I’ve been thinking about cardiovascular disease recently: for most of my patients (over 50), my #1 concern for them is cardiovascular risk. Heart disease is the most common chronic and fatal health condition affecting older people. While men’s cardiovascular health becomes problematic in their 50’s, by the age of 65 women have “caught up” (I should say, “declined”) to equal men in heart disease risk.
The medical profession sat up and took serious notice of the risk of heart disease in 1955 when President Dwight D. Eisenhower had his first heart attack. His recovery was overseen by Dr. Paul White who wisely encouraged him to stop smoking and to exercise. The dietary advice he gave was from the Plumbing School of Medicine: if you eat butter it will mysteriously migrate from your intestines to the lining of your arteries and clog them. Since then, it has been well established that dietary fats, especially saturated fats, do not cause heart disease. Saturated fat vilification is the reason red meat and butter have been scorned, and many of us were enticed to switch to margarine 50 years ago. Margarine, we now know, contains trans fats which increase the risk of heart disease.
If not butter, what then?
Obviously genetic risk matters to some degree, but there are also diet and lifestyle changes you can modify to reduce your own risk of heart disease.
I am just going to assume that you don’t smoke: it was never a good idea and it just gets worse with age.
As we’ve discussed elsewhere on this blog, type 2 diabetes starts with insulin resistance, and both are clearly identified as major risk factors for cardiovascular disease, with more profound adverse effects in women than in men. You may have heard that women are to some degree protected from getting heart disease, a protection that only applies before menopause. Whatever cardiac protection is enjoyed by younger women, that advantage disappears for those with diabetes and may even be reversed. It appears that women with diabetes are at greater risk than diabetic men for sustaining a heart attack. Regardless of diabetes, the risk increases for all women past menopause.
You can be reminded in the above-linked articles of strategies for reversing insulin resistance and type 2 diabetes. If you follow health trends, you might be aware of a new online company (Virta Health) that has just published its first paper showing remarkable reversal of diabetes using a low carbohydrate diet and lots of good health supervision! I think every positive change for healthy living can be enhanced with wise and supportive health coaching!
Specific risk factors that are part of diabetes, and independently contribute to heart disease risk include:
- Insulin resistance
- Unfavorable lipid tests
- Blood clotting tendency
- Unhealthy lining of your blood vessels
Obesity is hard to quantify: it’s not just your weight. I was at a CrossFit class with a well-muscled young woman whose doctor told her she was obese, based solely on her height to weight ratio. Her pounds were all in her muscle, she had no extra body fat! So let’s not consider weight.
A much better measure is your waist to height ratio. This is easier to measure than even your weight, and far more reliable. My CrossFit friend is 5’6”(66” tall) and her waist measures 28”, well below half her height. She is at low cardiovascular risk; someone whose waist is larger than half their height is at increased risk.
What is your height? Your waist measurement (at your belly button!) should be less than half that number;
...if it’s over half, you probably have insulin resistance.
Insulin resistance (IR) is the condition in which your insulin levels are higher than optimal, relative to the level of glucose in your blood. IR can be measured in several ways. The simplest calculation relies only on your fasting glucose and fasting insulin levels, and generates a value termed HOMA-IR. (Of course, you have to start by asking your physician to order a fasting insulin level with your routine labs.) Enter the values in this online calculator to see if you’re home free with a HOMA-IR of <1.0 or should be seriously worried with a value > 1.9. Insulin resistance is also calculated on an NMR lipid panel, if your physician orders that rather than a simple lipid panel.
Reversing insulin resistance can be achieved by finding a sustainable low-carbohydrate way of eating.
Less carb calories means you increase your calories from protein and healthy fats.
Exercise can help, but you “cannot outrun a bad diet.”
Wisdom in food choices always comes first; exercise can help.
Lipid panels offer plenty of information, even the simplest. Ideally on that simple lipid panel, your level of triglycerides is <100 mg/dL and your HDL-C is over 60 mg/dL. Genetics plays a role in these numbers, but by far the greatest way to achieve good values on these tests by reading the paragraph above, so scroll back up, it's worth a second ponder.
On a better test such as the NMR Lipid profile, we can look at two critical markers. The overall size of all your lipid-carrying particles are averaged into a direct scale of insulin resistance, called the LP-IR. I like to see values <25, though in some cases up to 45 can be normal. Higher than 45 is never normal; higher than 45 indicates significant insulin resistance. On that same panel we can look specifically at the riskiest type of particle, the smallest lipo-proteins (Small LDL-P) carrying cholesterol. When these small particles are numerous, they can be hazardous to an inflamed blood vessel, more for their size and number, not for the cholesterol they carry.
Blood clotting abnormalities, where there is an increased tendency to clot, make a heart attack or stroke more likely. These changes can be genetic, related to inflammation, or seen in women using oral estrogen.
Proper hormone replacement (topical, bio-identical) is clearly protective when initiated at the transition to menopause.
Starting hormones more than a decade after menopause can help sleep, bone health, and brain health;
it is not clear whether late initiation of hormones can help or even hurt cardiovascular risk.
Inflammation is a risk factor for many diseases, including cardiovascular disease. The simplest measure is fairly commonly done, the hsCRP (highly-sensitive C-reactive protein value, also referred to as “cardiac specific” inflammation.) Additionally, some specialty labs measure more hazardous inflammatory markers such as oxidized LDL particles or Lp-PLA2. All these markers of inflammation respond well to healthy diet and lifestyle choices, sometimes including supplements or adjusting hormone levels.
A low-carb diet, emphasizing more omega-3 fatty acids (fish, eggs, and fish oils)
and less omega-6 fatty acids (vegetable and seed oils, processed foods) can help lower inflammation.
Unhealthy lining of the blood vessels is called endothelial dysfunction. Our blood vessels are lined with a single layer of delicate cells that must withstand forceful impact of our blood circulating and be able to repair themselves if injured. Specialty labs can measure molecules called ADMA and SDMA to reflect the level of health or injury.
Without those special tests, you can normalize your vitamin D levels (ideally through sun and supplements if necessary), and choose foods that are kind to your blood vessels!
Eat lots of leafy greens, and perhaps grate a raw beet onto your salad!
The greens and beets increase your body’s production of nitric oxide which helps us keep healthy blood vessels.
It’s not just diet, exercise and supplements.
Saving the rest and the best for last. I would be leading you astray if I didn’t include what might be the two most important determinants of heart health and health in general.
Find meaning in your life
Sleeping well is (ideally) from dusk or dark til dawn, mostly un-interrupted, in a cool and dark room.
Meaning may be a spiritual community, a great group of exercise friends or a film-appreciation group. You might volunteer for a local organization or donate intentionally to causes you believe in. Having a sense of purpose seems to promote good health and longevity, with a 23 percent reduction in mortality and a 19 percent reduction in cardiovascular events among those people who had meaning to their lives, and felt their lives were worth living.