Lifestyle Treatment of Coronary Heart Disease


The heart is one of your most important organs and during one year will beat between 30 and 40 million times. It is therefore important to keep the heart muscle healthy. Cardiovascular disease is among the most common cause of death, but is largely preventable. So let’s start the new year by promoting a heart-friendly lifestyle.

Although cardiovascular disease is among the most common cause of death, the good news is that around 80% of all heart attacks (1) and strokes can be avoided by following five lifestyle tips. From being at the top of the world in cardiovascular mortality in the 70s, development here in Norway has taken a positive direction. Today we are doing as well as the Mediterranean countries, but history and science tell us that there is potential for additional improvement.

A brief history of heart disease

Heart trouble in Egypt

Cardiovascular diseases have existed for a long time. “She was born before Jesus”, wrote Aftenposten newspaper in April 2016, and “in March she [finally?] got an appointment at hospital”. It is not only archaeologists and historians who are interested in examining Egyptian mummies. A number of mummified Egyptians are today receiving the heart examination they would have wanted while they were still alive. In one study (2), radiologists and cardiologists CT-scanned the hearts of 20 mummies and discovered atherosclerosis in half of them. The embalmed persons most likely had a high social status and it seems that at least the upper class in Egypt struggled with our time’s leading cause of death, cardiovascular disease.

Chinese austerity

In several areas of the world, people barely knew about cardiovascular disease until recently. During a three-year period from 1973 to 1975, in two areas in Sichuan and Guizhou province with a total of 425,000 inhabitants, not a single death from coronary heart disease was recorded in people under 64 years of age (3). In Norway, the figure is approximately 400 deaths (4). Although the Chinese countryside has traditionally been characterized by simple living conditions, this seems to be good for heart health.

Norwegian war diet

Strøm and Jensen, two Norwegian researchers in the 1950s, investigated the mortality from cardiovascular disease in this country and found that more and more Norwegians died of such diseases during the 1920s right up to 1940 (5). During the Second World War, however, a significant decrease was seen in the number of Norwegians who died of such diseases. The war created more challenging living conditions for the population, including in the food sector. Kaare H. Bønaa writes in the article “Mortality from heart attack” (6) that “the changes in diet during the war meant less intake of energy and less intake of dietary fat. “In addition, people smoked less and were more physically active. Strøm and Jensen thus showed that mortality from cardiovascular diseases can change rapidly in line with changes in lifestyle.”

After the war, cases of cardiovascular disease increased, especially in the upper social strata and for a period went under the name “director’s disease”. Today, however, the directors and other people with a high socioeconomic status are among the most heart-healthy in the population, while people with low education and income have for a long time had the highest incidence of cardiovascular disease. However, in recent years, a positive development has also been observed in this part of the population.

Risk factors for heart disease

Risk factors for cardiovascular disease can be divided into modifiable and non-modifiable factors. It is difficult to do anything about heredity, gender and age, all three of which affect the risk of cardiovascular disease. A number of medical conditions including arthritis, severe psoriasis, hereditary high cholesterol, diabetes and chronic kidney failure also increase the risk of cardiovascular disease. In addition, atrial fibrillation is a significant risk factor for cerebral infarction.

Smoking

With regard to modifiable risk factors, smoking is one of the most important. People who smoke 20-30 cigarettes daily have between double and triple the risk of developing coronary heart disease compared to non-smokers. Now it is not the case that if you stop smoking today, the risk of cardiovascular disease will disappear tomorrow. It takes about two years from the time you stop smoking until the risk of cardiovascular disease is reduced to the same level as in non-smokers.

High blood pressure

High blood pressure is the most common cause of stroke in Western countries. High blood pressure is harmful to the blood vessels and can both initiate atherosclerosis and make this process go faster. In addition, high blood pressure causes the plaque in the blood vessels to become more unstable and thus can tear or loosen and trigger an acute heart or brain attack.

Obesity

Norwegians are becoming a heavy people. About half of us are overweight and the extra kilos are one of the biggest challenges for public health. Obesity can lead to cardiovascular disease primarily through creating a low-grade inflammatory state in the body, which can initiate atherosclerosis. Obesity also increases the risk of diabetes, elevated cholesterol, triglycerides and blood pressure, all of which are important risk factors for cardiovascular disease.

Physical inactivity

Unlike previous generations, people today have the opportunity to opt out of physical activity. In the past, activity was a necessity, either in the context of work, transport or domestic activities. Inactivity increases the risk of not only cardiovascular disease but a whole range of conditions including obesity, diabetes, osteoporosis and several forms of cancer. The most common reasons given for not engaging in physical activity are (7)

  • “don’t have time” (37%),
  • “I can’t bear it”
  • “I would rather spend my time on other things”

A look under the skin reveals that we are made for movement. The musculoskeletal system forms a significant part of the human body and both the heart, health and the body in general are strengthened by physical activity. A sedentary lifestyle appears to be as dangerous for the heart as smoking and high cholesterol.

Nutrition

What we eat can greatly affect heart health. Unhealthy diet is today the risk factor that takes the most lives in Norway (8). In particular, we eat too little fruit, vegetables, legumes and nuts. The vast majority of diet-related deaths are due to cardiovascular diseases. More on this later.

Psycho-social risk factors

Heart health is affected by more than our physical lifestyle. We see more and more that the human being is a whole where mental health affects physical health and vice versa.

A few months ago, a large study was published which showed that a lack of social relationships seems to be able to increase the risk of stroke and coronary heart disease by around 30% (9), which is equivalent to obesity or light smoking. Furthermore, people with depression have an increased risk of developing cardiovascular disease and also have a worse prognosis in the case of established cardiovascular disease (10).

Cardiovascular disease can be prevented

Although cardiovascular disease is the most common cause of death in Norway, the vast majority of strokes and heart attacks can be prevented through lifestyle changes. Even with the worst genetic starting point, the risk of future cardiovascular events seems to be almost halved through a heart-friendly lifestyle compared to an unhealthy lifestyle (11).

Healthy diet

The health authorities recommend eating plenty (5 a day / 500 grams) of all types of vegetables, fruit and berries. In addition, whole grain products are recommended. Low-fat dairy and lean meat products are recommended over fatty alternatives. In addition, the health authorities recommend fatty and lean fish two to three times a week. “Eat food. Not too much. Mostly plants”, also applies to the prevention of cardiovascular disease. The health benefits of a diet centered around plants are well documented. In a recent report (12) (position paper) from the largest American association for dietitians, The Academy of Nutrition and Dietetics, we read that a vegetarian diet is associated with a reduced risk of cardiovascular disease. This is explained through the reduction of important risk factors such as obesity, high blood pressure and improvement of cholesterol and blood sugar levels. Vegetarians have a reduced risk of both developing and dying (20-30 percent reduction) from ischemic heart disease. Of the various vegetarian diets, the report points out that a well-planned vegan diet is probably the most heart-friendly. Vegans have a higher intake of fiber, the lowest intake of saturated fat, a healthier weight and a better cholesterol level compared to other types of vegetarians and non-vegetarians.

Plenty of fiber, which we find in fruit and vegetables, is beneficial for reducing cholesterol. In an interesting Canadian study (13), which perhaps should have been labeled “don’t do this at home”, the participants ate 5 kg of vegetables and fruit daily, as well as some nuts. After 14 days, LDL-cholesterol was reduced by 33 percent, which shows the potential of a plant-based diet. Otherwise, the participants did not gain weight from all the food. In general, cholesterol rises the more saturated fat you eat. By replacing about 20 grams (5% of the daily total caloric intake) of saturated fat with unsaturated fat, the risk of heart disease is significantly reduced (14).

Low alcohol intake

A high alcohol intake (more than two drinks for men, and more than one drink for women) increases the risk of cardiovascular disease. A moderate or low intake of alcohol (less than 30 grams/day) seems to be able to reduce cardiovascular disease, but does not reduce overall mortality. Even a moderate intake of alcohol increases the risk of, among other things, breast cancer and colon cancer. Many of the same effects that alcohol has on the cardiovascular system can be achieved through physical activity and a healthy diet.

Avoid smoking

About 9% of adult Norwegians smoke daily or occasionally. Tobacco smoke is harmful to the blood vessels for several reasons. Among other things, smoking can initiate atherosclerosis, it makes the blood “thicker”, increases the bad LDL-cholesterol and reduces the good HDL-cholesterol. Quitting smoking is probably the most heart-friendly measure a smoker can take, and after a couple of smoke-free years the risk of cardiovascular disease is down to the same level as in non-smokers. If you find it difficult to quit smoking, there are effective aids, including nicotine replacement therapy and medications, which can make the path to a smoke-free life easier.

Physical activity

Physical activity has so many health benefits that it cannot be obtained in pill form. When it comes to cardiovascular health, exercise leads to, among other things, lower blood pressure, increased capillary density and blood supply in the heart muscle, reduced risk of thrombosis, as well as improved lipid profile and vessel dilation. A small Norwegian study (15) showed that heart patients who exercised three times a week for a total of 12 weeks experienced a reduction of the plaques by an average of 10% (not statistically significant) and in addition the plaque became more stable. There was just as great an effect of 4×4 intervals, as with sessions of 60 minutes of moderate intensity (e.g. fast walking). In general, it is recommended to be active 40 minutes a day and preferably set aside an hour one day a week for more intense activity. A little is still better than nothing and the more activity, the better. The training sessions can easily be divided into smaller blocks and seem to give the same positive effect.

Reversal of coronary heart disease?

Relatively few studies have been done on the effect of lifestyle treatment on the reversal of coronary heart disease and atherosclerosis.The report on vegetarian diet from the Academy of Nutrition and Dietetics points out that a low-fat vegan and vegetarian diet, combined with other lifestyle factors, has been shown to be able to reverse atherosclerosis. This was observed by the dr. Dean Ornish as early as 1990 in a study (16) of 48 people with coronary heart disease. The participants in the study received either standard medical treatment, or intensive lifestyle treatment which included the following lifestyle measures:

  • Low-fat vegetarian diet: Only 10% of daily calories from fat, but no restrictions on total calorie intake.
  • Dairy products equivalent to 5mg of cholesterol, for example one glass of skimmed milk, were allowed.
  • No caffeine
  • Stop smoking
  • Stress management
  • Physical activity, 3 hours a week

After one year, the participants with intensive lifestyle treatment had reduced their LDL cholesterol by 37%, and in 82% of the participants the atherosclerotic plaques had begun to decrease. Already after three weeks, the lifestyle group experienced approximately a 90% reduction in episodes of chest pain (angina). Similar results were also published in 2014 by dr. Caldwell Esseslstyn (17), who followed 195 people with coronary heart disease for almost four years. While the participants received regular medical treatment, the participants followed the diet described below:

  • Plant-based diet with an emphasis on coarse cereals, legumes, vegetables and fruit.In addition, they took a daily supplement of vitamin B12 and a multivitamin tablet.Foods to avoid:
  • Dairy products, fish, meat and oils.
  • In addition, the participants were advised to avoid refined foods, avocado, nuts and large amounts of salt.
  • Physical activity was recommended, but was not required to participate in the study.

Only one of the 177 participants who stuck to the program (avoiding dairy products, fish, meat and oils) experienced new cardiovascular events. However, 13 of the 21 participants who did not adhere to the program experienced new cardiovascular events. In other words, 99.4% of participants who adhered to the program avoided new serious cardiovascular events, such as heart attacks and strokes. Although more research is needed in this area, these two studies suggest the powerful effect that a healthy lifestyle can have on one of our most common lifestyle diseases and causes of death. With regard to coronary heart disease, it seems that the diet should be almost plant-based in order to achieve reversal of the disease. Such a diet is unfortunately sometimes referred to in medical circles as too radical to be recommended, and is therefore rarely presented to heart patients. At a time when more and more Norwegians are choosing a heart-friendly lifestyle in the direction of the one described above, one might ask whether it is perhaps at least as radical to cut open the chest and undergo bypass surgery.

Conclusion

Cardiovascular disease is the most common cause of death in Norway and in the Western world. Heart attacks and strokes are usually serious events that can leave lasting marks on the body and mind. It is therefore pleasing to observe that Norwegians live more heart-friendly today than a few decades ago. However, most of us have a lot more going on. By including the five lifestyle habits mentioned below, around 80% of all strokes and heart attacks can be avoided (1,18).

  • Avoid tobacco
  • Healthy diet: “Eat food.Not too much.Mostly plants.”
  • Physical activity 40 minutes daily and set aside 60 minutes one day a week for more intense activity/training
  • Normal weight / no abdominal obesity
  • If you drink alcohol, drink only in moderation

If you already have coronary heart disease, a more intensive lifestyle change, as mentioned in connection with the studies by dr. Ornish and dr. Esselstyn, could increase the possibility of reversing the condition.

References

  1. Åkesson A, Larsson SC, Discacciati A, Wolk A. Low-Risk Diet and Lifestyle Habits in the Primary Prevention of Myocardial Infarction in Men. J Am Coll Cardiol. 2014;64(13):1299-1306.
  2. Hjertetrøbbel i gamle Egypt | forskning.no.
  3. Campbell T, Campbell T. China Study.; 2012.
  4. Hjerte- og karsykdommer – faktaark med helsestatistikk
  5. Strøm A, Jensen RA, Oslo MD, Oslo MD. MORTALITY FROM CIRCULATORY DISEASES IN NORWAY 1940-1945. Lancet. 1951;257(6647):126-129.
  6. Dødelighet av hjerteinfarkt – Tidsskrift for Den norske legeforening. http://tidsskriftet.no/article/2079924/. Accessed March 20, 2016.
  7. Hansen B, Anderssen S, Steene-Johannessen J, et al. Fysisk aktivitet og sedat tid blant voksne og eldre i Norge – Nasjonal kartlegging 2014 – 2015. Helsedirektoratet. 2015.
  8. Risikofaktorene som veier tyngst i beregningene for Norge – FHI. https://www.fhi.no/hn/sykdomsbyrde/hvilke-risikofaktorer-veier-tyngst-/. Published 2015.
  9. Valtorta NK, Kanaan M, Gilbody S, Ronzi S, Hanratty B. Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies. Heart. April 2016.
  10. Hare DL, Toukhsati SR, Johansson P, Jaarsma T. Depression and cardiovascular disease: a clinical review. Eur Heart J. 2014;35(21):1365-1372.
  11. Khera A V., Emdin CA, Drake I, et al. Genetic Risk, Adherence to a Healthy Lifestyle, and Coronary Disease. N Engl J Med. November 2016:NEJMoa1605086.
  12. Melina V, Craig W, Levin S, et al. Position of the Academy of Nutrition and Dietetics: Vegetarian Diets. J Acad Nutr Diet. 2016;116(12):1970-1980.
  13. Jenkins DJ, Kendall CW, Popovich DG, et al. Effect of a very-high-fiber vegetable, fruit, and nut diet on serum lipids and colonic function. Metabolism. 2001;50(4):494-503.
  14. Li Y, Hruby A, Bernstein AM, et al. Saturated Fats Compared With Unsaturated Fats and Sources of Carbohydrates in Relation to Risk of Coronary Heart Disease. J Am Coll Cardiol. 2015;66(14):1538-1548.
  15. Madssen E, Moholdt T, Videm V, Wisløff U, Hegbom K, Wiseth R. Coronary atheroma regression and plaque characteristics assessed by grayscale and radiofrequency intravascular ultrasound after aerobic exercise. Am J Cardiol. 2014;114(10):1504-1511.
  16. Ornish D, Brown SE, Billings JH, et al. Can lifestyle changes reverse coronary heart disease? Lancet. 1990;336(8708):129-133.
  17. Esselstyn CB, Gendy G, Doyle J, Golubic M, Roizen M. A way to reverse CAD? J Fam Pract. 2014;63(7):356-364b.
  18. Larsson SC, Åkesson A, Wolk A. Primary prevention of stroke by a healthy lifestyle in a high-risk group. Neurology. 2015;84(22):2224-2228.

Allan Fjelmberg, MD, MPH, DipIBLM

As a Norwegian based medical doctor certified in Lifestyle Medicine he currently serves as the medical director of Skogli Health and Rehabilitation Center, Lillehammer. Through consultations, presentations, articles and other public health-related activities, he motivates people to utilize the potential that a healthy lifestyle has both in prevention and treatment of disease.

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