Preventing cardiovascular disease: a nutrition design
Findings from a plethora of recent scientific reviews and meta-analyses evaluating dietary patterns, food groups, and nutrients in the prevention of CVD (cardiovascular disease), have been consistent with the proposed notion that a Mediterranean dietary style is efficacious in preventing stroke mortality and lowering the risk of heart attacks.
Scientists are unanimous in extolling the benefits of a diet rich in olive oil and fresh foods, and in pointing to specific components of the US mainstream dietary culture in the form of palatable but nutrient-deficient foods, high in toxic fats and sugars, as first line offenders in chronic disease etiology. Hence, a plausible preventive nutrition design, suitable for the US population, cannot be a copy-and-paste version of a millennia-old way of life in a different ecosystem such as the Mediterranean region. Adopting a style of eating that is as close as possible to a Mediterranean one, here in America, warrants that we first identify common foods that adversely impact our health, and at the very least reduce their consumption to levels that do not increase our odds of developing chronic disease. What makes this all the more treacherous is that many of these offenders are processed and pseudo-functional foods, ubiquitous in our commercial food system, and fraudulently labeled as ‘healthy’. Studying the enemy before engaging in battle is power.
A five-step nutrition design for metabolic and cardiovascular health
As a foreword, I would like to firstly impress upon you that the overarching recommendations to lower saturated fats and dietary cholesterol, and reduce sodium to a minimum, have been unambiguously dispelled by medical research across the board in recent times. Both of those dietary guidelines do not, in fact, stack up with scientific evidence, which has repeatedly resolved that saturated fats are not intrinsically determining factors in the etiology of CVD and stroke. As it turns out, insulin flooding, in response to unrestrained glucose intake, with the ensuing insulin resistance and cascade of metabolic disruptions, is regarded by science as the cause of metabolic syndrome and cardiovascular disease. As a matter of fact, healthy dietary fats slow down the insulin response to foods, and for the much dreaded sodium to create problems, your body has to be depleted of potassium and other minerals, which happens in states of insulin resistance: in short, it all circles back to glucose consumption. You can read more about how the sugar industry, processed foods manufacturers, seed oil and trans-fat producers have managed to fraudulently shape public understanding of nutrition here.
1. First step to a reset: reduce your intake of sugars to a judicious minimum
The concept of relativity and dose dependency apply to the amount of sugars and carbohydrates you can have on a daily basis, since, according to countless studies, individual blood sugar responses vary at equal intakes after other variables are controlled for. In states of advanced insulin resistance-related conditions such as liver disease and cardiovascular disease, the level of consumption at which damage from sugars may occur is very low, hence it is best to seek the help of a nutrition clinician to establish an individualized protocol. For baseline prevention, in otherwise healthy individuals whose lifestyle, poor diet and family history may raise concerns of future adverse cardiovascular outcomes, of for anyone looking to simply fend off potential risk factors, some basic modifications in terms of both quality and quantity intake are advisable.
Knowing which foods to avoid is the first step in sugar intake management, but navigating through the boundless hodgepodge of hyperpalatable, sugar laden processed foods can be difficult for individuals whose lifestyles are not conducive to cooking fresh foods every day. Many processed foods appear to be above suspicion, since the added sugars often do not confer a preponderant sweet taste, and even ready-made foods from gourmet shops and take-out places are almost always made with unhealthy fats and added sugars. Below are some examples of sugar snares to be aware of.
The obvious:
Table sugar; maple syrup; fructose-based sweeteners like agave and honey; mainstream bakery products; confectionery (desserts, sweets, cookies, donuts, candy and conventional dark chocolate), fruit juices (yes, freshly squeezed ones too); soda; ice cream; chocolate and yogurt coated nuts; sweet-and-sour foods; frosted, flavored and fruit-enriched cereals.
The covert:
Whole wheat/whole grain bakery products, since they are still 80% starch (the negligible amount of fiber, added to white flour, cannot slow down glucose absorption to any significant degree); commercial cereal, including the ‘plain’ kind; commercial balsamic vinegar (look for the aged product imported from Italy); salad dressings; nut butters; sugar-free labeled fruit jellies, jams and spreads; most brands of commercial sliced bread (fructose is added, on top of its own carb content); sweet-and-sour foods in restaurants; conventional ketchup and mayonnaise; commercial milk and yogurts (particularly the nonfat and low-fat kinds); highly processed cheeses like spreads and ‘singles’; jarred pasta sauces; boxed foods like macaroni and cheese; barbecue sauce; hoisin and teriyaki sauce; frozen ‘lean’ dinners; instant soups; canned soups; instant noodles; frozen breakfast foods; frozen vegetables with sauce added; coffee creamers; deli meats; commercial cheese products; fast foods like burgers, fried chicken and fries; salads from fast food places; plant-based milks, exception made for the unsweetened kinds; meal replacement bars, protein bars and protein shakes; potato chips, many kinds of popcorn and other kinds of snacks.
It’s easy to see that the covert sugar list is much longer, and impossible to thoroughly complete. All processed foods contain some form of sugar: in the aggregate, keep in mind that once fat is taken out of the equation (in low-fat foods), the relative concentration of sugar increases by default. Even in savory products, sugars are often surreptitiously added for texture, to create a subliminal layer of sweet taste, and sadly, to trigger dependence. Check the labels carefully and learn to recognize sugar by any other name (there are about 60 different ones). For reference, here are some of the most common aliases for sugars on the labels:
sucrose
fructose
high fructose corn syrup
galactose
maltose
dextrin/maltodextrin
agave nectar
barley malt
buttercream
treacle
syrup (any and all)
fruit juice concentrate
Fructose in particular deserves a thumbs down all of its own. Several studies have shown that at comparable amounts, glucose and fructose have different effects on metabolic health. The main difference is in the type of fat mass increase: whereas excessive glucose consumption translates into more subcutaneous fat, the kind that sits around waiting to be burned off for energy, the pathway of fructose metabolism primarily leads to deposition of visceral fat, the kind that causes inflammation, endocrine disruptions, cardiovascular problems and a litany of other damages. You can read more on fructose here.
My caveat to anyone trying to cut back on sugar to lose body fat and stay healthy: avoid getting caught up in the dietary guideline number game. The USDA Dietary Guidelines for Americans 2015-2020 sets an RDI (recommended dietary intake) for sugar at 10% of daily calories, which is 12 teaspoons or 48 grams in a 2000 calorie diet. Recommendations from the World Health Organization from 2015, as well as from the American Heart Association, are even more stringent, claiming that only 5% of daily calories should come from sugar. These numbers refer to added sugars, which are now mandatorily divulged on food labels, but certainly fail to tally with the pervasive presence of refined carbohydrates or hidden sugars in the SAD. As much as guidelines may be commended for raising awareness, I see a few problems with fixed intakes: for one, no one walks around with a calculator and a log. Many people are not going to check the labels for sugar on ultra-processed savory foods, much less suspect that there might be sugars in salty fast foods, simply because we generally tend to see our victuals as either sweet or salty, unless otherwise specified. Truth be told, no one knows how much added sugar is in a bucket of fast food chain fried chicken, or in a burger and fry combo, in a small fountain soda or in a vanilla chai latte. Also, people with higher calorie intakes may be mislead into consuming sugars above or even below their glucose tolerance threshold (which doesn’t necessarily go hand in hand with biometrics and needed daily calories), but, most importantly, processed foods are chockful of countless other chemicals that interfere with the metabolism of sugar, even in moderate amounts. Bottom line: forgo the math and avoid fast foods and over-processed foods at all cost, as much as possible.
Read more on the importance of decreasing sugar for cardiovascular health in my articles on non-alcoholic fatty liver disease, and on glycated LDL.
2. More than just free radical scavengers: the power of antioxidants
Long touted for their anti-cancer benefits, only in recent years have antioxidants gained due accreditation for decreasing the risk of CVD, particularly with regards to the prevention of atherosclerosis. There is increasing evidence that these compounds have multiple molecular targets, modulate pro-inflammatory gene expression, interact with phospholipid membranes, and modulate pathways related to chronic inflammation and energy metabolism.
Antioxidants protect heart and arteries primarily by supporting HDL functionality. As discussed in my previous article on cardiovascular prevention, the key step in plaque formation is not merely an abundance of LDL and a shortage of HDL: in the artery walls, small LDL particles are detected and ingested by specialized white cells called macrophages; once fattened with enough LDL, these white cells begin to form foam compounds that eventually turn into dangerous obstructive plaque. Central to this discussion, however, is the fact that chemical degradation of LDL is what induces this process, since macrophages can only detect and engulf LDL if it is oxidized due to excess blood glucose. Circulating HDL particles provide potent protection of LDL from oxidative damage by free radicals, impeding plaque formation from the outset, and allowing excess LDL particles to be reabsorbed by the liver for final excretion. HDL can do this because it is made up of at least 100 different compounds with antioxidant and anti-inflammatory properties.
However, an optimal amount of HDL in the body is a Goldilocks value: too low HDL (<30) is insufficient for CVD protection, too high (>55/65) is proxy for poorly functional HDL, meaning some of its chemical components are not in balance. In all case scenarios, impaired antioxidant properties of HDL may go undetected. For instance, individuals with high inflammatory markers such as C-reactive proteins, which could be a consequence of heart attacks, may process HDL negatively, with no evidence from mainstream testing. HDL is not a therapeutic target in quantitative terms, hence the focus on identifying therapies that improve HDL functionality. Since conventional drugs have shown no favorable effects on HDL functionality yet, a diet and lifestyle modification is the only viable approach.
The role of antioxidants in CVD prevention is not limited to HDL functionality and prevention of LDL oxidation. In the cardiovascular system, cells constantly generate reactive oxygen species (ROS) as a by-product of normal cellular respiration. While necessary as signaling and balancing molecules, if not matched by the presence of cellular antioxidants in our endogenous antioxidant defense system, these ROS trigger a state of oxidative stress that is permissive of vascular events through many destructive alterations. In fact, the cell mitochondria and specialized cell organelles called peroxisomes are antioxidant manufacturing sites that aptly counteract DNA damage, endothelial dysfunction, inflammation, immune responses, thrombus formation and a whole cascade of vascular changes that is conducive to the formation of atherosclerotic plaques. However, in states of oxidative distress, they may need external sources of antioxidants to assist in coping, meaning they need to be replaced through diet. Antioxidants are natural substances that exist in foods as vitamins, minerals and other compounds.
Adequate intake of antioxidants can only be achieved through a diet that is rich in:
organic vegetables of all colors: tomatoes (both raw and cooked), bell peppers (all colors), carrots, celery, red onions, yellow and green zucchini, eggplant, green leafy vegetables (kale, spinach ,chard are examples), cruciferous vegetables (broccoli, cauliflower, Brussel sprouts, cabbage, Bok choy, arugula)
fresh fruit (in moderation due to the sugar content); organic berries are the best choice for individuals on glucose controlled dietary regimes
Extra Virgin Olive Oil
dark chocolate, organic whenever possible
red wine and coffee, in moderation
nuts, particularly walnuts (purchased with the shell on), pistachios, pecans, cashews, macadamias
seeds: freshly ground flaxseeds, chia seeds, hemp seeds, pumpkin seeds, sunflower seeds, sesame seeds
pasture raised/organic eggs; grass fed meats and organ meats
wild fish, particularly sockeye salmon, rich in Omega-3s, CoQ10 and astaxanthin, an antioxidant which is 500 times more potent than Vitamin C
grass fed cheeses and butter
fresh organic herbs such as basil, mint, parsley, dill, lemon thyme, rosemary and cilantro
high quality spices such as clove (a super-antioxidant), oregano, nutmeg, black or white pepper, turmeric, cinnamon, saffron, rosemary, wild marjoram and lemon thyme
My caveats
*Garlic, green tea and some herbal teas and remedies, though rich in antioxidants and other heart-healthy compounds, may interfere with blood thinners, calcium channel blockers and blood pressure medications by both increasing or decreasing their effectiveness. The same is true for dark green vegetables, rich in Vitamin K, which may decrease the effectiveness of blood thinners. Please always make sure your physician is aware of any dietary changes and/or increases in consumption, so your medications can be adjusted accordingly.
*Antioxidant supplementation may replenish our antioxidant stores in times of stress, fatigue or illness, or in situations when access to healthy foods is limited. People who suffer from health conditions that require medical supervision will need to discuss supplementation with their physician.
* The single, most important piece of advice I give people seeking to generally improve their health is to increase their daily intake of vegetables to 7 - 10 cups per day, since vegetables are also a great source of potassium and other minerals, indispensable to cardiovascular functions. However, individuals affected by SIBO (small intestinal bacteria overgrowth), or intestinal distress following the ingestion of vegetables and beans, which may be caused by certain plant constituents such as solanine and lectins, may want to refer to a functional nutrition specialist or an RD before increasing the amount of vegetables, as well as beans and nuts, in their diets, since increased intestinal permeability may trigger a systemic inflammatory response.
3. Managing inflammation: increase the good fats, decrease the bad ones
Omega-3 fatty acids have been making headlines in the last few decades in the fight against CVD and several other chronic diseases. They are known to aid in maintaining optimum levels of cholesterol in the body to manufacture hormones, bile acids and vitamin D. They have been central to research on inflammation for being able to modulate the inflammation response by the immune system, igniting it on crisis cue and switching it off when no longer needed (so it won’t go off on a rampage and damage tissues). Research data on the benefits that the anti-inflammatory Omega-3s have on cardiovascular health are strong enough that European and American cardiac societies have included Omega-3s in their treatment guidelines for cardiac diseases. These fatty acids are known to decrease triglycerides, increase HDL, lower LDL, but most notably protect LDL particle membranes from oxidation: cardiovascular research has conclusively proven that oxidation and inflammation of LDL, not its values on your blood panel, are the definitive marker for cardiac events.
Omega-3s are essential fatty acids, meaning the body cannot manufacture them spontaneously and therefore need to be obtained through the diet on a continuing basis. Some of the primary sources of Omega-3s include:
marine sourced (the most biologically available ones): seafood and fatty fish like salmon, tuna, mackerel, sardines, herrings and trout
animal sourced: Grass fed meats, organic eggs from pasture-raised chickens, and organic dairy
plant sourced: chia seeds, flaxseeds; walnuts, almonds, macadamia, pecans; olives and olive oil; bell peppers, broccoli, Brussel sprouts, navy beans and avocados
as for supplementation, with the exception of wild caught, fresh Cod Liver Oil, which has garnered consensus under researchers’ microscopes, science findings with relation to the effectiveness of integration with fish oil supplements have been discordant, suggesting that introducing foods in the diet that are natural sources of Omega-3s is still the only surely efficient way to replenish and maintain optimal blood levels
Conversely, Omega-6 fatty acids lead to inflammation of tissues and membranes, oxidative stress and several metabolic complications that lead to cardiovascular disease. Below is a list of the Omega-6 rich foods to steer clear of:
vegetable and seed oils: soybean oil, corn oil, safflower oil, canola oil, grapeseed oil, cottonseed oil, walnut and peanut oils
processed foods: boxed, canned or preserved in vegetable oil (see list above), commercially fried and baked, frozen ready-made meals, cookies, chips and snacks, ready mixes
fast food chain burgers, fries, fried chicken, soups and salads from mainstream corporate chains
conventional (non-organic or pasture raised) meats, eggs and dairy
peanuts and peanut butter
sodas, fruit juices, ice cream, cookies and conventional, multinational brand cereals
The needs for Omega-3s in the diet vary among individuals around an average of 1 to 2 grams per day, while for Omega-6s, in light of their abundance in the Western diet, recommendations are made to limit them to max 4 fold the Omega-3 amount. You can read the full article on Omega fats here.
4. Keep your microbiome happy : the less known role of fiber in cardiovascular health
Fiber is perhaps the only dietary component widely recommended to patients in the world of allopathic medicine, albeit most often in the form of over-the-counter supplements or processed breakfast items, rather than as a component of a whole food diet. What people are not typically told is that fiber’s job is not merely to ‘keep things clean’ by sweeping away colon waste products and toxins - as it happens, constipation often worsens from upping fiber consumption too fast.
Fiber is a carbohydrate but has zero impact on insulin as it is virtually undigestible, meaning we do not have the enzymes to break it down, but the community of biologically beneficial bacteria living in our gut, our microbiome, feeds and thrives on it, which is why fiber is said to be prebiotic. The phytonutrients contained in fiber, such as vitamins and minerals, feed colon cells, keeping them healthy and strong. Fiber has the ability to slow down transit times of foods in the entire GI tract, which translates into blood sugar control. However, the by-product of fiber digestion is what we’re primarily after when including fiber in our daily habits: once fermented by the microbiome, beneficial compounds called short chain fatty acids, or SCFAs, are systemically released. These compounds contribute a great deal to our health, in that they help regulate blood sugar and PH, and dampen post-prandial low-grade inflammation, which is associated with an increased risk of (among others) insulin resistance, diabetes type 2, and atherosclerosis. SCFAs also support the immune response in the intestinal tissues, and elicit an innate immune response in all other tissues of the body against bacterial infections.
Fiber can be soluble or insoluble. Soluble fiber absorbs water, forming a gel-like substance that slows down the absorption of foods, as previously mentioned. Insoluble fiber does not absorb water, it adds bulk to the food and helps to move it through the intestines. The majority of the following fiber rich foods contain a combination of both:
vegetables: artichokes, avocado, broccoli, cauliflower, kale, swiss chard, collard greens, spinach, celery, carrots, beets and beet tops, arugula, broccoli rabe
beans: lentils, cannellini beans, garbanzo beans, kidney beans, split peas
fruit: raspberries (highest content) and all other berries, pomegranate seeds, apples, pineapple, cherries, olives
seeds: flaxseeds, chia seeds, hemp seeds, sunflower seeds, pumpkin seeds
nuts: walnuts, almonds, pecans, brazil nuts, macadamia, cashews, hazelnuts
grains: quinoa [GF], buckwheat [GF], oats, bulgur wheat, wild rice [GF]
A type of fiber called resistant starch has been garnering increasing attention among functional nutrition advocates. This is a type of carbohydrate that bypasses the quick breakdown stage of carbohydrates in the mouth and in the small intestine, making it a safe component of glucose-controlled regimens since it does not cause a swift rise in insulin, and begins fermenting only once it reaches the large intestine. Basically, resistant starch behaves like soluble, fermentable fiber in the gut, feeding our microbiome and yielding beneficial SCFAs, such as butyrate, as a by-product. However, to increase the ‘resistance’ of the starch, some of the foods that contain it should be consumed cooked, completely cooled off and eaten cold or lightly reheated. Here is a list of resistant starch foods:
cooked and cooled off: potatoes, brown and white rice, oats, chickpeas, lentils, green peas, quinoa
raw: green bananas, green mangoes, green papayas, plantains, onions
As a general rule, consuming resistant starch foods along with other fiber-rich foods, particularly green leafy vegetables, greatly enhances the benefits of this type of prebiotic fiber. For individuals with IBS syndrome, it may be a good idea to opt for resistant starch foods and non-fibrous vegetables and fruits. You may find a list of soluble fiber foods here.
5. Sleep your way to heart health: melatonin, your vitamin zzz
Behold the antioxidant power of a good night’s sleep! Our sleep/wake cycle is primarily regulated by two neurohormones: serotonin, produced during the day, and melatonin, produced in the dark. Melatonin is a universal antioxidant and anti-inflammatory, meaning it is active in all tissues of the body, but it also stimulates enzymes that produce other endogenous antioxidants, while it suppresses prooxidant enzymes by improving mitochondrial function. Melatonin is known to reduce night blood pressure in patients with nocturnal hypertension, and it controls various physiologic processes, including mood regulation, anxiety, sleep, appetite, immune responses, and cardiac functions. Should you need one more reason to decrease sugar intake: increasing insulin downregulates levels of melatonin, while melatonin decreases insulin. Moreover, sleep itself is an antioxidant, in that its biological mechanisms include the removal of excess free radicals by increasing production and efficiency of endogenous antioxidants.
Foods containing melatonin or promoting the synthesis of it:
tomatoes, tart cherries, kiwis,
olives and Olive Oil
pistachios, almonds, walnuts
red wine (particularly some wines from the Piedmont and Tuscany regions in Italy)
tart cherries
pasture raised chickens, turkey and organic eggs
fatty fish like salmon, sardines, mackerel, tuna
organic milk and dairy
Make sleep a priority by limiting exposure to blue lights from TV screens, computers and phones, and stop eating at least 3 hours prior to going to bed. Sleep in a cool room to help increase melatonin, and always be sure to stay hydrated.
_______________________________________________________________
*Disclaimer: the above generic nutrition advice for the prevention of cardiovascular disease is based on up-to-date scientific research and is neither intended to diagnose or treat any condition, nor attempting to replace medical advice. If you have or are at risk for cardiovascular disease, or are currently undergoing medical treatment for a metabolic condition, please only use my advice as reference and consult your physician prior to making any significant changes to your dietary regimen.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7231110/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3075927/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3297980/
https://pubmed.ncbi.nlm.nih.gov/24115747/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5597817/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4315737/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5969776/
https://pubmed.ncbi.nlm.nih.gov/14732734/
https://pubmed.ncbi.nlm.nih.gov/23535335/
https://pubmed.ncbi.nlm.nih.gov/21420242/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4756104/
https://carleton.ca/healthy-workplace/wp-content/uploads/soluble-fibre.pdf