Understanding Heart Disease
Recognizing the causes of Heart Disease
Atherosclerosis starts with recurrent injury of our blood vessels that leads to cholesterol or lipid deposition and scarring that occurs over many cycles of injury and healing throughout our life. The cholesterol or lipids that get deposited in the walls of our blood vessels and become oxidized and toxic to the cells and tissue around it.
Based on the concept of chronic recurrent injury to the blood vessel the causes of heart disease are forms of chronic injury including:
• High blood pressure
• Smoking
• High cholesterol
• Poor diet
• Lack of exercise
• Obesity
• Environmental causes – pollution
• Elevated blood sugar including prediabetes and diabetes
• Genetics that result in abnormal lipid levels or increased cholesterol levels
Based on the concept that a heart attack is due to increased inflammation and clotting at the site of fatty atherosclerotic lesions, elements that can increase the risk of a heart attack include:
• Autoimmune diseases such as lupus
• Inflammatory Bowel Diseases including Crohn’s and Ulcerative Colitis
• Arthritis such as Rheumatoid and Psoriatic
• Respiratory viruses including Influenza and Covid
• Oral gum disease
• Diabetes
• Elevated lipid known as Lp(a)
How to Prevent Heart Disease
Prevention of heart disease can be thought in a variety of ways.
For patients who have no evidence of heart disease, the goal is true prevention – prevent “hardening of the arteries.” For most of patients at this stage, assuming they do not have a strong family history of early heart attacks or strokes, the focus is on lifestyle. Keeping active, eating the right foods and minimizing weight gain.
Keeping Active:
The goal for activity is twofold.
On one side cardio workouts such as running, biking and swimming are critically important to maintaining cardio-pulmonary function, endurance and general health. They are also a good weight to burn calories and keep weight off as well.
On the other side, resistance training, such as weight training, pushups, pullups, swimming and yoga build muscle. Muscle tissue is how we optimally manage our blood sugar and insulin levels. It also strengthens our core muscles which enhances our health span as we age. Thus, maintaining (during dieting) and building muscle is an optimal approach to minimizing cardiometabolic disease now and as we age.
Eating the right foods:
In a society with such easy access to food, eating should be divided into two topics: what we eat and how we eat.
What we eat has become a confusion topic for many given the myriad of diets that are discussed in the public. Certainly, the number of calories consumed is important, but equally important is the quality of the food. Critical is to what extent and how rapidly the food that is consumed induces insulin release and what is the current level of sugar storage in the liver (see below on how we eat).
Here is a simple example, oats are considered a superfood, packed with fiber and nutrients, lower cholesterol levels, have a low glycemic index (low insulin release) and keep us full longer. The same cannot be said for instant oats. Due to the processing (think of this a partial digestion), instant oats have lower fiber content, high glycemic index, do not slow our digestion and do not keep us full for long, and worse yet, often have a sugar-based flavor packet that significantly worsens the nutritional benefits of the overall meal.
By the same analogy, raw vegetables are good to eat. While they may be rich in carbohydrates, the carbohydrates are complex and our body is often unable to digest the fiber made up of complex carbohydrates, so that we do not absorb these sugars as we eat them (low glycemic index, not much insulin release). However, when we cook them, and depending how long we cook them, these fibers breakdown before we eat them. Therefore, more of the sugars contained in the vegetables are available for us to absorb (high(er) glycemic index).
How we eat:
How we eat can in many ways be as important as what we eat. We did not evolve during a time when we had easy access to food. Furthermore, we had to work for our food, whether it be hunting or farming. For this reason, our body is extremely efficient at storing the energy in our meals. Much of this is regulated by the release of insulin when we eat sugars. There is only one organ in our body that can store sugar and release it when we need it (late at night when we are sleeping), and that is the liver. Our livers store sugar as a macromolecule known as glycogen. As our blood sugar drops, the liver breaks down the glycogen into glucose and releases it into the blood stream. When we eat, in response to the insulin released, our liver takes up glucose and stores it as glycogen. Empty, our liver will use 60%+ of our insulin to store most of the sugar in a meal. This system works great, unless our liver is already full.
If the liver is full, all the sugar from a meal will go into our blood stream and be taken up by fat and muscle. Insulin taken up by fat leads to more triglyceride storage in the fat tissue, insulin in muscle leads to sugar being stored and used by muscle.
• So why does intermittent fasting work, it gives the body time to empty the liver of glycogen so that during the time we eat, most of the sugar will end up in the liver.
• Why does having more muscle mass work, greater metabolic rate that uses up more insulin limiting fat uptake of triglycerides.
• Why is regular exercise, walking, or moving important, it mobilizes the glycogen in the liver.
• Why is eating and snaking ultra processed foods bad? The liver is full, insulin is released and the high sugar load goes into the blood stream.
Summary:
While in some respects overly simplified, based on the comments above, one can understand what we eat and how we go about eating together determine how food will lead to weight gain and risk of heart disease. As a final comment, one should recognize that the combination of the food on one’s plate determines the overall effect it will have.
For example, if one has a choice of a 500 kcal steak and a sugared soda (120 kcal) or a 1000 kcal steak and a glass of water, many will say the smaller steak with the soda is better, after all, it is 380 kcal less. While a logical conclusion, the real issue is that the sugared soda will lead to rapid insulin release and significantly alter how the 500 kcal steak is digested compared to the 1000 kcal steak with water.
This example aside, it is important to recognize that moderating red meat intake clearly is an important part of any strategy to limit heart disease.
For patients who have evidence of heart disease, such as a prior stent, bypass or a heart attack, or a diabetic without a history of heart disease, the lifestyle habits discussed above are very relevant, but medical therapy and additional diagnostic testing to make sure that prevention is maximally affective are necessary.