Changes in Diet and Exercise Better Than Prescription Drugs for Preventing Heart Attack Recurrence

Heart disease is an ailment of modern civilization and behavior – and it's one, therefore, that can be treated effectively and with dramatic results by making fairly simple lifestyle changes. People in African villages do not need bypass operations. Studies have consistently shown that rates of heart disease are higher in Western cultures, that heart disease rates go up in countries that adopt Western diet and lifestyles, and that modifications of diet reduce heart disease. Some of the differences may not be attributable to the diet per se, but rather to how food is raised and the industrialization of American agriculture (eg the effects of corn fed versus pasture fed animals). However it is clear that the majority of heart disease is caused by factors associated with Western Civilization, such as poor diet and a lack of exercise.

There are also "non-medical" factors not directly related to lifestyle that increase the risk for heart disease, like low income, lack of social support, depression, marginalization in society, and stress in childhood. I can not fix all of these social ills with this book, but I just want you to understand that it is not as simple as a "one disease, one pill" kind of thing.

Exercising for just 30 minutes a day reduces your risk of developing heart disease by 30%. This can include anything from running, playing tennis, or just vigorous walking. And there is no need to obtain a minimal heart rate. If you are older and do not run or play a sport you should incorporate a daily 30 minute walk into your routine. That is better for you than statins by any measure. And there are no hidden side effects of exercise that we do not know about yet, other than spraining your ankle.

If you have risk factors and do not yet have heart disease, you should address them. Improving your diet will help you lower cholesterol and prevent heart disease. In fact, following the low fat diet advocated by the National Cholesterol Education Program lowers LDL cholesterol equally well as treatment with a statin, with no side effects (Jenkins et al 2005).

The so-called Mediterranean Diet (vegetables, legumes, fruit, cereals, and fish) reduces heart disease risk and prolongs life (Trichopoulou et al 2005). Patients with heart disease who followed the Mediterranean diet had a 50-70% reduction on recurrent heart attacks (de Lorgeril et al 1999). These results are twice as good as any medication.

It's a pretty simple diet to follow over the long term. Eat at least one serving of fruit every day, which I define as one apple, one banana, one peach, one cup of blueberries, and so on. Have three or four servings of vegetables every day – a cup of broccoli, two or three cups of leafy greens, a cup of tomatoes, etc. Five to seven one cup or 2 ounce servings of whole grains, beans, and starch such as cracked wheat, whole-wheat pasta, lentils, and sweet potatoes should also be consumed on a daily basis. Meat and other animal proteins, like eggs and dairy, should be limited to once or twice a week. People who followed this diet had mortality cut in half over a four year time period. This diet substitutes unsaturated fats (olive and nut oils) for saturated fats (butter, animal fat), and also includes wine and nuts. In fact, olive oil has been shown in laboratory studies to improve endothelial function (Translation: increases the flexibility of your coronary arteries, which can be beneficial for reducing your risk of heart attacks).

You may have heard about the recent Women's Health Initiative (WHI) study which showed that a low fat diet did not reduce heart disease (Howard et al 2006). The problem with that study is that it lumped all fats together. We now know that some fats are better than others. For example there are fats in things like olive oil and fish that actually promote good health. As an example of that, the generic low fat diet of WHI reduced LDL cholesterol by only 10 points, whereas a diet high in fruits and vegetables, soy, and nuts, and low in animal fat, dropped cholesterol by 30%, which was equivalent to the effects found with a statin (33%) (Jenkins et al 2005).

The low carb diet does not prevent heart disease. Look at the doctor who developed it-he died of a heart attack. Women from the Nurse's Health Study (82,802) filled out questionnaires about diet and then were followed for 20 years. Low carbohydrate intake was not associated with reduced heart disease. Eating a high sugar diet increased the risk of heart disease by 90%. High vegetable intake was associated with a 30% reduction in heart disease (Halton et al 2006).

Eating fish is good for your heart; beware of eating a lot of fish high in mercury (a pollutant that gets into fish), like swordfish and tuna, during pregnancy, as it can cause birth defects. Foods that are a part of the Mediterranean diet like fish, olive oil, and nuts, increase "good" HDL cholesterol and reduce the "bad" LDL cholesterol. These foods are high in omega-3 fatty acids (like docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) and low in omega-6 fatty acids). It is often pointed out that ancient diets had a ratio of omega-3 to omega-6 of 1: 1 whereas current diets have much higher amounts of omega-6, largely through the substitution of calories in the forms of leafy plants with grains and seeds.

When I was a medical student at Duke in 1985, I distinctly remember sitting on the front porch of my house in Durham, North Carolina, and reading The New England Journal of Medicine, where an article described how the Inuit people of the Arctic, who had a diet high in fish and low in meat, had much lower rates of heart disease. That observation led to the idea that the omega-3 fatty acids in fish prevented heart disease, which naturally led aggressive marketers to try and put it in a pill or a bottle and sell it. However there is a lot of stuff in fish and it is not clear what it is exactly you get out of it in terms of health benefit (or what you avoid by eating fish instead of other stuff).

de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N (1999): Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: Final report of the Lyon Diet Heart Study. Circulation 99: 779-785.

Halton TL, Willett WC, Liu S, et al (2006): Low-carbohydrate-diet score and the risk of coronary heart disease in women. New England Journal of Medicine 355: 1991-2002.

Howard BV, Van Horn L, Hsia J, al. e (2006): Low-fat dietary pattern and risk of cardiovascular disease: The Women's Health Initiative randomized controlled dietary modification trial. Journal of the American Medical Association 295: 655-666.

Jenkins DJ, Kendall CW, Marchie A, et al (2005): Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants. American Journal of Clinical Nutrition 81: 380-387.

Trichopoulou A, Orfanos P, Norat T, et al (2005): Modified Mediterranean diet and survival: EPIC-elderly prospective cohort study. British Medical Journal 330: 991-998.