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Cholesterol Doesn't Tell The Whole Story

Q: I'm a 50-year-old man, I'm 10 pounds overweight, my cholesterol is a little high and my father had a fatal heart attack in his late 50s. My doctor recommends that I either go on a rigid low-fat diet or take a "statin" type cholesterol-lowering drug to lessen my risk of a heart attack. But are there other reasons, besides cholesterol, that cause arteries to harden with plaque and cause people to get heart attacks?
A: Good question. It's important to look beyond cholesterol to other very relevant factors - particularly nutritional - relating to heart disease. It is something I wish more physicians would do: It might lessen our obsession with cholesterol-lowering drugs. I believe in lowering cholesterol levels, but did you know that approximately half the number of heart attacks occurs in people who do not have high cholesterol levels? So, you see how critical it is to look beyond cholesterol if you are interested in protecting your heart and arteries.
     There are several reasons why heart attacks occur. If your platelets (one type of white blood cell involved in the process of clotting) become too sticky - that is, if they adhere too readily to each other or to rough, irregular surfaces in your arteries, like a plaque - they will clump together and form a clot or thrombosis inside an artery. If this happens in one of your coronary arteries, the blood flow and oxygen supply to the corresponding part of your heart will be injured, possibly irreversibly, which is what a heart attack is.
     But there are several populations in the world with significant plaque in their arteries (Greenland Eskimos, Somalis, Masai, and the Udaipur of northern India) who have a very low incidence of heart attacks. These populations, incidentally, have a very high-fat diet. So did Americans at the beginning of this century. We ate as much saturated fat then as Americans did in 1961, when deaths from heart attacks in this country were near an all-time high - well over 500,000 deaths annually. But heart attacks in the USA were a rare event in 1900.
     One primary difference in the diet between then and now is the rampant use of partially hydrogenated vegetable oil, introduced early in the century. This oil is the result of a process requiring intense heat, which chemically changes what would normally be a liquid oil at room temperature to a solid, and as a result creates what are called trans fatty acids.
     Trans fatty acids alter the balance of prostaglandins, an extremely important class of hormones in the body. There are favorable and unfavorable prostaglandins, and the kinds of fat in our diet largely control this balance. Too much partially hydrogenated oil will favor the bad prostaglandins. This makes your platelets too sticky and makes your coronary arteries far more susceptible to spasm, another common cause of heart attacks, even in individuals who do not have plaque or elevated cholesterol levels. So these oils can assault your heart by two mechanisms. You will find hydrogenated vegetable oil on the labels of hundreds of foods: margarine, mayonnaise, bread, crackers, cookies, muffins, mixes, cereals, chips, frozen foods, candy bars and artificial creamers. The list goes on and on. According to many nutritional experts, partially hydrogenated oil is one of the most damaging substances in our diet. You can find packaged foods that lack this type of oil, but you may need to shop in a health food store or locate a supermarket that has a natural foods section.
     Sugar also renders platelets more sticky, and you know how sugar permeates our diet. In the United States, some estimates report refined sugar consumption average to be over 130 pounds per person per year. This is another substantial difference in our diet today compared to 1900. Sugar also can raise blood levels of triglycerides and lower the levels of the favorable HDL cholesterol, increasing susceptibility to heart attacks.
     Another factor behind heart attack is a lack of essential nutrients in our refined diets. For instance, white flour, even enriched, lacks magnesium (and a host of other important nutrients nature endowed whole grains with). It just so happens that a lack of magnesium contributes to platelet stickiness and coronary artery spasm, as well as rendering the heart far more susceptible to dangerous rhythm disturbances - all of which can lead to heart attacks. The lack of magnesium also increases the chance of stress-induced heart attack. If you consume very little fruit or vegetables, the resultant lack of vitamin C will also make your platelets sticky.
     The condition of the heart itself, an incredible muscle, can also directly play a role in susceptibility to a heart attack. With inefficient metabolism, it has a lower tolerance for oxygen deprivation and therefore is more likely to incur injury under stress. This will happen with insufficient vital metabolic nutrients such as magnesium, vitamin B6, copper, selenium, coenzyme Q-10, L-carnitine and taurine. A sedentary lifestyle may also render the heart less tolerant of oxygen deprivation.
     There's also a widely held theory that it's not ordinary LDL cholesterol that causes plaque formation, but LDL cholesterol that has been damaged by oxidization. This damage might be caused by certain forms of cooking, for instance in the scrambling of an egg in the frying pan instead of boiling it in the shell. Exposure to oxygen in the presence of high heat will damage the cholesterol in the yolk. (I recommend soft-boiled or poached eggs -the safest way to eat eggs, even for heart patients)
     Fats and oils also are subject to oxidation inside the body, more so if antioxidant nutrients are deficient. Several years ago, a World Heath Organization study demonstrated that the incidence of death from heart attack correlated best with vitamin E deficiency. When beta-carotene and vitamin C deficiencies were factored in, the correlation was even higher. It was suggested that these nutrient deficiencies were possibly more important risk factors for fatal heart attacks than the traditional ones: high cholesterol, high blood pressure, diabetes, cigarette smoking and obesity. Cardiologists are finally beginning to prescribe vitamin E.
     In recent years, another important cause of heart attacks has surfaced: elevated levels of homocysteine. (Actually, we have known about the importance of homocysteine for nearly twenty-five years, but it can sometimes take this long, or longer, for important medical discoveries to accepted.) This is an amino acid metabolic byproduct in the body that normally should be converted into another byproduct. However, this next biochemical step requires certain nutrients to catalyze or "push" the reaction. With insufficient amounts of folic acid and vitamins B6 and B12, the reaction cannot proceed, and homocysteine will accumulate to levels that are toxic to arteries and initiate plaque formation. Vitamin B6 is one of the vitamins most easily lost through cooking and processing. Folic acid comes in deep green leafy vegetables (kale, collard, bok choy, chard, etc.), not the usual fare of most Americans. Elevated homocysteine levels can easily be detected by a blood test. (You might also be aware that elevated homocysteine is linked as well to various cancers, dementia and other forms of cognitive decline, osteoporosis, and other parameters of accelerated ageing. So by lowering homocysteine levels you will protect far more than your cardiovascular system.)
     In recent years cardiologists at Harvard and elsewhere have advanced the concept that arteriosclerosis is primarily an inflammatory disease, that the build-up of plaque is not simply a result of too much fat and cholesterol in the blood, but the body's attempt to heal over or repair an injury to the inner wall of arteries. We have used a blood test for decades to measure the degree of inflammation in the body (CRP or C reactive protein). However, a refined version of this test, high sensitivity CRP or cardio CRP, has been developed to measure the degree of arterial inflammation. Although the test isn't perfect (it may be high due to other forms of inflammation like rheumatoid arthritis), it is now considered to be the most predictive test for heart attacks and strokes. It certainly is not meant to replace cholesterol screening or other cardiovascular tests, but enhances our risk assessment for heart attacks and strokes.
     One possible trigger for arterial inflammation and arteriosclerosis is infection. If you think it was a stretch for the medical profession to embrace the homocysteine theory of heart disease and then the inflammatory theory of heart disease, one of the more difficult leaps has been to embrace the theory of arteriosclerosis as an infectious disease and to treat individuals with arterial plaque with as something as simple as antibiotics. Enough studies have shown the presence of the bacteria, chlamydia pneumoniae, residing in the plaques of arteries that some physicians now prescribe a course of antibiotics for their patients with known arteriosclerosis -- to prevent heart attacks and strokes. Other organisms have also been implicated (mycoplasma pneumoniae, helicobacter pylori, cytomegalo virus, and Epstein Barr virus). As infection is a well-known trigger of inflammation and increased free radical pathology, we can begin to see the connections between many of the "newer" suggested cofactors for arterial disease.
     When you realize the diversity of mechanisms that can lead to a heart attack, you can begin to appreciate that many variables need to be addressed - not just the most well publicized one of lowering blood cholesterol levels.

This information is provided for educational purposes only and is not intended as a substitute for professional advice. Although the material may help you understand a diagnosis or treatment, it cannot serve as a replacement for the services of a licensed health care practitioner. Any application of the material set forth is at the reader's discretion and sole responsibility.

Email your questions for Dr. Golan to use a subject for his website article.

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