THE ROLE OF NUTRITION AND CARDIOVASCULAR DISEASES 2024

By Dr Frank Yap, MD -

1. What Causes Coronary Artery Disease?

Coronary artery disease is caused by atherosclerosis which narrows the coronary arteries. Atherosclerosis the process in which deposits of fatty substances, cholesterol, cellular waste products, calcium and other substances build up in the lining of an artery. This build-up is called the plaque.

If the plaques grow large enough they can reduce the blood flow through the artery. But what is more dangerous is that because of the turbulent blood flow created by the plaque, cuts into the inner lining of the artery occur and blood clots form. The blood clots can occlude the artery of break off ane travel to another part of the body.

With a diminished blood supply, the heart muscle cannot function and thus the person will experience angina chest pain and shortness of breath. Initially it is only when the patient exerts himself, but as the narrowing of the coronary artery progresses, the pain will even occur when the patient is at rest. 

Total occlusion of the artery will lead to death of the segment of heart muscles that the artery supplies - leading to myocardial infarction or a "heart attack".


2. Risk Factors for Cardiovascular Disease

Males and people with family history of premature cardiovascular disease have an increased risk of atherosclerosis. Other independent risk factors include:

  • Elevated cholesterol
  • High blood pressure
  • Cigarette smoking
  • Diabetes
  • High homocysteine levels
  • Obesity
  • Stress
  • Family History


a. Elevated Cholesterol

High cholesterol is a health risk for atherosclerosis and heart diseases. The good news is that the risk can be reversed by lowering the cholesterol level in a person. Cholesterol can't dissolve in the blood and has to be transported to and from cells by special carriers called lipoproteins. There are several kinds but the two to focus on are low-density lipoprotein (LDL) and high-density lipoprotein (HDL).


i. What is LDL cholesterol?

Low-density lipoprotein is the major cholesterol carrier in the blood. In excess, it builds up in the walls of the arteries, causing it to form a plaque that can clog those arteries. That is why it is called the "BAD" cholesterol. Lower levels of LDL cholesterol reflect a lower risk of heart disease.


ii. What is HDL cholesterol?

About a-third of the blood cholesterol is carried by HDL. HDL tends to carry cholesterol away from the arteries back to the liver, where it is excreted from the body. Some experts believe that HDL removes excess cholesterol from the plaque and thus slows down their growth. 

HDL cholesterol is hence known as the "GOOD" cholesterol as a high level seems to protect against heart disease. Conversely a low level of HDL (less than 40 mg/ml) indicates a greater risk.


iii. Cholesterol and Diet

The body makes its own cholesterol. In addition, cholesterol is obtained from food: from animal sources such as egg yolk, meat (especially organ meats like liver, brain and kidney), poultry, fish and high fat milk products. We should try to consume less than 300 mg of cholesterol a day.

(Source: Cholesterol, Lowering the Levels (American Heart Association)


b. High Blood Pressure / Hypertension

It is estimated that one every four American adults has high blood pressure. Once high blood pressure develops, it usually lasts a lifetime. 

High blood pressure increases your risk for getting heart disease and/or kidney disease and for having a stroke. It is especially dangerous because it often has no warning signs or symptoms. Regardless of race, age, or gender, anyone can develop high blood pressure. 

A consistent blood pressure reading of 140/90 mmHg or higher is considered high blood pressure, another term for hypertension. 

Adopting healthy lifestyle habits is an effective first step in both preventing and controlling high blood pressure. If lifestyle changes alone are not effective in keeping your pressure controlled, it may be necessary to add blood pressure medications.


i. How did you get hypertension?

Diets high in salt and fat and low in fruits, vegetables, and whole grains predisposes to high blood pressure. It is more common in affluent countries.


ii. What are the symptoms of hypertension?

Hypertension usually causes no symptoms, so over time, damage to your arteries, heart, and brain can occur before the condition is diagnosed. 


iii. How do you prevent high blood pressure from occurring?

You can prevent and control high blood pressure using certain lifestyle factors even if you have a genetic disposition..

  • Follow a healthy eating pattern
  • Reduce salt and sodium in your diet
  • Maintaining a healthy weight
  • Being physically active
  • Limit alcohol intake
  • Quit smoking


iv. What's the right diet for hypertension treatment?

Several studies funded by the National Heart, Lung, and Blood Institute have found that the DASH diet (Dietary Approaches To Stop Hypertension), which is very similar to the Pritikin Eating Plan, lowers blood pressure as well as or better than any drug. 

Both DASH and Pritikin promote menus that are low in fats, salt, cholesterol, red meat, and sweets; high in fruits, vegetables, whole grains, and beans; and moderate in seafood, poultry, nuts, and low-fat or non-fat dairy foods. (3)

(3) National Heart Blood and Lung Institute Guide


c. Smoking

Many studies detail the evidence that cigarette smoking is a major cause of coronary heart disease, which leads to heart attack. 

These include fatty build-ups in arteries, several types of cancer and chronic obstructive pulmonary disease (lung problems). Atherosclerosis (build-up of fattysubstances in the arteries) is a chief contributor to the high number of deaths from smoking. (4)

(4) American Heart Association Scientific Position - Cigarette Smoking & cardiovascular Disease


d. Diabetes

Diabetes can lead to many health problems including cardiovascular diseases. Both type 1 diabetes and type 2 diabetes are independent risk factors for Coronary Heart Disease. (5,6,7)

(5) Wilson PW, D'Agostino Ril. Levy D. Belanger AM, Silbershatz H. Kannel WIB. Prediction of coronary heart divesse using risk factor categories. 1998 May 12:97(18):1837-47,

(6) Wilson PW Diabetes mellitus and coronary heart disease. Am | Kidney Dis. 1998:32:589-5100

(7) McGill HCJ. McAlahan CA. Determinants of atherosclerosis in the young Parhobiological Determinants of A erosclerosis in Youth (PDAY) Research Group. Am J Cardiol. 1998,82-30T-367.


3. Symptoms of Cardiovascular Disease

a. Coronary Heart Disease

Angina Pectoris --> Shortness of breath, sweating, dizzy

Unstable angina --> Chest pain at rest, palpitations, sweating

Heart Attack --> extreme chest pain, sweating, cardiac arrest, death, and heart failure

b. Cerebrovascular Disease

Mini stroke --> one sided weakness, loss of speech for minutes

Stroke --> one sided weakness, facial weakness, and difficulty in swallowing

c. Peripheral Vascular Disease

Intermittent claudication --> pain on walking, pale, poor foot pulses Gangrene pain, ulcers, gangrene.


4. The Role of Nutrition on Cardiovascular Diseases

The role of nutrition is crucial in preventing cardiovascular diseases. A healthy diet will lower the risk of the major risk factors such as elevated cholesterol, high blood pressure, obesity and diabetes. 


a. Cholesterol Lowering Diet

Listed below is a very good and practical diet to keep your cholesterol in check (8). It limits the amount of fats consumed (especially saturated fats) and advocates lots of fruits and vegetables.

Don't be too harsh on yourself. Attempt the easy changes first, such as skinning the chicken, or eating a slice of fruit to replace a fatty snack. Drastic and sudden changes to one's diet are often accompanied by failure and return to the former dietary habits. Accept that there will be occasional lapses, but don't be harsh on yourself for indulging occasionally.

i. Decreased total fat/oil

Modify cooking methods grill/steam/boil/microwave/bake reduce use of oil and fats

ii. Avoiding saturated fat

Butter, hard margarine, whole milk cream, high fat cheese, fatty meals, bacon and sausages, coconut oil, santan, products containing hydrogenated oils like coffee whitener, 

iii. Mono and polyunsaturated oils/margarine

Not more than 2 tablespoons per day (including the amount in products based on these)

Examples include olive oil, sunflower oil, corn oil, palm oil, soybean oil, peanut oil, polyunsatured margarine

iv. Increased intake of food high in protein but low in saturated fat

Skinned chicken, fish, bean curd (tofu, egg white, legumes)

v. Increased intake of complex carbohydrates, increased fruit, vegetables and legumes for fibre

20-25gm fibre/day, half derived from fruit and vegetables

All fruits, fresh vegetables, legumes (lentils, peas, beans), unrefined cereals including oats, wholemeal flour, tubers

vi. Decreased dietary cholesterol

<300 mg/day

Allow up to 2 egg yolks per week. Avoid organ meat like liver, heart, brains kidney.

Allow a small/reduced amount of prawns/crabs/oysters/cockles once or twice a week


b. Lowering Blood Pressure

Research has shown that following a healthy eating plan can both reduce the risk of developing high blood pressure and lower an already elevated blood pressure.

For an overall eating plan, consider the DASH eating plan. "DASH" stands for "Dietary Approaches to Stop Hypertension," a clinical study that tested the effects of nutrients in food on blood pressure. 

Study results indicated that elevated blood pressures were reduced by an eating plan that emphasize fruits, vegetables, and low-fat dairy foods and is low in saturated fat, total fat, and cholesterol. The DASH eating plan includes whole grains, poultry, fish, and nuts and has reduced amounts of fats, red meats, sweets, and sugared beverages.

A second clinical study called "DASH-Sodium", looked at the effect of a reduced dietary sodium intake on blood pressure as people followed either the DASH eating plan or a typical American diet. Results showed that reducing dietary sodium lowered blood pressure for both the DASH eating plan and the typical American diet. The biggest blood pressure-lowering benefits were for those eating the DASH eating plan at the lowest sodium level (1,500 milligrams per day).


c. The DASH Diet

The DASH eating plan shown below is based on 2000 calories a day. The number of daily servings in a food group may vary from those listed depending on your caloric needs.

i. Grains & grain products

7-8 servings, each serving consisting of..

  • 1 slice bread
  • 1 cup ready-to-cat cereal
  • 1/2 cup cooked rice, pasta, or cereal

ii. Vegetables

4-5 servings, each serving consisting of..

  • 1 cup raw leafy vegetable,
  • 1/2 cup cooked vegetable,
  • 6 ounces vegetable juice

iii. Fruits

4-5 servings, each serving consisting of..

  • 1 medium fruit, 1/4 cup dried fruit
  • 1/2 cup fresh, frozen, or canned fruit
  • 6 ounces fruit juice

iv. Low-fat or fat free dairy foods

2-3 servings, each serving consisting of..

  • 8 ounces milk
  • 1 cup yogurt
  • 1/2 ounces cheese

v. Lean meats, poultry, and fish

2 or less servings, each serving consisting of 3 ounces cooked lean meats, skinless poultry, or fish.

vi. Nuts, seeds, and dry beans

4-5 servings per week, each serving consisting of..

  • 1/3 cup or 1/2 ounces nuts
  • 1/2 cup cooked dry beans
  • 1 tablespoon or 1.2 ounce seeds

vii. Fats & oils

2-3 servings, each serving consisting of..

  • 1 teaspoon soft margerine
  • 2 tablespoons light salad dressing
  • 1 teaspoon vegetable oil

viii. Sweets

5 servings per week, each serving consisting of..

  • 1 tablespoon sugar
  • 1 tablespoon jelly or jam
  • 1/2 ounce jelly beans
  • 8 ounce lemonade


5. Best Supplements for Cardiovascular Disease

a) Garlic

Four meta analysis of clinical trials of garlic on humans show that it has cholesterol lowering effects of between 8-15%. (9, 10, 11, 12) Studies have also shown that garlic has anti-clotting properties for heart protection - by its fibrinolytic activity (clot breaking) (13, 14) and inhibition of platelet aggregation (clot forming). (15, 16)

(9) Silage C & Neil, A. Garlic as a lipid lowering agent - a meta-analysis. J R Coll Physician Lond 1994, 28:39-45

(10) Warshafiky, S et al. Effect of garlic on total serum cholesterol - A meta-analysis. Ann Intern Med 1993, 119.599-605

(11) Neil, HA et al. Garlic powder in the treatment of moderate hyperlipidemia: a controlled trial and meta analysis. I R Coll Physicians Lond 1996, 30:329-334

(12) Stevinson, Cet al. Garlic for treating hypercholesterolemia. A meta-analysis of randomized clinical triala. Ann Intern Med 2000, 133-420-429

(13) Bordia, AK et al. Effect of essential oil of garlic on serum fibrinolytic activity in patients with coronary artery dis case. Atherosclerosis 1977, 28:155

(14) Chutani, SK et al. The effect of fried versus raw garlic on fibrinolytic activity in man. Atherosclerosis 1988, 38-417-421

(15) Bordia, A. Effect of garlic on human platelet aggregation in vitro. Atherosclerosis 1978, 30-355-360

(16) Kiesewetter, 11 et al Efect of garlic on thrombocyte aggregation, microcirculation, and other risk factors. Int J Clin Pharmacol Ther Toxicol 1991, 29:151-155

b) Fibre

Our average diet contains about 10-15 grams of fibre, less than half of the 30 grams of fibre recommended by most dieticians and doctors. This is because of industrialization, we eat a lot of our grains processed and milled instead eating wholegrain with the fibre intact.

c) Lecithin

Lecithin is a component of a number of foods. Many of the positive effects of lecithin consumption are based on the fact that lecithin is a major source of choline. 

Choline is a lipotropic substance (affinity for binding fat) which functions in the body as an agent in the digestion of fats. It is believed that choline helps the body to burn fat, and thereby acts as a catalyst for weight loss. As choline increases fat metabolism it is also believed to lower cholesterol.

Choline is also part of the neurotransmitter acetylcholine. A sufficient intake of choline, primarily via the intake of lecithin is believed to have some positive effects on some mental functions especially those connected to memory. 

Lecithin sold as a supplement is usually extracted from soybean. Another prime source of lecithin is egg yolk.

d) Antioxidants

Antioxidants may be useful for cardiovascular diseases. They prevent oxidation of the bad cholesterol the leads to blockage of the arterial walls. (17, 18, 19)

(17) www.americanheart.org (antioxidant vitamins)

(18) Bear. M et al Secondary prevention with antioxidants of cardiovascular disease in enditage renal disease (SPACE randomized placebo.controlled trial. The Lancet, October 7, 2000 Vol 356 1213-1217

(19) Stephens, NG Randomised Controlled Trial of Vitamin E in patients with Coronary Duesse: Cambridge Heart Antioxidant Study (CHAOS) The Lancet, March 23, 1996. Vol 347;781-785

e) Omega 3

Clinical trials have shown that omega-3 fatty acid supplementation can reduce the risk of heart disease. (20)

  • Reduces risk of heart attacks (21)
  • Reduces triglycerides (22)
  • Mildly reduces blood pressure (23)
  • Decreases risk of arrhythmias, which can lead to sudden death (24)
  • Prevents clots (anti-thrombotic effects) (25)
  • Stroke (26)

(20) Kris Etherton et al. ALIA Scientific Statement. Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease. Circulation 2002, 106: 2747

(21) Bucher, IIC et al. N-3 polyunsaturated fatty acids in coronary heart disease a meta analysis of randomized con trolled trials. Am | Med. 2002; 112:298-304

(22) Harris, WS. N-Fatty acids and serum lipoproteins human studies. Am | Clin Nutr. 1997, 6015 suppl) 16455-16545

(23) Morris, MC et al. Does fish oil lower blood pressure? A meta-analysis of controlled trials Circulation 1993; 88:523-533

(24) Hallaq 11 et al. Modulation of dihydropyridine-sensitive calcium channels in heart cells by fish oil fatty acids Proc Natl Aca Sci USA.92; 89:1760-1764

(25) Mori, TA et al, Interactions between dietary fat, fish and fish oils and their effects on platelet function in men at risk of cardiovascular disease. Arterioscler Thromb Vasc Biol 1997, 17:279-286

(26) Keli, 50 et al. Fish consumption and risk of stroke: the Zutphen Study, Stroke 1994, 25:328-332

g) B-Complex Vitamins

High plasma homocysteine level is an independent risk factor for cardiovascular diseases. 

A survey (meta-analysis) of 12 studies reports a 25% reduction in plasma homocysteine concentration with a mean supplementation of 0.5 mg to 5.7 mg folic acid per day, and additional 7% lowering has been observed after the addition of vitamin B12 (mean 0.5 mg). (27) The effect of vitamin B6 in lowering homocysteine is less remarkable.

(27) Lowering blood homocysteine with folic acid based supplements: meta-analysis of randomised trials. Homocysteine Lowering Trialists' Collaboration. BMI. 1998,316:894-898

h) Gingko

It has been traditionally used to promote blood circulation and to promote good health. Studies show that gingko inhibits blood cells from sticking together, thus preventing the formation of blood clots that can lead to heart attack or stroke. (28)

(28) Mindell, E. Earl Mindells Anti-Aging Bible 1996. A Fireside Book Published by Simon & Schuster page 86-87

i) CoEnzymeQ10

Coenzyme Q10 is a fat-soluble vitamin-like substance found in every human cell and is essential in facilitating in providing the cells with energy. Lowered CoQ10 has been observed in patients with cardiac failure. Some studies has been done in patients with congestive cardiac failure and angina but the numbers of patients is small and of short duration.

Benefits include..

  • Heart disease
  • Angina
  • Antioxidant benefits
  • Healthy blood pressure and cholesterol

j) L-Carnitine

L-carnitine is found in the heart and skeletal muscles. Its primary job is to carry activated fatty acid across the mitochondria - the powerhouse of the cell that provides energy to the heart and skeletal muscle cell. 

Deficiency of L-carnitine is rare but enthusiasts claim that it protects against heart disease and can improve endurance and stamina during exercise, and promote it as an aid for weight loss.

Benefits include..

  • Protects against heart disease
  • Improves stamina
  • Helps burn fat during exercise


Related Articles

Low-Carb Diets: What You Need to Know

Antioxidant Supplements For Heart Disease


Sources

3. National Heart Blood and Lung Institute Guide

4. American Heart Association Scientific Position - Cigarette Smoking & cardiovascular Disease

5. Wilson PW, D'Agostino Ril. Levy D. Belanger AM, Silbershatz H. Kannel WIB. Prediction of coronary heart divesse using risk factor categories. 1998 May 12:97(18):1837-47,

6. Wilson PW Diabetes mellitus and coronary heart disease. Am | Kidney Dis. 1998:32:589-5100

7. McGill HCJ. McAlahan CA. Determinants of atherosclerosis in the young Parhobiological Determinants of A erosclerosis in Youth (PDAY) Research Group. Am J Cardiol. 1998,82-30T-367.

8 Malaysian Consensus Statement on Management of Hyperlipidaemia 1997

9. Silage C & Neil, A. Garlic as a lipid lowering agent - a meta-analysis. J R Coll Physician Lond 1994, 28:39-45

10. Warshafiky, S et al. Effect of garlic on total serum cholesterol - A meta-analysis. Ann Intern Med 1993, 119.599-605

11. Neil, HA et al. Garlic powder in the treatment of moderate hyperlipidemia: a controlled trial and meta analysis. I R Coll Physicians Lond 1996, 30:329-334

12. Stevinson, Cet al. Garlic for treating hypercholesterolemia. A meta-analysis of randomized clinical triala. Ann Intern Med 2000, 133-420-429

13. Bordia, AK et al. Effect of essential oil of garlic on serum fibrinolytic activity in patients with coronary artery dis case. Atherosclerosis 1977, 28:155

14. Chutani, SK et al. The effect of fried versus raw garlic on fibrinolytic activity in man. Atherosclerosis 1988, 38-417-421

15. Bordia, A. Effect of garlic on human platelet aggregation in vitro. Atherosclerosis 1978, 30-355-360

16. Kiesewetter, 11 et al Efect of garlic on thrombocyte aggregation, microcirculation, and other risk factors. Int J Clin Pharmacol Ther Toxicol 1991, 29:151-155

17. www.americanheart.org (antioxidant vitamins)

18 Bear. M et al Secondary prevention with antioxidants of cardiovascular disease in enditage renal disease (SPACE randomized placebo.controlled trial. The Lancet, October 7, 2000 Vol 356 1213-1217

19 Stephens, NG Randomised Controlled Trial of Vitamin E in patients with Coronary Duesse: Cambridge Heart Antioxidant Study (CHAOS) The Lancet, March 23, 1996. Vol 347;781-785

20 Kris Etherton et al. ALIA Scientific Statement. Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease. Circulation 2002, 106: 2747

21. Bucher, IIC et al. N-3 polyunsaturated fatty acids in coronary heart disease a meta analysis of randomized con trolled trials. Am | Med. 2002; 112:298-304

22. Harris, WS. N-Fatty acids and serum lipoproteins human studies. Am | Clin Nutr. 1997, 6015 suppl) 16455-16545

23. Morris, MC et al. Does fish oil lower blood pressure? A meta-analysis of controlled trials Circulation 1993; 88:523-533

24 Hallaq 11 et al. Modulation of dihydropyridine-sensitive calcium channels in heart cells by fish oil fatty acids Proc Natl Aca Sci USA.92; 89:1760-1764

25. Mori, TA et al, Interactions between dietary fat, fish and fish oils and their effects on platelet function in men at risk of cardiovascular disease. Arterioscler Thromb Vasc Biol 1997, 17:279-286

26. Keli, 50 et al. Fish consumption and risk of stroke: the Zutphen Study, Stroke 1994, 25:328-332

27. Lowering blood homocysteine with folic acid based supplements: meta-analysis of randomised trials. Homocysteine Lowering Trialists' Collaboration. BMI. 1998,316:894-898

28. Mindell, E. Earl Mindells Anti-Aging Bible 1996. A Fireside Book Published by Simon & Schuster page 86-87

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