Assessing Your Risk—A Better Understanding

Atherosclerosis, a thickening of the arterial walls, is the most common cause of heart disease. For years we have been fixated on our cholesterol numbers—HDL, LDL, and total cholesterol—as a way to monitor our risk of developing heart disease. But these numbers show only half the picture. It turns out that the number of LDL particles, the degree of oxidation of LDL particles, and dysfunction or damage to the blood vessel lining are actually the driving forces behind the development of blood vessel plaques and heart disease. Because cholesterol is fat-soluble and blood is mostly water, the body uses lipoproteins to carry cholesterol through the bloodstream. VLDL (very low density lipoprotein), LDL (low density lipoprotein), and HDL (high density lipoprotein) are the main lipoproteins in our bloodstream that ferry cholesterol, fats (including triglycerides), and fat-soluble vitamins. You can think of lipoproteins like boats carrying cargo (cholesterol) along a river (the bloodstream). When we get a standard lipid panel (aka cholesterol test) from the doctor, those numbers are measures of the amount of cholesterol (cargo) being carried, but not a measure of the number of lipoproteins (boats). The number of lipoproteins and specifically the LDL (also referred to as LDL particles) is a far more important marker for heart disease than cholesterol numbers alone. This is because the more LDL particles there are, the greater the likelihood they will get stuck in the blood vessel lining, just as, when a river is crammed with boats, collisions are more likely to occur. Once stuck in the blood vessel lining, LDL particles are more likely to oxidize, which provokes an immune-inflammatory response that ultimately leads to plaque formation and heart disease. 

Unfortunately, LDL particle number is rarely measured in conventional medicine, but you can catch a glimpse of it with the standard lipid panel. Elevated triglycerides and low HDL together may indicate elevated LDL particle number, even when the LDL cholesterol level is normal. This is because when there are more triglycerides, less space is available on LDL particles to carry cholesterol and, therefore, more LDL particles are needed. Using the boat metaphor: the more cargo there is to move around, the more boats are required. If your standard lipid panel suggests that you may have elevated LDL particles, a Nuclear Magnetic Resonance (NMR) LipoProfile^® Test, which directly measures LDL particle number, may provide a more accurate picture.

The ratio of total cholesterol to HDL cholesterol is also important to consider, since this ratio may be as predictive of risk as LDL particle number. An optimal ratio of total cholesterol/HDL is below 4.³

Underlying Causes—Getting to the Root

Now that you understand that elevated LDL particle number, oxidation of LDL particles, and dysfunction of or damage to the blood vessel linings are the driving forces behind heart disease, let’s take a look at the main underlying causes of these forces: blood sugar imbalance, oxidative stress, and inflammation.  

Blood Sugar Imbalance

The number one dietary factor affecting cardiovascular health is not saturated fat or cholesterol, as we’ve long been told, but anything that causes high blood sugar and insulin levels, such as sugar and refined carbohydrates. When we regularly eat sugary foods and refined carbohydrates or even just more carbohydrates than our bodies can handle, our blood sugar and insulin levels can become chronically elevated, which wreaks havoc on our cardiovascular system in a couple ways. First, excess blood sugar binds to proteins, including the proteins that make up the arteries, creating advanced glycation end products (AGEs). AGEs can directly damage the blood vessel lining, and they also promote oxidation and inflammation, which damage (oxidize) the LDL particles and make them more likely to damage the blood vessel lining. Finally, any blood sugar that can’t be utilized by the body for energy is turned into fat (aka triglycerides) and the more triglycerides there are, the more LDL particles are needed to carry them—again increasing the risk of damage to the arteries. Maintaining healthy blood sugar levels is the first step in protecting the heart.

Oxidative Stress

Free radicals are highly reactive molecules that are generated as part of normal bodily functions but can also be introduced from external sources, such as drugs, preservatives, exhaust fumes, cleaning fluids, rancid fats, alcohol, chlorinated drinking water, and heavy metals. Free radicals can also result from radiation (X-rays and excessive sun exposure) and emotional and physical stress. Antioxidants are the antidote to free radicals, and if there are enough antioxidants available, the body can counter the effects of free radicals. A problem arises when we don’t have enough antioxidants. In this scenario, known as oxidative stress, excessive and uncontrolled free radicals can damage nearly any protein in the body, and the blood vessels are particularly susceptible. Free radicals also set off a cascade of chronic inflammation, which contributes to blood vessel damage and dysfunction and increases the chances that LDL particles will become oxidized. Brightly colored fruits and vegetables are your first and best source of antioxidants and antioxidant precursors.

Inflammation

We now understand that inflammation is a major driver of heart disease and that inflammatory blood markers such as C-reactive protein, fibrinogen, and homocysteine are strong predictors of impending coronary artery disease. Inflammation can also lead to oxidative stress, which leads to more inflammation and creates a vicious cycle of damage and dysfunction. Shifting your diet, supplement routine, and lifestyle can have significant impacts on inflammation.

Diet – the Foundation of Heart Health

Perhaps some of the most controversial topics surrounding heart health have stemmed from differing types of dietary advice. When there are “experts” in the media touting so many types of diets, how do you know what is right for you? It boils down to two main concepts: individuality and consuming whole, traditional foods. Our bodies were not designed to handle processed flours and sugars, hydrogenated oils, and soda all day long. Beyond eating whole foods, you must determine which diet plan works best for your individual genetic makeup through experimentation.

For many years fats and cholesterol were thought to be bad, but the truth is, more recent and better-quality studies have found that eating cholesterol and saturated fat doesn’t cause heart disease. Eating cholesterol does not raise blood cholesterol in about 75% of people.⁴ In the remaining 25%, known as hyper-responders, eating cholesterol does cause a modest increase in blood cholesterol, but the LDL/HDL ratio stays the same, so the risk of heart disease is not increased.⁵ Saturated fats have also received a bad rap, but the research has shown that diets higher in saturated fats (combined with lower carbohydrate intake) lower triglycerides, improve blood pressure, and generally don’t increase the risk of heart disease.^{6 7} Focus on healthy fats from whole-food sources, such as coconut and coconut oil; olive oil; butter and ghee; omega-3s from wild-caught, cold-water fish; olives; avocadoes; and nuts and seeds. Steer clear of chemically modified fats (e.g., trans- and interesterified fats) and refined vegetable oils high in omega-6 fats, such as soy, corn, safflower, and sunflower oils, which negatively impact cardiovascular health and contribute to inflammation. As for refined-grain products and sugar, which were long thought to be harmless, we now know that diets high in sugar are associated with increased cardiovascular disease mortality.⁸ Additionally, increased intake of processed foods, and in particular, ultra-processed foods, is associated with increased C-reactive protein levels (which indicates high levels of inflammation) and double the prevalence of subclinical coronary atherosclerosis.^{9 10} Not only do sugar, refined carbohydrates, and processed foods increase inflammation and cause blood sugar imbalances, they also displace far healthier foods, such as anti-inflammatory vegetables and fruits, grass-fed meats, and cold-water fish high in omega-3 fats (e.g., salmon, sardines, anchovies, and herring).

Ticker-supportive Supplements

When supporting the heart, it is important to focus on reducing free-radical damage, quenching inflammation, and stabilizing blood sugar. Bringing these body functions into balance will optimize heart function and improve circulation. Always build your supplement routine on the foundation of a good multivitamin, which will help to fill any vitamin and mineral gaps, and consider the following for even more support.

EPA and DHA are powerful omega-3 fatty acids that reduce blood clotting, promote healthy levels of nitric oxide to maintain normal blood pressure, and modulate inflammation.¹¹ Supplemental EPA and DHA can be found in fatty, cold-water fish oil and cod-liver oil or algae-derived EPA/DHA vegan alternatives.

Magnesium modulates inflammation and supports optimal blood sugar balance. It also supports healthy blood pressure. Unfortunately, 50% of Americans don’t get the recommended magnesium intake daily.¹²

Vitamin D deficiency has been associated with increased risk of hypertension; adequate amounts support heart health in a myriad of ways.¹³ Specifically, vitamin D modulates inflammation, promotes healthy blood vessel lining function, supports healthy blood sugar levels, and is necessary for healthy blood pressure.¹⁴

Vitamin C is necessary to produce healthy collagen and elastin—two structural proteins that help to maintain the integrity of the vascular system. When vitamin C levels are low, and the blood vessels are weakened, damage is more likely, which over time leads to increased deposition and accumulation of LDL particles in the vascular wall, promoting atherosclerotic lesions.¹⁵ Vitamin C also plays a role in healthy levels of glutathione, our body’s most potent free-radical scavenger, and is an antioxidant in its own right.

Vitamin K2 is critical for activating osteocalcin and matrix GLA protein (proteins involved in directing calcium in the body), which helps to keep calcium in the bones and out of the arteries to maintain arterial flexibility.¹⁶

Coenzyme Q10 (CoQ10) protects the body from free radicals and helps preserve vitamin E.¹⁷ It is found in the greatest concentrations in the heart and liver and is used by the body to transform food into energy. It can increase the heart’s tolerance to a shortage of oxygen¹⁸ and appears to modulate blood pressure by reducing resistance to blood flow.¹⁹

Garlic helps inhibit inappropriate blood clotting and reduces blood pressure, triglycerides, and LDL cholesterol levels while increasing HDL cholesterol.^{20 21} This pungent herb also has antioxidant properties and protects the heart from insufficient blood flow.²²

Vitamin E reduces blood clotting and is an antioxidant that protects cell membranes and other fat-containing compounds in the body, particularly LDL cholesterol.²³ Only when LDL is damaged (oxidized) does cholesterol appear to contribute to heart disease.

Carnitine helps the heart work more effectively. The heart is highly dependent on the energy produced from fatty acids for normal functioning. Carnitine’s main job is to transport fats to the cells to be used to produce energy. This nutrient also lowers triglycerides and supports healthy blood sugar levels and blood pressure.^{24 25 26 27}

Hawthorn is thought to exert many beneficial effects on the heart and blood vessels. These include improved blood flow and strengthening of the contractions of the heart muscle. Hawthorn may also improve circulation to the extremities by lowering the resistance to blood flow in peripheral blood vessels.²⁸ The bioflavonoids in hawthorn are potent antioxidants.²⁹

Turmeric has been shown to modulate platelet aggregation as well as inflammation.^{30 31} A standardized extract of turmeric can be taken in capsules or tablets daily and it can also be incorporated into the diet as a spice.

Bergamot is a type of citrus fruit that is valued for its abundant flavonoids and polyphenols. You may be most familiar with it as the oil that flavors earl grey tea. Supplements of bergamot, in both animal and human studies, have been shown to help reduce total and LDL cholesterol and triglycerides, while increasing HDL cholesterol.^32 33 It also specifically appears to increase the number of large, fluffy LDL particles (those associated with a lower risk of cardiovascular disease), while reducing the number of small, dense LDL particles (those associated with an increased risk of heart attack).^{34 35} Bergamot is believed to be beneficial due to its phytochemicals which exert antioxidant effects.³⁶

While diet is important and a good first place to start, don’t forget about other modifiable lifestyle factors to keep your heart in tip-top shape. Exercise and movement in general are critical. Moving more, sitting less, and incorporating exercise into your life promotes healthy blood sugar balance, healthy blood pressure, and healthy weight maintenance. Make sure to catch enough zzz’s, too, because sleep deprivation has been associated with hypertension, coronary heart disease, and diabetes.³⁷ And finally, take steps to reduce and/or manage stress. In one study, 12 weeks of yoga, breathing exercises, and meditation significantly reduced oxidative stress and inflammation.³⁸

It has been estimated that 90% of heart disease is caused by modifiable diet- and lifestyle-factors, which means any positive change you make in your diet, supplement routine, or lifestyle can have a powerful effect on your heart, keeping it healthy for years to come.

References

1. Futterman, L., Lemberg, L. (1998). Fifty percent of patients with coronary artery disease do not have any of the conventional risk factors. Am J Crit Care, 7(3), 240-244. https://doi.org/10.4037/ajcc1998.7.3.240
2. Bowden, J., Sinatra, S. (2012). The Great Cholesterol Myth. Beverly, MA: Fair Winds Press.
3. Kresser, C. (n.d.). High Cholesterol Action Plan: Week 3. Available from https://highcholesterolplan.chriskresser.com/
4. Dominik, A., Miller, P., et al. (2016). Meta-analysis of egg consumption and risk of coronary heart disease and stroke. Jour of Amer College of Nutrition, 0:1-13. Retrieved from https://pubmed.ncbi.nlm.nih.gov/27710205
5. DiMarco, D., Fernandez, M., (2019). Differences in response to egg-derived dietary cholesterol result in distinct lipoprotein profiles while plasma concentrations of carotenoids and choline are not affected in a young healthy population. Curr Dev Nutrition. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC68189
6. Shih, C., Hauser, M. et al. (2019). Changes in blood lipid concentrations associated with changes in intake of dietary saturated fat in the context of a healthy low-carbohydrate weight-loss diet: a secondary analysis of the Diet Intervention Examining The Factors Interacting with Treatment Success (DIETFITS) trial. Am J Clin Nutr., 109(2):433-441. Retrieved from https://pubmed.ncbi.nlm.nih.gov/30649213/
7. Siri-Tarino, P., Sun, Q. (2010). Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am Jour Clin Nutr., 91(3):535-546. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2824152/
8. Yang, Q., Zhang, Z., Gregg, E.W., Flanders, W.D., Merritt, R., Hu, F.B. (2014). Added sugar intake and cardiovascular diseases mortality among US adults. JAMA Intern Med, 174(4), 516-524. DOI: 10.1001/jamainternmed.2013.13563
9. Kuczmarski, M.F., Mason, M.A., Allegro, D., Zonderman, A.B., Evans, M.K. (2013). Diet quality is inversely associated with C-reactive protein levels in urban, low-income African-Americans and white adults. J Acad Nutr Diet, 113(12), 1620-1631. doi: 10.1016/j.jand.2013.07.004
10. Montero-Salazar, H., Donat-Vargas, C., Moreno-Franco, B., Sandoval-Insausti, H., Civeira, F., Laclaustra, M., Guallar-Castillón, P. (2020). High consumption of ultra-processed food may double the risk of subclinical coronary atherosclerosis: the Aragon Workers’ Health Study (AWHS). BMC Medicine, 18, 235. DOI https://doi.org/10.1186/s12916-020-01678-8  
11. Mohebi-Nejad, A., et al. (2014). Omega-3 Supplements and Cardiovascular Diseases. Tanaffos, 13(1):6-14. Retrieved from
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153275/
12. Rosique-Esteban, N., et al. (2018). Dietary magnesium and cardiovascular disease: a review with emphasis in epidemiological studies. Nutrients 10(2):168.
13. Kunutsor SK, Apekey TA, Steur M. Vitamin D and risk of future hypertension: meta-analysis of 283,537 participants. Eur J Epidemiol. 2013;28(3):205-221.
14. Messa P, Curreri M, Regalia A, Alfieri CM. Vitamin D and the cardiovascular system: an overview of the recent literature. Am J Cardiovasc Drugs. 2014;14(1):1-14.
15. Cha, J., Niedzwiecki, A. et al. (2015). Hypoascorbemia induces atherosclerosis and vascular deposition of lipoprotein(a) in transgenic mice. Am J Cardiovasc Dis; 5(1):53-62
16. Wilson, L. (2013 Feb). Vitamins K and D: A power duo for health. Natural Grocers Health Hotline.
17. Higdon, J. (2003, last update 2018). Coenzyme Q10. Oregon State University, Linus Pauling Institute. Retrieved November 2, 2020 from https://lpi.oregonstate.edu/mic/dietary-factors/coenzyme-Q10
18. Sinatra, S. T. (2005). The Sinatra solution: Metabolic cardiology. Laguna Beach, CA: Basic Health Publications.
19. Casgrande, D., Waib, P.H., Jordāo, A.A., Jr. (2018). Mechanisms of action and effects of administration of Coenzyme Q10 on metabolic syndrome. Journal of Nutrition & Intermediary Metabolism. 13, 26-32. https://doi.org/10.1016/j.jnim.2018.08.002
20. Higdon, J. (2005). Garlic. Retrieved November 02, 2020, from https://lpi.oregonstate.edu/mic/food-beverages/garlic
21. Thomson, M., Al-Qattan, K. K., Bordia, T., Ali, M. (2006). Including garlic in the diet may help lower blood glucose, cholesterol, and triglycerides. J Nutr, 136(3), 800S-802S. https://doi.org/10.1093/jn/136.3.800S
22. Blumenthal, M. (2003). The ABC Clinical Guide to Herbs. New York, NY: Thieme.  
23. Rizvi, S., Raza, S.T., Ahmed, F., Ahmad, A., Abbas, S., Mahdi, F. (2014 May). The role of vitamin E in human health and some diseases. Sultan Qaboos Univ Med J. 14(2), e157-e165. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3997530/
24. Fathizadeh, H., Milajerdi, A., Reiner, Z., Kolahdooz, F. Chamani, M., Amarani, E., Asemi, Z. (2019). The effects of l-carnitine supplementation on serum lipids: a systematic review and meta-analysis of randomized controlled trials. Curr Pharm Des. 25(30), 3266-3281. DOI: 10.2174/1381612825666190830154336
25. Davini, P., Bigalli, A., Lamanna, F., Boem, A. (1992). Controlled study on L-carnitine therapeutic efficacy in post-infarction. Drugs Exp Clin Res, 18(8), 355-365. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/1292918
26. Mingrone, G., Greco, A.V., Capristo, E., Benedetti, G., Giancaterini, A., De Gaetano, A., Gasbarrini, G. (1999). L-carnitine improves glucose disposal in type 2 diabetic patients. J Am Coll  Nutr, 18(1), 77-82. DOI: 10.1080/07315724.1999.10718830 
27. Xu, Y., Jiang, W., Chen, G., Zhu, W, Ding, W., Ge, Z., …Cui, G. (2017). L-carnitine treatment of insulin resistance: a systematic review and meta-analysis. Adv Clin Exp Med. 26(2), 333-338.  DOI 10.17219/acem/61609
28. Blumenthal, M. (2003). The ABC Clinical Guide to Herbs. New York, NY: Thieme. 
29. Levy, B. (May 24, 1997). Benefits of bilberry and hawthorn. HerbClip, NO 052471-110. Austin, TX: American Botanical Council. Review of McCaleb, R. The fruits of healing Delicious! Retrieved from http://cms.herbalgram.org/herbclip/129/review41634.html
30. Tabeshpour, J., Hashemzaei, M., Sahebkar, A. (2018 Nov). The regulatory role of curcumin on platelet function. J Cell Biochem, 119(11), 8713-8722. DOI: 10.1002/jcb.27192
31. Pulido-Moran, M., Moreno-Fernandez, J., Ramirez-Tortosa, C., Ramirez-Tortosa, M.C. (2016). Curcumin and health. Molecules, 21(3), 264.  DOI: 10.3390/molecules21030264
32. Mollace, V., Sacco, I., Janda, E., Malara, C., Ventrice, D., Colica, C., Visalli, V., Muscoli, S., Ragusa, S., Muscoli, C., Rotiroti, D., Romeo, F. (2011). Hypolipemic and hypoglycaemic activity of bergamot polyphenols: from animal models to human studies. Fitoterapia, 82(3), 309-316. https://doi.org/10.1016/j.fitote.2010.10.014
33. Miceli, N., Mondello, M. R., Monforte, M. T., Sdrafkakis, V., Dugo, P., Crupi, M. L., Taviano, M. F., De Pasquale, R., & Trovato, A. (2007). Hypolipidemic effects of Citrus bergamia Risso et Poiteau juice in rats fed a hypercholesterolemic diet. Journal of agricultural and food chemistry, 55(26), 10671–10677. https://doi.org/10.1021/jf071772i
34. Toth, P. P., Patti, A. M., Nikolic, D., Giglio, R. V., Castellino, G., Biancucci, T., Geraci, F., David, S., Montalto, G., Rizvi, A., & Rizzo, M. (2016). Bergamot Reduces Plasma Lipids, Atherogenic Small Dense LDL, and Subclinical Atherosclerosis in Subjects with Moderate Hypercholesterolemia: A 6 Months Prospective Study. Frontiers in pharmacology, 6, 299. https://doi.org/10.3389/fphar.2015.00299
35. Mollace, V., Scicchitano, M., Paone, S., Casale, F., Calandruccio, C., Gliozzi, M., Musolino, V., Carresi, C., Maiuolo, J., Nucera, S., Riva, A., Allegrini, P., Ronchi, M., Petrangolini, G., & Bombardelli, E. (2019). Hypoglycemic and Hypolipemic Effects of a New Lecithin Formulation of Bergamot Polyphenolic Fraction: A Double Blind, Randomized, Placebo- Controlled Study. Endocrine, metabolic & immune disorders drug targets, 19(2), 136–143. https://doi.org/10.2174/1871530319666181203151513
36. Nauman, M.C., Johnson, J.J. (2019). Clinical application of bergamot (Citrus bergamia) for reducing high cholesterol and cardiovascular disease markers. Integr Food Nutr Metab, 6(2), DOI: https://doi.org/10.15761/IFNM.1000249
37. Nagai, M., Hoshide, S., et al. (2010). Sleep Duration as a Risk Factor for Cardiovascular Disease – a Review of the Recent Literature. Cardiology Reviews, 6(1):54-61. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2845795/
38. Tolahunase, M., Sagar, R., et al. (2017). Impact of yoga and meditation on cellular aging in apparently health individuals: a prospective, open-label, single-arm exploratory study. Oxid Med Cell Longev. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5278216/