Understanding the disease

Cardiovascular disease (CVD) generally refers to conditions in which the blood vessels to the heart are blocked or narrowed. This is generally related to the process of atherosclerosis, in which plaque builds up in the walls of the arteries, making it difficult for blood to flow through and increasing the potential for blood clots, which can stop the flow, leading to heart attacks and strokes.¹ At the core of this disease are the arteries, the blood vessels that deliver oxygen and nutrient-rich blood from the heart to the rest of the body. Blood vessels are made up of three distinct layers: The outermost layer is largely connective tissue and forms support for the artery. The middle layer is mostly smooth muscle, which changes the diameter of the blood vessels to either increase or decrease blood pressure. The innermost layer is a thin layer of connective tissue covered by a thin layer of cells known as the endothelial lining. The endothelial cells line the entire circulatory system and are crucial to vascular health. The endothelial layer forms a smooth, permeable barrier and is a major regulator of vascular homeostasis, influencing blood flow (vasoconstrictions and vasodilation), coagulation, vascular tone, and inhibition of inflammation. And mounting evidence suggests that endothelial dysfunction is an early marker for the development of atherosclerosis.^{2 3} Protection of the endothelial lining is key to protecting the cardiovascular system.

While mainstream thought would have you believe that preventing atherosclerosis is as easy as avoiding saturated fat and lowering your cholesterol, the truth is more complicated. The process by which plaque forms in the arteries is a lot less linear and much more web-like, tangled up by  metabolic processes gone awry. When endothelial cells are damaged, a cascade of events is set into action, leading to the formation and accumulation of plaque in the arteries. There are many factors that damage the endothelial lining including smoking, high blood pressure, inflammation, stress, and health conditions like diabetes. And contrary to what we’ve been lead to believe, the number one dietary factor affecting the endothelial lining is not saturated fat or cholesterol, but sugar, or more accurately, anything that leads to excess blood sugar.

Sugar’s not so sweet role in cardiovascular disease

To understand sugar’s role in the development of cardiovascular disease, it is important to understand what happens in the body when you ingest sugar (or any food that the body converts to sugar, such as refined carbohydrates). The body requires glucose (sugar) for some of its energy production and glucose requires insulin to move it into the cells where it is used to create energy. While essential in small amounts, excess glucose and insulin can be dangerous. Glucose can bind to tissues and proteins, damaging them, and over time can lead to the formation of substances called Advanced Glycation Endproducts, or AGEs. AGEs permanently damage bodily proteins, including endothelial cells, disrupting their function and promoting inflammation.⁴ The delicate endothelial cells are particularly susceptible to the effects of high blood glucose and AGEs, and once damaged they become stiff and do not flex properly.⁵ AGEs may also transform LDL cholesterol into a form that is particularly prone to accumulate in the arteries.⁶ (Oh, there is the cholesterol connection! But remember, that is cholesterol that has been damaged by AGEs, not healthy cholesterol.)

Excess blood glucose also leads to the formation of free radicals, which further damage the endothelial lining and leads to oxidative stress.⁷ Oxidative stress is a condition when the body’s antioxidant systems are overburdened, leading to damaged proteins, fats, and DNA and to the formation of more AGEs. This process becomes a vicious cycle, with AGEs leading to oxidative stress and oxidative stress creating more AGEs and all along both processes are increasing inflammation and damaging the endothelial lining, making plaque accumulation more likely and increasing the chances of LDL oxidation.

Because glucose can be so damaging, the body works hard to remove any excess from the blood stream. Insulin directs small amounts to be stored as glycogen for later use, then packages the rest up as triglycerides to be stored as fat, often around the waist (the “spare tire” effect). This extra fat increases inflammation,⁸ which if you recall, damages endothelial cells. But triglycerides are problematic for more reasons than just fat accumulation.

Triglycerides, because they are fats, must be carried through the watery blood stream by protein carriers. One you may be familiar with is the LDL particle (often referred to as LDL cholesterol). These protein carriers carry triglycerides, but they also carry cholesterol, fat-soluble vitamins, and antioxidants through the bloodstream. A common misconception is that LDL and HDL are different types of cholesterol, but in reality, the cholesterol is all the same, it is the protein carrier that differs. As it turns out, for many people, LDL particle number may be a better predictor for cardiovascular disease than the standard cholesterol ratios.⁹ The exact reason why increased LDL particles are so dangerous to the arteries is not fully understood, but it is believed that the more there are, the more likely they are to enter the arterial wall and oxidize.^{10 11} Which brings us back to triglycerides. LDL particles can only carry so much, so if there are more triglycerides that need to be transported—because there is too much glucose in the body—there will likely be more transport vehicles as well. (Interestingly enough, an increase in LDL particles does not necessarily mean an increase in cholesterol.) More LDL particles means a greater chance of arterial infiltration and oxidation and thus a greater chance of cardiovascular disease.

To add to this tangled web is the fact that once metabolism is damaged, as in prediabetes, diabetes, and overweight, these processes are aggravated by the fact that cells don’t respond to insulin like they are supposed to, eventually becoming insulin resistant. This means there is more glucose and insulin circulating in the bloodstream, creating more damage, inflammation, triglycerides, and ultimately, more LDL particles. In fact, diabetics are four times more likely to die of heart disease then non-diabetics.¹² It turns out that it is not just diabetics at risk though. Recent research has shown that even slightly elevated blood glucose levels—in the high end of normal—can set these damaging processes into action.¹³

Lose the sugar, not the (healthy) fat

So excess blood glucose drives cardiovascular disease in several ways. First, it leads to the formation of AGEs and free radicals that directly and indirectly damage the endothelial lining. Second, it increases triglycerides, increasing fat storage and possibly LDL particle number. Lastly, it increases metabolic damage in the form of insulin resistance. Taken as a whole, it is not a pretty picture.

Protecting the cardiovascular system involves keeping the blood sugar balanced. And what spikes blood sugar? You may be surprised. Of course you know the usual suspects: refined sugar and flours. But did you know all sugars (even those unrefined ones like honey and maple syrup) and all grains (even whole grains, especially when ground into a flour) are also culprits?¹⁴ Each person’s response is slightly different, but in general cutting way back or even completely eliminating the foods that spike blood sugar will do wonders for protecting the cardiovascular system.

As important as what you exclude from your diet is what you include. Eating balanced meals at regular intervals, beginning with breakfast, is the first step. A balanced meal keeps blood sugar stable while supplying essential vitamins, minerals, and antioxidants needed for optimal cardiovascular function. A balanced meal always contains:

• Protein from humanely raised and sustainably farmed and/or sourced animals, ideally fed a diet that matches their biology (e.g., cows should eat grass, not corn).
• Healthy fat from unrefined oils such as olive oil, coconut oil, butter, and sesame oil. Also include food sources like avocados, nuts and seeds, olives, wild cold-water fatty fish, and eggs. 
• Lots of brightly colored veggies to provide a power punch of antioxidants, which protect against free radical damage and oxidative stress. Vegetables are also a good source of fiber, which helps stabilize blood sugar.

In addition to dietary changes, take a holistic approach and include supplements that will offer even more support. The following are proven to support healthy blood sugar balance, and some even have added cardiovascular benefits.

• Alpha-lipoic acid (ALA). This potent antioxidant helps protect tissues from the oxidative damage caused by chronically high glucose levels. It has also been shown to decrease fasting glucose, insulin, and insulin resistance, and improve long-term blood sugar levels. Additionally, it can reduce both triglycerides and LDL cholesterol.^{15 16}
• Black seed oil. A review of 13 clinical trials on the blood sugar lowering-effect of black seed oil found that its use decreased fasting blood sugar, insulin levels, and insulin resistance. This antioxidant-rich oil has also been shown to reduce blood pressure, LDL cholesterol, triglyceride levels, and to neutralize the oxidation of LDL cholesterol (oxidized LDL is a major step toward developing atherosclerosis).^{17 18 19 20}
• Chromium. This mineral plays a crucial role in insulin function, and research has shown that supplementation improves insulin sensitivity and maintains healthy blood sugar levels over the long term.²¹
• Magnesium. Supplementation with this important mineral improves fasting and post-prandial (post-meal) glucose levels and insulin sensitivity and decreases markers of inflammation. Magnesium is also a superstar when it comes to cardiovascular health, supporting healthy blood pressure, normal heart rhythm and energy production in the heart, and a healthy balance of LDL and HDL cholesterol. It is estimated that at least half of all Americans don’t get enough magnesium through diet, making supplementation necessary.^{22 23 24}
• Gymnema sylvestre. The Hindi name for this herb translates to “destroyer of sugar.” Research is just beginning to catch up to gymnema's long history of use for blood sugar balance, but it appears to work in part by increasing the efficiency of insulin and slowing the absorption of glucose in the blood. It can also reduce sugar cravings!²⁵ 

Although mainstream thought would have you believe otherwise, it turns out that sugar is a bigger threat to cardiovascular health than cholesterol and saturated fat. And metabolic dysfunction, especially in the form of diabetes and pre-diabetes, is a major contributor to CVD. At the end of the day it is actually pretty simple: Protect your cardiovascular system by avoiding foods that spike blood sugar and eat balanced meals comprised of nutrient dense foods, including healthy saturated fats. Unraveling long-held beliefs can be daunting, but in the case of cardiovascular health, well worth the trouble.

Recipes

• Mushroom, Bacon and Spinach Frittata Recipe
• Chicken Vegetable Stir Fry

References

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17. Written by Editor Updated on 15th January 2019, and Editor. “Glycosylated Haemoglobin & Diabetes. HbA1c Facts, Units, Diagnosis, Testing Frequency, Limitations, Control & Conversion. How Blood Glucose Levels Link to A1c.” Diabetes, 2 July 2020, www.diabetes.co.uk/what-is-hba1c.html.
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