortunately,
as mentioned earlier, smoking with excessive coffee consumption is a
popular, quite pleasurable, but very unhealthy way to lose weight. The
author believes that the overall answer rests primarily in a carefully planned
nutritional program and lifestyle program. Good nutrition assists in the fight
against flab, the smoothing of temperament, the struggle with substance
abuse and the promotion of a general feeling of well-being. Because of the
importance of optimal nutrition for optimum health, this area is reserved for
further detailed discussion.
182
CHAPTER 5
DIETARY ADJUSTMENTS
183
Reversing Atheroma?
Preventive healthcare strategies are difficult to enact and most
healthcare interventions occur at the tertiary level when disease states are
manifest. An individual may shop for a cure for established cardiovascular
disease with a self-reliance that is driven by the fear of continuing ill health
or death. These circumstances lead to situations where compliance with
treatment for established disease is always more apparent than compliance
with preventive strategies.
There are several sources of evidence that dietary and other lifestyle
changes can certainly stop the progression of coronary heart disease and
reverse the process of atheroma in some cases. The benefit of lifestyle
change in improving or reversing arteriosclerotic heart disease comes from
the many studies of Ornish (1982). The idea that heart disease due to
atheroma can be reversed has been around for about a century but it took 50
years to be registered as a credible treatment approach.
The idea of the “low fat way to a healthy heart” has its roots at the
start of the Framingham Study in 1948. The low fat route to health became
most popular as a result of more contemporary champions such as Dean
Ornish and Nathan Pritikin. The approach of Ornish served to duplicate
many of the suggestions of Dr. Nathan Pritikin. The recognition of the work
of Ornish and Pritikin is so important and widespread that their methodology
deserves careful consideration.
Intervention Summary
Stress Management Training: 5 Hours Daily of Each of:
188
Diet: Daily Composition of Diet:
Table 35: Interventions that have been applied by Ornish and his
colleagues. These interventions resulted in objective improvement in
cardiovascular health in patients with ischemic heart disease.
INSERT
189
considered by the author to be the classic basis of current work on the
promotion of cardiovascular health by natural means. In a foreward to
Pritikin’s book (“The Pritikin Program for Diet and Exercise”), the
renowned physician Dr. Dennis P. Burkitt likened Pritikin’s
recommendations on lifestyle to the style of life encountered in third-world
countries. In third-world countries, there is a much lower prevalence of
cardiovascular and other degenerative disease that afflict more affluent
Western societies. Dr. Dennis P. Burkitt received more than unjustified
“flak” for his proposals than any other contemporary physician but he has
achieved complete exoneration in recent years.
Whilst the author has been free with his criticism of several dietary
approaches to promote cardiovascular health and weight reduction, he wants
to have some friends left. It is fair to state that comparisons among diets
may be unfair to a certain degree because they are apples and oranges. For
example, Atkins conceived his plans primarily with weight loss in mind and
Pritikin had cardiovascular health at the root of this thoughts. However,
during the process of analysis of dietary approaches, two key nutritional
principles came to light which support the recommendations of the author to
include soy and essential oils in a diet that is optimal for both weight loss
and cardiovascular health. Just as it is unwise to just lower cholesterol, it is
equally as unwise to plan a diet only with one disease state in mind.
196
CHAPTER 6
NUTRITIONAL INFLUENCES ON
CARDIOVASCULAR DISEASE
197
Nutritional Therapy to Lower Lipids: The Dietary Supplement
Dietary supplements are a relatively new class of products that are
sold over-the-counter mainly in health food stores and, increasingly, in
pharmacies. In the USA, the Dietary Supplement Health Education Act
(DSHEA) of 1994 permits a somewhat restricted health claim to be applied
to dietary supplements but this claim must be limited to a relatively non-
specific claim about wellness or a potential improvement in body structure
or function (see Appendix I for a review of DSHEA).
198
Some Important Dietary Details
The selection of the ideal fat composition of a diet is an
extraordinarily complex subject. In general, saturated fatty acids will tend to
promote atheroma, whereas monounsaturated fats and polyunsaturated fats
are not atherogenic. There is an important observation that when a
polyunsaturated fat is hydrogenated, as occurs during common food
processing (e.g. margarine), it becomes atherogenic, just like a saturated fat.
The notion that most types of margarine are protective against heart disease
is probably fallacious and whether or not margarine is “healthier” than butter
has created enormous debate. Whilst butter contains cholesterol and many
margarines do not, neither butter nor margarine are good choices for the
serious dieter. The
best way to deal with this dilemma is to use fresh vegetable or olive oil as a
Nutrient Comment
199
Carnitine Chromium of these nutrients are not as well
Niacin(B3) Selenium defined as they are for soy protein
Vitamin C Magnesium containing isoflavones or fish oil.
Table 37: Nutrients that are used in dietary supplement which lower blood
cholesterol. Some nutrients can be used to lower cholesterol with variable
success. The author proposes that these nutrients can be taken in food or
dietary supplement format as an adjunct to a low-cholesterol diet to lower
blood cholesterol. The most effective dietary supplements to lower
cholesterol are soya protein containing isoflavones and fish oil containing
omega 3 series fatty acids. Dietary supplementation with fish oil and soy
protein are highly effective adjunctors to a low-cholesterol diet in lowering
blood lipids. Fiber is strongly recommended by the author.
200
answers rest in a recognition of the beneficial effects of certain dietary fats
and essential fatty acids. A grossly deficient fat diet does result in a low
serum cholesterol and LDL, but HDL (good cholesterol) may also decrease.
The implications of lowering HDL cholesterol are not entirely known and to
add to the confusion, polyunsaturated fats (good fats) in the diet may also
lower HDL. This has led many thought leaders to espouse the benefits of
using monounsaturated fat as the ideal source of fat.
Not all saturated fatty acids are necessarily atherogenic. The main
offenders include palmitic, myristic and lauric acid which are ubiquitous in
animal fat. Some foods have been rejected inappropriately as unhealthy
because they contain saturated fat. Coconut oil, cocoa butter and eggs fall
into this category. Eggs are rich in cholesterol but as much as 50% of the fat
in eggs is monounsaturated and they are a rich source of lecithin, which can
be considered an antiatherogic principle.
Dietary Fiber
Soluble fibers, such as those found in apples (pectin) or beans (guar),
are generally more effective at reducing blood cholesterol levels than
insoluble fibers. The role of soluble fiber in decreasing cardiovascular risk
has been grossly underestimated. In a review of the lipid-lowering ability of
fibers, Anderson and Tietyen-Clark (1986) reviewed several controlled
scientific studies that indicated that oat bran or beans in the diet can reduce
cholesterol by 19%, whereas, guar, pectin and psyllium supplements in the
diet can lower cholesterol by 8%, 15% and 16%, respectively. These
findings imply that a diet that is high in fiber content is a very useful adjunct
to promote cardiovascular wellness.
The fiber content of beans, some fruit, carrots and a variety of cereals
have been shown to lower cholesterol when incorporated into the diet.
Much attention has focused on oat bran as being particularly valuable in the
control of blood cholesterol, but it may not be more effective than other
types of fiber, especially many of the soluble fibers. Dr. VanHorn (1988)
undertook a study in 236 healthy volunteers who were following the
American Heart Association guidelines on diet and noted a reduction of
blood cholesterol over a period of one month. After this initial period, the
volunteers were split into two groups, one of whom received oatmeal
supplements and one that did not. It was determined that aatmeal caused
204
reductions in blood cholesterol. This and other studies show the beneficial
effect of dietary supplementation with oatmeal on lowering blood
cholesterol. Oatmeal is advised because it is inexpensive and quite effective.
The efficacy of oat bran is impressive and like soy protein it has been
proposed as a real option to avoid drug therapy in the control of blood
cholesterol. Kinosian and Eisenberg (1988) performed an important study
that examined oat bran as an alternative to drugs for treating high blood
cholesterol. This study looked at the cost-effectiveness of oat bran versus
two prescription cholesterol lowering drugs (colestipol and cholestyramine).
In this study, oat bran was perceived as more cost-effective than these drugs
with a conclusion that this natural option may be preferable to drug therapy.
Whilst more potent lipid-lowering drugs have emerged since this study was
performed in 1988, there is no reason to reject effective natural options to
lower cholesterol, such as soluble fiber or soy protein.
Focus on Fiber
Dietary fiber is widely acclaimed as possessing general health
benefits. Fiber in the diet is residue present in plant foods that is not readily
digested by human digestive enzymes. Fiber has been called “unavailable
carbohydrate”, since it contains complex polysaccharides that are not a
significant energy source because of their lack of assimilation by the body.
A minor amount of energy is derived from certain fibers in the form of
absorbed fatty acids. Plant fiber is delivered into the colon (large bowel),
where it is metabolized and fermented by bacteria to produce volatile fatty
acids, gas and energy.
205
The delivery of the fiber to the colon is very important in
understanding the effect of fiber on human physiology. First, most types of
fiber are hydrophilic (adsorb, absorb, and retain water), and they produce
bulk for the colon to exert its actions. This bulk assists in normalizing motor
function and bulks up the stool. People who consume a high-fiber diet have
softer, bulkier stool than those who consume a low-fiber diet. Fiber can alter
the normal bacterial populations present in the large bowel, and it can
promote the growth of more friendly type of bacteria.
Fiber in Soya
The fiber content of crudely processed soyabeans is of major interest
in the potential promotion of cardiovascular health. Soya fiber shares many
of the physical properties of the plant-derived fibers, which are characterized
by their water-holding ability and their resistance to digestion. Resistance to
digestion causes bulking of the stool. Individuals who consume water-
holding (hydrophilic) indigestible fiber have more bulky stool, and the
weight
of stool passed in a 24-hour period is substantially increased by the addition
209
of fiber to the diet.
Bran fiber Fibrous outer layer Poorly soluble with water hold-
of cereal grains, ing dependent on particle size.
usually wheat
Plantago Species
(Ispaghula) Small dried ripe seeds; Colorless transparent mucilage
ovata cellulose-containing forms around insoluble seed
P. pysllium walls of endosperm and
indica mucilage-containing
epidermis
210
Dietary fiber is generally derived from the supporting structures of
vegetation. These supporting structures are often found in the coverings of
vegetables and are abundant in the stems and leaves of plants. Overall, fiber
is composed of plant polysaccharides (complex sugars) and lignins that are
not amenable to easy degradation by digestive enzymes that are secreted by
the human gastrointestinal tract. However, fiber can be degraded by
bacteria, which are abundant in the large intestine of humans. The bacterial
decomposition of fiber in the colon may produce gas and untoward bloating
of the abdomen.
The effects of dietary fiber on the body are far reaching and differ
depending on the type of fiber under consideration (Table 39). Dietary
fibers have been generally classified into two broad categories; soluble fiber,
such as that found in soyabeans, apples, and legumes, and insoluble fiber,
such as wheat bran, which is rich in cellulose, lignin, and pentosan
polysaccharides.
211
Insoluble fibers are generally more resistant to digestion or fermentation, but
all types of dietary fiber can exert complex effects on the gastrointestinal
tract. These effects include interference with the absorption of metals, fats,
minerals, and other nutrients. Soluble fibers, such as those found in
soyabeans, can be fermented in the colon to produce short chain fatty acids,
which can stimulate colonic activity, but these types of fiber do not
contribute
to fecal bulk in the same manner as insoluble fibers, such as bran of other
plant husks.
Physiochemical Clinical
Property Type of Fiber Physiological Effects Implications
212
sacchardies losses of minerals mineral
(e.g., pectins) (±), trace elements balance,
(±), heavy metals probably
compensated
for by colonic
salvage, after
fermentation
of fiber; anti-
toxic effect
industry, and on the other, this interest has led to the marketing and
generation of the scientific support to promote several commercially
available insoluble fiber products that are marketed as pharmaceuticals and
over-the-counter medications.
213
importance of Zutphen’s study has been grossly underestimated in
contemporary medical literature. Its strength was that it was a 10-year
prospective analysis of diet and death in 871 middle-aged men in Holland
between 40 and 59 years of age. In summary, this study showed that men
with a low intake of dietary fiber had about a three times greater risk of
death from all causes than men who had a high intake of dietary fiber. It
was of major importance that the study showed clearly that the risk of death
from a variety of causes seemed to decline with an increasing intake of
dietary fiber. The Zutphen study indicates that a diet rich in fiber (of the
order of about 35 g/day) is protective against death from several chronic
disease in Western societies.
One of the major reasons that these health benefits of soya fiber and
other dietary fiber products may not be generally known by consumers is
related to the strict regulation the FDA placed on labeling of dietry
supplements in the past. However, the Dietary Supplement Health
Education Act of 1994 permits labeling claims on dietary supplements
where scientific agreement exists to support the claim of health benefits
(Appendix I).
There are no merits to coffee or cola drinking for the person at risk of
cardiovascular disease. One alarming study undertaken in Norway indicated
that coffee consumption is a predictor of coronary death and it operates at a
level more than can be explained by its known effects on raising blood
cholesterol. Unfortunately, decaffeinated coffee does not clearly afford
protection. The jury remains out on the caffeine content of coffee and risk.
However, caffeine, in coffee or cola, is to be avoided in the individual with
established heart disease because it can alter heart rate and rhythm, as well
as increasing platelet reactivity. There is no reason to avoid decaffeinated,
diet cola for the person who seeks cardiovascular wellness.
Vitamins
A great deal of work exists on the role of vitamins in the prevention or
treatment of cardiovascular disease but much of the data are conflicting.
Few healthcare givers would argue with the concept that antioxidant
vitamins (vitamins A, C and E) could exert a beneficial role in allaying
atherosclerosis and heart disease but much emphasis has been placed on
niacin because of its cholesterol lowering ability.
Niacin has been shown to lower cholesterol and it may reduce the risk
of myocardial infarction and death. However, niacin has unpleasant and
significant side effects, such as “flushing”, which have limited its use and
treatment. Niacin should always be undertaken with medical supervision.
One serious limitation of niacin therapy is its relative contraindication in
221
patients with Type II diabetes mellitius. In this situation, niacin may cause
poor blood sugar control and increases in serum uric acid.
Minerals
The role of mineral supplementation in the prevention or treatment of
cardiovascular disease is still very unclear. Some minerals that promote free
radical reactions and lipid peroxidation, such as copper, may be
contraindicated. In contrast, calcium and magnesium are essential for
normal contractile function of the heart. Table 41 summarizes information
on minerals and atherosclerosis but it is necessary incomplete. Again, the
reader
222
clotting
time.
223
Iron (Fe) Fe may contribute to atheroma formation.
224
soy isoflavones, bioflavnoids and lecithin. The effects of some of the many
nutrients on atherosclerosis are summarized in Table 42.
226
CHAPTER 7
227
Overlooking Diet as the Key to Cardiovascular Health
Several options exist for the reduction of blood cholesterol, including
diet, exercise, alteration of the type of protein consumed in the diet, and drug
therapy. There has been an exponential increase in the use of cholesterol-
lowering drugs in clinical practice, but such drugs are expensive, associated
with unpleasant side effects, and, on occasion, they can be frankly dangerous
(Table 43). The main type of synthetic pharmaceuticals that are used for
their cholesterol-lowering effects and their adverse effects are shown in
Table 43. These drugs are expensive, and in the author’s opinion, they are
overused in conventional medical practice at the expense of considering
dietary adjustments as first line options.
Fibric acids
Clofibrate Increase activity of Cause of gallstones
Gemfibrozil lipoprotein lipase Gastrointestinal
distress
and lower tri- Myopathy
glycerides
Modest effect only
on LDL and HDL
Probucol Lowers LDL and Gastrointestinal distress
protects LDL Lowering HDL is
against oxidation dangerous
but lowers HDL Prevention of heart
disease not well
documented
blood cholesterol. It may be that many patients are being placed at risk from
these drugs. For example, Ornish et al (1990) demonstrated that diet was
highly effective not only in reducing blood cholesterol but also in causing a
variable regression in atherosclerotic disease. Ornish (1990) has proposed a
holistic program involving lifestyle change to improve cardiovascular health,
but this program may be impractical for many individuals.
229
Soya Protein Isolates are Effective at Lowering Cholesterol
The preoccupation with cholesterol-lowering strategies has led to a
situation where the important effects of dietary protein sources on
cholesterol have been overlooked. It has been recognized for approximately
100 years that animal protein may promote atherosclerosis and that
vegetable protein lowers cholesterol and, by inference, the risk of atheroma.
The main types of abnormalities of blood lipids are summarized in Table
44. Unlike the need to match one cholesterol-lowering drug with one type
of blood lipid disorder, soya protein in the diet is effective for most types of
hypercholesterolemia. Dr. James Anderson of Kentucky has demonstrated
in his article in the New England Journal of medicine in 1995 that many
studies indicate that soya protein lowers cholesterol. Soya protein
supplementation of the diet is the
Lipoprotein
Abnormal Laboratory Lipoprotein Phenotype
Blood Lipid Findings Patterns Classification
Hyper-
cholesterolemia High Cholesterol High LDL Cholesterol Type II
Mild 200-239 mg/dl 130-159 mg/dl
Moderate 240-300 mg/dl 160-210 mg/dl
Severe ≥ 300 mg/dl ≥ 210 mg/dl
Hyper-
triglyceridemia High Triclycerides
Moderate 250-500 mg/dl High VLDL Type IV
Severs >500 mg/dl High VLDL and high Type V
chylomicrons
Mixed
Hyperlipidemia High Cholesterol
(>240 mg/dl)
High Triglycerides
230
(>250 mg/dl)
231
cases. In these studies, it was notable that soya protein significantly reduced
low-density lipoproteins (LDL, so-called bad cholesterol), an effect that
often occurred independently of dietary fat or cholesterol intake.
232
Vessby et al. 6 TSP 37
Widhalm 11 ISP 20
Widhalm et al. 23 ISP 18
Wolfe et al. 7 ISP 47
Table 45: Characterists of 38 Studies Used in the Analysis Reported by Anderson et al.a
a
) Modified from Anderson et al. N Engl J Med 333:276-282, 1995. b) ISP, isolated
soya protein; TSP, textured soya protein.
This soy study by Dr. Anderson in 1995 has had a major impact on
conventional and alternative medical practice. Anderson and his colleagues
have traced work that demonstrates that vegetable protein in the diet, as a
replacement for animal protein, appears to be associated with a lower risk of
coronary artery disease. The major reason for this finding relates to the
ability of vegetable-based diets, particularly soya-based diets, to lower blood
cholesterol. This ability of soya protein to lower blood cholesterol and
protect against vascular disease (atherosclerosis) has been recognized for
nearly a century!
233
Is Soy Rabbit Food?
The importance of the work of Anderson et al. (1995) is that it flies in
the face of statements by the Nutrition Committee of the American Heart
Association, which erroneously concluded that soy protein decreases serum
cholesterol concentrations in rabbits but not in humans. This learned body
must now reconsider its findings given the convincing data provided by
meta-analysis of studies of soya proteins cholesterol-lowering effects.
Anderson et al. (1995) have shown conclusively that the consumption of
soya protein-containing isoflavones ins the diet, in contrast to animal protein
in the diet, significantly decreases serum concentrations of total cholesterol,
LDL cholesterol, and triglycerides without significant effects on HDL
cholesterol.
The amino acid composition of the diet seems to exert major effects
on serum cholesterol levels, at least in animals. It would appear that
increases in arginine are associated with decreases in blood cholesterol
concentrations. The amino acid content of soya protein may exert effects on
elevated blood cholesterol. Finally, there is a possibility that alterations in
cholesterol absorption and the constituents of bile occur as a consequence of
soya intake, but this cholesterol-lowering mechanism is not clearly defined.
Some scientists believe that substitution of soya protein in the diet for
meat or dairy protein may affect the metabolism of lipoproteins and
235
cholesterol in complex ways. These mechanisms of action of soya protein
are believed to be due to increasing the turnover of very LDL (VDLD) or
apoprotein B (a molecule involved in regulation of VLDL) or perhaps to
effects on LDL receptor activity.
The hypothesis that plasma amino acids and their effect on the
insulin/glucagon ratio offer an explanation for the cholesterol-lowering
effects of certain dietary protein combinations, is of special note. Soya
protein contains large amounts of glycine and arginine, which tend to reduce
blood insulin levels. Low insulin levels decrease the hepatic (liver)
synthesis of cholesterol. In contrast, animal proteins are low in glycine and
arginine but tend to contain more lysine than vegetable proteins. Lysine
tends to raise insulin levels, and it promotes cholesterol synthesis. This
occurrence is confirmed by the recognition that the greater the lysine content
of certain foods, the greater of likelihood that blood cholesterol will
increase. There is no question that vegetable protein, such as soya protein, is
more effective at controlling blood cholesterol than diets that are based on a
recommendation of meat protein, even when lean meat is incorporated in the
diet.
238
How Does Soy Promote Cardiovascular Wellness?
One major aspect of the explosive interest in soy foods is the
recognition of their potential to treat or prevent cardiovascular disease. Soy
foods and recipes with bulk fractions or derivatives of soybeans have
become increasingly popular. When soy is taken in these formats some
uncertainty exists about the types or amounts of the various health giving
fractions of soy that are incorporated into the diet. This drawback, together
with the lack of palatability and inconvenience of some soy foods, has led to
major activity in the Dietary Supplement Industry to produce products that
can deliver certain
specific fractions of soy in dosages that may assure the health giving
benefits that can be ascribed to soy.
What is in a Soyabean?
The soybean is a complex legume with quite an amazing diversity of
bioactive nutrients. The components of soybeans that have relevance to the
239
promotion of cardiovascular wellness are summarized in Table 46. There
has been a considerable amount of interest in the cholesterol-lowering ability
of soy protein. Soy protein is a principle ingredient in some cholesterol-
lowering dietary supplements. It is true to say that the actual mechanism of
the cholesterol-lowering effect of soy remains unknown to some degree.
However, recent evidence suggests that the composition of soy protein per
se has complex effects on lipid metabolism and the isoflavones
profiles. Table 47 indicates the most recent research on the cholesterol-
lowering effects of soy at the time of writing of this book. It describes the
mechanisms of such effects. These data were presented at the Second
International Symposium on the Role of Soy in Preventing and Treating
Chronic Disease which was held at the Brussels Conference Center in
Belgium between September 15-18, 1996.
240
fatty acids. It is a phospholipid with diverse
functions on blood lipids and cell membranes.
Isoflavones
(genistein, daidzein) Isoflavones have a well defined role in cholesterol
lowering and possess anti-atherogenic and anti-
thrombotic effects.
Soy Protein Protein of soy origin has a very convincing role for
soy protein in lowering cholesterol and improving
blood lipid profiles.
Potter, S.M.; Effects of Soy Protein Soy protein (40 gm/day) with
Baum J.; et al & Isoflavones on variable isoflavone contents
Plasma Lipid Profiles lowers risk of cardiovascular
in Post-menopausal disease in post-menopausal
Women females by lowering cholestrol
and improving lipid profiles.
241
Kurowshal, E.M.; Role of the Main Whole soybean products can
Jordon, J.; et al Components of Whole improve lipid profile by virtue
Soybean Products, Soy of their protein content and the
Protein and Soy Oil, in effect is greater in subjects with
Reducing Hypercholes- higher LDL and lower HDL.
terolemia
242
et al Fraction of Soybean reducing effect of soy protein
Protein could be due to binding of soy
peptides with steroids in the gut
or peptides that are absorbed
with a direct effect on lipid metabolism.
243
Lovati, M.E.; a and a’ Subunits From potential importance of the 7S
7S Soy Globulin, is soy globulin in the up-regulation
Correlated With Their of LDL receptors.
Up-Regulation of LDL-
Receptors
Summing Up On Soy
Many popular magazines, newspapers and consumer books highlight
the health giving properties of the soybean. However, it is apparent that the
amount and range of the health giving fractions of soybeans that are required
244
to achieve the health benefit, cannot be obtained from ordinary soyfood
supplement of the diet. In the author’s opinion, this creates a real need for
responsible dietary supplements that are made with a high degree of quality
control. Such dietary supplements will probably emerge in the near future.
There is a switch away from animal protein to vegetable protein
incorporation
246
in the human diet for a variety of reasons. Soy protein is a much more
ecologically sound source of protein than animal protein and it appears to
have many recognizable health benefits.
247
arteriosclerosis to some of the reports of sudden death in young adults.
Other studies in Italy have confirmed the alarming incidence of high blood
cholesterol levels in children from the Northern parts of Italy. There has
been a similar increase in the intake of dietary fat and cholesterol in African
countries where high blood cholesterol has emerged among the more
affluent black population among urban areas.
On the one hand, some physicians such as Dr. Frank Oski (Chief of
Pediatrics at the Johns Hopkins University), have indicated that there are no
advantages to cow’s milk, whereas on the other hand, physicians such as Dr.
Ronald E. Kleinman (Chairman of the American Academy of Pediatrics
Committee on Nutrition) think that such opinions are well founded.
250
CHAPTER 8
251
Do Not Skip This Chapter!
Understanding the importance of omega 3 and omega 6 essential fatty
acids in the diet is hard work, even for the healthcare professional. Before
readers skip this stuffy chapter of this book they should pause a moment and
consider that essential fatty acid deficiency is probably one of the most
important, overlooked influences of cardiovascular and general health. It is
estimated that four one fifths (80%) of the population of Western
communities take insufficient quantities of essential fatty acids in their diet.
This situation may be more important than vitamin deficiency.
So important is this issue that the author would like to point to several
contemporary sources of information that can supplement a reader’s
knowledge of the subject. In addition, no apology is necessary that the
author has been somewhat repetitive in his description of the concepts that
underlie the health importance of essential fatty acids in the diet.
Perseverance is rarely popular or enjoyable but it is often effective.
The world of medicine has net yet taken “its cap off” to the pioneers
of the field of essential fatty acid research, but will they soon? The pioneers
in
popularizing these important concepts include Dr. Udo Erasmus, Dr. Edward
N. Signel, Dr. Caroline Shreeve, Dr. David Horrobin, and Dr. Michael T.
Murray. Their works are highlighted in the bibliography of this book, where
their readable accounts of the health implications of selected fats and oils are
summarized.
One key area in the understanding of fatty acids is that the presence of
a double bond in the unsaturated type of fat. The unsaturated bond tends to
make the fatty acid component less stable than that found in the saturated
fat, where the fatty acid has a single bond. This means that unsaturated fatty
acids tend to be more active chemically and capable of reacting with a
variety of chemical substances that “crop up” in metabolic processes in the
body. These metabolic processes which involve reactive, unsaturated fatty
acids, include reactions with oxygen, sulfur (to form sulfydryl groups), or
water (to form hydroxyl groups). The term polyunsaturated fatty acid
merely refers to unsaturated fatty acids that have two or more double bonds
within the molecule. The general use of the term “polyunsaturated” fat
applies to omega 6 fatty acids which are found in vegetable oils that are used
often in food and cooking. In contrast, omega 3 fatty acids are often referred
to as “super-unsaturated” fatty acids to distinguish them from the garden
variety omega 6 type fatty acids. There is a general belief that increasing the
dietary intake of polyunsaturated fatty acids in the diet is an ideal goal. This
belief has not worked to general benefit because it has led to the modern
255
dietary habit of consuming polyunsaturated fats at expense of forgetting the
omega 3 factors or EPA and DHA which are cardiovascular protectors.
Table 50: The protean effects of essential fatty acids and prostaglandins on
body function.
Fatty Acid Derivatives e.g., DHA EPA GLA, DGLA and e.g.,
Found mainly in Arachidonic Acid
Animals(6) or Fish(3)
Table 51: A simple schematic to understand the role of omega 3 and omega
6 fatty acids as precursors of compounds that are germane to health body
259
functions. The schematic is an oversimplification of the pathways in
question and is presented for an easier understanding of the complex issues.
There are mammalian sources of EPA and DHA which include food
that is normally termed “offal”. Offal is composed of key animal organs,
such as the pancreas, adrenal glands, brain tissue and gonoal tissue. Offal is
eaten sometimes as a special delicacy. Unfortunately, offal is loaded with
cholesterol and should be avoided as a regular inclusion in the diet. The
sources of different types of essential fatty acids and their derivatives in the
diet is shown in Table 52.
260
Linoleic Omega 6 Vegetable Oils, Sunflower
and seeds or nuts Walnut
Soybean
Blackcurrant
Oil, and
Pumpkin
Seed Oil
Table 52: Dietary sources of essential fatty acids and their derivatives.
261
The answer rests in part in studies of the disease profile of races that
ingest large quantities of omega 3 fatty acids in fish oil. For example,
Eskimo populations living under traditional conditions have a very high
consumption of fat and protein in the diet, but a remarkably low incidence of
cardiovascular disease. The Inuit language of the Eskimo contains more
than
40 words to refer to snow, but there is no word in this native tongue to
describe heart disease. It is of interest that the term Inuit means “eaters of
raw meat”. Inuits or Eskimos (natives of Greenland) in their natural habitat
live largely upon both raw and cooked flesh and fat derived from fish or
marine mammals, such as seals. Marine mammals and fish of cold water
origin are the most abundant source of omega 3 fatty acids in the form of
EPA and DHA.
Not every individual finds “fatty”, cold water fish palatable in this
quantity. The fish most likely to contain significant quantities of omega 3
fatty acids, include yellow fin tuna, cod, rainbow trout, sea bass, herrings,
mackerel, salmon, shark, swordfish, grouper and sardines. Several of these
fish are rather uncommon in food shops in Western locations and they tend
to be quite expensive. This and other factors has led to the recognition that
dietary supplementation with fish oil may be the more realistic option for
those individuals who wish to supplement their diet with omega 3 fatty
acids.
263
Dr. Richard Passwater PhD has drawn attention to be the ability of
fish oil to lower blood pressure in his book entitled “The New Super
Nutrition”. Dr. Passwater related the experience of researchers at the
Brompton Hospital in London where sixteen patients with mild hypertension
were shown to have a lowered blood pressure over a six week period in a
placebo-controlled crossover study. This research indicated that fish oil
supplementation of the diet could provide a safe, acceptable therapy for
patients with mild essential hypertension, where systolic hypertension was
preponderant. Studies in the United States at Vanderbilt University in
Tennessee have confirmed these earlier findings in London, England, where
relatively large doses (50 ml) per day of fish oil were found to produce
modest reductions in systolic blood pressure.
Fat Fatty
Content Acid Composition (% ofTotal Oil)
Name (%) 18:3w3 18:2w6 18:1w9 18:0 16:0
hemp 35 20 60 12 2 6
flax 35 58 14 19 4 5
pumpkin 46.7 0-15 42-57 34 0 9
soybean 17.7 7 50 26 6 9
walnut 60 5 51 28 5 11
wheat germ 10.9 5 50 25 18
evening
primose 17 81 11 2 6
safflower 59.5 75 13 12
sunflower 47.3 65 23 12
grape 20 71 17 12
corn 4 59 24 17
sesame 49.1 45 42 13
rice bran 10 1 35 48 17
265
rape (canola) 30 7 30 54 7
peanut 47.5 29 47 18
almond 54.2 17 78 5
olive 30 8 76 16
avocado 12 10 70 20
coconut 35.3 3 6 91
palm kernel 35.3 2 13 85
beech 50 32 54 8
brazil 66.9 24 48 24
pecan 71.2 20 63 7
pistachio 53.7 19 65 9
hictory 68.7 17 68 9
Table 53: This information is modified from the book by Dr. Udo Erasmus
titled “Fats That Kill”. Whilst a formal cost-effect analysis has not been
performed by Dr. S. Holt on the health benefits of seed oils, Dr. Holt
believes that soybean oil may be very cost-effective as a source of essential
oils because it is cheap and ubiquitous.
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benefits of linoleic acid are still the focus of intense research and their
effects on the human body remain underexplored. The manifestations of
linoleic acid deficiency are protean. Omega 6 fatty acids, like omega 3 fatty
acids, promote cardiovascular and general health.
Table 54: Signs, symptoms and disorders that have been attributed to
essential fatty acid deficiency. The reader is cautioned that these problems
are not specific to fatty acid deficiency and occur due to other reasons.
fatty acids their effects on occasion may be quite different. For an ease of
understanding, the health implications of omega 3 versus omega 6 are best
considered to be somewhat contrarian. The results of deficiency of LNA are
as complex as those of LA. LNA has been associated with cardiovascular
disease, central nervous system changes, including behavioral problems,
paraesthesia (pins and needles in the arms and legs), motor incoordination,
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muscle weakness, impairment in learning ability, visual loss, and growth
retardation.
Fatty Acids
Omega 6 Omega 3
↓ Delta 6 Desaturase ↓
Enzyme
↓ Elongase Enzyme ↓
Di-Homon-Gamma Intermediate
-Linolenic Acid
_ _ ↓
“Health “Unhealthy “Healthy
Pathway” Pathway” Pathway”
Intermediate
↓
Delta 4 Desaturase
DHA
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Table 55: The metabolic pathways of omega 3 and omega 6 fatty acids and
their role in the production of prostaglandins and leukotrienes.
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Types of Leukotrienes
Omega 6 Omega 3
_ _ _ _
*Prostacyclin t Thromboxane *Prostacyclin t Thromboxane
PG12 TXA2 PG13 TXA3
NOTES:
(*) Prostacyclin PG12 is antiaggregatory for platelets and PG13 is more
potent in this effect.
(t) Thromboxane TXA2 is proaggregatory and TXA3 is less potent in this
effect.
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Table 57: This table shows the terminal portions of the pathways of
metabolism of the omega 3 and omega 6 fatty acids as precursors of
prostaglandins. The converstion of the omega 3 fatty acid, linolenic acid to
eicosopentanoic acid is less efficient in the presence of large amounts of the
omega 6 fatty acid linoleic acid.
In addition to the presence of some type of fish oil that may not be
particularly beneficial to health, it is important to note that fish oils may be
easily damaged by heat, light, or oxygen. Eating raw fish is common in
certain countries such as Japan but much of the fish oil is contained within
the skin or subcutaneous area of the fish and this fraction of fish is often
excluded during the preparation of sushi or sashimi. It has been suggested
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that in some instances, the inspection of fish by food regulatory agencies is
often less stringent than the inspection of meat. Much fish sold in stores in
Western communities is not fit for consumption in raw form. The notion
that freezing fish at very low temperature is capable of removing toxins or
parasites is quite misleading.
Ideal Intakes?
The ideal amount of alpha-linolenic acid (LNA) in the diet is even
more of a guess than the optimal amount of linolenic acid (LA).
Extrapolations of required amounts of essential fatty acids from body
composition have been undertaken but it is likely that inaccuracies exist
using this assumption alone. However, it is generally accepted that about
one quarter to one half the amount of LNA is required in comparison to LA,
which translates into approximately 5 to 9 grams of LA per day for a 70
kilogram human. These figures are only best guesses.
Any understanding of the optimal amounts of EPA and DHA that are
required must take into account the importance of the variability of the daily
requirement depending upon the many aforementioned factors. If an
average human can transform LNA into EPA at a rate of about 2 to 3% per
day of the LNA administered, then the body can make approximately 4 to 6
grams of EPA daily from LNA. This is a projected, and by some an
assumed, daily requirement of EPA and DHA that appears quite
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astonishingly large to many individuals. If this is a required daily amount, it
represents a need for several servings a fresh fish weekly, or a combination
of supplementation of diet with precursors of EPA and DHA, such as oils
containing LNA, assuming the conversion occurs optimally.
Several dietary supplements have been made with fish oil and an
average fish oil capsule that contains 1,000 milligrams of fish oil with
varying concentrates of omega 3 fatty acid may have to be taken in a dose of
approximately 20 capsules a day to meet the body need in the face of omega
3 fatty acid deficiency. The whole situation is very confused by the
variability in the requirements for omega 3 fatty acids in states of disease,
stress, lack of other dietary co-factors and many other variables. In disease,
a therapeutic amount of omega 3 fatty acids may be required which is
anticipated to be much greater than the requirements to maintain states of
homeostasis. It is believed that once the body is saturated with essential
fatty acids in the presence of deficiency then the subsequent amount of fish
oils required to maintain adequate bioavailability of EPA and DHA is much
lower. This reasoning assumes tolerance of fish oil supplements and their
absorption and assimilation by the body.
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Table 58: A regimen of supplementation of the diet with fresh oils that is
useful. This regimen was suggested by Dr. Edward N. Siguel.
A Word of Caution
The reader may be slightly frustrated with the lack of clarity
concerning an optimal amount of fish oil supplementation of the diet.
However, it should be noted that at tolerated levels (toleration being defined
as comfortable intake of fish oil in crude format) no adverse effects of fish
oils are to be expected by the average individual. There is one important
word of caution and that is that at very high levels, fish oils can cause
abnormal clotting function with a bleeding tendency.
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Much of the fish that passes our lips is prepared in a format that is not
only deficient in essential fatty acids but probably contains toxic byproducts
of fats by virtue of frying. The British tradition of fish and chips has
evolved into the procurement of low-fat fish (low in EFA and DHA) with
potatoes deep fried in damaged, saturated fat that contains carcinogens. The
predilection of individuals from the north of Britain for their fish and chip
diet may explain the reason why areas in the north of England and lowlands
of Scotland have among the highest incidences of heart disease and cancer in
Europe.
Approximate Temperature
Fat of Decomposition oC
Corn Oil 227
Butter 208
Lard 218
Margarine 225
Olive Oil 175
Soy Oil 210
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Table 59: Fats are readily decomposed by frying or heating. Average
temperatures at which fats become decomposed are listed for common fats
or oils. Note that the healthy fats in olive oil are the easiest to decompose
with heat.
heating. Thus, cooling habits may turn a healthy fat into an unhealthy fat
containing food more unhealthy.
There have been many other dietary adjustments over the past 100
years but in addition to a switch in the ratio of omega 6 to omega 3 fatty acid
in the diet, there has been an increasing preponderance of the inclusion of
high cholesterol, high saturated fat foods. Studies of disease profiles in
Eskimos has indicated a lower prevalence of common killer disease, such as
cardiovascular disease, inflammatory disease, and idiopathic inflammatory
disease (EG inflammatory bowel disease), and this has been ascribed to the
presence of omega 3 fatty acids in the diet. However, other factors clearly
operate in determining disease profiles. These other factors include other
dietary inclusions and lifestyle. The life expectancy of the Eskimo or Inuit
is not admirable and the prevalence of stroke is quite high among Inuits,
presumably, as a result of a high salt intake that may promote hypertension.
The native Inuit living in traditional circumstances has a deficiency of water
soluble vitamins such as vitamins B and C. In addition, a Inuit diet is
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relatively deficient in vitamin E.
The relative amounts of omega 6 and omega 3 fatty acids in the body
varies dramatically depending on the tissue in question. The omega 6 to
omega 3 fatty acid ratio in nervous tissue is approximately 1:1, whereas the
ratio in adipose tissue deposits is approximately in a range of 3 to 7 to 1.
On average the ratio of omega 6 to omega 3 throughout most body tissue is
about 4 or 5:1. I believe that an optimal ratio of omega 6 fatty acids to
omega 3 fatty acids in the diet should be somewhere between 2 to 5:1.
Remember, this ratio becomes unimportant if the co-factors required for the
function of essential fatty acids are not present in the diet and if the diet is
not generally well balanced.
In contrast, the omega 3 fatty acids, EPA and DHA, may replace the
omega 6 fatty acid derivative, arachidonic acid, as a substrate for the
cyclooxygenase enzyme system with a resulting decrease in the synthesis of
thromboxane A2. If these omega 3 fatty acids in fish oils replace the omega
6 fatty acids as substrates for prostaglandin synthesis, the type 3 series
prostaglandins will be preferentially produced and the expense of the type 2
prostaglandin series. A decrease in the production of thromboxane A2 will
shift the balance away from vasoconstriction and platelet aggregation
towards a set circumstance of vasodilatation and a state of anti-aggregation
of platelets. Incorporation of fish oils into the diet results in the production
of a different form of thromboxane A2 which is a much weaker
vasoconstrictor and platelet aggregator than classic thromboxane A2.
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Series 1 Prostaglandins
Series 1 prostaglandins include the prostaglandin E1 which prevents
platelet stickiness and promotes cardiovascular well being. In addition,
prostaglandin E1 has important actions in the urinary tract where it facilitates
sodium and water excretion. In addition, prostaglandin E1 tends to suppress
inflammatory responses, promotes the action of insulin, improves
neurological function, regulates calcium metabolism, improves immune (T
cell) function and has important cardiovascular effects. These
cardiovascular effects include vasodilatation, reduction of blood pressure
and an addition of the release of arachidonic acid from cell membrane.
The importance of this study was that in the patients with type 5
hyperlipidemia cholesterol levels decreased by almost one half, and
triglyceride levels decreased by a factor of almost three quarters. The 50%
and 70% approximate reductions in cholesterol and triglyceride levels
respectively, were noted despite the higher content of fat and cholesterol in
the fish diet compared with the two other diets. It was of special interest in
this study that the group taking the vegetable oil diet which was considered
to be a “therapeutic” product had a significant and alarming rise in blood
triglyceride levels.
Dr. Dyerberg and Dr. Bang are two Danish scientists who joined with
Dr. Sinclair, a nutritional researcher from Britain to study Eskimos in their
native habitat. They collected blood samples from Eskimos in northern
areas of Greenland and submitted them to an analysis of clotting function
and lipid analysis. The findings of these analyses were very intriguing. The
bleeding time of Eskimos was found to be prolonged and clotting tendencies
were diminished. In addition, LDL levels in the blood were low
coincidental with the finding of the presence of EPA and DHA (omega 3
fatty acids) in the blood.
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On the one hand, fish oils at certain doses may exert more subtle
physiological effects, but at high doses they may exert astounding
therapeutic effects. Overall, the literature indicates that the lipid or
cholesterol lowering benefits of fish oil is related to the dose of fish oil taken
and it may be related also to the degree of hyperlipidemia experienced by the
individuals. This situation is somewhat similar to the beneficial effects
observed with soy protein on blood cholesterol levels where subjects with
very high blood cholesterol seemed to achieve the best cholesterol reducing
benefit.
Table 62: The mechanisms by which EPA exerts beneficial effects on the
cardiovascular system.
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Fish Oil Supplements
There are several options available to supplement the dietary intake of
omega 3 fatty acids from fish oil. First, is the eating of fatty (oily) fish of
cold water origin in sufficient quantities to give health giving amounts of
omega 3 fatty acids. This option is not practical for many individuals
because of factors, such as cost, lack of palatability of fish diets and general
inconvenience.
There are practical problems with the taking of many commercial fish
oil concentrates. First, many are not palatable and may not have
concentrations of EPA and DHA that are relatively low. This requires tht
large quantities of some oil products need to be taken.
Many cod liver oil preparations are not standardized and may have to
be taken in large volumes to guarantee the health benefits that can be
anticipated only from specific amounts of DHA and EPA. God liver oil in
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unpalatable, given the breath a feculent odor and, when taken in excess, it
invariably causes abdominal upset with cramp and diarrhea. These
disadvantages have been overcome to some degree by encapsulation of fish
oil but the most satisfactory mode of administration is in a delayed release
format.
Conclusion
The health benefits of fish oil inclusion in the Western diet is
unequivocal. This underscores the value of dietary supplements in
healthcare, since eating large amounts of food that contain the essential
health giving nutrients, in this EPA and DHA, is not practical or often
feasible.
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CHAPTER 9
BOTANICAL INFLUENCES ON
CARDIOVASCULAR DISEASES
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Botanicals Influences on Cardiovascular Diseases
Botanical extracts have been used for centuries for the prevention and
cure of disease. Despite the length of use of such agents, relatively few
scientific studies are available to support their use in the prevention or
treatment of disease. Medicinal herbs have had major applications in the
treatment of cardiovascular disease resulting in the assignment of nebulous
terms to describe their cardiovascular benefits. For example, digitalis,
derived from the foxglove, was once popularly described as a heart tonic or
cardiac stimulant. Of course, digitalis is the basis of one of the commonest
prescriptions for cardiac disease. In fact, the derivation of pharmaceuticals
from plants is the basis of pharmacognosy through which modern day
synthetic drug therapy was largely developed. More than one-quarter of all
current prescription drugs are derived from plants.
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This situation has become overcome to some degree in countries such
as Germany, where botanical formularies exist for standardized herbal cures.
However, many countries lag behind Germany’s lead in this area of the
regulation of botanical health products. The conventional medical literature
is full of reports of serious and sometimes fatal adverse effects of medicinal
herbs. This has led to a suspicion by the conventional medical practitioner
that many herbs are dangerous and possess only dubious benefit.
Active
Botanical Ingredient Effect
Active
Botanical Ingredient Effect
Table 63: A list of botanical products with their putative active ingredients
that have been used with variable success to combat cardiovascular
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problems and atheroma. The author stresses that not all of these botanicals
are fit for human consumption. Some may not be safe and the evidence to
support their use of often weak. Self-medication is not advised. Seek the
advice of a qualified medical practitioner before using any herbal remedy for
cardiovascular disease.
Garlic
Dr. Erich Block of the State University of New York has referred to
garlic as the “spice of life” (Koch and Lawson, 1996). Koch and Lawson
(1996) have reviewed extensively the basic science and clinical applications
of garlic (Allium sativum and related species of plants) in their excellent and
comprehensive book. So convincing is the scientific information to support
the health giving benefits of garlic that the author strongly recommends its
inclusion in the diet. Garlic and onions do not appeal to all palates and there
are a variety of ways of taking odorless dietary supplements containing the
health giving fractions of garlic, especially in relationship to cardiovascular
health.
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consideration of its potential therapeutic effects and applications (Tables 64
and 65).
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- Activates fibrinolysis - Decreases carcinogen induced
- Enhances blood flow cancer in many animal models
Table 64: Potential therapeutic applications of garlic and its fractions are
summarized. For a detailed review, the reader is referred to the book
“Garlic: The Science and Therapeutic Applications of Allium Sativum and
Related Species” by Koch and Lawson, 1996.
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- Smooth muscle relavant in chronic inflammatory
process
Table 65: Potential therapeutic applications of garlic and its fractions are
summarized in continuation from Table 64.
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amounts of garlic preparations that were used in the studies. The actual
mechanism whereby garlic exerts these beneficial effects on blood lipids
remains to be fully characterized. Most evidence seems to suggest that
allicin is the active constituent that exerts the cholesterol lowering effects.
Based on clinical studies, the optimal dose of allicin is the order of 0.05 - 0.1
mg/kg of body weight to achieve the lipid lowering effect. This represents
an amount of fresh garlic of 2-3 grams per day and the duration of therapy
required to achieve the effect is 4 to 8 weeks. Immediate or short-term
effects of garlic on blood lipids are not to be expected.
Procyanidolic Oligomers
Anyone, except the most committed organic chemist, may want to
skip this section because of the “off-putting” title. This would be a mistake
because these flavonoids that are ubiquitous in plants are among the most
exciting biochemical finds in modern nutritional practice. To narrow down
the focus of this discussion, procyanidolic oligomers can be considered to
include or be synonomous in some cases with pycnogenol, leukocyanidins
and complexes of polyphenols or flavonoids.
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these compounds may play a role in the regulation of blood glucose.
Ginkgo has been used largely for its psychoactive effects which are
alleged to cause an elevation of mood and a relief of depression. It appears
that ginkgo can enhance cerebral circulation (blood flow to the brain),
thereby increasing the nutrient and oxygen presentation to brain cells. In
addition, ginkgo has an overall beneficial effect on blood circulation and its
content of quercetin and other bioflavonoid compounds, such as flavone
glycosides, may add to its beneficial health effects. It is recommended that
ginkgo be taken in supplements that have a standardized flavoglycoside
content of approximately 20% or more.
In both animal and human studies, ginkgo has been shown to inhibit
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platelet aggregation by a direct effect on platelet-activating factor. The
effects of ginkgo are not immediate and in the experience of many
healthcare givers, it may take up to three or four months before any
beneficial effect is noted; especially if the desired effect is an enhancement
of blood circulation. Anecdotal clinical observations indicate that
improvement in blood circulation can occur up to as long as nine months or
one year following initiation of therapy with ginkgo. The optimal dose of
ginkgo is not known but is recommended to be approximately 40 or 50 mg
of an average supplement that contains a standardized extract of ginkgo
containing at least 20% of flavoglycosides.
The story of the health benefit of red wine and grapes involved the
observations that the death rate from cardiovascular disease in France,
particularly coronary artery disease, is much lower than it is in Britain or
North America. The reason for this lower death rate from coronary artery
disease may be due, in part, to the high consumption of red wine and grapes
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in France. Studies of the nutritional profile of French people versus British
and American citizens indicate that the intake of saturated fat in the diet is
quite similar. A famous study that was published in the Lancet in 1979
implied that the lower heath disease rate in France was most notable in
regions of the country where red wine was consumed preferentially. The
results of this study have caused some argument, since it is known that
moderate alcohol intake may tend normalize blood lipids and increase HDL
levels. Thus, some scientists have attributed the lower death rates from
cononary artery disease in the French to a higher rate of moderate alcohol
consumption.
Green tea has been increasingly popular because of its alleged ability
to inhibit platelet function and prevent thrombosis, together with a
cholesterol lowering effect. It is important to note that it is only green tea
that has the most beneficial effects on cardiovascular health. Most tea that is
consumed throughout the world is in the form of black tea. Black tea is
produced by taking the leaves of Camellia sinensis (tea bush) and removing
the leaves which are then dried, fermented and roasted. Green tea is
processed in a different manner than black tea. Green tea is produced by
taking fresh leaves from the tea plant and treating them with heat to prevent
fermentation. It is the lack of fermentation of green tea leaves that results in
the residual content of health giving polyphenol compounds. Green tea,
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when appropriately processed, contain significant quantities of vitamin C
and E, together with a reasonable range of minerals.
Selecting the right kind of green tea is quite an exercise. The teas
vary greatly in terms of their processing and source. The variability of the
origin and processing methods of green teas make them somewhat of an
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unreliable source of polyphenols in terms of consistent dosing. Furthermore,
if tea is not prepared correctly then the polyphenols can become damaged or
oxidized. If an individual desires to drink tea then the best varieties of green
tea include gyokuro, sencha and gumpowder teas. It is not advisable to
exceed more than 4 or 5 cups of green tea per day, especially if a variety of
green tea is chosen that contains a significant amount of caffeine.
Anti-inflammatory action
Anti-arthritic effects
Reduces oxidative stress
Potential longevity benefit?
Maintains normal capillary function
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Improves red cell membrane flexibility
Improves skin elasticity and smoothness
Anti-allergic actions e.g., hay fever
Reduces diabetic retinopathy
Enhances immune function
Beneficial in stomach ulcers
Reduces risk of phlebitis, varicose veins
May reduce tissue edema
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Whilst tremendous interest exists in the health applications of
procyanidoli oligomers, the evidence for their benefit in cardiovascular
disease is still somewhat scant. Interest in the cardio protective potential of
bioflavonoids was fueled by studies that suggest that their presence in red
wine was associated with a lower prevalence of heart disease in drinkers of
red wine (St. Leger et all, 1979; Gaziano et al., 1993). In addition, the
Zutphen Elderly Study (Hertog et al., 1993) drew attention to the inverse
330
correlation between the dietary intake of flavonoids and the incidence of
heart disease (the lower the flavonoid intake, the higher the incidence of
heart disease). This relationship between flavonoid intake and heart disease
was found to be present in the Zutphen Study even after correcting for other
lifestyle or dietary influences on the incidence of heart disease (Hertog et al.,
1993).
The idea that there are free radicals generated in the body as a
consequence of processes such as food assimilation and energy production,
or as a consequence of a variety of external influences, forms the basis of
free radical theory. To prevent free radical damage to cells, it is possible to
provide drugs or agents in the diet that are sometimes referred to as free
radical scavengers. Good examples of free radical scavengers are a class of
compounds which are referred to as antioxidants. The body has many
“built-in” defenses to deal with free radicals that are generated by metabolic
processes or other mechanisms.
Ginger
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Ginger in a non-toxic herb that is safe to take in large doses. Ginger is
known to have versatile health benefits, including wellness promoting
effects on the gastrointestinal tract and the cardiovascular system. One
important study that was published in the New England Journal of Medicine
in 1980, indicated that ginger may reduce blood cholesterol levels by
unknown mechanisms. In addition, extracts of ginger may reduce platelet
stickiness and have antithrombotic effects that are similar to garlic and
aspirin. Whilst there is some argument about the effect of ginger on blood
pressure, some studies have indicated that ginger may cause modest
reductions in elevated blood pressure.
Ginseng
Ginseng is one of the most popular herbal tonics that is used on a
worldwide basis for many health benefits. The potential health benefits that
have been ascribed to the use of ginseng are summarized in Table 68
Ginseng is commonly available in health food stores in three distinct types.
The first type is Panax ginseng, which is often termed Chinese or Korean
ginseng. This type can be distinguished from Panax quinquefolium, which
is known as American ginseng. The third type of ginseng is termed Siberian
ginseng, but this type of ginseng does not belong to the same genus of plants
(Panax) like Chinese or Korean and American ginseng. However, Siberian
ginseng, Chinese or Korean ginseng and American ginseng all belong to the
same family of plants which are termed Araliaceae.
The name ginseng means the essence (“sing”) of man (“gin”). It is the
root of the plant that is used as the source of herbal concoctions and the
shape of the root of the plant resembles the shape of the human body to
some degree. In ancient Chinese medical writings, it was the morphological
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resemblance of the ginseng root to the human body that led to the belief by
ancient Chinese scholars that the root of the ginseng plant represented “the
essence of the earth in the shape of the human”. This belief was extended to
ascribe several health benefits to ginseng, including powers of healing,
recuperation, rejuvenation and general revitalization.
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Guggul
Guggul has been extensively researched in India as a “heart
medicine”. Several studies have indicated that guggul is able to reduce
blood cholesterol and triglyceride levels by a factor of up to 30% when taken
over a period of approximately twelve weeks. Extracts of guggul have been
shown to both reduce LDL cholesterol and increase HDL cholesterol.
Guggul has not been popularized in Western medicine for cardiovascular
wellness to the same degree as other botanicals. However, some authorities
have argued that guggul may have as much therapeutic “treatment” potential
as garlic and other lipid lowering agents, such as soy protein containing
isoflavones. A number of laboratory experiments have indicated that
extracts of guggul may exert an antithrombotic effect by reducing platelet
stickiness. This potential dual effect of guggul compounds on lowering
blood lipids and reducing platelet aggregation makes this botanical a very
interesting natural approach to cardiovascular well-being.
Fo-ti
Fo-ti is a traditional Chinese medicine that is used for a variety of
medical purposes. It is most famous for the promotion of longevity and
wellness. Research performed in China has shown that fo-ti in relatively
large doses will reduce blood cholesterol levels and assist in the prevention
of the formation of atherosclerosis. The active components of fo-ti include
lecithin which has been associated in some studies with reduction in blood
cholesterol levels. Fo-ti seems to be safe when taken in relatively large
doses but the beneficial effects of this Chinese medicine on cardiovascular
health is not as clear as the benefit that can be ascribed to agents such as soy,
garlic or essential fatty acids.
Table 69: Nutrients and natural agents that have been described as capable
of lowering elevated blood pressure. Individuals with high blood pressure
are recommended to seek medical advice and attention. Do not self-
medicate to lower your own blood pressure.
sources of salt have a great deal to offer in protecting the body from pressor
(blood pressure elevating effects) of salt per se.
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The best way to break the salt habit may not be just to quit using salt
but to replace it in culinary activities with well selected, tasty herbs and
spices. A number of true “salt substitute” products are available that contain
no salt. However, one should be aware that a number of “salt substitutes”
contain salt (sodium chloride). The most creative combinations of spices
and herbs that can be used as salt substitutes include: onions, garlic, peppers,
citrus peal, carrots, oregano, celery seed, marjoram, thyme, cumin,
coriander, mustard and rosemary. The adventurous salt substituter has the
option of mixing their own spice concoction to assist in kicking the salt
habit.
A “Salty” Education
Ordinary table salt may have started from a natural salt source but the
processing methods strip it of its natural mineral companions. Normal salt is
usually prepared from a saline solution that is kiln dried at very high
temperatures. In this process, many trace minerals with health-giving
potential are lost. After drying, table sale has many chemical additives,
including: potassium iodide, silico aluminate, tri-calcium phosphate,
magnesium carbonate, sodium bicarbonate and yellow prussinate of soda.
With the exception of iodide addition, these other agents are added to
provide an ideal physical appearance to salt, prevent caking and ensure free
flow of the material through a salt shaker. It is interesting that additions
have nothing todo with health but more to do with aesthetics that make it
easier for a consumer to “get hooked” on the salt habit.
The individual who is able to stick with a low-salt diet that focuses
only on the exclusion of salt addition at the table does not stand to benefit to
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a major degree from salt exclusion in the diet.
Several fruits are notably high in potassium and relatively low in their
sodium content. An outstanding source of dietary potassium is the banana.
An average size banana contains approximately 500 mg of potassium but
only approximately 2 mg of sodium. There have been some scientific
studies that have looked at populations of individuals who eat bananas and
there is some evidence that, on average, their blood pressure tends to be
lower than populations that do not consume this fruit. Other good sources of
potassium, with relatively low sodium, include oranges, lemons, peaches,
melons, potatoes and lima beans.
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CHAPTER 10
348
Optimal Nutrition
Everyone talks about optimal nutrition, but few individuals can
comply with the ideal diet. This dilemma is amenable to some solution by
the use of well chosen dietary supplements. Whilst one could be criticized
for this approach of supplementing an existing diet rather than primary, but
radical, modification of the diet, it is obvious that even the most dedicated
homemaker would have difficulty in finding, preparing and affording an
“optimal” diet for a family. The start of the solution to obtaining a
nutritional program for cardiovascular health rests in a consideration of basic
dietary principles.
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The amount of a substance that is absorbed is termed “the
bioavailability” of the substance. Bioavailability is a very important issue in
nutrition. If something is not given in a bioavailable format, then it is
merely excreted in the stool. If the objective is merely to get something into
the system, such as a readily absorbed water soluble vitamin, e.g., vitamin C
or vitamin B, then there is no need whatsoever to use a delayed-release
preparation. Despite this, delayed-release vitamin C preparations have
emerged in the health supplement market with promises of greater health
benefit. This type of misleading advertising should not be encouraged and is
patent nonsense. It is not possible to give a comprehensive account of the
importance of pharmaceutical formulations except to say that if a product is
presented in a specific format, then adequate reason should be given for the
specific formulation. Formulations of natural remedies leaves the door open
for the unscrupulous manufacturer to engage the consumer in fads whilst
they “dish up” fallacious arguments.
This semi-fluid slurry of acid chyme enters the upper small intestine
where it is neutralized by a number of alkaline digestive juices that are
secreted by the pancreas (pancreatic juice), the liver (bile containing bile
salts) and intestinal juice (succus entericus). Pancreatic juice facilitates the
absorption of fats, carbohydrates and protein by virtue of its content of
enzymes called lipase, amylase and trypsin. In addition to secreting
digestive enzymes, the pancreas is important as the body’s source of insulin
which is secreted into the blood stream rather into the small intestine. Bile
does not contain digestive enzymes but it assists in the emulsification of fats
prior to their digestion. Intestinal juice is very complex and a lot of
digestive activity occurs at the surface of the cells that line the small
intestines. At this interface between the digestive lumen (hollow of the
small intestine) and the wall of the small intestine, proteins are broken down
to small elements and sugars are further digested into small units.
In the small intestine much of the nutrients are absorbed by the simple
process of diffusion. Carbohydrates tend to be absorbed as simple sugars
called monosaccarides and protein is absorbed as amino acids and small
peptides. The digestion of fats is an extremely complex process but fats are
broken down to their basic units of glycerol and fatty acids which are then
absorbed, preferentially through lymphatic channels called lacteals. In
contrast, sugars and proteins tend to preferentially be absorbed into the
blood stream. There are certain nutrients that are absorbed in quite complex
ways. For example, vitamin B12 requires the presence of a certain factor that
is secreted by the stomach and pancreas (called intrinsic factor) and it is
absorbed preferentially in the lower reaches of the small intestine.
Understanding Vitamins
Must information has accrued about the importance of vitamin intake
for health. Overall, vitamins function in body metabolism and they facilitate
many chemical reactions in the body. Vitamins are generally classified into
two groups which include the fat soluble vitamins A, D, E and K and the
water soluble vitamins which compose the vitamin B complex and vitamin
C.
Table 70: Some facts on levels of fitness, lifestyle and general health issues
among children in the United States based upon data presented by Dr.
Charles Kuntzleman in his book entitled “Healthy Kids for Life” (1988).
The support for these statements comes from the National Health and
Nutrition Examination Survey (HANES). The HANES has that implied that
there is a direct relationship between the weight of a child and the amount of
time that a child may spend watching television. It has been estimated that
data from the HANES implies that the occurrence of childhood obesity
increases by approximately by 2% for each additional one hour that a child
watches television. The factors that determine this association are made
obvious in the cartoon on the front cover of the book. These factors appear
to operate in adults to the same degree that they operate in children. Sitting
on a couch and sharing cigarette smoke, eating simple sugars and excessive
361
salt and fat are obvious example of behavior that this to be avoided. The sad
situation is that children tend to take their lead from adults. This is well
portrayed in the cartoon that signifies the occurrence of the Cholesterol Time
Bomb.
Page 1 of 2
Myth Comment
Controlling cholesterol Emphasis is placed upon cholesterol screen-
can wait. ing in childhood and intervention with diets
to correct blood cholesterol levels of over 150 mg%.
Children’s diet are The food industry has presented more high-
getting better. fat food based upon consumer demand.
Milk is need for Dairy products are rich in saturated fats and
calcium and protein. cholesterol. Vegetable based diets contain
adequate calcium and protein and milk is not
necessarily the best source of calcium. In
363
Southeast Asia, soy milk has overtaken
dairy
milk and it is “ideal”.
Page 2 of 2
Myth Comment
Low fat diets lack Calories from fat that are replaced by vege-
vitamins and minerals. tables, fruits, grains and legumes can
provide
adequate sources of vitamins and minerals.
A low fat diet means Dr. Attwood indicates that children’s diets
limited choices. that exclude meat and dairy foods have a
greater variety of foods.
Low fat diets retard There may some flaws in studies that have
growth. reported growth retardation in children on
low fat diets. Excluding the need for
essential fatty acids in early life, there is
little evidence to suggest that elimination of
saturated fat and cholesterol poses any
negative health effects, unless this elimina-
tion is not replaced by an adequate range of
healthy food.
No one knows what is Children eat too much fat and not enough
really best for my child. complex carbohydrates. Modern diets are
low in fiber. Unequivocal evidence now
exists that low fat diets in childhood may be
preventative against coronary artery disease
in later life.
Table 71: Twelve myths that have been proposed by Dr. Charles R.
364
Attwood in his book entitled “Dr. Attwood’s Low-Fat Prescription for
Kids”. The comments are taken in part from the author’s interpretation of
Dr. Attwood’s writings.
Recent evidence exists that the elderly are in fact the group for which
natural options may be the most ideal treatment approach. Elderly people
with mild hypertension should always be considered a prime target by a
healthcare giver for natural options or lifestyle intervention rather than drug
therapy. The reasons for this are obvious. Elderly people may not tolerate
the side effects of anti-hypertensive medication and the benefits of “strict”
blood pressure control in the elderly are not as well defined as they are in
younger people, even though they are reasonably well defined.
Elderly people may be less attentive to their diet and may engage in
frequent variations in salt or alcohol intake in their diet. Substance abuse in
the elderly is much more common than has hitherto been supposed by many
healthcare givers. Self reliance (or plain stubborn behavior) may increase
with age and elderly people may be very resistant to discussion about their
lifestyle habits. Advanced age may bring to some individuals a tendency for
relaxed behavior and errors of judgment. Measures that improve
compliance with medication in the elderly are particularly important issue
and it is recognized that errors in the taking of medication are quite common
in the elderly. Periodically, every healthcare giver should ask an elderly
patient who is taking medications to empty their cupboard and bring the
contents to the office for examination. It is quite surprising what elderly
people may take in terms of over-the-counter remedies. It is even more
surprising these days that people will mix dietary supplements and
prescription medications without any concern or consideration for their
potential interactions. These problems are not confined to the elderly even
though they may be more common in individuals of advanced years.
Finally, and very important, the human body has a decreasing capacity
to handle both synthetic and natural medications with age and, therefore,
adjustments of dosages of some medications or dietary supplements are
frequently required in the elderly. Diminished kidney function occurs with
age and this means that compounds cannot be excreted or metabolized by
the body in a normal manner. Specific concerns for health maintenance in
369
the elderly are of increasing significance as the elderly population increases.
Vitamin A 5
Vitamin B6 13
Vitamin B12 63
Niacin 55
Riboflavin 33
Thiamin 52
Calcium 23
Phosphorus 44
Iron 23
Table 72: A large hamburger (7.5 ounces) from the most popular fast food
restaurants worldwide may contain a reasonable array of vitamins and
minerals which are expressed in percentages of recommended daily
allowances (RDA) for an adult woman. Source: Consumer Report article
cited by Zimmerman DR, in Zimmerman's Complete Guide to
Nonprescription Drugs. Visibible Inc. Press, Detroit, MI, 1993. Such data
vary by time. The problem with much fast food is its content of saturated
fats, trans-fatty acids, cholesterol and salt.
373
Dietary Supplements Present Options
One solution to the problem of established hypercholesterolemia in
children is the use of dietary supplements with lipid lowering properties. Dr.
C. Sirtori has emphasized the potential role of soy protein supplementation
of the diet as an effective means of lowering blood lipids in children. If fact,
Dr. Sirtori has gone as far as indicating soy protein inclusion in the diet may
be a first line option for lowering blood lipids in childhood. The good news
is that many soy beverages have a taste and consistency that is not too
dissimilar from ‘unhealthy’, ice cream-loaded, dairy milk shakes. This is an
excellent option to consider. There are dietary supplements containing soy
protein isolates that are currently available in beverage formats. Some
individuals have proposed soy milk as exerting potentially beneficial effects
on blood lipids but less evidence exists to support this intervention in
comparison to supplementation of the diet with soy protein isolates.
374
“Optimal” blood cholesterol levels in children are debatable but they
should be generally lower than those in adult. A good range for blood
cholesterol in childhood is 140 - 150 mg%, which is equivalent to an adult
range below 200 mg%. Kids with high blood cholesterol will often grow up
to become adults with high blood cholesterol. Intervention in early life
should improve cardiovascular health and it could reduce the prevalence and
incidence of coronary heart disease.
Plant estrogens are “weak” estrogens that can block the more
powerful effects of endogenous estrogen. This “blocking effect” explains, in
part, why phytoestrogens may be a “better option” than potent synthetic or
animal derived estrogens that are used in conventional HRT. Soya
isoflavones have very versatile health giving benefits. The principle soya
isoflavones include the compounds genistein, daidzein and glycitein. These
isoflavones have become available in predictable amounts in certain dietary
supplements. Much research has occurred with these isoflavones to
characterize their biopharmaceutical effects. The benefit of phytoestrogens
may relate both to their much weaker effects than human, animal or
synthetic estrogens and their different target organs of action in the human
body.
379
The isoflavones genistein, daidzein and glycitein exist in soybeans as
a variety of chemical forms called glycosidic conjugates. Their chemical
nature will vary depending on the method of food processing or the degree
of fermentation of the soy product. It is not often appreciated that major
compositional changes in isoflavones occur with soybean processing.
Information that has been abstracted from studies of the isoflavone content
of commercial soybean foods indicate that a variable content of isoflavones
exist in different varieties of soybean. Soy flour has an isoflavone content
similar to crude soybeans. Soy granules and textured protein are heat treated
and they contain more b -glucosides which are 6"-0-acetyl derivatives of
genistin and daidzin. Heat treatment results in the decarboxylation of the 6"-
0-malonyl glucosides, because they are heat sensitive. The chemistry of
isoflavones is complex but worth noting because the right soy food or
dietary supplement has to be chosen to contain the right isoflavones to exert
the desired health benefit.
Soy milk and other “oriental” beverages derived from soybeans are
efficient sources of isoflavones but they tend to have a relatively reduced
380
concentration of the malonyl derivatives of the principal isoflavone types.
In Western soy foods, tofu has emerged as a favorite, but tofu is generally
low in isoflavones compared with other soy foods because it is subjected to
aqueous processing. Tempeh is produced by enzymatic hydrolysis of
soybeans with a result that aglycone forms of isoflavones predominate. The
overall isoflavone content of tempeh and other fermented soy (e.g. miso or
natto) may often be lower than that of tofu. Overall, tofu and fermented soy
foods cannot be considered a practical means of incorporating enough
isoflavones into a Western diet because of their lower relative isoflavone
content, compared with soy milk, soy flour and non-alcohol extracted soy
protein isolates. The average Westerner may “gag” on the end of the spoon
that delivers enough tofu to provide enough health giving isoflavones. It has
been estimated that more than one-half a pound of common tofu needs to be
eaten to provide enough health giving isoflavones. Thus, great variation
exists in the types and amounts of soy isoflavones that can be presented as
foods or dietary supplements.
Other factors operate in the optimum choice of a soy food that can be
used as an efficient source of isoflavones for a Westerner. Crude soy
products are flatogenic (produce intestinal gas) and they are often
unpalatable. As noted, the volume of tofu or miso required to deliver
enough isoflavones for a putative health benefit (>50 mg/day of isoflavones)
is large and miso, tempeh and tofu share a general lack of palatability in
Western society. Tempeh and miso may often contain additives by the time
they reach Western stores and although miso can be a delicious culinary
additive, it is often loaded with salt. Overall, soy protein isolates produced
by methods that do not involve aqueous alcoholic extraction processes,
381
emerge as the most cost-effective, efficient and practical source of soy
isoflavones for a Westerner. These isolates are versatile bulk food for the
manufacturers of shelf stable soy meals, soy beverages and soy desserts.
Many studies that have been performed in several in vitro and in vivo
models demonstrate that isoflavones are capable of binding to estrogen
384
receptors and they often exhibit varying degrees of “weak” estrogenic
activity. In addition, some animal studies demonstrate an anti-estrogenic
effect of isoflavones. Furthermore, it is documented that isoflavones can
counteract the effects of relatively high doses of synthetic estrogens by
“competitive” receptor binding or other mechanisms.
A Miracle of Menopause?
Earl Mindell in his popular, consumer book titled, Earl Mindell’s Soy
Miracle (a Fireside Book by Simon and Schuster, New York, 1995) points to
the value of soya in suppressing menopausal symptoms. Earl Mindell
clearly reports the results of studies by Canadian researchers of Japanese
women where menopausal complaints such as “hot flushes or flashes” are
much less in Japanese than in Western women. The use of a dietary
supplement which contains enough isoflavones to achieve daily intakes of
isoflavones similar to those taken by Japanese women in their diet may be
beneficial in suppressing moderately severe symptoms of the menopause.
Oriental females tend not to have troublesome menopausal symptoms. This
lack of menopausal symptoms in Orientals is most likely a function of soya
isoflavones. Dietary supplementation with phytoestrogens may offer a
possible alternative to the commencement of synthetic, or animal derived,
hormone replacement therapy, with all its known drawbacks.
Studies in the United Kingdom by Dr. Sue Harding and her colleagues
(SISRS, 1996) corroborate the findings of the benefit of soy isoflavones in
the treatment of menopausal symptoms that have been observed in both
Australia by Dr. Eden and his colleagues and the USA by Dr. Woods and his
colleagues. This UK study is notable in that it included females with severe
vasomotor symptoms and it was performed in a rigorous double-blind
crossover format with a placebo control. Results in 20 of the 27 menopausal
females in the study were reported at the Second International Symposium
on the Role of Soy in Preventing and Treating Chronic Disease (Sept. 15-18,
1996, Brussels, Belgium, SISRS, 1996).
The fact that 85% of post-menopausal females in the USA do not use
HRT, makes a dietary consideration for menopausal relief, such as soy, a
390
major public health potential, according to Dr. Burke. This situation,
together with the knowledge that dietary intake of soy protein containing
isoflavones may account for the reduced risk of several chronic diseases,
dictates the need for further studies to clarify the role of phytoestrogens as a
natural alternative to synthetic HRT.
392
Doses of Isoflavones for Health Benefits?
The circumstances surrounding our understanding of the health
benefits of isoflavones are clouded, to some degree, by the lack of definition
of the optimal dose of isoflavones that could be used as natural HRT. The
most reasonable approach would be to choose a recommended level of daily
isoflavone intake that does not exceed the amount of isoflavones that are
consumed in existing diets that contain plentiful amounts of soy. In the
author’s opinion, this dose lies somewhere between 50 and 100 mg of
isoflavones per day for the adult, and at this dose range toxicity is unlikely.
Dr. Susan Potter and her colleagues (1996) have performed many
studies on the effects of soy protein and the mechanism of such effects in
lowering blood cholesterol. In a recent study of 66 hypercholesterolemic
post-menopausal females who received soy protein containing variable
amounts of isoflavones, it was noted that soy protein with isoflavone exerted
positive influences on blood lipids, thereby decreasing the risk of
cardiovascular disease in the post-menopausal state. This conclusion is
supported by the finding of several anti-atherogenic factors in soybeans,
including antioxidant properties to protect against low density lipoprotein
oxidation and the inhibition of platelet aggregation with an anti-thrombotic
effect. The anti-thrombotic effects of isoflavones contrast with the
thrombotic potential of conventional HRT.
398
Carnitine is available in capsules or tablets as a dietary supplement
and it is most often present in meat products in the diet. There is some
argument as to which chemical type of carnitine is most effective and many
experts believe that it is the L-carnitine that has to be taken preferentially
because D-carnitine may not be quite as effective. Dietary supplements
containing carnitine have this agent present in the L form. An average
recommended daily dose of carnitine is approximately 400 mg per day.
Chromium
Much interest has focused on the ability of the trace element
chromium to regulate blood glucose by facilitating the function of insulin.
There is no question that chromium has an important role to play in the
metabolism of fats and glucose, but exaggerated claims about chromium
supplementation as a weight loss measure are somewhat questionable.
Excessive dosing with chromium for weight loss may not be safe.
400
There are certain physiological events that effect the cardiovascular
system with aging. Such events include a reduction in the efficiency of heart
muscle function which results in a reduced cardiac output. This reduction in
cardiac output becomes a very significant issue for an elderly person when
they are in a situation of stress. Overall, it can be summarized in
understanding that the elderly heart has less ability to respond to the
demands of work because its performance is less efficient. The mature heart
requires greater energy expenditure than the heart of a young person.
404
Vitamin and Minerals
(Vitamin Supplements
Convenient)
will not exclude meat or dairy foods and some good arguments exist for their
limited inclusion in a healthy balanced diet. The move towards a vegetarian
type of diet is perhaps becoming increasingly acceptable in the West and it
confers several advantages for health promotion.
Not only should an individual examine the foods that are eaten to
405
promote health, there is much importance in “better” dietary habits. These
“habits” are important to consider because they involve behavior
modification. Behavior modification in eating styles is a very necessary
component of revising dietary intakes. However, there are “several traps”
among the opinions about what many people may consider their normal
eating habits.
There are some little tricks for better eating. Chewing food
thoroughly may help suppress appetite and it improves the digestive process.
Making more of a “ritual” of a meal is useful, with the setting of time aside
and even the use of a stopwatch to lengthen eating time. The individual who
eats to a sensation of fullness has usually overeaten. Some experts advise a
departure from the dinner table with some residual hunger, but this is a
difficult feat for many. It you starve yourself, have binges, vomit of your
own volition, or have strange emotions about food, you may have an eating
disorder. For this situation, an experienced professional’s advice is
406
required!
408
CHAPTER 11
WEIGHT CONTROL
409
Cautions for the Dieter
Being too fat (or too thin) is dangerous to an individual’s health. The
obese individual places more mechanical stress on their heart and body than
the person of normal body weight. The author has never met a grossly-
obese, adult patient that did not have arthritis or pain in weight bearing
joints. Stress on the heart is not immediately apparent. If any individual is
very fat, has obesity dating back to childhood, or has adverse medical
consequences of obesity they should seek supervision advice from the more
informed healthcare giver. Few physicians or givers of natural health care
have great experience or knowledge of the treatment of severe states of
obesity, so the healthcare seeker is advised to choose their physician wisely.
Bear in mind that treating obesity is a multi-billion dollar industry that is
laden with quacks and quick-fix methods of weight loss.
It has been suggested that eating disorders are more prevalent among
females, especially in the 15 to 30 year age group. Estimations of the
prevalence of eating disorders in this age group may shock the uninformed.
With variable expression of severity, up to one-third of all females aged 15-
410
30 years may have an atypical eating disorder, up to 1 in 20 may have
bulimia nervosa, 1 in 100 may have anorexia nervosa, whereas, about 1 in
20 are obese. Exact information on the prevalence or incidence of eating
disorders is very difficult to estimate because the afflicted do not readily
disclose their problem and will not respond to common survey methods.
The major characteristics of common eating disorders are summarized in
Table 33. Many purveyors of dietary advice forget the importance of
spotting the “inappropriate dieter”. Catastrophes can ensue from assisting
the bulimic or anorexic to lose weight! Current fad diets do not consider
these important public health issues. Eating disorders (Table 75) can be a
more immediate threat to life than cardiovascular disabilities.
411
- May have many but not all of the diagnostic
criteria of anorexia or bulimia nervosa
- May be recovering from or transitioning toward
anorexia and bulimia
Table 75: The Characteristics of the Main Four Types of Eating Disorders
are summarized. Recognition of features in an individual should prompt the
seeking of medical advice. Eating disorders are potentially life threatening.
412
longevity.
Diets alone defuse only limited aspects of the Cholesterol Time Bomb
and are not the complete answer to cardiovascular or more general health.
Diets are usually planned for a reason, be it weight loss, cholesterol
lowering, altering nutritional status or variable combinations of these
objectives. The author believes that seeking a diet that achieves all three is
ideal.
The “balanced diet” is the optimal choice since this selection helps
control hunger, is not monotonous and it improves overall health.
Understanding why the diet in question or consideration was developed
assists in matching dietary interventions for changing needs. For example,
weight reducing diets should be time dependent and a maintenance diet that
is more relaxed can be introduced subsequently to control weight or prevent
weight gain. Some diets can improve overall health or correct existing
disease.
Diet/Characteristics Comments
415
Dr. Stillman’s Quick Inches - Few merits
Off Diet - Modification of 1950’s Rice Diet
(low protein, high - Accelerated early weight loss is water loss
carbohydrates) - YoYo regain of weight can occur
- Nutritionally deficient
(Continued)
Diet/Description Criticisms: Valid or Otherwise?
416
traditional American diet to a - Good accompanying manual
more ‘vegetarian’ diet that is - Recognizes omega 3 benefits, under-
high in complex carbohydrates estimates omega 6 benefits
and low in saturated fats) - Forgot to emphasize soy
The Beverly Hills Diet or - The notion that fruit melts fat is not valid
The Fit for Life Diet - Causes diarrhea
(Emphasizes fruit intake) - May gain weight
The Dean Ornish Program - Very sound program that has been
(A complete lifestyle program subjected to objective research
with low cholesterol objective - Compliance problems
for cardiovascular wellness)
(Continued)
Diet/Description Criticisms: Valid or Otherwise?
417
- Stimulates overeating
Table 77: This table contains subjective comments based on a study of the
diets by the author and consultations with medical practitioners and patients
who have experiences. Some of the commonly used diet programs are listed
with putative or actual concerns about their application. With exception of
the well accepted Ornish Program, the other dietary methodologies have
been somewhat lacking in careful clinical study. Assessments of their safety
and efficacy have been anecdotal. This situation may make criticisms of the
diet plans appear anecodotal, so the author has focused on generally
accepted medical interpretations of the basis, if any, for the dietary
interventions.
418
CHAPTER 12
OBESITY
419
Overview of Obesity
It is generally correct to state that: “individuals who eat too much will
tend to be overweight and those who do not eat enough will tend to be
underweight”. These general principles are forgotten by at least 25 percent
of the United States population who are overweight and small percentage
who are underweight by conventional definitions. Weight control and
obesity management are among the largest industries in North America, and
it is estimated that about one-quarter of the population expend about $30
billion on weight control aids in one year. Approximately 15 percent of the
population are on some form of diet continuously, and three -quarters of all
midteen girls try to lose weight. The causes of obesity are often complex but
usually involve overeating combined with some type of emotional factors in
individuals who are prone to obesity. Several identified causes of obesity
are shown in Table 78. Being fat will break your heart at some stage.
Social gluttons
Familial predisposition
Genetic obesity
Diet composition
Eating patterns
Lack of activity
Emotional factors
420
Medical Causes
Drugs
Surgery
Brain disease
Endocrine causes
Abnormal metabolism
Height
(Without Shoes) Weight in Pounds (Without Clothing)
422
Men
5 1 105-113 111-122 119-134
5 2 108-116 114-126 112-137
5 3 111-119 117-229 125-141
5 4 114-122 120-132 128-145
5 5 117-126 123-136 131-149
5 6 121-130 127-140 135-154
5 7 125-134 131-145 140-159
5 8 129-138 135-149 144-163
5 9 133-143 139-153 148-167
5 10 137-147 143-158 152-172
5 11 141-151 147-163 157-177
6 0 145-155 151-173 166-187
6 1 149-160 155-173 166-187
6 2 153-164 160-178 171-192
6 3 157-168 165-183 175-197
Women
4 9 90-97 94-106 102-118
4 10 92-100 97-109 105-121
4 11 95-103 100-112 108-124
5 0 96-106 103-115 111-127
5 1 101-109 106-118 114-130
5 2 104-112 109-122 117-134
5 3 107-115 112-126 121-138
5 4 110-119 116-131 125-142
5 5 114-123 120-135 129-146
5 6 118-127 124-139 133-150
5 7 122-131 128-143 137-154
5 8 126-136 132-147 141-159
5 9 130-140 136-151 145-164
5 10 133-144 140-155 149-169
There are so many methods for assessing the amount and distribution
of body fat that even nutritionists become confused. The most reliable
423
simple techniques involve measurement of relative weight or recordings of
skinfold thickness. A person’s weight can be expressed as a percentage or
ratio of desirable, ideal, or acceptable weight using tables from the
Metropolitan Life Insurance Company’s Build and Blood Pressure Study
performed for the Society of Actuaries (Chicago, 1959). This information
was updated in 1983 for inclusion in the Metropolitan Height and Weight
Tables. More recent guidelines have appeared that define ideal weight, but
in the author’s opinion, these re-definitions are of little overall significance
in assessing obesity.
Percent of Sample
Country Overweight Obese
Italy 33 28
United States 32 63
Yugoslavia 19 29
Finland 15 14
Netherlands 13 32
Greece 11 11
Japan 2 2
426
The risks and complications of obesity are shown in Table 81. Being
overweight carries a risk of premature death, but obese individuals often
have other risk factors for early death, including hyperlipoproteinemia,
hypertension, coronary artery disease, renal failure, and other serious
disorders. One cannot underestimate the social toll of obesity, and this is a
key to understanding the defeat felt by many obese people. American and
other Western societies exude constant messages about ideal body types,
which, with other social issues, can lead to exceptional and often extreme
discrimination against the obese person. Such discrimination is
inappropriate and totally unacceptable.
“Tailor-Made” Diets
Glucose intolerance *
427
Diabetes mellitus *
Hypertension *
Hypercholesterolemia *
Cardiac disease: atherosclerotic disease, congestive heart failure
Pulmonary disease: sleep apnea, chronic lung disease
Cerebrovascular disease, stroke *
Cancer: breast, uterus, colon, prostate *
Gallbladder: stones *
Pregnancy risks
Surgery risks
Renal failure
Gout
Infertility
Degenerative arthritis *
Early death
Psychological problems: poor self-image
Social problems: discrimination in jobs, education, and marriage
lack of regard for the promotion of healthy weight loss may sometimes be
more of a risk than the obesity itself. Soya, particularly soya protein, can
assist in counteracting some of the complications of obesity. In essence,
soya will assist in reversing risks of glucose intolerance, arthritis,
hypercholesterolemia, hypertension, renal disease, gallstones, cardiac
disease, and obesity-associated cancer, all of which are susceptible to the
beneficial effects of soya. These aspects of the health benefit of soya have
been discussed in detail in earlier chapters.
428
Critical Elements of Diets
The critical elements in the management of obesity are diet with
reduced calorie and fat intake, nutrition education, and often, behavioral
modification techniques. It is recognized that fat in the diet of Western
society is a pivotal element in promoting obesity. Many nutritional surveys
have shown that Western populations have changed their diets over the past
century to increase calorie intake from fat while decreasing the dietary
intake of calories derived from complex carbohydrates. It is significant that
if calorie intake is kept the same, a diet rich in fat will produce enhanced
gain of body fat. This finding is well documented in animal experiments.
430
Balanced low-calorie diet* Hunger, preoccupation with food and
frequent failure.
Table 82: Commonly used types of diet for weight loss or obesity
management. (*) Balanced low-calorie diets with fiber and soya addition
presented creatively with other lifestyle adjustments are the best option.
centers of research excellence. For practical purposes, the simplest and least
misleading definition of obesity is to measure an individual’s Body Mass
Index (BMI).
431
The BMI is easily calculated by dividing weight by the height of an
individual squared. An 80 kg person who is 2 meters (m) tall has a BMI of
80 ÷ 2m x 2m, which equals 20. The normal range of weight in terms of a
BMI is 19 to 24.9. The simple calculation used above was chosen because
an average weight is about 70 kg for a male and a weight of 80 kg may
conjour up the idea that the person was chubby. However, the importance of
height in the equation is revealed because 2 meters is taller than average –
this is an example of height allaying fatness. The mathematical projections
work in the opposite direction. An 80 kg person who is 1 meter tall has a
BMI of 80 ÷ 1m x 1m, which equals 80. A BMI of 80 generally constitutes
malignant obesity with impending death.
432
What Causes Obesity?
Predictably, the answer to this question is very far from simple.
However, the consumer of weight loss plans, books or products needs some
insight into the pathophysiology of obesity in order to make an informed
30 - 39.9 2 Obese
25 - 29.9 1 Overweight
Table 83: Four grades of being fat can be readily determined from Body
Mass Index measures, calculated as weight divided by height squared. The
formula for BMI can be used to define underweight. Some muscular
individuals will be misclassified into grade 1 even though they may have no
excessive body fat.
433
choice of weight loss program or diet. Understanding why one may be fat is
a major step in the battle to getting thinner.
Obesity occurs when the net amount of energy intake is greater than
the net utilization of energy over a period of time. The overall occurrence of
obesity is age dependent and the peak prevalence of obesity occurs in
Western countries usually between the age of 55 and 65, when about one-
quarter of all women and one-fifth of all men are obese. The risk factors for
obesity in females and males of these age groups have been defined to some
degree. A female is more likely to be fat during her mature years if she has
had more than three pregnancies, is not married and is of lower
socioeconomic status. Both genetic and environmental factors play a
variable role in the causation of obesity. Genetic or familial differences in
how people handle energy intake and the utilization of energy by the body
may be important considerations.
434
of weight gain can be approached in an effective manner but require
sustained dietary intervention with special care to provide nutritional
principles that help prevent chronic degenerative diseases in the mature
adult.
For the menopause, soy protein containing isoflavones has been seen
as a key dietary adjunct. Isoflavones may suppress menopausal symptoms.
Soy foods are often low in calories and soy protein lowers cholesterol,
promotes cardiovascular wellness, prevents osteoporosis and it may prevent
age-related cancer incidence for cancers of the breast and prostate in males.
435
CHAPTER 13
MAKING RECOMMENDATIONS
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Pulling It All Together
Unlike many books on natural health, this book has not been a series
of pretty pictures, promises of exotic cures or recommendations for a “way-
out” lifestyle. It is apparent that there are many natural ways to
cardiovascular health and even more apparent, that many of these ways to
health are based in simple common sense. During my extensive travels in
Southeast Asia, I spent a great deal of time trying to understand the factors
that would promote longevity. The Chinese revere the statue of “the
longevity man” with his characteristic charismatic smile. Having spent
some time with monks in several Buddhists temples, I began to learn that
their secret of a long, healthy and happy life was not a great secret, it was
more a function of lifestyle. Try as one may, it is not possible to live the
cloistered existence of a Buddhist monk, but it is possible to learn from their
experience.
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The bouquet of barbed wire contains many damaging factors for
cardiovascular health and these factors are not amenable to a single
intervention. The natural substance purveyors and practitioners of natural
health who promise a beneficial outcome from a simple herbal intervention
are more guilty than the physician who prematurely prescribes a synthetic
medication. For example, five cloves of garlic per day with two packs of
cigarettes will not result in cardiovascular health. Table 84 summarizes
what the author has termed the “CardioPlan” which is a holistic approach to
cardiovascular health.
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Dietary Maneuver Health Outcome
Prevents Heart Treats Heart
Disease Disease
Table 85: Dietary Changes That Both Prevent and Treat Heart Disease
Directly and Indirectly. NOTE: (x) = Signifies lowers cholesterol; (z) =
Signifies beneficial cardiovascular effects independent of lowering
cholesterol; and (y) = signifies direct or indirect effect on lowering blood
pressure.
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approach is to have an individual with dietary intent understand the value of
food or dietary supplements and make their own informed choices. This is
one major area that a healthcare giver, such as a dietitian, can be of major
assistance. It would be wrong to expect a physician to give specific meal
planning information. First, he or she will often consider themselves too
busy. Second, he or she does not often know enough about the nutritional
value of foods. Culinary arts do not form a part of the undergraduate
medical curriculum. Incidentally, nor does training in nutrition. Finally, the
“would-be” dieter may be a little suspicious of the physician who wrote a
diet plan with an appended cookbook, since few such authors can even boil
an egg.
The right diet has the right objectives for the client.
It should provide balanced nutrition, if possible.
The benefits should be obvious to the dieter.
For weight loss, the diet must supply less energy than the person’s energy
requirements.
When calorie intake is below 1,800 calories per day, mineral and vitamin
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supplements are required.
The diet must have a high degree of acceptability. Monotony spells failure.
It should be part of a lifestyle adjustment regimen.
Its success is equally dependent on food exclusion and healthy food
substitution.
Table 87. The plan that the author proposes is for weight reduction and
cardiovascular health combined. The key to the plan is that it is not merely a
diet but an adjustment of the calorie intake of the diet that will make the
dietary plan effective at weight loss (Table 88).
The author believes very strongly that serious dieting requires the help
of a qualified healthcare giver. Concepts on the role of various nutrients or
supplements in health promotion change overtime. One of the main features
of the dietary recommendations by the author is that soy protein and
essential fatty acids are the most underestimated nutritional interventions for
cardiovascular health. It is hoped that the reader will try and challenge the
uninitiated healthcare giver with this knowledge. The author believes that
this adjunctive dietary intervention of adequate essential fatty acids and soy
will make a real difference to cardiovascular health in Western Society.
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Special Diets for Special People
There are several highly effective short-term diets for weight loss that
have been used quite successfully in conventional medical practice. It
should
A special health role exists for soy, essential fatty acids and fiber.
Low saturated fat, normal protein intake of vegetable preference, low simple
sugars, high complex carbohydrate, low salt and cholesterol conscious.
Varying foods preferred.
Calorie intake reduction is the key to weight loss. Calorie intakes of less
than 2000 calories per day require supervision of a healthcare
professional.
Train yourself to eat properly, e.g. only when hungry, chew well, make a
meal on occasion.
Decrease intake of: animal foods, fried foods, and especially beef, cheese,
butter and margarine. Watch for more ‘unhealthy’ fruits, e.g. avocado,
coconut and nuts high in saturated fat. Avoid alcohol, food colorants,
additives or sugar.
Increase intake of: vegetables, fish, grains and low fat, non-salted, fresh
nuts. The author believes that NutraSweet is safe.
Supplement Western Diets with fiber (>25 gm/day), soy protein containing
isoflavones (>25 gm/day), omega 3 and omega 6 oils in varying ways
described in this book.
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Table 87: Specific “Dietary Recommendations” by the Author
How fat and How much at risk may I be? (Ask a healthcare giver)
Do I know enough about food facts and fallacies? (Ask a healthcare giver)
Are essential fatty acids and soy healthful? (Ask a healthcare giver who
took the time to find out the answer)
Table 88: Key Steps in the Diet Plan Proposed by the Author
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be stressed that these diets require careful, obligatory close medical
supervision. A widely applied diet for the treatment of more severe forms of
obesity is the very low calorie diet (VLCD). This diet is used by some
physicians as an option for rapid weight loss in the short-term, often to avoid
surgery. It finds a special use in very obese people who have failed standard
dieting regimens.
Other diets that are used for rapid weight loss in the more obese
person include the Milk Diet which is popular in the UK and the Egg White
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Diet, or other single food low caloric approaches that have gained some
popularity in the United States. They are, at best, short-term crutches and
they may be counter-productive by stimulating weight upon their cessation
(the YoYo effect). The YoYo effect of weight regain is regarded by many
as very unhealthy and it has been associated with a risk of cardiovascular
disease.
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The recommendation of these natural agents is generally safe even in
the presence of co-existing cardiac medication. However, an individual is
advised to seek the advice of a healthcare giver when multiple medications
are taken. Several dangers exist with natural therapies. For example,
essential fatty acids of the omega-3 series may enhance the effect of
anticoagulants and these circumstances require some monitoring. In
addition, several botanical agents may act synergistically or counteract
synthetic drugs.
Soy Protein (at least 25 grams per day) contain isoflavones (at least 50 to
80 milligrams per day) is recommended to lower cholesterol and exert
important antioxidant effects that can prevent atherosclerosis.
Garlic which has versatile cardiovascular effects can be taken in doses of
600 milligrams to 1 gram of pure or concentrated garlic or garlic
extract powder, or 1.8 to 3 grams of fresh garlic equivalent, or 1,800
to
3,600 mcg of allicin per day. A cardiac-specific vitamin supplement
is
recommended which contains adequate amounts of vitamin C, E and
B
complex, together with chromium, magnesium and the addition of Co-
enzyme Q10.
Essential fatty acids, especially omega-3 fatty acids from fish oil in a
delayed-release format.
A polyphenol containing supplement with active bioflavonoids to deliver
approximately 50 to 100 milligrams of mixed bioflavonoids daily.
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Table 89: Natural substances that are recommended to be included in the
CardioPlan. NOTE: This CardioPlan is not recommended to substitute for a
healthy balanced diet and individuals with significant cardiovascular disease
are advised to seek the attention of an experienced healthcare giver.
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APPENDIX A
THE DIETARY SUPPLEMENT HEALTH
AND EDUCATION ACT OF 1994
The past several decades have seen a growing awareness of the key
role nutrition plays in the quality of our health; it is now widely recognized,
for example, that low fat diets can help prevent certain cancers and heart
diseases. As manufacturers of health foods and nutritional supplements
sought to bring this information to the attention of the public – including, in
some cases, hyperbole about “brain food” and other questionable claims –
Congress began to question whether health claims should be allowed for
foods and supplements. Congress passed the Nutritional Labeling and
Education Act (NLEA) in 1990 in an effort to provide the Food and Drug
Administration (FDA) with the tools and direction it needed to determine
which health claims could properly be made. The FDA took a position in
response to the NLEA, which many, including some in Congress, took to
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reflect an overeagerness to place undue restrictions upon claims made for
dietary supplements. In response to this concern, and buoyed by an
unusually strong public response, Congress passed the Dietary Supplement
Health and Education Act of 1994 (DSHEA).
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The Act provides useful guidelines as to what constitutes an unsafe
product. If a substance is considered to present a significant or unreasonable
risk of illness or injury under the conditions of the recommended use on the
label or in accompanying labeling, then it is deemed unsafe.
The FDA has to judge the safety of a product, in part, based on the
labeling. This should encourage manufacturers to apply warning statements
on products. This will lead to safer use of dietary supplements because
warnings and cautions are quite permissible and specific dosage instructions
should be disclosed by manufacturers or distributors wherever possible.
The Act recognizes that public policy should be that a consumer could
make an informed judgment about the use of a dietary supplement based on
accurate information on the benefits of dietary supplements. This section is
very important for those individuals in the industry who are involved in the
creation of a platform for the advertising or promotion of dietary
supplements and it presents many opportunities for creative marketing of
dietary supplements. Such creativity should occur with conformity to the
Act.
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The Commission of Dietary Supplement Labels will be comprised of
seven members with appropriate experience and expertise. These
individuals will make a final report of their activity to the President and the
U.S. Congress. The commission will have a very broad charge in order to
facilitate the collection of information and coordinate hearings on matter
relevant to dietary supplements. Any required rulemaking that emanates
from the recommendations of the Commission will have to be completed
within 2 years of the submission of the report of the Commission or the final
regulations on health claims for dietary supplements will be voided.
Conclusion
The DSHEA has far-reaching consequences for the use of dietary
supplements by consumers. FDA interpretation of the Act will be a critical
element in assessing the success of the DSHEA in reaching its stated goals
of providing consumers with safer, properly labeled dietary supplements that
are, or may be, supported with information as to their use and benefit.
To position a health food company for the future will require a team
approach involving medical, scientific, and legal advice and the utilization
of promotional services that are knowledgeable about the new provisions set
forth in the DSHEA. On the horizon is increasing regulations, probable
industry consolidation, and a rapid disappearance of those health food
companies that do not have the foresight to position themselves for
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important future regulatory issues.
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