How Do You Prevent Heart Disease? (vitamin D might not help, but there’s plenty you can do)

We all have one ... let's keep it beating.

We all have one … let’s keep it beating.

Recently one of my favorite bloggers, Ferrett Steinmetz, had some chest pain, and as a precautionary measure went to the ER to get checked out. His initial tests came back normal, but the chest pain continued, and his blood work showed abnormal results. Ferrett had experienced a heart attack, and was immediately scheduled for surgery.

It got me thinking about heart disease.

Heart disease is incredibly common. It’s the leading cause of death in the United States.

So what can we do to prevent it?

For years the medical establishment told us that eating a low-fat, low-cholesterol diet was the best thing we could do to prevent heart disease. Even my last doctor tried to peddle this advice. I changed doctors.

Cardiologists who have been paying attention to the research now associate heart disease with factors like lack of exercise, diets high in refined carbohydrates, poor blood sugar control, inflammation, and sedentary lifestyle (lots of sitting — see infographic below). Dietary cholesterol doesn’t matter so much, and a moderate intake of saturated fat is probably not harmful (though monosaturated fats like olive oil may be preferable). Healthy fats (butter from grass-fed cows, olive oil, coconut oil, fatty fish) are a more “heart-healthy” source of fuel than grain products (even whole grains).

Bill Davis (author of Track Your Plaque and Wheat Belly) is one such forward-thinking cardiologist. Davis recommends a wheat-free, no refined vegetable oil (corn/sunflower/soy/canola), low-carbohydrate diet, as well as certain supplements (which he also sells) including vitamin D, fish oil, niacin, and coenzyme Q10. He also recommends foods such as olive oil, garlic, and tea (all associated with lower heart disease). Is he peddling products? Sure … but his approach is still leagues ahead of the conventional wisdom on heart disease.

Ferrett had to undergo triple bypass surgery. Thankfully, he survived, and is now recovering at home.

Cholesterol and Genetics

23andMe.com tracks fifteen SNP’s that are related to an increased or decreased risk of coronary heart disease (if you have a 23andMe account you can click here to see your heart disease risk profile).

The most significant SNP is rs3798220 (snpedia/23andMe). People carrying the C allele produce higher levels of lipoprotein(a), and have more than a twofold increased risk of heart disease. I feel fortunate to carry TT, but C carriers get a compliment from Dr. Davis. He calls them the “perfect carnivores” in this post, and claims this variant is more resistant to dehydration, tropical disease, and is more likely to be intelligent (I’m not sure what Davis is basing these claims on, but they’re interesting).

AG or GG at rs10455872 is also associated with higher Lp(a) levels and increased risk of coronary heart disease. 23andMe users can see their genotype for this SNP here.

Heart disease risk for rs3798220-C carriers can be somewhat mitigated by low-dose aspirin therapy, at least in women. Estrogen HRT also lowers lipoprotein-a/Lp(a) levels. Among Bantu fishermen, higher fish intake was also associated with lower Lp(a).

Why are elevated Lp(a) levels associated with coronary heart disease? Lp(a) is similar to low-density lipoprotein (LDL), which is more likely to stick to arterial walls and clog them up (while the big HDL molecules bounce around harmlessly).

Environmental Risk Factors

In addition to genetic risk, these environmental risk factors are pretty well established. Unlike diet, there is little controversy around these risk factors for coronary heart disease:

We’re stuck with our genes, but these factors are avoidable. Don’t buy a house next to a freeway. If you smoke, making quitting a priority (if you’re under 40, the damage may be largely reversible). And get a standing desk (or convert — I added eight 12″ dowels to my IKEA desk — now it’s a standing desk).

Dietary Fat and Cholesterol

For decades, both fat intake and lipid cholesterol levels were associated with heart disease, but neither has been shown to be causative. The most famous high-fat diet correlation turned out to be Ancel Keys cherry-picking data for one of his presentations (though Keys may have been unfairly maligned by the paleo community, as this post explains).

What about cholesterol? As of 2010, the U.S. government was still recommending that we consume no more than 300mg of cholesterol a day (2 eggs contain about 370mg), even though a large body of research has failed to find any connection between dietary cholesterol and coronary heart disease. We’ll see if the 2015 guidelines update this recommendation.

Chris Kesser has written a number of articles debunking the idea that dietary cholesterol and saturated fat cause heart disease. I recommend his site.

Still, certain types of lipid cholesterol measurements are associated with an increased risk of coronary heart disease, specifically LDL-P (low-density-lipoprotein particle number). We don’t want large numbers of tiny cholesterol particles floating about in our bloodstreams — they tend to clog up the works.

What raises LDL levels? While Lp(a) levels (discussed above) are related primarily to genetics, LDL levels are highly influenced by diet. High carbohydrate/high sugar diets seem to be the main culprit.

Cholesterol, Vitamin D, Sunlight, and Nitric Oxide

Some researchers believe that high cholesterol levels are merely a biomarker for coronary heart disease risk, and don’t cause heart disease at all. Chris Masterjohn explains how cholesterol is converted to vitamin D, and that sunlight is necessary for this process. So high lipid cholesterol might simply indicate that you aren’t getting enough sun, and that your vitamin D levels are too low. Low vitamin D levels are associated with a higher risk of coronary heart disease.

So all we have to do is take supplemental vitamin D, and we should reduce our risk of heart disease, right?

Not so fast.

In terms of heart disease, blood levels of vitamin D may be a red herring biomarker, just like high cholesterol levels.

Dermatologist Richard Weller has done some fascinating research in this area. He found that people from northern latitudes with less sun exposure generally experience more heart disease. Even after controlling for smoking, diet, and socioeconomic factors, people from sunnier areas experience markedly less heart disease.

Weller discovered that the skin stores large amounts of nitrates and nitrites, which are converted to nitric oxide by exposure to sunlight. Nitric oxide released into the bloodstream lowers blood pressure and dilates (relaxes and opens) blood vessels. Weller showed that this effect was not related to vitamin D levels; the amount and intensity of sunlight (about 30 minutes of sun in Edinburgh, during the summer) was not sufficient to raise vitamin D levels. But it was enough to convert skin nitrates and nitrites into nitric oxide, and lower blood pressure.

It’s not that vitamin D isn’t good for you. We know vitamin D increases calcium absorption, prevent rickets, and reduces the risk of many cancers (especially colon cancer). But in terms of heart disease, low vitamin D may just be a biomarker for low sun exposure, and therefore low plasma nitric oxide levels.

How does nitric oxide prevent heart disease? In addition to lowering blood pressure, nitric oxide inhibits the oxidation of low-density lipoprotein, which is a known risk factor for heart disease.

What about skin cancer risk? Weller, a dermatologist, points out that heart disease is a much bigger killer than skin cancer (by a factor of 100). And thirty minutes of Scottish sunlight is probably not going to cause much skin damage.

I live in the Bay Area and we get plenty of sun, but I’m rarely in it. My calves are British-schoolboy white. Moving forward, that’s going to change. According to Weller, even ten minutes of California winter sunshine is enough to activate nitric oxide (NO) release. I won’t be sporting a tan anytime soon, but I might be moving into a light beige.

Other Ways To Raise Nitric Oxide Levels

What if sunlight exposure isn’t an option, either due to latitude or lifestyle?

There are other ways to boost nitric oxide. The primary one is exercise, which has shown to be heart-protective.

Dark chocolate also boosts NO levels and reduces blood pressure.

So does red wine.

So there are options to boost nitric oxide levels. And more than heart health is at stake; adequate NO levels are vital for sexual response in both men and women.

What About Supplements and Medications?

Which supplements and medications have the best evidence for protecting against heart disease?

Niacin has a decent track record, though a large trial by Merck combining statins and niacin showed no benefit. Personally I can’t tolerate large doses of niacin — the flush response is too much, and it messes with my digestion. Niacin may be especially effective for rs3798220-C carriers who produce higher levels of Lp(a), but low-dose aspirin is also effective.

Statins are often prescribed, but show no benefit for people who don’t already have coronary heart disease. Low-dose daily aspirin is just as (or more) effective, and much cheaper. Both statins and low-dose aspirin can have serious side effects, including internal bleeding and increased risk of macular degeneration for the latter.

Coenzyme Q-10 may be heart protective, and can help lower blood pressure. Oily fish like salmon is a good source, but since levels decrease with age, those of us over 40 might consider taking supplemental CoQ10. Statins tend to lower levels of coenzyme Q-10, and supplemental CoQ10 may protect against some of the side effects of statins.

Of all the supplements I have considered, vitamin K2 (found in fermented foods, aged cheeses, poultry liver, and grass-fed dairy products) seems to be the most promising in terms of actually preventing coronary heart disease. This study found an inverse relationships between dietary vitamin K2 and heart disease in older women.

I eat most of those foods, and recently I also started taking 50mcg of vitamin K2 (the Mk-7 form, derived from nattō) several times a week (I’ve tried actually eating nattō, but I can’t stand the taste).

Vitamin K2 controls where calcium goes in the body via modulation of the hormone osteocalcin. How exactly does this process work? Here’s a excerpt from this article.

The possible role of vitamin K2 in preventing coronary plaque development has emerged from observations of its effects on several bone proteins, whose main function is to keep calcium where it belongs in the body.

Osteocalcin is a calcium-regulating protein that is controlled by vitamin K2. When vitamin K is present, osteocalcin normally undergoes a process called carboxylation, which binds osteocalcin to the mineral portion of bone. However, in vitamin K2 deficiency, osteocalcin cannot perform this function, resulting in unrestrained calcium resorption (removal) from bone tissue that leads to osteoporosis.

The opposite situation seems to occur in the arteries. Calcium is deposited because another protein called matrix GLA-protein, which is a calcification inhibitor and is also K2-controlled, cannot undergo the process of carboxylation in a vitamin K-deficient state. Because only carboxylated matrix GLA-protein inhibits calcification, undercarboxylated matrix GLA-protein has been found to occur in unusually high concentration at the edge of calcified and atherosclerotic plaques, suggesting it plays an active role in depositing calcium in plaque.4 Impairment of the function of osteocalcin and matrix GLA-protein due to incomplete carboxy-lation results in an increased risk for developing osteoporosis and vascular calcification, respectively.

So if you want your arteries to remain uncalcified, you should absolutely make sure you are consuming enough vitamin K2.

What about fish oil? Consuming fatty fish multiple times a week is clearly associated with reduced risk of coronary heart disease, but it’s less clear if supplemental fish oil is beneficial. I do both, but use a lower dose of fish oil (only 2-3g on most days).

Linus Pauling hypothesized that arterial plaque is only created in the absence of adequate vitamin C levels. Researchers at the Linus Pauling Institute make a strong case for raising the RDA to 200mg a day (high enough not only to prevent scurvy, but to reduce mortality from a wide range of diseases). Other research has shown that vitamin C supplementation lowers levels of C-reactive protein (CRP is a biomarker of inflammation that is linked to heart disease). Population studies in the 1990′s found that vitamin C supplementation is associated with increased longevity, specifically from reduced cardiovascular disease. I’ve taken vitamin C for decades (though I no longer megadose, as very large doses of vitamin C can reduce copper absorption).

Summary

Heart disease is the biggest killer in the United States, and most other developed countries. We can reduce our risk by doing the following:

  • reduce sitting (get a standing desk and limit TV couch time)
  • exercise daily (long walks and taking the stairs count)
  • get some sun on your skin daily (but don’t burn)
  • eat dark chocolate and drink red wine
  • eat a low-grain, low refined vegetable oil, low-sugar diet (not necessarily low-carb; some foods containing carbohydrates like whole fruit and properly cooked beans probably have more benefits than drawbacks)
  • eat “good fats” including olive oil, butter from grass-fed cows, coconut oil
  • get enough dietary vitamin K2, and consider supplementing up to 100mcg/day
  • eat oily wild-caught fish multiple times a week (canned salmon is a less expensive source)
  • eat green leafy vegetables to supply nitrates for NO production
  • consume at least 200mg of vitamin C a day from food and supplements
  • have impeccable dental hygiene; periodontal disease is strongly linked to heart disease (brush and floss daily and thoroughly, don’t eat sticky carbs and acidic juice, chew xylitol gum, consume fat soluble vitamins [D, K2, A], and see a dentist on a regular basis — I’ll do a detailed post on this topic in the coming months)

Did I miss anything? May you all live long and prosper!

Sitting is Killing You

34 responses to “How Do You Prevent Heart Disease? (vitamin D might not help, but there’s plenty you can do)

  1. Very interesting post. I have heart disease and am a women. My family has a strong history of heart disease with my father, his father and both brothers having a heart attack in their mid-40′s. I had mine at 45 and I was eating and now still eat a whole foods diet of organic fruits, veggies, seeds and nuts and wild fish mostly. I was running and boxing at the time, so I figured my issue was mostly genetic. After my event, I started taking pantethine (Jarrow brand works the best for me), artichoke extract and also starting taking fiber in a pill in addition to edible fibers. My LDL is still not where is should be, but is better than it was. I do get sun, but am low in vitamin D, so I supplement. I like the idea of MK-7 because it seems to not only protect against heart disease, but also osteoporosis. Thanks for the information.

  2. Fascinating that sunlight produces NO. Sunlight also sulfates Vit D and cholesterol, an interesting interview at http://articles.mercola.com/sites/articles/archive/2011/09/17/stephanie-seneff-on-sulfur.aspx

    I suspect that sun-caused skin damage is a consequence of high omega-6 fats, and that when you eat no more that 4% PUFA that you won’t have any. I used to burn really easily, since switching to a Perfect Health-type paleo I haven’t had any problems.

  3. I am standing here eating dark chocolate and drinking red wine after eating fish cooked in olive oil and the second sip of wine is to help with the vitamin D afte which I turn on the electric tooth brush. You think I am kidding. Not so and thanks for this blog. It is a life saver. Your friend the Bantu fisherperson.

  4. J.D.
    I own a website and am focusing on Heart Health for February. I am looking for bloggers to contribute stories/thoughts/etc. If you are interested in contributing, please contact me @ admin@thegypsynurse.com

    • Hi Candy — you are welcome to reblog this post, or anything else you find of interest on my site. I’d be happy to write a short introduction for your site in particular. Cc’d to your email.

  5. Oh, okay, NOW I understand why all my office mates have switched to standing desks. I turned one down because it looked so dumb and I get plenty of exercise. I’m rethinking that choice right this minute!

  6. Excellent, very informative post, J.D. In the real world, just getting people to sincerely and consistently focus on their health seems to be a challenge. Many folks tune in for a week or a month and then have a “relapse”. For those who make the effort, however, the rewards are priceless. In the discussion about cholesterol, let’s mention those whose numbers are totally whacko – like mine. Inherited from my father……overall 260, LDL 95, HDL 135, VLDL 45……good grief! It’s the relative relationship that’s important there – my HDL is through the roof (proportionately to LDL), giving a below-average risk for coronary disease. You mentioned that you changed doctors. I run a non-profit and support group for people with chronic viral hepatitis. I always tell people – you have to be able to talk to your doctor and you have to trust your doctor with the truth about your lifestyle, your habits (good and bad) and your concerns. If you can’t be honest with your doctor, you need to find a different doctor. Otherwise, all you have is a less-than-perfect, non-productive and very expensive bad habit. Making sure your doctor knows everything is especially critical if you’re headed into any kind of surgery or treatment regimen. In reality, though, if you’re doing everything right, you won’t be seeing your doctor very often anyway! Let’s aim for that……

  7. hi J.D. …………really enjoyed your post on standing….and while I agree that sitting all day has detrimental effects on our health and is totally unnatural, I was wondering if too much standing is as bad as some say…you know, varicose vains, swelling of feet and legs, back pain…etc…ideally one would be on the move most of the time, but standing still for hours??? thanks !!

    • Agreed … I think movement is the key … but after switching to a standing desk it now feels natural. I tend to take quite a few breaks (sometimes sitting down, sometimes walking around).

  8. I agree with you about the standing desk; I’ve been using one for the past 3 years. Sitting down all day now makes me very uncomfortable – can’t imagine how I used to do it. During the work day I sit down to eat lunch and take phone calls, and move about as well during the day. It feels perfectly natural to be working on my feet, and I find that the 3:30 exhausted slump is a thing of the past.

    Love your blog!

  9. I take the Green Pastures Fermented Cod Liver Oil mixed with High Vitamin Butter Oil, in which as I understand it the latter is a great source of K2. I’m taking them largely to help remineralize my teeth (they feel stronger and harder for sure), but glad to hear it may help with heart disease as well!

  10. Great article J.D. and glad to see that you also dipped into the genetics – there are also some SNPs that greatly impact blood pressure and hence influence CHD. The only significant omission I can see is inflammation, and this is heavily influenced by both diet and certain SNPs. Keep up the good work…

    • Thanks Paul. Diet and inflammation … probably worth an entire post at some point. Feel free to recommend/link if you know of any great existing articles on that topic.

  11. Calcium supplements are linked to an increased risk of cardiovascular disease, but only in men:

    http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/37175

    Another reason to take vitamin K2, especially if you take vitamin D (which increases calcium absorption).

  12. I just find out I have type 1 diabetes. I have to take insulin. Got any advice on how I should cope? Do you think it will affect my metal/electronic music route?

    • Diet and exercise can help a great deal for Type 2, but I’m not sure for Type 1. Glucose monitoring technology has come a long way in recent years, so you have quite a few options.

      Cutting out refined carbs can only help (white bread, soda, etc.).

      I don’t see any reason you can’t keep making music — there are many many successful musicians with diabetes.

  13. Awesome post JD. Love your blog. I do have one critique:

    I wish you would have advocated for a treadmill desk. Standing all day at your desk in one spot, typically causes lower back strain. I found this out first hand, but have little to no issue on a treadmill desk. Many people now advocate them. Over the course of several months, walking distance adds up. ie: LA to NY on their “Desk-mill”. Slow movement walking + no sitting = win. The main problem is these desks are still expensive, unless you are into building your own. That and finding your comfort zone to slowly move and work at the same time.

    • Also the MK4 vs MK7 is kind of murky? I heard something like 1/3 of people don’t absorb MK7 too well, and it builds up in their body. So MK4 would be recommended for those people. But it is more expensive. Any thoughts on this?

    • My wife got a treadmill for her standing desk, but found she was unable to walk and complete fine-motor design tasks at the same time. For myself I prefer frequent breaks and walking around my neighborhood. Good to know that a treadmill desk is working well for you — might be a good option for others as well.

  14. A somewhat glaring omission from this post is reducing salt intake, as I was reminded after reading this article:

    http://www.nytimes.com/2013/02/24/magazine/the-extraordinary-science-of-junk-food.html

  15. In a large, high quality study, Mediterranean diet beats low-fat diet significantly in terms of reducing heart disease. The version of the Mediterranean diet used in the study centers around vegetables, fruits, beans, nuts, fish, chicken, wine, and liberal use of olive oil. Check it out: http://www.nytimes.com/2013/02/26/health/mediterranean-diet-can-cut-heart-disease-study-finds.html

  16. TMAO (associated with arterial plaque) used to be associated with dietary choline (found in egg yolks), but more recently has been linked to carnitine (found in red meat) http://www.nytimes.com/2013/04/08/health/study-points-to-new-culprit-in-heart-disease.html

  17. Pingback: To Protect Your Heart, You Need to Bleed | J.D. Moyer

  18. Pingback: To Protect Your Heart, You Need to Bleed | HumanOS

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