Heart disease remains in the number one killer in the United States. Heart disease claims 610,000 deaths, or 1 in every 4 deaths each year according to the CDC. This is the case despite all the research and new medical treatments for heart disease. Not only that, but the number of patients dying from heart disease actually increases every year. We are not even keeping up with the disease. Perhaps something is wrong with what we are doing.
We believe the main reasons heart disease remains the number one killer is our approach to treating it is incomplete and somewhat misguided. We only focus on addressing a handful of cardiac risk factors: smoking, cholesterol, high blood pressure, and diabetes. These are the so-called major modifiable risk factors for heart disease. Yet, these traditional risk factors fail to identify about half the population that suffers from heart disease.
To some degree we have dumbed-down treating heart disease to treating cholesterol (its importance is over emphasized in our opinion – see our article, The Great Cholesterol Myth of Today), high blood pressure, and managing diabetes.
Below is a more complete list of cardiac risk factors. Our belief is that we should target each of these risk factors when present in an individual. Many of these risk factors are never assessed by most physicians.
- Excess total cholesterol
- Excess LDL cholesterol (bad cholesterol)
- Low HDL (good cholesterol)
- Excess glucose
- Excess homocysteine
- Excess C-reactive protein (CRP)
- Low Vitamin D
- Low Vitamin K
- Excess triglycerides
- Low EPA/DHA (omega-3)
- Low testosterone (males)
- Excess estrogen (males)
- Excess insulin
- Nitric oxide deficiency
- Excess fibrinogen
- Oxidized LDL
To really reduce your risk of heart disease you want to reduce these cardiac risk factors to optimal levels, not just “normal” levels.
What are optimal levels for some of these other risk factors? That’s what we are about to go over. So sit tight. Most of us are familiar with recommendations for the blood pressure and cholesterol. We will focus on recommendations for the non-traditional cardiac risk factors in this discussion.
You want a fasting blood glucose level below 86 mg/dl (though under 100 is normal). Below 85 mg/dl some studies have shown heart disease to be reversible. Related to blood glucose are insulin levels. Ideally, a fasting insulin level should be below 5 mcIU/ml (though under 17 is considered normal in most labs). Insulin is the fattening hormone. When insulin is elevated it prevents the body from using calories stored in fat. In our experience it is difficult to lose meaningful weight with insulin levels consistently above 12.
Triglycerides should be less than 100 mg/dl (though under 150 is considered normal). Triglyceride is a fatty substance related to cholesterol. It may actually be more important than cholesterol. Plus, you want a trigyleride/HDL ratio less than 2. HDL is the so-called good cholesterol.In fact, the triglcyeride/HDL ratio may be a better predictor of heart disease than LDL and total cholesterol. Eating sugars and starches will raise triglycerides and LDL cholesterol so avoid those as much as possible in your diet (excluding sugars naturally found in fruits and vegetables). Fish oil lowers triglycerides quite effectively.
Homocysteine is a breakdown product of methionine which is an amino acid. Homocysteine accumulates when there is a methylation defect due to a deficiency of an enzyme called cystathionine b-synthase. Homocysteine initiates and facilitates progression of atherosclerosis. Homocysteine levels should be below 8 mcmol/l. Vitamin B12, vitamin B6, folate, and trimethglycine (TMG) can be taken as supplements to lower homocysteine.
C-reactive protein is an inflammation marker. Inflammation raises the risk of heart disease and other chronic diseases. C-reactive protein should be under 1.0 mg/l and preferably even below 0.5 mg/l (though under 3.0 is normal). Statins do lower C-reactive protein and that might be the main reason, as opposed to their cholesterol lowering effects, they do prevent some heart attacks. Aspirin and fish oil lower C-reactive protein as well.
Vitamin D levels should be at least above 50 ng/dl, though anything above 30 ng/dl and less than 100 ng/dl is considered normal. Low vitamin D has been associated with twice as many heart attacks. Vitamin reduces inflammation. Our skin makes vitamin D when exposed to sunlight but our ability to make vitamin D decreases as we age. I personally take 7,500 IUs of vitamin D a day and my vitamin level hovers in the mid 70 range.
Low nitric oxide contributes to endothelial dysfunction which is at the root of atherosclerosis. Tests for nitric oxide are not readily available, but Neogenis has test strips that one can purchase to get a rough idea of their nitric oxide production. With the test strips you can see how your nitric oxide level responds to various foods and other interventions. The endothelium is the one cell thick inner layer of blood vessels that controls hundreds of chemical reactions and ultimately controls the suppleness and diameter of blood vessels thereby controlling blood flow. Arginine, citrulline, and pomegrate can elevated nitric oxide levels as does most green leafy vegetables and any form of exercise improves nitric oxide production.
Currently there are no recommendations for vitamin K. There are different types of vitamin K. K2 is most important in terms of cardiac risk factors. Vitamin K2 keeps calcium in the bone and prevents it from depositing in the blood vessels. Consider taking 90 to 100 mcgs of Vitamin K2 in the form of MK-7 a day. But, do not take it if you are taking the blood thinner Coumadin without speaking to your physician as it well negate the blood thinning effects of coumadin. Coumadin unfortunately depletes primarily vitamin K. Patients on Coumadin long-term typically have osteoporosis and hardening of the arteries. Many, in fact, have more calcium in their aortas (main artery in the body) than they do their thoracic and lumbar spines.
EPA and DHA are healthy omega 3-fatty acids found in fish oils. Though blood tests exist to measure EPA/DHA they are not readily available. Most would do well to obtain a daily dose of 1,400 mg of EPA and 1,000 mg of DHA a day either through eating fish or taking fish oil supplements. Note: the EPA and DHA concentration ranges from 1/3 to 2/3 of a milligram. In other words, a 1,000 mg capsule of fish oil has 360 mg to 720 mg of EPA and DHA combined. The EPA/DHA dose is what matters. Fish oil is one area where buying quality may save you money when you compare EPA/DHA doses to grocery and drug store brand versions.
Fibrinogen is a protein that plays a role in blood clotting. High levels are associated with higher risk of clotting and heart attacks. Fibrinogen tends to be higher when inflammation is high. Optimal fibrinogen levels are below 300 mg/dl. Vitamin C and fish oil can lower fibrinogen.
We have discussed hormone levels in several articles on this site. Ideally, we recommend patients maintain estrogen, progesterone, DHEA, and testosterone levels in the range of someone in their thirties (for each sex) which is usually in the upper half to upper third of the reference range. In men low testosterone and/or high estradiol are additional cardiac risk factors.
Here is something interesting. Many men mid 50 and older have higher estrogen levels than women of similar age.
In most labs a normal testosterone is 300 ng/dl to 1,000 ng/dl. The upper half the range is 650 ng/dl while the upper third of the range is 870 ng/dl. We recommend men be at least above 650 ng/dl though many do well with lower levels from a symptom stand point. But, some studies show lower rates of heart disease, cancer, and all cause mortality with levels in the upper half of the range.
Cardiac Risk Factors and Diet
Many of these cardiac risk factors can be improved by eating a low glycmeic diet with emphasis on vegetables and fruits as sources of carbohydrates and regular physical activity which reduces inflammation and improves hormone levels, insulin sensitivity, and helps with body fat loss.