Since the 1980s, public attention has been drawn to the importance
of cholesterol as a risk factor. Unfortunately, the mass media also provided a forum for a few nay-sayers who maintained that diet and cholesterol reduction would do little to prevent heart attacks. With the evidence we now have at our disposal, that was akin to saying that the earth is flat!
The controversy in 1989 and spilling over into 1990 made for sensational journalistic coverage, but lacked any scientific credibility. The fact remains that elevated cholesterol levels are one of the major risk factors in the development of heart disease, and a principal contributor to the leading cause of death in the Western world.
The authors of the books and magazine articles which made some people question the value of giving up their bacon and egg breakfasts and their cheeseburgers for lunch simply chose to ignore some of the more recent and dramatic data. They concentrated on pointing to early studies in which the results were not convincing.
Why did those older research projects fail? For the most part, it was a matter of not going far enough in intervention efforts. The average Westerner consumes about 40 per cent of his or her kilojoules as fat and about 500 to 600 milligrams of cholesterol daily. Simply cutting down the fat intake to 35 per cent and the cholesterol consumption to 300 milligrams wasn’t enough to achieve a significant cholesterol reduction in the blood. Today we know better.
The evidence begins in early childhood. Researchers in a number of centres throughout the United States have correlated children’s diet with their cholesterol levels. Dr Gerald Berenson at Louisiana State University studied the children in the town of Bogalusa outside New Orleans for 16 years.
During that time, a number of children died as a result of accidents, homicides and suicides. Upon autopsy it was learned that children as young as 10 and 11 years old already had fatty streaks of cholesterol buildup in the aorta and arteries. The higher cholesterol levels were, the greater the signs of early atherosclerosis. Dr Berenson concluded that heart disease begins in childhood and often relates directly to the diet.
Misfortune provided additional evidence during the Korean and Vietnamese wars. Soldiers who fell in battle were autopsied, and doctors found their arteries significantly blocked with cholesterol-laden plaque. Researchers also autopsied Korean and Vietnamese soldiers who, obviously, consumed a much different diet. Their arteries were clear.
Reducing cholesterol levels can have an impact on the rate of heart disease. The Lipid Research Clinics Coronary Primary Prevention Trial in 1984 proved that. Patients achieving an average 0.5 mmol/1 drop in the levels of the “bad” LDL cholesterol demonstrated a 17.2 per cent reduction in the actual incidence of coronary heart disease.
The authors of the published study state that for subjects following the program to the letter, LDL levels fell by 35 per cent. Total cholesterol levels dropped 25 per cent. This much of a difference, they say, would reduce the incidence of coronary heart disease by 49 per cent. The practical implications are clear: the risk of heart disease drops two per cent for every one per cent decline in total cholesterol levels.
Virtually all the early cholesterol studies focused on preventing heart disease in healthy individuals or those at risk of developing the disease. This approach is called primary prevention. But what about people like you and me, those who have already had a heart attack and, obviously, have heart disease already established? Our goal is to prevent another heart attack, and to extend our lives. This kind of intervention is termed secondary prevention and we have a tremendous amount of evidence to prove that it really works. Not only can we stop heart disease dead in its tracks, but we can actually reverse the process.
The first carefully controlled study was done at the University of Southern California by Dr David Blankenhorn and his associates. He has studied 162 coronary bypass surgery patients, each of whom underwent angiography to carefully measure the amount of blockage in his or her arteries at the beginning of the project and at intervals thereafter. Half the patients were given a fat-modified diet in which fat compromised about 20 per cent of total kilojoules, and were given the bile acid-binding drug colestipol and niacin. We’ll discuss those and other cholesterol-lowering substances later. The other group was placed on a modified diet and given a placebo in place of the colestipol and niacin.
At the end of the two-year period, the first group showed a 26 per cent reduction in total plasma cholesterol, a 43 per cent drop in LDL, and a 37 per cent rise in HDL. Looking at the angiograms done at the end of the study and comparing them with those done two years earlier, researchers found that not only was the progress of the disease stopped in those on the diet-colestipol-niacin program, but also there was reversal of the atherosclerotic plaque buildup in more than 16 per cent of patients, as compared with 3 per cent in the placebo group. Those in the other group, however, exhibited a worsening of their disease, with arteries more seriously blocked.
Those patients were then tracked for another two years. Again, the treatment group improved significantly while the control group showed deterioration.
Dr Blankenhotn has been adamant in his presentations of these data that everyone having a bypass operation should receive aggressive therapy to reduce cholesterol in order to prevent the need for a second surgery. Unfortunately, only a small percentage of bypass patients currently receive this kind of advice and treatment.
Another study demonstrating the value of secondary prevention was done at the University of Washington. There Dr Greg Brown studied 146 men 62 years old or younger who had a family history of heart disease, high levels of total and LDL cholesterol, and evidence of blockage of the arteries on an angiogram. Of those men, 120 completed the study.
At the end of two and a half years, atherosclerosis worsened in 46 per cent of patients treated with diet and placebo. In the groups receiving either niacin and colestipol or Mevacor and colestipol, half as many patients showed progression of disease and 35 per cent showed improvement. In addition, Dr Brown said, the aggressively treated patients showed a 75 pet cent reduction in clinical events such as heart attack or death.
Using a program that calls for no drugs, but that does require dramatic lifestyle changes, Dr Dean Ornish at the University of California School of Medicine in San Francisco has demonstrated that even severe heart disease can be reversed. Half of his group made extensive modifications in diet and lifestyle. They ate a low-fat vegetarian diet that allows no animal products other than egg whites and skim milk and uses no fats or oils whatsoever. The patients also practised yoga stress reduction techniques and engaged in daily exercise. The other group received standard advice calling for less fat in the diet.
After one year, 82 pet cent in the treatment group showed some overall regression of disease as measured on angiograms. For those getting usual care, 53 per cent showed progression of disease. There’s no doubt that this approach works, and we’ll discuss it further in the treatment section of this chapter.
How low must cholesterol levels fall? Dr Jeremiah Stamler at Northwestern University in Chicago has observed that while shooting for a cholesterol level of 5.2 is a step in the right direction, the incidence of heart disease begins to appear at 4.1 and slowly increases to 4.6.
After 4.6 there is a dramatic surge in heart disease, and after 5.2 it soars. His recommendation, then, for the entire population is to aim for the 4.1 to 4.6 range.
What does it take to completely remove the risk posed by cholesterol levels? Dr William Castelli, medical director of the Framingham study in Massachusetts, has said that he’s never seen a heart attack in a patient whose cholesterol is 3.9 or less, even when HDLs are low. To reverse the disease that’s been getting worse throughout a lifetime, Dr Castelli proposes “membership” in what he calls the “3.9/5″ club. He believes that getting cholesterol levels down to 3.9 for five years will lead to reversal of heart disease.
In Dr Ornish’s reversal program, total cholesterols fell from an average of 5.8 to 3.5. In the control group there was no significant change in cholesterol levels and, as noted, the disease worsened.
The handwriting is on the wall and on the pages of the medical journals. Get those cholesterol levels way down, much lower than 5.2. That number might be just fine for the general population, especially for those without other risk factors such as family history or cigarette smoking or high blood pressure. But for those of us with heart disease already present—and having a heart attack or bypass surgery is proof of that, even without an angiogram to back it up—we need to work a lot harder.
I must say, however, that as strongly as I feel about cholesterol reduction, we can never forget that it’s just one of the steps to be taken for total recovery from heart disease. All those other steps play important roles: controlling high blood pressure, quitting the cigarettes, losing extra weight, and playing the “inner game” of stress control and relaxation.
In discussing this with Dr Ornish at a heart association meeting, I found that some of his patients did not achieve as dramatic cholesterol reductions as others. Yet they did manage to control their disease. He said that might be because they didn’t eat the foods which clog the arteries, even though their cholesterol levels didn’t come down appreciably. He also believes the element of mental control cannot be over-emphasised as part of a reversal program.
I can add my own personal experience to underline his feelings. My own cholesterol level at the time of my second bypass surgery was 7.3. With the program I described fully in The 8-Week Cholesterol Cure, and which I’ll outline in this chapter, I brought that number down to levels that have ranged between 4.1 and 4.6 for the past several years. But I also do my exercise religiously and practise a number of stress control and relaxation techniques. The angiogram showing my clear arteries demonstrates that the program works very well.
There’s no doubt, in any case, that cholesterol control is an essential pan of any recovery program. You’ll want to have your level measured on a regular basis to be certain that you’re keeping your numbers down.
*106\85\2*
Cardio & Blood/ Cholesterol