27 Lifetime Protection for Your Heart

The sad story I am about to tell should be as familiar as the back of your hand once you have read the rest of this book: An individual with metabolic vulnerability to weight gain eats the sugar-filled, nutrient-impoverished diet of the Western world. It doesn't make him feel great, but he assumes his various complaints are a natural part of getting older. Pounds begin to gather; then a few more, then a lot. Now he acquires the risk factors that set him apart from most people who don't have a weight prOblem. Yes, those risk factors. Let's hear them one last time:

· Insulin levels that are far too high.

· Blood pressure that is rising, ever rising.

· Triglyceride levels that have gone absolutely ballistic.

· Total cholesterol that's through the roof.

· HDL that's down in the cellar.

· Blood sugar that's gone straight up.

What's next? There's an excellent chance that he is heading for diabetes. He—or she—is far from happy now and grasps for one variation or another of the typical carbohydrate-saturated American diet. Along the way, he may even push his dietary fat down to where the government says it should be. Victory? Well, no, That achievement won't prevent an eventual visit to the cardiac ward of the local hospital. After all, dietary fat never was the primary source of the problem.

That snapshot of a life depicts the lifestyle of many people, but it need not be yours. You now have the tools to correct and control your vulnerabilitie—the risk factors for heart disease. You'll know why these tools work once you've read this chapter. You're doing a heart health plan that is precisely tailored to the needs of a person who's susceptible to weight gain. Atkins is the deliverance from your susceptibility.

What Didn't Happen, and Then What Did

Ten years ago, I used to smile somewhat painfully at the blasts of anger aimed at me by my attackers. They said I didn't respectthe low-fat gospel. "Eating a controlled carbohydrate, high-fat diet was dangerous" they said. "Cholesterol would elevate wildly. Heart attacks would sprout like mushrooms in the rain."

Then something strange happened: The last decade of the twentieth century transformed everything. Millions of people did Atkins. Physicians could not ignore the fact that not only did these bold nutritional adventurers lose weight and feel fine, but they nearly always also showed improvements in their blood-lipid chemistries, which—when it comes to predicting the furore—are the holy grails of medicine.

No doubt many doctors raised as disciples of the low-fat creed looked at those results and wondered: Why? How does following Atkins is do it? Why doesn't those people's cholesterol go up? Why do they seem so healthy? What does the guru of controlled carbohydrate eating know that I don't?

Many of them—because doctors arc an inquiring bunch have since started to learn what I already knew. It never was a secret formula hidden away in a locked laboratory. The "secret" has been published repeatedly fight out in the open in many of the world's most respected medical journals. The research that has made controlled carbohydrate nutrition so popular today was trotting along steadily iff the 1970s and 1980s; by the late 1990s it was moving at a fast canter, and it is positively galloping now.

So here it is, and you should know it.

The Cluster Effect

What we are learning—careful readers will not be surprised is that the risk factors for heart disease cluster together. A very prominent cluster is found among the overweight. A little over a decade ago, Norman Kaplan, MD, of the University of Texas's Southwestern Medical Center, dubbed four risk factors the "Deadly Quartet;' These four—upper-body obesity, glucose intolerance, high triglyceride levels and hypertension—were consequences of a single cause) That cause was our old friend, hyperinsulinism.

Kaplan made a diagram to make this relationship clear.

Hypertension

Glucose

Intolerance Hyperinsulinemia Hypertriglyceridemia

Uupper-Body Obesity

Kaplan had the good sense m notice the obvious. These conditions, he reasoned, occur in subjects with high insulin levels, and are likely to coexist in the same person. Thirty-nine million people in the United States are obese (twenty percent over ideal body weight), and fifty million people are hypertensive. Among the obese, hypertension is three times more common than among the non-obese. High triglyceride levels are twice as common among the obese than among the non-obese. The association is even stronger if one includes patients with upper-body obesity. The middle-aged man's paunch is related to metabolic factors that put him at risk for a heart attack.

If you stin wonder how strong these associations are, tisten to Albert Rocchini, MD, a medical scientist at the University of Minnesota. He writes: "It has been estimated that by the fifth decade of life, eighty-five percent of diabetic individuals are hypertensive and obese, eighty percent of obese subjects have abnormal glucose tolerance and are hypertensive, and sixty-seven percent of hypertensive subjects are both diabetic and obese."

That's a pretty awe-inspiring—or more accurately—a terror-inducing cluster! Do you see yourself there? If you stand in one corner of the picture, the odds are good that—barring a nutritional change—you'll eventually occupy the whole image.

Kaplan's insight about the Deadly Quartet was probably depender, as much modem thought about insulin is, on the work of Gerald Reaven, MD, of Stanford University. In his study of insulin, he has been pursuing the close connection between hyperinsulinism and cardiovascular risk factors with indefatigable zeal for over thirty years now. One piece of the puzzle that Reaven examined was that hypertension—which no serious medical theorist has ever questioned as a risk factor for both stroke and heart disease—is intimately related to hyperinsulinism. In 1989, in a major article titled "Hypertension as a Disease of Carbohydrate and Lipoprotein Metabolism;' he wrote, "Patients with untreated hypertension have been shown to be resistant to insulin-stimulated glucose uptake and are both hyperinsulinemic and hypertriglyceridemic... " Let me translate into simpler language: If you have high blood pressure, you probably also have high insulin and triglyceride levels.

In 1988, Reaven noted a clustering of risk factors for coronary artery disease, all of which were associated with high insulin levels and increased insulin resistance. These included hypertension, high triglyceride levels and decreased HDL cholesterol the kind of cholesterol that has been found to be heart protective. Reaven has dubbed this collection of risk factors Syndrome X, and the name has stuck. Medical articles refer to the syndrome, and popular health books discuss it. It's a buzzword now, and since its implicit message is be careful of excess carbohydrate intake, I can only be happy about that.

Triglycerides and HDL

Meanwhile, responding in part to the urgent message of Syndrome X, medical research has moved beyond the limited predictive power of total cholesterol as an indicator of who will or will not get a heart attack. Many scientists now regard high triglycerides, high LDL (bad cholesterol) and low HDL (good cholesterol) as far more potem indicators. A series of papers coming out of Germany in the early 1990s indicated that men who had the combination of high triglycerides and low HDL were six times more likely to have heart attacks than men with the opposite propensities.

A 1997 study led by Michael Gaziano, MD, of Harvard Medical School carried fids relationship even further. He investigated the heretofore ignored ratio of triglycerides to HDL and found it significantat all levels. A high ratio means a big number when triglycen'des are divided by HDL level. People whose ratio was in the upper twenty-five percent were sixteen times more likely to have coronary trouble than were those in the lowest twenty-five percent. That predictive number is a striking finding for heart disease flak. William CastelIi, MD, director of the famous Framingham study on heart disease, commented back in 1992, "The findings [from his study] swing the pendulum and show that high triglyc-erides can be a significant risk factor for some patienta?

A study published in Circulation by a research team in Helsinki showed that those with high triglycerides plus an unfavorable LDL/HDL cholesterol ratio could lower their heart attack risk rate by seventy-one percent when these problems were corrected.

An insulin Assault

Now let's reverse this line of thought. High blood pressure, high triglycerides, low HDL and being overweight all turn out to be consistently associated with high insulin levels. If that's the case, then presumably high insulin itself should predict heart disease. Four significant studies done in Wales, Finland, France and Canada support this theory:

1. The Caerphilly, Wales, heart disease study, which observed 2512 men aged 45 to 59, found a connection between fasting plasma insulin levels and heart disease that existed independently of other risk factors.

2. In the Helsinki Policeman Study, 1,059 men aged 30 to 59 were tracked for five years. The data revealed that fatal (and nonfatal) heart attacks were most common in those who had the highest insulin levels,n

3. The Paris prospective study followed 7,246 men for an average of sixty-three months. Again coronary heart disease was proportionate to insulin levels, and the relationship was greater when the subjects were obese.

4. A study done in Quebec was published in The New England Journal of Medicine in 1996. The researchers had collected blood samples from 2, i03 men. Over five years, 114 of them had heart attacks. The insulin levels of these individuals were eighteen percent higher on average than those of the rest of the group?

These large, statistically powerful epidemiological efforts really put insulin high on the list for concern when combined with the work done by Dr. Reaven. The total picture that he dubbed Syndrome X is becoming exceedingly clear. The abuse of highly tetined and starchy catbohydrates in most regions of the modem world constitutes a long-term abuse of the body's insulin system. As that system begins to crumble glucose intolerance and hyperinsulinism occur together with other damaging events. Arterial passageways are injured by insulin itself and by unhealthy cholesterol ratios. Arterial damage high blood pressure, which will be even more aggravated in an overweight person. And let us not forget how being over-weight, combined with blood-sugar and insulin imbalances, has resulted in an estimated twenty million diabetic Americans plus an even greater number of pre-diabetic citizens.

For your heart health, it's vital to know about this combination of factors that cluster together to form Syndrome X. When you're doing Atkins, you're following the very nutritional approach that corrects this entire syndrome while nourishing yourself with healthy foods.

So heart disease isn't just about the other guy. No such luck. (And who would wish it on anyone?) If you've straggled with your weight, the message of this chapter is of crucial importance to you!

Better Late Than Never

My first forays into weight control began nearly forty years ago when I was a young cardiologist with a rapidly escalating weight problem and a strong desire to find a hungerfree way to deal with it. When I saw that my initial attempts worked, I was delighted. When I mw how much better I felt, I was happier still. But imagine my pleasure and astonishment when I began to comprehend the relationships between dietary cad.hydrates and blood-sugar and insulin levels and the ability to eradicate the need for heart, high blondptessure and diabetes medications. In turn this led to my seeing how much healthier my patients were without the pharmaceuticals. This meant that I was working with a cutting-edge nutritional approach to helping overcome heart disease. This was unquestionably a defining moment in my life. What I now call the Atkins Nutritional Approach was born.

In the intervening decades, I have worked with thousands of heart patients, counseling them to abandon their junk food and eat the natural, healthy food that the Atkins plan emphasizes. And the results continue to support my thesis.

Occasionally, I need to convey the message twice. Fifteen years ago, Stanley Smith came to see me. At the age of 54, as he was helping a neighbor push his broken car into the garage, he had suddenly slumped to the pavement with chest pains. His wife knew a patient of mine who had achieved success doing Atkins, and the Smiths made an appointment with me soon after. Stan weighed 315 pounds and had extreme hyperinsulinism. After six months of doing Atkins, his weight was down to 225, his insulin had stabilized, his blood pressure medication was a thing of the past and, in his own words, "I felt 29 years old instead of 54."

Start felt so good that in the next year or two he went back to his carb-laden ways. "I'd have a loaf of bread, half a gallon of ice cream and a quart of milk at one sitting," he recalls.

I didn't see Stall for more than a decade. In that time, his weight ratcheted back up to 310 and he returned to his blood pressure medication. Then about a year ago, on a flight from Florida to New York, he started having chest pain so severe that when the plane landed, he was rushed to a hospital. There he narrowly avoided a close encounter with the operating table. The next week I saw him in my office.

Talk about ceja vu. I put Sum back on the Atkins program he had abandoned ten years before and prescribed nutritional supplements. I also gave him adjunctive therapy including EECP (see "Twenty-First Century Diagnosis and Treatment" on pages 356-358). Naturally, I told him not to exert himself for a while. Sum tells the rest:

"Every week my wife drove me to my appointments with Dr. Atkins. For the first two weeks, I needed a wheelchair to get out of the car and to the elevator. By week three, I was able to push the wheelchair, using it to steady myself. Week four, I could shuffle up alone. By week five, I was nble to drive in myself and walk from the parking garage. Over the next eight months I continued to see Dr. Adcins, and by then I was again leading a completely active, normal lifestyle.

"I'm still doing Atkins. I'm also painting the outside of my house, waxing my sedan and doing yard work. I go fishing and wear boots up. to my knees to avoid the native stingrays. Those boots get heavy when they're wet, but carrying around the weight is no longer a problem. At age 69, I feel more robot and vigorous than I did when l was 50?

Stall got lucky. He could have died or suffered permanent, debilitating heart injury before he returned to the Atkins plan. He looks pretty good now; he has lost 60 pounds and is still losing 2 pounds a month, his lab work has improved astonishingly, and I am beginning to believe he will never go back to eating the way he ate before.

Go for the Whole Program, Friendsl

What I've said in previous chnw. ers almost makes my general position on your heart health self-explanntory. The vast majority of you will find that on a controlled carbohydrate regimen your recognized risk factors for present and future heart problems will steadily improve and will remain good as long ns you follow this nutritional approach.

Your total cholesterol will probably go down—that's the most common result but even if it doesn't or if it increases slightly, your ratio of HDL to LDL cholesterol is more likely to get better and your ratio of triglycerides to HDL is even more likely to do so. Those ratios are the real McCoy in terms of dell'mining risk of a future coronary event. And if you were progressing toward diabete—one of the great, grand gateways to heart diseaso—the improvements in your blood-sugar and insulin levels should astonish and delight your physician.

Half of all Americans still die of some form of heart disease. PS I hope you will take the malign potential of this disease so seriously that you will eat the Atkins way for a lifetime—and follow the other components of nutritional supplementalion and exercise. These two factors are not merely gaudy ribbons that I wave in front of you to impress you with the fact that the Atkins plan isn't only nbout weight loss.

I have stubhornly insisted throughout this book that you should exercise. It's good for your mood, good for your muscles, good for your energy level, especially good for your heart. Even if you've never exercised, it is not too late. (And you'll probably enjoy it once you start.)

The same adviee applies to supplemental nutrients. Only the most hidebound physicians have failed to appreciate their value by now. Fve written whole books promoting vitanutrients, so I' m sure you know l'm serious. Supplementation can have major positive effects on heart function. For supplements that address cardiovascular disease, see Dr. Atkins' Vita-Nutrient Solution.

The Atkins Nutritional Approach is like a three-legged stool, resting on a controlled carbohydrate way of eating, nutritional supplementation and exercise. Rely on just one or two of the legs, and the stool will not support you. But follow the whole plan faithfully, and you WIll be firmly positioned for ongoing cardiovascular health.

The Dangers of Trans Fats

Many Americans are still unaware that the most grossly harmtul heart health trend of the last century was the gradual replacement of healthy natural fats and protein foods with foods such as margarine. They are constructed with hydrogenated and partially hydrogenated oils, which both contain fats never found in Nature. Called trans fats—meaning transformed from their natural state—they are manufactured by heating vegetable oils at a high temperature and bombarding them with hydrogen gas to form more stable oils. The process creates trans fats constructed of twisted, unnatural molecules that the body cannot process. The food industry sticks these hydrogenated and partially hydrogenated oils into virtually all baked goods and other junk food. The reasons are economic ones: Unlike butter, olive oil or other natural fats, trans fats have a shelf life from now to Doomsday.

Walter WOlatt, MD, chairman of the deperlment of nutrition at the Harvard School of Public Health,was co-author of a 1993 report on the 85,095 women who were tracked in the Harvard Nurses Study. Women with a high intake of trans fats were one and a half times more likely to develop coronary heart disease than women with a Low Intake of these so-called "foods." Clearly this was not only due to the deleterious effects of eating junk food. For many people, the real shocker in this study was the slatistic that women who ate the equivalent of four or mere teaspoons of margarine per day had a sixty-six percent greater risk of heart disease than women who ale little or no margarine. But when it comes'to bt JEer, this vast study found no association betweon its consumption and the probability of contracting heart disease? .

Willetrs report is shocking only If yOU have not had an eye on the research. Other scientists have demonstrated that while saturated fat (fats that are solid at room temperature, such as butter or the fat marbling a steak) has been reported to have both good and bad effects on cholesterol levels, the effects of trans-fatty acids are purely negative. Research also has shown that Iipoprotein(a), one of the mere damaging forms of chemical substances In cholesterol, consistently increases as a result of eating trans-fatty acids. creases as a result of eating trans-fatty acids.

This compelling research has had little effect on the packaged-food industry,but has, at least, persuaded some fast food chains to stop cooking with hydrogenated oils.And the FDA is considering mandating the listing of trans fats on the Nutrition Facts panel of food labels starting in 200w.Then,although foods would still contain these dangerous fats,you could choose to not purchase them.If enough consumers reject these foods,manufacturers would have to change their formulations.

In addition to boycotting junk foods, I strongly urge you to avoid cooking with margarine or vegetable shortening (that white, creamy stuff that comes in a can). Butter, olive oil and lard worked very well for our heart-healthy ancestors. Or If you find It dtffictdt to resume eating saturated fat use olive, canola or grape seed oil.

Food for Thought

If you've been saturated for years with old journalistic cliches about the terrors of fat and'protein and the virtues of carbohydrate, W sinking your teeth into these crunchy little, thought nuggets. Your physician might find them revealing as well.

· 1991: A Canadien tsam subalRuled meat and dairy protein for carbohydrate in the diets of ten men and women with high cholesterol. The group lowered their total cholesterol by an average of six and a half percent,lowered their average triglycerides by twenty-three percent and raised their HDL cholesterol by an average of twelve percent.

· 1996: The INTERSALT, an international blood pressure study comparhg 10,020 men and women in thirty-two counties, found mat people with a dlatary protsin intake of thirty percent above the average had lower blood pressure than people with a lower intake of protein.

· 1997: In a twenty-year follow-op of 832 men tracked in the world-famous Framingham Heart Study, researchers matched inddence of stroke (there were sixty-one in all) with dietary intake. The men with the highest intake of dietary fat had the fewest strokes; the men with the lowest had the most strokes.

· 1998: A Seattle team analyzed the data from seventeen different population-based studies that reported the relationship between triglycerides and heart disease. Men with higher triglycerides had a thirty-two percent increased risk of heart disease; women with higher levels had a seventy-six percent increased risk.

· 1999: The Harvard Nurses Study did a fourteen year follow-up on 80,082 women, comparing incidence of heart disease. Findings show that the higher the intake of protein, the lower the risk of heart disease in this group of women who were 34 to 59 years old at the outset of the study.

Twenty-First Century Diagnosis and Treatment

If you have any combination of risk factors, symptoms or family history that makes you wonder about your longterm prospects for heart disease, look for a physician with a really up-to-date approach. I recommend that he or she not only understand the conventional risk factors that we've talked about in this chapter, but also be familiar with other indicators of cardiac risk and test you for them. Note: These ranges are based on our forty years of clinical experience. The indicators include:

· Total cholesterol: Normal is considered 120 to 240 mg/dL; ideal is less than 200 mg/dL.

· Low-density Ilpoprotein (LDL) is the bad cholesterol. Normal levels range between 60 and 160 mg/dL; ideal is less than 130 mg/dL (the lower the better).

· High-density Ilpopmleln (HDL) is known as the good choleeterol.Normal levels range between 35 and 80 mg/dL; ideal is more than 50 mg/dL (the higher the better).

· Trlglycerlde levels range normally between 30 and 160 mg/dL; ideal is less than 100 mg/dL (the lower the better).

· HDL to total cholesterol ratio: A measurement of your cardiovascular risk; average risk females: 4.4; average risk males: 4.9. (Ideal is to be below average. For both, the lower the better.)

· Homocysteine is a by-product of defective protein metabolism. An etevated level is a powerful marker for heart disease and stroke risk. I-figh homocysteine levels also indicate a defideno/of folio acid, a B vitamin. (Homocysteine level can be reduced with the intake of vitamins B6, B12, and forlic acid.) A normal level is 5 to 15 mmol/L; ideal is less than 8 mmol/L.

· Upoproteln(a) is a high-risk component of LDL cholesterol. In the last ten years it has been recognized as a strong risk factor for heart disease and stroke. Elevated levels may indicate insufficient intake of vitamin C, which is nccded to maintain healthy blood vessels. A normal level is below 20 mg/L; ideal is less than 15 mg/L.

· C-reactive protein is an antibody. !t appears that some heart attack victims actually have an infeclious component to their disease, which has little to do with following a sound dietary approach, The result is chronically inflamed blood vessels that ere widely regarded as part of the atherosclerotic disease process. High levels of C-reactive protein have been found to increase the risk of heart disease by four and a half times? The ideal is less than .55 mg/dL. Elevated levels would indicate you are at risk.

Therapy for heart disease goes far beyond bypass surgery and stents. I hope that your doctor will be open to the virtues of a less invasive but highly effective procedure called EECR.

Enhanced External Counter Pulsation (EECP). If you have diagnosed heart problems and a positive stress test, EECP is used to create collateral blood vessels supplying the heart muscle. Sometimes called a "natural bypass," EECP uses blood pressure cuffs applied to the patient's legs, which are repeatedly inflated and deflated, to force blood up from the legs to the heart. It has been government tested and funded, is currently being administered at four hundred sites in the United States and is reimbursed by health insurers. I strongly recommend it for our heart patients, so much so that the cardiology unit at The Atkins Center for Complementary Medicine provides about one hundred EECP treatments weekly.

The Lessons of History

Why did heart disease become a major problem when it did, and why is it so much more common in certain countries? Those questions have significant nutritional implications. Forty years ago, Ancel Keys, PhD, a prominent American nutritiontst, argued that heart disease was common in countries that had high-fat diets. He drew a 9raph of seven nations to show that more fat meant mere heart attacks? This was an Influential finding until a few years ago when George V. Mann, of Vanderbilt University, discovered that Keys had carefully selected those nations to make his case but suppressed the data in his preliminary report that showed exercise had a far mere significant correlation with coronary heart disease risk than did any other factor.

A famous British nutritionist of the same period, Dr. John Yudkin, took a different view. He thought heart disease correlated with sugar consumption, it's difficult to isolate information on food habits in different natiorm? Nearly all developed nations have high fat consumption and high sugar consumption. And nearly all underdeveloped nations have neither. Heart disease is high in the developed nations, but why?

One explanation proposed by T.L Cleave, MD, in his book Saccharine Disease Disease: The Master Disease of Our Time, argues that increesss in the incidence of coronary artery disease couid be tmoed to increases in relined carbohydrate intake. He noted that diabetes, hypertension, ulcers, colitis and heart disease, to name a few, were all virtually nonexistent in primitive cultures until refined carbohydrates were introduced. He proposed his "Rule of Twenty Years' noting that it took that long after the introduction of refined carbohydrates before diabetes and heart disease began to appear.

Cieave's hypothesis does give one explanation of what brought about the heart disease epidemic in the industrialized world. Let's look at a couple of atypical western countries. In Iceland, heart disease (and diabetes) was almost unheard of until the 1930s, although the Icelanders ate a diet tremendously high in fat. In the early 1920s, however, refined carbohydrates and sugar arrived in the Icelandic diet, and true to Cieave's Rule of Twenty Years, the degenerative diseases arrived on schedule. Likewise, tn the former Yugoslavia and in Poland, the development of high heart disease rates in the mid-twentieth century occurred in decades when the sugar rate was quadrupling and the animalfat intake was falling.

I wouldn't regard these national trends as proof, they certainly are suggostive. Suggestive also is the fact that in the Mediterranean countries fat consumption has been steadily increasing for the past thirty years and heart attack rates have basn steadily falling.

The hypothesis that blames heart disease on high-fat diets is not on the ropes just yet, but it has taken some hard body blows, and is looking distinctly wobbly on its pins.