A Heart Healthy Lifestyle
February is American Heart Month and chances are you know at least one person with heart
disease. Cardiovascular disease (CVD) is an umbrella term for all conditions affecting the heart and blood vessels. About 1 in 3 deaths in the United States are due to cardiovascular disease.
Conventional nutrition guidelines (less saturated fat, dietary cholesterol, and salt and more
unsaturated fats and grains) for reducing the risk of cardiovascular disease are controversial and have undergone significant criticism throughout the years. The key is to understand what causes cardiovascular events (such as a heart attack or stroke) or death rather than what is only associated with an elevated lab value. Choosing what to eat is a decision we face every day, and we make choices based on many factors (health, finances, taste, cravings, convenience, etc.). It is often difficult to know whether our food choices are supporting or undermining our health, so let’s unpack what we do and don’t know about reducing our risk for cardiovascular disease.
It is well established that chronic stress negatively effects our health, especially our
cardiovascular system. One study estimates that “mental stress, for instance, is able to raise cholesterol by 10-50% in the course of half an hour.” (1) Chronic stress can cause high blood pressure and is associated with an increased risk of cardiovascular events. Surprisingly, social isolation is predictive of mortality equally or better than many standard risk factors such as high cholesterol (2). Therefore, it is essential to consider the potential impacts that mental stress and trauma have on someone’s physical health.
A lack of quality sleep is a significant “physical” stress on the body. Sleep apnea, for instance, raises the risk of heart failure by 140% and risk of coronary heart disease by 30%. 3 Adults need roughly 8 hours of restful sleep, but the average American gets less than 7.
Most people know that smoking is the main cause of lung cancer and COPD, but did you know that 1 in every 4 deaths from cardiovascular disease is attributed to smoking? Chemicals in cigarette smoke damage blood vessels, causing inflammation and an increased risk of atherosclerosis, stroke, peripheral arterial disease, and abdominal aortic aneurysm.
Physical activity has a tremendous impact on cardiovascular health. Some research suggests
physical inactivity predicts mortality the same or better than traditional risk factors such as smoking, diabetes, and coronary heart disease (4).
So, what about food and nutrition?
Cardiovascular disease is largely driven by inflammation and oxidation, so nutrition
recommendations usually center around reducing these processes. Research strongly supports consuming plenty of vegetables, fruit, and other high fiber foods (such as whole grains). Sadly, a 2015 report from the CDC found that only 9% of Americans eat enough vegetables (2.5-3.5 cups/day) and 12% eat enough fruit (1.5-2 cups/day). 5 Plant foods are abundant in phytochemicals that reduce inflammation and oxidation. It is also well-established that sugar and refined carbohydrates as well as fried foods and
processed meats should be limited. Alcohol should be consumed in moderation or not at all.
More controversial are dietary fats and dietary cholesterol. There is the highest level of concern about trans fats (also known as “partially hydrogenated oil”). Thankfully, these are no longer “Generally Recognized as Safe” and have almost completely been removed from the food supply. Dietary cholesterol is exogenous and does not have a significant impact on endogenous or serum (blood) cholesterol. If we consume dietary cholesterol, our liver simply makes a little less to maintain a good balance. One study, for instance, showed that people who ate more eggs (which contain dietary cholesterol) had less LDL cholesterol and more HDL cholesterol (6). The idea that unsaturated fats are “healthy” and saturated fat is “unhealthy” is one of the most widely promoted nutrition myths. The hypothesis was that since saturated fat increases total cholesterol, it must be bad for heart health. However, research does not indicate that consuming more saturated fat increases the risk of a CVD event or death. The American Diabetes Association, for example, has adjusted their verbiage surrounding higher fat diets and suggest that “macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and
metabolic goals” and that “evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with or at risk for diabetes" (7).
One study goes so far as to say that “there is no evidence to support the recommendation that individuals with family history of high cholesterol should consume a low saturated fat, low cholesterol diet.” Instead, it summarizes that “a low carbohydrate diet (LCD) significantly improves cardiovascular disease biomarkers, compared with a low fat diet" (8).
Some sources of saturated fats include meat, poultry, dairy, dark chocolate, coconut, and palm oil. Unsaturated fats are categorized as mono-unsaturated fats (olive oil, nuts, seeds, avocados) and Omega 3 (fatty fish, walnuts, chia seeds) and Omega 6 polyunsaturated fats (vegetable oil, peanut butter, meat, chicken, nuts, potato chips, seeds).
While Omega 3 fatty acids are anti-inflammatory, Omega 6 polyunsaturated fats are susceptible to oxidation (especially if they have been highly processed). One study explains that “smoke point does not predict oil performance when heated. Oxidative stability and UV coefficients are better predictors when combined with total level of PUFA [polyunsaturated fat]" (9). Extra virgin olive oil and avocado oil, for instance, have significantly better oxidative stability than Canola oil. Therefore, consuming highly processed vegetable oils such as soybean oil and sunflower oil can increase inflammation.
The American Heart Association suggests limiting sodium intake to less than 2,300 mg a day,
1,500 mg a day for most adults, and 1,000 mg a day to improve heart health. These guidelines have received mounting criticism. One research article suggests that “there is no scientific basis for a public health recommendation to alter sodium intake,” 10 since 90% of the worlds’ population currently consumes a sodium intake that is not associated with increased mortality. Meanwhile, dietary potassium (from vegetables, fruit, avocados, salmon, etc.), does not get much attention. Adequate potassium intake can help normalize blood pressure. Traditional lab values such as total cholesterol, HDL, and LDL have been shown to be less accurate predictors of CVD events and death than previously thought. One comprehensive review, titled “LDL-C does not cause cardiovascular disease” boldly claims that the cholesterol hypothesis is based on “misleading statistics, exclusion of unsuccessful trials, and by ignoring numerous contradictory observations" (1). Another study concludes that “low HDL is associated with CHD risk in White but not Black adults” and that “current high-density lipoprotein cholesterol–based risk calculations could lead to inaccurate risk assessment in Black adults" (11). Lesser-known tests such as LDL-P (low density lipoprotein particle), coronary artery calcium (heart scan), and C-reactive protein are gaining traction for their accuracy in predicting risk of CVD events or death. Saturated fat tends to increase large, buoyant LDL particles that have less impact on CVD while not changing or potentially decreasing small, dense LDL particles that are atherogenic and
prone to oxidation.
In conclusion, it is well-established that a heart healthy lifestyle should include plenty of
physical activity, low stress, proper sleep, adequate amounts of vegetables, fruit, minimally processed fats, fiber, and protein. Smoking cessation and limiting or avoiding alcohol is very important. Fried foods, refined carbohydrates, and highly processed oils should be limited.
It is misleading to demonize a single nutrient, such as saturated fat. The whole dietary pattern and lifestyle must be taken into consideration and nutrition recommendations must be personalized.
Please reach out if you would like to work with me one-on-one to improve your health and nutrition!
Nathan Slinkard, MS, RD, LD
1. Ravnskov, U., de Lorgeril, M., Diamond, D. M., Hama, R., Hamazaki, T., Hammarskjöld, B., Hynes, N., Kendrick, M., Langsjoen, P. H., Mascitelli, L., McCully, K. S., Okuyama, H., Rosch, P. J., Schersten, T., Sultan, S., &amp; Sundberg, R. (2018). LDL-C does not cause cardiovascular disease: A comprehensive review of the current literature. Expert Review of Clinical Pharmacology, 11(10), 959–970. https://doi.org/10.1080/17512433.2018.1519391
2. Pantell M, Rehkopf D, Jutte D, Syme SL, Balmes J, Adler N. Social isolation: a predictor of mortality comparable to traditional clinical risk factors. Am J Public Health. 2013 Nov;103(11):2056-62. doi: 10.2105/AJPH.2013.301261. Epub 2013 Sep 12. PMID: 24028260; PMCID: PMC3871270.
3. Jean-Louis, G., Zizi, F., Clark, L. T., Brown, C. D., &amp; McFarlane, S. I. (2008). Obstructive sleep apnea and cardiovascular disease: Role of the metabolic syndrome and its components. Journal of Clinical Sleep Medicine, 04(03), 261–272. https://doi.org/10.5664/jcsm.27191
4. Ekaterina Smirnova, PhD, Andrew Leroux, ScM, Quy Cao, MS, Lucia Tabacu, PhD, Vadim Zipunnikov, PhD, Ciprian Crainiceanu, PhD, Jacek K Urbanek, PhD, The Predictive Performance of Objective Measures of Physical Activity Derived From Accelerometry Data for 5-Year All-Cause Mortality in Older Adults: National Health and Nutritional Examination Survey 2003–2006, The Journals of Gerontology: Series A, Volume 75, Issue 9, September 2020, Pages 1779–1785, https://doi.org/10.1093/gerona/glz193
5. Centers for Disease Control and Prevention. (2021, February 16). Only 1 in 10 adults get enough fruits or vegetables. Centers for Disease Control and Prevention. Retrieved February 24, 2023, from https://www.cdc.gov/nccdphp/dnpao/division-information/media-tools/adults-fruits-vegetables.html
6. DiMarco DM, Missimer A, Murillo AG, Lemos BS, Malysheva OV, Caudill MA, Blesso CN, Fernandez ML. Intake of up to 3 Eggs/Day Increases HDL Cholesterol and Plasma Choline While Plasma Trimethylamine-N-oxide is Unchanged in a Healthy Population. Lipids. 2017 Mar;52(3):255-263. doi: 10.1007/s11745-017-4230-9. Epub 2017 Jan 13. PMID: 28091798.
7. American Diabetes Association; 5. Lifestyle Management: Standards of Medical Care in
Diabetes—2019. Diabetes Care 1 January 2019; 42 (Supplement_1): S46–S60.
8. Diamond DM, Alabdulgader AA, de Lorgeril M, Harcombe Z, Kendrick M, Malhotra A, O'Neill B, Ravnskov U, Sultan S, Volek JS. Dietary Recommendations for Familial Hypercholesterolaemia: an Evidence-Free Zone. BMJ Evid Based Med. 2021 Dec;26(6):295-301. doi: 10.1136/bmjebm-2020-111412. Epub 2020 Jul 5. PMID: 32631832; PMCID: PMC8639944.
9. Alzaa, D. F. (2018). Evaluation of Chemical and Physical Changes in Different Commercial Oils during Heating.
10. Graudal N. A Radical Sodium Reduction Policy is not Supported by Randomized Controlled Trials or Observational Studies: Grading the Evidence. Am J Hypertens. 2016 May;29(5):543-8. doi: 10.1093/ajh/hpw006. Epub 2016 Jan 27. PMID: 26817656.
11. Zakai NA, Minnier J, Safford MM, Koh I, Irvin MR, Fazio S, Cushman M, Howard VJ, Pamir N. Race-Dependent Association of High-Density Lipoprotein Cholesterol Levels With Incident Coronary Artery Disease. J Am Coll Cardiol. 2022 Nov 29;80(22):2104-2115. doi: 10.1016/j.jacc.2022.09.027. PMID: