Heart & Sole: Put Your Best Foot Forward


Let’s face it, the foot is pretty easy to neglect. It is an amazing piece of architecture housing 25% of all joints. It is our foundation for the body’s upper scaffolding.

There is also an indisputable link between foot health and heart health. Because your feet are located farthest from the heart, they are the last place to receive blood supply for tissue and nerve endings. Stop walking for as little as 2-3 days and you may find that your heart has already started to become deconditioned.

As physicians, we rarely consider the importance of healthy feet. However, warning signs of potential problems may indeed first manifest in the foot. This may include the first sign of diabetes or its complications, deficiency of certain vitamins and minerals and many others.

It is essential that we keep our feet healthy, especially as we age. Ironically, most people including physicians don’t realize that feet change with age.

It is likely that the shoes sitting in your closet for the past 8 years don’t fit anymore.

It is never too late to strengthen your feet.

It is important to perform balance exercises on a daily basis.

I recommend:

  1. Inspect your feet daily: when you have your annual physical exam, take off your shoes and socks so that your health care provider can examine your feet as well.
  2. Wear the correct shoes: Let’s get real – those narrow cut high-heeled, stiletto shoes that barely have space for your toes may be good as an instragram photo but they do nothing to support you in real life!
  3. Exercise your feet daily: just the simple act of lifting and spreading all 10 toes will have a remarkable effect. Do yoga!
  4. Love them. The more love you throw at your feet, the better they will be.

Lisa Miller, DPM is a holistic podiatrist at the Johns Hopkins Community Physicians. She has nearly 30 years of experience and expertise in preventive foot health and is currently completing her training in Yoga certification.

Is a Good Marriage Cardioprotective?


New research indicates that a good marriage indeed protects the heart. For example, a study of 2262 middle-aged Finnish men (average age, 53 years) followed for more than 25 years found that men who reported to be “very satisfied” in their marriages were 50% less likely to experience sudden cardiac death compared to those who were dissatisfied.  Another study conducted in elderly Chinese men and women (75 years and older), found that after an acute coronary syndrome, living with a spouse was associated with much greater survival rates  1-year after the event than without a spouse.

The bottom line: A Healthy Marriage equals a Healthy Heart!

Michael Miller, MD is a cardiologist and Professor of Medicine, Epidemiology & Public Health at the University of Maryland School of Medicine in Baltimore, Maryland USA.

Do You Have a New Year’s Resolution?


Believe it or not, making a New Year’s resolution increases the likelihood that your resolution will succeed by ~10-fold (although sometimes it may seem like years to accomplish)!  Nevertheless it is well worth worth your while to make at least one resolution for the New Year.  Among the 3 most common New Year’s resolutions are to 1) quit smoking 2) lose weight & 3) increase exercise.  Below are tips to help successfully attain these goals in 2019.

  1. Quit Smoking:  It takes the average smoker 7 trials before successfully quitting. Fortunately, we now have a solid arsenal of weapons in our cancer and heart disease prevention toolbox.  They including nicotine containing chewing gum, patches and a variety of medications.  However, the first recommendation is to avoid/remove the stimulus that triggers the first cigarette of the day.  For example, if a cup of morning java is the trigger, then switch to tea (or another drink).   In our University Cardiology practice,  what I have found successful is the nicotrol inhaler, “artificial” cigarettes that contain nicotine without the other 2,000+ toxic ingredients.   Start off with ~6 cigarette cartridges a day and titrate down to zero over the next 6 weeks.  Because cigarette smokers are used to holding a cigarette as part of their smoking experience, this method helps to wean off cigarettes by simulating cigarette smoking and using progressively lower of nicotine to help break this destructively addictive habit.
  2. Lose Weight: We recommend a gradual weight loss program aiming to lose no more than 1-2 pounds a week because greater amounts over a short-period is often counterproductive. Some weight loss diet books start with an “induction phase” designed to expedite weight loss through severe caloric restriction (in other words, your body starves during the initial weeks of the diet). Most people don’t (intentionally) gain 15-20 pounds over several weeks so why try to lose so much weight so quickly?  It turns out that this approach is not only metabolically unhealthy in middle-aged and older women (weight loss is not sustained) but also potentially dangerous.   I have evaluated and treated patients who developed heart-related problems such as an abnormal heart rhythm after trying such restrictive diet programs  (check out Heal Your Heart” for further details and for safe, heart-healthy dietary recommendations). 
  3. Increase Exercise:  The good news is that you do not need to run marathons to gain benefit for your heart and overall health.  Just identify the aerobic activity (or activities) you enjoy most and set aside times each week that you can consistently follow.  For example, if you enjoy walking, aim for a total of ~30-40 minutes daily at a moderate brisk pace (3-4 mph).  Equally important is not to sit for extended periods of time (30 minutes or longer).  At work, aim to rise from your desk 2-3 times every hour, stretch and/or walk around the office.  After dinner, instead of diving into your couch, try a leisurely walk; when watching TV, stand up and stretch every 20-30 minutes or during commercials.

Wishing you and your family a Happy and Heart Healthy New Year!

Michael Miller, MD is a cardiologist and Professor of Medicine, Epidemiology & Public Health at the University of Maryland School of Medicine in Baltimore, Maryland USA.  He is Chair of the American Heart Association, Arteriosclerosis, Thrombosis & Vascular Biology Council on Clinical Lipidology.

Reflections on the Holiday Season: Part 2

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As 2018 comes to an end, it’s time once again to reflect on observations made during this year as we build upon new experiences in 2019 and beyond aiming to improve heart and overall health.

  1. Complete Your Dinner Meal Within 4 Hours of Bedtime:   While some might consider this to be part of an intermittent fasting program where eating is limited to a relatively short-time frame each day (ranging from 6 to 12 hours), finishing your meal hours before sleep is designed to keep the enzymes that process fats and carbs from working in overdrive during sleep.  But this is most likely to be successful if you follow #2 below.
  2. Do a Light Activity After Your Dinner Meal:   Such activities might include a 20-30 minute walk or light jumping on a rebounder (mini-trampoline).  Alternatively, if you are watching TV, get up during commercial time and stretch or walk around the area.  This can also help you to gain a good night’s sleep.
  3. Limit caffeine intake to within 8-10 hours before bedtime:  If you have insomnia, have your final cup of coffee of the day at least 8 hours before bedtime, due to the long-lasting effects of caffeine.
  4. Hug your loved ones daily:  Hugging releases the chemical oxytocin, which was recently shown to regenerate heart cells. Can a daily hug mend a broken heart?   In fact, exciting new research suggests that oxytocin may turn out to play a more important role in heart health than previously appreciated…. so stay tuned!
  5. Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland USA.  His book:  “Heal Your Heart: The Positive Emotions Prescription to Prevent & Reverse Heart Disease” focuses on natural ways to improve your heart and emotional health.



The Surprising Truth about Statins


This past week the American Heart Association released a Scientific Statement on the safety of statins, chaired by Dr. Connie Newman.  Serving as a co-author with a number of my colleagues, our task was to thoroughly review all the scientific evidence dating back several decades when statins were first introduced to treat high cholesterol. Over this period,  there is no question that statins have revolutionized the practice of medicine by consistently demonstrating benefit in women and men at increased cardiovascular risk. But a lingering concern has been the extent to which statins may be harmful.  After all, a number of books have suggested that statins are harmful…to this day, I have patients who refuse to take a statin because they believe it will cause their liver to fail, cause diabetes and cause cataracts!  If any of this were true, do you really believe that physicians would prescribe this medication?   Of course not!  The evidence is clear- if you have a normal liver, a normal fasting glucose level (less than 100 mg/dL) and normal eye function,  statins will not cause any of these problems.

That is not to say that everyone prescribed a statin can tolerate it without any difficulty. While our statement indicates that the vast majority taking statins have no problems, some will encounter statin-associated muscle symptoms (SAMS).  Listed below are some of the tell-tale signs associated with SAMS.

  1. SAMS occurs on both sides of the body.  For example, if your left but  not right knee aches, it is not due to the statin.
  2. SAMS is most likely to affect large and proximal muscle groups.  For example, shoulders and thighs rather than hands and feet are more likely to be related to a statin.
  3. SAMS is most likely to occur in predisposed individuals.  For example, older women with small muscle mass and/or impairment in kidneys and thyroid function raises risk.
  4. SAMS recedes when the statin is discontinued.   If you believe that you are experiencing SAMS, contact your physician to discuss appropriate steps to be taken. Symptoms generally recede within days of statin discontinuation.  Sometimes, a different statin may be better tolerated.  Some “tricks-of-the trade” that I’ve successfully used for my patients can be found in “Heal Your Heart“.

Michael Miller, MD is a cardiologist and Professor of Medicine, Epidemiology & Public Health at the University of Maryland School of Medicine in Baltimore, Maryland USA.  He is Chair of the American Heart Association, Arteriosclerosis, Thrombosis & Vascular Biology Council on Clinical Lipidology.

New Cholesterol Guidelines: New Insights


Five years into the making, the new cholesterol guidelines build upon the previous 2 guidelines that were released in 2001 and 2013, respectively.  The new guidelines focus on proven cholesterol-lowering therapies that reduce the risk of cardiovascular disease including myocardial infarction (heart attack), stroke, coronary bypass surgery, etc.   Having worked in the cholesterol field for the past 3 decades,  I will share some insights as to why the new guidelines have been well received to date.

  1. Lowering high levels of LDL (bad cholesterol) reduces risk: At birth, the average LDL is ~30 mg/dL.  These levels will rise to ~50-70 mg/dL by a child’s 1st birthday.  In fact, if we maintain these “physiologic” LDL levels throughout life, the overall risk of heart related problems is low, provided we live a healthy lifestyle and don’t smoke cigarettes,  be physically active, manage our stress levels etc.  If you have heart disease, the new guidelines recommend to lower your LDL intensively (by at least 50% from your starting point) and to attain levels below 70 mg/dL. If you don’t have a history of heart-related problems but are at increased risk, the new guidelines recommend to lower your LDL in some cases to less than 100 mg/dL.
  2. Lifestyle represents the initial treatment for high LDL: Try foods that lower LDL.  They include barley, beans and brussels sprouts (for a full list of the best LDL lowering foods, check out “Heal Your Heart“).
  3. Statins represent the primary medication for treating high LDL:  When lifestyle fails to effectively lower LDL, statins are the medications of choice.  I will discuss statins in greater detail in an upcoming blog but the bottom line is this- statins have a decades long track record; study-after-study have consistently demonstrated reduction in cardiovascular risk.  Depending upon your level of risk, discuss with your physician or health care professional whether statin therapy is the right choice for you.
  4. Newer non-statin therapies may now be considered if LDL levels remain elevated: The new cholesterol guidelines now recommend that if LDL levels remain elevated after diet and statin therapy or if statins are not (well) tolerated, to consider non-statin LDL lowering therapies.  These include ezetimibe and the PCSK9 inhibitors.  Both of these therapies add incremental benefit to statins and further reduce cardiovascular risk beyond lifestyle and statin treatment alone.
  5. We’ve come a long way over the past 30 years.  When I entered this field, statins were not yet available and treatment options for high LDL were much less effective and not as well tolerated.    The new cholesterol guidelines build upon decades of testing and experience in this field.  It has been my privilege to have witnessed first hand the great strides made in men and women with high LDL who are now able to reduce levels to a normal range and reduce their cardiovascular risk.
  6. Michael Miller, MD is a tenured Professor of Cardiovascular Medicine, Epidemiology & Public Health at the University of Maryland School of Medicine in Baltimore, Maryland USA.

3 Spices to Spruce up the Holiday Season


During the holiday season we tend to overindulge on a variety of foods that are not the healthiest for our hearts.  But the good news is that certain spices popular during the holiday season can also keep your heart healthy and boost your spirits.  Here are several spices that are a definite win-win and guaranteed to spruce up your holiday season.

  1. Cloves: Clove oil is among the best natural sources containing eugenol, a powerful anti-inflammatory and antioxidant compound.  Studies have found administration of clove oil to reduce cholesterol, triglycerides and excessive fat in the liver and to inhibit blood clot formation, A small, unpublished study in diabetics also found that as little as 1 gram of cloves a day (~12 clove pieces) for 1 month was associated with decreases in glucose, cholesterol and triglycerides.  And if you don’t like cloves, you can use it as a natural repellent for ants (who detest the scent).
  2. Cinnamon: Studies in diabetics have found that consuming cassia extract, capsules or raw powder (~1 teaspoon daily) produced meaningful reductions in glucose, cholesterol and triglyceride levels.  Check out our recent review paper for more details.
  3. Nutmeg:  Used in popular sauces, pies and holiday drinks (e.g., eggnog), this aromatic spice can promote a “Jekyl & Hyde” response. That is, in small amounts (pinch to 1/4 teaspoon) nutmeg has a calming effect and when added to a glass of warm milk ~2 hours before bedtime can lead to a more restful sleep.  However, at high doses (~2 tablespoons), nutmeg can produce toxic effects, including heightened anxiety and hallucinations.  In other words, just a “little dab will do you”…enjoy!
  4. Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland USA.  His book:  “Heal Your Heart: The Positive Emotions Prescription to Prevent & Reverse Heart Disease” focuses on natural ways to improve your heart and emotional health.

Is Intermittent Fasting Right For You?


Years before it became fashionable, I recommended to my patients interested in optimizing their heart health not only to eat their last meal at least 4 hours prior to bedtime but to also keep their dinner meal light (for more details see  “Heal Your Heart…” below).

As a researcher involved in numerous fat-feeding studies, it is well established that after we eat a meal containing fat, our triglycerides levels (blood fats) not only increase but can spike upwards of 2-3 fold with peak levels occurring ~4 hours after the meal.   Similarly, consuming carbs leads to a rapid rise in blood glucose and insulin levels that taper down over the next several hours (in the absence of insulin resistance).  The rise in blood glucose levels tend to be slower after consuming complex carbs contained in dietary fiber than in processed and refined carbs found in soft drinks (soda) and candy. However, if you keep your dinner meal light and engage in mild physical activities (such as an after dinner walk), you will boost your metabolism by revving up proteins involved in digesting fats and carbs thereby maintaining triglyceride, glucose and insulin levels under better control.  Left untreated, high levels of blood fats, glucose and insulin promote weight gain, insulin resistance, hypertension, diabetes as well as raise the risk of a heart attack and stroke.

It turns out that intermittent fasting (IF) can also help to boost metabolic (and vascular health) because increasing the number of hours in the fasting state reduces weight, blood pressure and blood levels of triglycerides, glucose and insulin.  For example, in a recent study of men at increased risk of diabetes, eating for 6-hours a day improved insulin sensitivity and blood pressure without increasing the urge to eat.  Keep in mind that a 6-hr time window for eating may be quite difficult especially if you work long hours; my most successful patients adhering to this regimen also have more flexible schedules. That is, they generally eat breakfast ~10 AM and conclude their dinner meal ~4 PM with weight loss in the 10-20 lb range (and in some cases more than 25 lbs).  Because IF represents a lifestyle change rather than a fad diet, weight loss can be sustained for years.  While many of my patients have found 6-hour IF to be too restrictive, they are able to maintain an 8 and especially 10 hour eating period (e.g., ~8 AM- 6PM) daily.  Whatever IF approach you decide on, the majority of calories should be consumed during breakfast-lunch followed by a light dinner with no snacking afterwards.

In addition to weight loss, my successful IF patients tell me they sleep better, have more energy, are happier and more productive.  Even though it can be very effective, make sure to speak to your physician and determine whether IF is an appropriate lifestyle consideration for you.

Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland USA.  His book:  “Heal Your Heart: The Positive Emotions Prescription to Prevent & Reverse Heart Disease” focuses on natural ways to improve your heart and emotional health.





4 Health Benefits of Mushrooms


Mushrooms may be among the most underrated superfoods, but make no mistake, they possess a veritable boatload of vital nutrients and properties guaranteed to enrich your heart, spirit and overall health. Whether they are cultivated or obtained in the wild (such as the yellowfoot mushrooms illustrated above), listed below are 5 reasons why I avidly endorse the consumption of these edible delicacies on a daily basis.

  1. Antioxidant Powerhouse: Edible mushrooms are an excellent source of antioxidants such as polyphenols (e.g., flavanoids), polysaccharides (e.g., beta-glycan) and vitamins (e.g., C and E) that help to neutralize free radicals from promoting cell damage, cancers and age-related diseases of the heart and brain. Consumption of edible mushrooms as part of a healthy lifestyle prescription may help to maintain and improve quality of life.
  2. Lowers Blood Pressure: Eritadenine is a compound isolated from shitake and other mushrooms that inhibits ACE (angiotensin-converting enzyme). ACE inhibitors are medications that are commonly used to treat elevated blood pressure.  in addition, mushrooms are a good source of dietary potassium, thereby providing another avenue to help reduce high blood pressure.
  3. May Reduce Weight: Have you heard of the mushroom diet?  If you are looking to shed some weight, try substituting portobello mushrooms for red meat and you may lose 5-10 pounds!
  4. Reduces Depression and Anxiety: Consuming the edible mushroom, “Lion’s Mane” has been shown to alleviate symptoms of depression and anxiety.  This should not be confused with psilocybin, another compound isolated from mushrooms that may elicit hallucinogenic behavior and result in panic attacks.
  5. Michael Miller, MD is a Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland USA.  His book, “Heal Your Heart: The Positive Emotions Prescription to Prevent & Reverse Heart Disease” focuses on proven methods to manage stress and improve cardiovascular health.

Reflections on the REDUCE-IT™ Study


Among the highlights of this year’s American Heart Association meeting in Chicago was the REDUCE-IT Study, masterfully presented by my colleague, Dr. Deepak Bhatt and simultaneously published in the New England Journal of Medicine. The study examined the use of a highly concentrated and purified form of EPA, icosapent ethyl, in more than 8,000 men and women with high triglycerides and either cardiovascular disease or high-risk patients with diabetes.

We’ve known for many years that having high levels of LDL (the bad cholesterol) promotes heart disease and effective therapies such as statins, reduce rates of heart attacks and strokes.   And while high triglycerides also increase the likelihood of adverse heart-related outcomes, garnering support to conduct a large clinical trial aimed at studying men and women with elevated triglyceride levels was lacking. Elevated triglycerides are common in the U.S. and other westernized societies; approximately ~1 in 3 adults have triglyceride levels above 150 and ~1 in 5 have levels above 200 mg/dL.

After several large pharma companies passed on supporting such a study in men and women with heart disease and high triglycerides, the small Irish biopharma company, Amarin stepped up to the plate… the end result is the REDUCE-IT study.

Men and women assigned to the active treatment arm received 4 grams of icosapent ethyl daily. EPA is found in oily fish, such as sardines, salmon, herring and mackerel, but if you believe you can consume that amount in 1 serving of these fish, think again. With a single 3.5 ounce (100 gram) serving of salmon, the amount of EPA approximates ~0.7 grams.   In other words, you would need to consume ~20 ounces (570 grams) of salmon each day to get the amount obtained with 4 grams icosapent ethyl!

To quote some of my colleagues, the results of REDUCE-IT were “unprecedented”, “game changer”, “sea change”, et cetera, because of the magnitude in the reductions of heart attacks, strokes and cardiovascular death compared to other contemporary lipid trials. In part, this reflects the fact that clinical trials that study patients with heart disease must utilize standard-of-care therapies. This would include statins, where cardiovascular risk is reduced by 25-35%. Consequently, it has been very difficult to show additional benefit on the background of statin therapy. Not surprisingly, early studies failed and it wasn’t until the past decade when more effective therapies (ezetimibe, PCSK9i) were able to show significant lowering of events in the range of 6-15%. Now contrast that with REDUCE-IT, where a more robust 25% decrease in heart attacks and strokes was observed as well as a 20% reduction in cardiovascular death. Importantly, REDUCE-IT is the first lipid-based study to show improvement in cardiovascular death on the background of statin therapy.

BOTTOM LINE: We finally have a safe and effective therapy to treat men and women with heart disease, diabetes and high triglycerides.

Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland USA.  He served on the Steering Committee for the REDUCE IT trial.