Controlling your weight, along with incorporating other healthy lifestyle changes, is not only your best defense against heart disease, it’s also your responsibility.

Building a heart healthy lifestyle

Cardiovascular disease still ranks as the number one killer in America (and in the world).¹ The Centers for Disease Control suggests that as many as 200,000 deaths from heart disease each year could be avoided through simple lifestyle changes.

“Lifestyle” is a catchall phrase for many factors that generally consist of dietary changes, behavior modification, and activity level. Your lifestyle is not only your best defense against heart disease and stroke, it’s also your responsibility.

The following four lifestyle factors account for the bulk of prevention:

Maintain a healthy weight: Being overweight or obese is not what causes the harm; it is the diseases that are associated with those weight conditions that cause the harm. These include high blood pressure, high cholesterol, stroke, and insulin resistance (a precursor to type-2 diabetes – a risk factor for heart disease). Even having a few extra pounds greatly increases the risk of heart disease. In a 14-year study, it was shown that moderately overweight (not obese) individuals have an increased risk of heart disease (50 percent higher for women² and over 70 percent higher for men³). The costs of these diseases and syndromes are enormous, and that doesn’t even begin to calculate the personal, physical, and emotional problems associated with increased BMI.

Engage in regular exercise: The American Heart Association suggests getting at least 30 minutes of physical activity five days a week and that this can help to lower your blood pressure, improve cholesterol, and help you maintain a healthy weight. Add strength training to your regime to help build and maintain lean body mass.

Eating a healthy diet: Food may well be your greatest opportunity to combat heart disease. The Mediterranean diet (which focuses on vegetable, fruit, fish, whole grains, and olive oil) has proved itself over and over to be beneficial to the heart.⁴ Whole grains, beans, and nuts/seeds are all good sources of plant sterols, which can help reduce cholesterol.⁵ Greens such as lettuce, spinach, collard greens, and vegetables such as beets, cabbage, radishes, and celery are all high in nitrates, which may help reduce blood pressure.⁶ It’s important what you are NOT eating on a Mediterranean diet as well as nutrient-poor, energy-rich foods high in saturated fat, cholesterol, sugar, and salt.

Smoking: Don’t smoke. If you do smoke, stop. There are many programs available to help you along the way.

In addition to the factors above, there are more lifestyle changes you can incorporate:

Cut the stress: Stress hormones over a long period can raise blood pressure and cortisol. Try going without your phone, take time to be quiet, meditate, and relax.

Sleep: People who sleep poorly have higher blood pressure, higher levels of cortisol, and other stress hormones. They also tend to have poor blood sugar control and higher inflammation.⁷

A recent study has suggested that lifestyle changes for women can have a large impact on their health. The study combined the above noted lifestyle changes along with a low-risk diet (consisting of a high intake of vegetables, fruits, whole grains, fish, and beans), and moderate alcohol consumption and discovered that these lifestyle changes were associated with a 92 percent decreased risk for sudden heart attack.⁸

It is true that lifestyle changes do take effort, but the benefits for making these changes have a great impact and are long lasting. Try choosing one or two to start and then move on to the next.

1. http://www.who.int/mediacentre/factsheets/fs310/en/index2.html
2. Manson JE, Willett WC, Stampfer MJ, Colditz GA, Hunter DJ, Hankinson SE, Hennekens CH, Speizer FE. Body weight and mortality among women. N Engl J Med. 1995;333:677-685.
3. Rimm EB, Stampfer MJ, Giovannucci E, Ascherio A, Spiegelman D, Colditz GA, Willett WC. Body size and fat distribution as predictors of coronary heart disease among middle-aged and older US men. Am J Epidemiol. 1995;141:1117-1127.
4. Dalen JE, Devries S. Diets to prevent coronary heart disease 1957-2013: what have we learned? Am J Med. 2014 May;127(5):364-9. PMID: 24384466.
5. AbuMweis SS, Marinangeli CP, Frohlich J, Jones PJ. Implementing phytosterols into medical practice as a cholesterol-lowering strategy: overview of efficacy, effectiveness, and safety. Can J Cardiol. 2014 Oct;30(10):1225-32. PMID: 25262863.
6. Hobbs DA, George TW, Lovegrove JA. The effects of dietary nitrate on blood pressure and endothelial function: a review of human intervention studies. Nutr Res Rev. 2013 Dec;26(2):210-22. PMID: 24134873.
7. Aldabal L, Bahammam AS. Metabolic, endocrine, and immune consequences of sleep deprivation. Open Respir Med J. 2011;5:31-43. PMID: 21754974;.
8. Akesson A, Weismayer C, Newby PK, Wolk A. Combined effect of low-risk dietary and lifestyle behaviors in primary prevention of myocardial infarction in women. Arch Intern Med. 2007 Oct 22;167(19):2122-7. PMID: 17954808.

What are plant sterols and stanols?

Plant sterols and stanols are two closely related molecules that make up cell membranes of plants. While that may not sound too interesting, sterols are chemically very similar to the cholesterol molecule found in humans.

Plant sterols were first discovered in the early 1920s and scientists have known since the 1950s that they can help reduce LDL cholesterol (the ‘bad’ cholesterol). Plant sterols, as the “plant” name suggests, are found in plants. They are most concentrated in plant oils such as corn oil, sesame oil, and cottonseed oil but can be found in almost every vegetable, fruit, nut, seed, grain, or legume. Plant sterols/stanols are able to block cholesterol absorption from the intestines; as a result, they lower the amount of cholesterol in the blood.

LDL cholesterol

LDL cholesterol has acquired the moniker “bad” cholesterol because high levels of LDL are associated with coronary heart disease, heart attack, and stroke. LDL cholesterol is the molecule that tends to stick to the walls of blood vessels, causing blockages, in a process called atherosclerosis.

Most health care professionals like to see a cholesterol number below 100 mg/dL. Many factors influence LDL-cholesterol levels such as diet, obesity, heredity, exercise, and smoking.

The science behind plant sterols

A substantial number of studies have been done on plant sterols and the reduction of heart disease, enough that the FDA now allows health claims for certain qualifying products containing plant sterols.¹

Studies have uncovered the following:

• Doses between 1.5-1.8 grams/day of plant sterols reduced absorption of cholesterol by around 30-40 percent.²
• Studies using a dose of 2.2 grams/day of plant sterols reduced absorption of cholesterol by around 60 percent.³

Blocking intestinal absorption of cholesterol can result in a total blood cholesterol level reduction of about 10 percent.⁴ Lowering total cholesterol by 10 percent is suggested to reduce overall cardiac risk by about 20 percent.⁵

Most of us don’t seem to get enough plant sterols in our diets; the average is around 80-700 mg a day. Studies suggest that a beneficial amount is between 1 to 2 grams, typically taken in divided doses (2-3 times a day).⁶

Combining diet for greater reduction

Plant sterols work well on their own, but are even more effective when you add in other lifestyle changes. A study that had participants follow a diet that substituted mono- and polyunsaturated fats for saturated fats resulted in a 9 percent reduction in LDL cholesterol, but adding in 1.7 grams a day of plant sterols resulted in a 24 percent reduction in LDL cholesterol.⁷ In another study, 1 gram a day of plant sterols, along with a diet strong in soy protein, almonds, and high in fiber, lowered LDL cholesterol by an average of 30 percent.⁸

It is clear that plant sterols and stanols can be an effective part of a whole lifestyle program for managing healthy cholesterol levels.

1. Food and Drug Administration. Health claims: plant sterol/stanol esters and risk of coronary heart disease (CHD). U. S. Government Printing Office. 2002. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr=101.83. Accessed 1/14/15
2. Normén L, Dutta P, Lia A, Andersson H. Soy sterol esters and beta-sitostanol ester as inhibitors of cholesterol absorption in human small bowel. Am J Clin Nutr. 2000 Apr;71(4):908-13. PMID: 10731496.
3. Richelle M, Enslen M, Hager C, et al. Both free and esterified plant sterols reduce cholesterol absorption and the bioavailability of beta-carotene and alpha-tocopherol in normocholesterolemic humans. Am J Clin Nutr. 2004 Jul;80(1):171-7. PMID: 15213045.
4. Abumweis SS, Barake R, Jones PJ. Plant sterols/stanols as cholesterol lowering agents: A meta-analysis of randomized controlled trials. Food Nutr Res. 2008;52. PMID: 19109655.
5. http://www.nhlbi.nih.gov/health-pro/guidelines/current/cholesterol-guidelines/final-report
6. Abumweis SS, Barake R, Jones PJ. Plant sterols/stanols as cholesterol lowering agents: A meta-analysis of randomized controlled trials. Food Nutr Res. 2008;52. PMID: 19109655.
7. Jones PJ, Ntanios FY, Raeini-Sarjaz M, Vanstone CA. Cholesterol-lowering efficacy of a sitostanol-containing phytosterol mixture with a prudent diet in hyperlipidemic men. Am J Clin Nutr. 1999 Jun;69(6):1144-50. PMID: 10357732.
8. Jenkins DJ, Kendall CW, Marchie A, et al. Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants. Am J Clin Nutr. 2005 Feb;81(2):380-7. PMID: 15699225.

DASH Diet

One of the most successful ways to reduce blood pressure is through diet.

The DASH diet (which stands for Dietary Approaches to Stop Hypertension) is a diet that is low in sodium and emphasizes whole grains, fruits, legumes (beans), vegetables, and low-fat dairy products as the bulk of calories consumed. Some fish, poultry, and red meat are allowed. Sweets and fats are also allowed but only in small amounts.

Following the DASH diet typically results in 11/7 mm Hg (systolic/diastolic) drop in blood pressure, but when combined with a weight-loss program, those numbers are typically even better, with a 16/10 (systolic/diastolic) mm Hg reduction.¹

Why does it work?

Scientists have long wondered if there was something in vegetables that might account for the blood pressure lowering effects of the DASH diet. The DASH diet is naturally low in sodium and removing salt can certainly help reduce blood pressure, but so can eating foods high in potassium, calcium, and magnesium.²

Recently, scientists have turned their attention to nitrates and discovered that nitrates may be the main reason the DASH diet works. Nitrates have for a long time been erroneously associated with cancer. A poorly designed study that suggested nitrates were harmful was the root of this belief. The study was debunked rather quickly,³ but the public perception has lingered.

Nitrates can be converted in the body to nitrite, then into a molecule called nitric oxide; and it is nitric oxide that is the endogenous signaling molecule known to relax blood vessels (which can lead to a reduced blood pressure).

Typical intake of nitrate in the United States is around 10-100 milligrams a day, with 85 percent of that intake coming from vegetables.⁴ That intake is greatly increased to 1,222 milligrams when people participate in the DASH diet.⁵ Increasing dietary nitrates has been independently shown to reduce blood pressure.⁶ Nitrates are also thought to increase exercise performance⁷ and improve blood flow to the brain.⁸

While scientists are still trying to discover just how much of the DASH diet’s effects are due to nitrates, early studies have suggested that increasing nitric oxide concentration at the artery wall seems to be the key. The benefits of a high-vegetable diet for heart and overall health cannot be understated.

It may take a while to adapt to a lower salt, high-vegetable diet for your own life, but your health is worth it.

1. Blumenthal JA, Babyak MA, Hinderliter A, et al. Effects of the DASH diet alone and in combination with exercise and weight loss on blood pressure and cardiovascular biomarkers in men and women with high blood pressure: the ENCORE study. Arch Intern Med. 2010 Jan 25;170(2):126-35. PMID: 20101007.
2. Aaron KJ, Sanders PW. Role of dietary salt and potassium intake in cardiovascular health and disease: a review of the evidence. Mayo Clin Proc. 2013 Sep;88(9):987-95. PMID: 24001491.
3. van Loon AJ, Botterweck AA, Goldbohm RA, et al. Intake of nitrate and nitrite and the risk of gastric cancer: a prospective cohort study. Br J Cancer. 1998 Jul;78(1):129-35. PMID: 9662263.
4. Gangolli SD, van den Brandt PA, Feron VJ, Janzowsky C, et al. Nitrate, nitrite and N-nitroso compounds. Eur J Pharmacol. 1994 Nov 1;292(1):1-38. PMID: 7867685.
5. Hord NG, Tang Y, Bryan NS. Food sources of nitrates and nitrites: the physiologic context for potential health benefits. Am J Clin Nutr. 2009 Jul;90(1):1-10. doi: 10.3945/ajcn.2008.27131. Epub 2009 May 13.PMID: 19439460.
6. Kapil V, Milsom AB, Okorie M, et al. Inorganic nitrate supplementation lowers blood pressure in humans: role for nitrite-derived NO. Hypertension. 2010 Aug;56(2):274-81. PMID: 20585108.
7. Lansley KE, Winyard PG, Bailey SJ, et al. Acute dietary nitrate supplementation improves cycling time trial performance. Med Sci Sports Exerc. 2011 Jun;43(6):1125-31. PMID: 21471821.
8. Presley TD, Morgan AR, Bechtold E, et al. Acute effect of a high nitrate diet on brain perfusion in older adults. Nitric Oxide. 2011 Jan 1;24(1):34-42. PMID: 20951824.