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Primary care physicians can help prevent, reverse cardiovascular disease
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Cardiovascular disease has become the leading cause of death worldwide, accounting for 31% of all deaths, or 17.5 million fatalities, globally in 2012, according to WHO.
In 2016 USPSTF released guidelines recommending statin use for the primary prevention of cardiovascular disease in adults. However, many experts have argued that addressing upstream causes of cardiovascular disease might be a better option, especially since in some patients, statins cause side effects ranging from muscle achiness to gastrointestinal distress, liver toxicity and even rhabdomyolysis, a potentially life threatening breakdown of muscle tissue.
Therefore, it is important for primary care providers to recognize that there is an effective alternative to statins. Prevention and even reversal of heart disease is attainable through substantial diet and lifestyle changes, according to several experts who spoke with Healio Internal Medicine.
Underlying causes and risk factors of CVD
The onset of CVD trickles down, progressively injuring and compromising the endothelium — the delicate, innermost part of the artery, Caldwell Esselstyn, MD, of Cleveland Clinic, told Healio Internal Medicine.
“The endothelium is a life jacket and protector of all our vessels because it makes an absolutely magical molecule of gas called nitric oxide.” he said. “Nitric oxide has a number of truly remarkable functions.”
According to Esselstyn, nitric acid protects people from developing blockages or plaque, and in people with CVD endothelium’s capacity to produce nitric acid is diminished.
“CVD is a toothless paper tiger that need never exist, and if it does exist, it need never progress. It is a foodborne illness,” he added. “CVD is virtually unknown in Okinawa, rural China, the Papua Highlanders of New Guinea, central Africa and the Tarahumara Indians of northern Mexico. They all thrive on whole food, plant-based nutrition with minimal oil or animal food. We have developed a billion-dollar health industry in this country for an illness that does not even exist in half of the planet. Our Western diet of meat, fish, fowl, dairy products, sugary and processed foods and oils destroys the capacity of the endothelium to produce nitric oxide, the gas responsible for maintaining the health and integrity of our blood vessels.”
Several other factors increase an individual’s risk for CVD, some that are unchangeable, such as age, sex and family history, and many more that can be controlled, such as smoking, obesity, an unhealthy diet and sedentary lifestyle, Rita Redberg, MD, MSc, FACC, of the division of cardiology at the University of California, San Francisco, told Healio Internal Medicine.
Obesity and sedentary lifestyle increase the risk for diabetes and high BP, thus further contributing to the risk of CVD, she said.
How CVD can be prevented
Making comprehensive lifestyle changes, can not only prevent, but even reverse the progression of CVD, including the most severe coronary heart diseases, Dean Ornish, MD, clinical professor of medicine at the University of California, San Francisco, and founder of Ornish Lifestyle Medicine, told Healio Internal Medicine.
Comprehensive lifestyle changes include consuming a whole foods plant-based diet that is also low in refined carbohydrates and fats and predominately consists of fruits, vegetables, whole grains, legumes and soy products in their natural whole form, as well as exercising moderately, social support and managing stress, he said.
Ornish and colleagues have conducted a series of studies and randomized trials over the last 40 years and found that these lifestyle changes significantly improved coronary blood flow and cardiac function in as little as 30 days. In addition, they showed, for the first time, that there was significant regression or reversal of coronary atherosclerosis or coronary artery blockages after 1 year, with additional reversal after 5 years, and this occurred in direct proportion to the degree of lifestyle change. He noted that none of these patients were taking cholesterol-lowering medications and showed an average 40% reduction of LDL cholesterol and reversal of heart disease in the first year. In stark contrast, the randomized control groups experienced worsening of coronary atherosclerosis after 1 year with continued progression after 5 years, according to Ornish.
“We also found that when you make lifestyle changes, it also changes your genes — it turns on the beneficial genes and downregulates the genes that promote chronic inflammation, which is often a root cause of heart disease and many other chronic conditions,” he added.
The Ras oncogenes that promote prostate, breast and colon cancer are also downregulated through lifestyle changes, thus potentially reversing, slowing and stopping the progression of these cancers in their early stages, he said. In only 3 months, more than 500 genes changed — “good genes were turned on and bad genes were turned off,” Ornish and colleagues found.
“Many people think that it has to be a new drug or laser or something really high-tech to be powerful and in our work over the last 40 years using these very high-tech, expensive, state-of-the-art scientific measures prove how powerful these very simple and low tech and low cost interventions can be,” Ornish said.
Small and simple measures, such as improving diet, engaging in regular physical activity and not smoking are powerful in preventing CVD, according to Redberg.
Lifestyle changes versus statins
In November 2016, the USPSTF released a recommendation statement in favor of using statins to prevent CVD.
“The recent USPSTF guidelines overestimated the benefit of statins for primary prevention, likely because some of the studies they relied on also included secondary prevention patients, who are more likely to benefit from statins,” Redberg said. “The task force did not have access to the primary data which limits the ability to analyze the evidence accurately. Furthermore, there is underreporting of adverse effects of statins in the industry-sponsored clinical trials, and patients report a higher incidence of adverse effects in actual use.” She called for making the cholesterol trial data publicly available.
A review article published in the Expert Review of Clinical Pharmacology reported that directors of clinical trials have minimized the significance of multiple adverse effects of statin treatment by using relative risk reduction.
CVD is not caused by lack of ingesting statins, according to Esselstyn.
“The recent USPSTF guidelines to expand the use of statin drugs to limit the CVD epidemic, completely misses the very foundation of disease prevention which is to treat the causation of the illness,” he said.
“The concept of advising statin drugs for the asymptomatic is ill-conceived, simply leading down the path of more ‘pharmageddon,’” he added. “At our fingertips is the seismic revolution for health: whole food plant-based nutrition which has the capacity to end CVD and 75% of chronic disease.”
While statins have well-established cholesterol-lowering benefits, diet and lifestyle changes are comparable to statins in preventing and reversing CVDs without the costs and adverse effects, Ornish said. If patients are not able to or not willing to make big enough changes, statins can be a valid alternative, he added.
“Unfortunately, statins become the reflex for some doctors particularly because they don’t have time to spend with their patients to counsel them in how to change their lifestyle and diet, to give them that support. That’s why it’s easier to just write a prescription, but it’s not optimal for patients,” he said.
According to Ornish, another main problem is that many doctors assume patients are more agreeable to taking statins but are not capable of making effective diet and lifestyle changes. However, data indicate that patients are willing to make these changes and when clinicians introduce this idea in a way that emphasizes that changing diet and lifestyle will make patients feel better quickly, adherence rates increase, he noted. Ornish’s nine-week lifestyle intervention program has a 91% adherence rate 1 year following initiation, while one-half to two-thirds of individuals who are prescribed statins are not taking them after 6 months, mainly because statins are “fear-based,” he said. “Statins don’t make you feel better, but lifestyle changes do because the underlying biological mechanisms are very dynamic — for example, most patients become angina-free in only a few weeks,” he said. Therefore, reframing the reasons for making changes from fear of dying to joy of living is significantly more sustainable, he said.
“For many people these choices are worth making because what you gain is so much more than what you give up and you don’t have these painful choices that you do when you take statins,” Ornish continued.
Furthermore, over time, taking statins is associated with increased likelihood of becoming obese and more sedentary in comparison to non-statin users, according to Redberg. A study published in JAMA Internal Medicine revealed that statin users consumed an additional 192 calories per day, corresponding to a 6- to 10-pound weight gain in one year. In contrast, the researchers found no significant changes in weight gain or eating habits among non–statin users. These data were based on a nationally representative sample of 27,886 adults from the United States aged 20 years or older.
“This is likely because of the false sense of reassurance that you don’t have to pay attention to lifestyle when you are taking a pill,” Redberg said. “Patients should certainly feel free to take statins, if they understand the small chance of benefit and the larger chance of adverse effects.”
In addition, type 2 diabetes is a significant risk for statin users, Ornish said. “The irony is we may be replacing one problem with another since heart disease is a major complication of diabetes,” he added. A review article published in SAGE Open Med in 2015 including data from 13 cohort studies and seven meta-analyses suggested that statins are associated with a small, yet significant increased risk of new-onset diabetes compared with placebo or no treatment.
“I’m not against the use of statins. If someone isn’t willing to make lifestyle changes, I think it’s important to prescribe them, but doctors shouldn’t assume that their patients are unwilling to make a significant lifestyle change,” he said.
PCPs role in preventing, reversing CVDs
“Part of the problem is that most PCPs only have 5 to 10 minutes or so with their patients and it’s very hard to do much of anything in terms of counseling them on their lifestyle in such a short amount of time,” Ornish said. “That’s why we’re trying to create a new paradigm of health care where Medicare and most insurance companies will pay for 72 hours of training,” allowing doctors to spend enough time with patients.
According to Esselstyn, it is crucial for PCPs to give patients time to really understand the importance of preserving or restoring the endothelium through whole food plant-based nutrition and significant lifestyle changes.
“The most frequently voiced opposition to plant-based nutrition is that the public won’t adopt it,” he said. “This grossly underestimates the capacity and willingness to change. The public curtailed smoking by 50% when they understood the health benefits and the same occurred with universal acceptance of seat belts.”
“It doesn’t take long to tell people that, but that minute or so of counseling can often have a big impact on patients because they trust their doctors and when they feel like their doctor really cares about them, expresses their caring for them and says these things are doable, it really makes a difference,” he said.
“Primary care is where the action is, that’s where the disease is brewing and that’s where the disease can be completely stopped before it becomes disease,” Elizabeth Klodas, MD, cardiologist and founder of Step One Foods, told Healio Internal Medicine. “It’s all about diet. It’s not about the drugs. If people only changed what they ate, most cardiologists would be out of work.” – by Alaina Tedesco
References:
Beckett RD, et al. SAGE Open Med. 2015;doi:10.1177/2050312115605518.
Diamond DM. Ravnskov U. Expert Rev Clin Pharmacol. 2015;doi:10.1586/17512433.2015.1012494.
Ornish D, et al. Lancet. 1990;doi:10.1016/0140-6736(90)91656-U.
Ornish D, et al. JAMA. 1998;doi:10.1001/jama.280.23.2001.
Ornish D, et al. PNAS. 2008;doi:10.1073/pnas.0803080105.
Sugiyama T, et al. JAMA Intern Med. 2014;doi:10.1001/jamainternmed.2014.1927.
Disclosures: Esselstyn and Redberg report no relevant financial disclosures. Ornish is the founder of Ornish Lifestyle Medicine and the author of The Spectrum. For more information, visit www.ornish.com. Klodas is the founder of Step One Foods and the author of Slay the Giant: The Power of Prevention in Defeating Heart Disease. For more information, visit www.steponefoods.com.