February always takes on a special meaning for me, as it is American Heart Month; a special time to reflect on all the many advances in cardiovascular medicine over the last several years. It’s also a time to look into the future. As long as heart disease remains the number one cause of death in both men and women, we will always have the need to keep searching for answers. After all, coronary heart disease is responsible for one in every six deaths in the United States.

With recent propaganda films like GAME CHANGERS and all the confusion that has resulted, I believe it’s my turn to step in and help make sense of all this.

Notice I said propaganda film and not documentary. A documentary expresses factual events (Merriam Webster). GAME CHANGERS, which is billed as a documentary uses misrepresented, cherry-picked and flat out false information to deceive the audience into thinking that animal based diets are harmful and that a plant based diet is evolutionary accurate and nutritionally complete.  This is simply not true. There are mounds of evidence that negate most of their claims.

I am anything but a purist. I’m not just one way. I’m not totally plant based or strictly carnivore. I believe in balance. There are way too many food elitists out there that will say or do anything to prove that their diet is the only way to go. My response: “Really? Prove it”. But they can’t. 

I have stated repeatedly that not one diet suits all. Avoiding dogma, I will continue to stand by this principle until someone can convince me otherwise.

There are simply too many variables to consider when choosing an appropriate diet plan:

• Genetics

• Individual goals (performance, weight loss, enhanced energy, longevity, etc.)

• Age

• Pregnancy /nursing 

• Food allergies or food sensitivities 

• Lifestyle (career, exercise, travel)

• Medical history (heart disease, hypertension, cancer, diabetes, obesity, autoimmune disease, dementia etc.)

• Lipid profile (cholesterol, size of the LDL or lousy cholesterol particle, triglycerides)

• Metabolic profile (diabetes, prediabetes, metabolic syndrome, non-alcoholic fatty liver disease, polycystic ovarian syndrome)

• Gut function (leaky gut, small intestine bowel overgrowth (SIBO), irritable bowel disease, inflammatory bowel disease (ulcerative colitis and Crohn’s disease)

So whether we are talking about a straight vegan diet, Mediterranean diet, paleo or ketogenic diet, all the variables listed above play critical roles in formulating diet plans.

These days I see more and more patients with self-imposed food restrictions. Besides going vegan, many are choosing to be gluten-free, sulfur- free, lectin-free, histamine -free, and diary-free. Now I clearly believe in restricting foods when talking about true food allergies and /or sensitivities. But we are going a bit overboard here.   

It seems as if everywhere you go you hear about the gut. I am totally in support of gut health. If your gut isn’t healthy, you aren’t healthy. But seriously I am seeing an increasing number of folks searching for the Holy Grail. They keep restricting one food group after another. We end up with a population of self-obsessed narcissists with eating disorders. They have developed an unhealthy relationship with food. And so often, they continue to feel miserable!

In essence, I don’t really care who is vegan, who is carnivore and who is in between. What I do care about is that you follow and enjoy what works for you, given your general health, and any true food allergies and bona fide food sensitivities.

So what constitutes a heart healthy diet? Let’s first dispel a couple of principles that need to be buried once and for all.

1. Fat is not the enemy despite the fact that the American Heart Association (AHA) still promotes a low cholesterol, low saturated fat diet. We know that cholesterol in food does not equate to cholesterol in the blood. There is nothing wrong with eating egg yolks, lobster, shell fish and coconut, at least in moderation.

All the negative press linking saturated fat to heart disease was based on poorly controlled observational studies from the 60’s and 70’s. It was demonstrated that saturated fat increased total cholesterol levels as well as LDL, the so- called “lousy cholesterol”. It was then surmised that this increase in cholesterol led to heart disease.

   But how important is total and LDL cholesterol anyway?  It’s simply one piece of the pie. Besides, cholesterol and LDL cholesterol are essential to life. More recently we have learned of potential beneficial effects of saturated fat. For example, saturated fat may increase levels of HDL (or healthy cholesterol). It may also reduce levels of Lp(a), a sticky, inflammatory fragment of LDL cholesterol.  Saturated fat may also increase the size of the LDL particle, which is favorable.   

Besides, it has never been conclusively proven that saturated fat leads to death from heart disease, or death from any reason for that matter.

1. Whole grains should not rest at the base of the food pyramid. Stemming from the 1990’s, recommended was “6-11 servings of bread, cereal, rice and pasta.” That sounds pretty preposterous today. Fortunately there have been changes over the years, but whole grains still seem to take precedence over healthy fats. 

THE REALITY: Sugar is a main culprit in heart disease. We know today that coronary heart disease is a disease of inflammation. Nothing, absolutely nothing you eat is as pro-inflammatory as sugar. It’s akin to pouring gasoline over the fire. Remember, all those grains that were once revered? They eventually break down into sugar.  

Clearly there are indirect relationships between sugar and heart disease through mere association with other entities:  hypertension, diabetes, metabolic syndrome, obesity and non-alcoholic fatty liver disease. 

Is there any direct effect of sugar on the heart? Observational studies have demonstrated this. But there have also been   prospective studies that showed a positive association of added sugar in the diet to death from heart disease 1

What about salt? This too has been vilified over the years as leading to hypertension and heart disease.  The body needs salt. It’s essential for proper nerve and muscle function. It also helps to regulate body fluids.

The AHA recommends no more than 2.5 grams of sodium per day. Thus amounts to one teaspoon of salt. Recent studies suggest that we can be more lenient without fear that it will harm our cardiovascular health. Those with kidney or liver disease, and those with a history of congestive heart failure do need to exercise caution. This also extends to those who are salt retainers. Unfortunately there is no test to detect salt retainers. It’s a trial and error phenomenon. 

THE MEDICAL ADVOCATE’S APPROACH TO A HEART HEALTHY DIET: 

Again, I don’t necessarily favor one diet over all others. Personally, I tend to follow a diet of natural, unprocessed, non-GMO foods. I insist on eating only organic fruits and vegetables, grass-fed beef, and wild seafood. I’m pretty firm on these principles. Being physically active, I don’t restrict my sodium (salt) intake, but then again, I refrain from processed foods, which is by far the biggest source of sodium in the standard American diet.

I choose to follow a diet somewhere between the Mediterranean and Paleo diet. There is no question that the data on the Mediterranean diet and prevention of heart disease is extensive. 2

 Still I see the benefits of going paleo. After all, if it doesn’t run in the wild or grow on a tree, bush or vine, does it belong on our plate?

Both diets emphasize unprocessed foods. I happen to believe a diet low in starchy carbs is healthier. That’s what separates paleo from Mediterranean.

What about the extremes such a total plant based diet (vegan) and a carnivore diet? I’m not closed off to either. They both serve a purpose, especially if it suits the individual. My recommendation is that folks adhering to these diets check out their micronutrients in an ongoing fashion. Nutrient deficiencies are commonly seen and are important to correct. 

What about going ketogenic? This is also a very useful diet in the proper patient. I prescribe it commonly in my practice, especially in those with a metabolic disorder. (diabetes, prediabetes, metabolic syndrome and obesity). Such disorders are commonly seen in cardiac patients.

What about fasting?  Again, in the proper patient it can be incredibly useful. I’ve been doing intermittent fasting for over 2 years, and it suits me well. I also follow the Fasting Mimicking Diet (FMD) as pioneered by Dr. Valter Longo at USC. But these diets are not for everyone.

I mention these diets for completeness sake only. They are not my go to diet for the average patient wishing to adopt a heart healthy diet. 

Note that you have several options. It’s not about going all out vegan, carnivore, or ketogenic. Don’t let anyone convince you of that.  Such diets may well appeal to certain populations, however, only the Mediterranean diet has withstood the test of time in preventing heart disease. 

As you become your own best medical advocate, you will undoubtedly find the diet that works best for you and your general health and wellness.

Happy Heart Month to you all!

Howard Elkin, MD

REFERENCES:

1. Q Yang, Phd et al.  Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults. JAMA Intern Med. 2014;174(4): 516-524

2. R. Estruch, MD,PhD. Primary Prevention of Cardiovascular Disease With A Mediterranean Diet. NEJM 2013; 368:1279-1290