Do Lifestyle Therapies Improve ED?


It has been estimated that ED (erectile dysfunction) affects approximately 50% of men aged 40 years and older. If you don’t believe me, all you have to do is listen to the continues barrage of ads promoting the “little blue pill”, that continues to be an advertising goldmine, despite entering its generic phase.  But with all joking aside, cardiologists take ED very seriously because this condition commonly predates the development of heart disease by 3-5 years.  To this end and led by my colleague, Dr. Rob Ostfield, we recently addressed the effect of lifestyle therapies in ED.  Below are the major takeaways from this review.

  1. ED promotes ED: The overwhelming majority of ED (erectile dysfunction) cases result from long-standing inflammation and other adverse changes to the inner lining of blood vessels (the endothelium).  In other words, factors that lead to ED (endothelial dysfunction) also promote ED (erectile dysfunction).  The most common risk factors are cigarette smoking, diabetes, high blood pressure and elevated cholesterol.
  2. Weight Loss: In overweight or obese men, weight loss of 5% or greater (accomplished through caloric restriction, low intake of saturated animal fat and 30 minutes of physical activity daily) is associated with improvement ED overweight and obese men.
  3. Mediterranean Diet: A Mediterranean-style diet, enriched in vegetables, fruits, whole grains, nuts, olive oil and fish (see my previous post “Which Diets Are Favored by Cardiologists? “), may improve and in some cases even normalize erectile function.
  4. Effect of Soy products: While a previous report suggested that soy might be associated with ED due to chemical similarities between soy and estrogen, larger-scaled studies have not demonstrated such an association.
  5. Improvement in Risk Factors: Quitting smoking and treating other risk factors for heart disease improves ED. In addition, certain medications such as beta-blockers and diuretics (“water pills”) can cause ED and may be switched out for other effective therapies if ED is present.

Dr. Michael Miller is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine, Baltimore and a member of the Nutrition Workgroup, American College of Cardiology and author of “Heal Your Heart” published by Penguin Random House.  Make sure to check out his HeartHealth Tip of the Day on Twitter @mmillermd1

Which Diets Are Favored by Cardiologists?


Having served as a member of the American Heart Association (AHA) Council on Lifestyle and Metabolic Health and the American College of Cardiology Nutrition & Lifestyle Workgroup, our team has recently examined the scientific evidence for dietary nutrients in promoting and/or worsening cardiovascular health.   Admittedly, the dietary portfolio of well conducted, large, randomized and long-term (3-5+ years) diet trials is scant when compared to drug studies. As a result, dietary evidence is often derived from smaller-scaled randomized studies performed over a shorter timeframe and from observational studies.  Nevertheless, there is sufficient information available for health professionals to make a determination as to which diets might be the most favorable for overall heart health.

With this in mind, we were commissioned by AHA several years ago to write a Presidential Advisory on Dietary Fats and Cardiovascular Disease.  Led by my colleague, Dr. Frank Sacks, we showed that the replacement of animal-derived saturated fat (such as beef and processed meats) with plant-derived unsaturated fats (such as nuts, seeds, avocado) or whole grains (such as barley, buckwheat, quinoa) was associated with a reduced risk of heart disease.  However, replacing saturated fat with simple carbs (such as added sugars) had no effect and substitution with trans-fats raised the risk of heart disease.  In other words, the bottom line is that plant-based fats (as above plus oils such as canola, safflower and olive) are heart-healthier when compared to animal-based saturated fats.

Not to be outdone by the AHA, the ACC also commissioned our Nutrition Workgroup to assemble a document entitled “Trending Cardiovascular Nutrition Controversies”.  Led by colleagues, Dr. Andrew Freeman and Penny Kris-Etherton, we summarized the heart-healthy and heart-harmful foods/diets based on the best available evidence. Complementing the AHA Presidential Advisory’s focus on fats, this document found plant-based proteins to be significantly more heart healthy than animal-based proteins.  We also added green leafy vegetables, nuts, berries and extra virgin olive oil to round out the most impactful, heart healthy foods. In contrast, we recommended against diets enriched in fried foods, processed meats and sugar-sweetened drinks.  Our follow-up paper, “A Clinician’s Guide for Trending Cardiovascular Nutrition Controversies: Part II” added foods enriched in omega-3 fatty acids (such as marine-derived fish), legumes, mushroom and selected beverages (tea, coffee and alcohol, in moderation).

When summing up these documents, the dietary picture is consistent with that consumed in the Mediterranean region.  In fact, many cardiologists, including yours truly, also favor fish as the primary source of animal fat.  This was highlighted in recent papers by my colleagues and members of our workgroup, Drs. Emilio Ros and James O’Keefe.  This in no way discredits other heart-healthy diets, including Dean Ornish’s lacto-ovo-vegetarian diet (click here for our recent paper that showed favorable effects of the atherogenic gut byproduct, TMAO with this diet compared to a high saturated fat diet).  In fact, some of my cardiology colleagues favor such low fat diets and other vegetarian or vegan diets.  At this time, however, there is a larger body of evidence supporting the Pesco-Mediterranean Dietary approach.

So when you’re ready, grab some berries, a handful of nuts, a fishing rod and your favorite vino…for our heart’s sake, let’s drink to that!

Michael Miller, MD, FAHA, FACC is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore.  Check out his HeartHealth Tip of the Day on Twitter @mmillermd1

Optimizing Emotional Health During COVID-19 & Beyond


When it comes to face-to-face (or teleconference) discussions with your physician/health care professional as it relates to risk factors for heart disease, it is likely that they will be centered on your smoking history, blood pressure, cholesterol and glucose levels.  Yet, it has been estimated that ~1 in every 4 cardiovascular events (heart attacks/strokes) is attributable to emotional stress.  So why has such minimal emphasis been placed on a less traditional risk factor that many of us believe should be centralized?  After all, emotional stress can raise all 4 traditional risk factors as well as a host of other factors implicated in cardiovascular risk (poor sleep habits, high triglycerides, inflammation, etc).

There are at least 3 reasons for the low prioritization of emotional stress as it relates to heart disease.  First, we are given limited instruction in medical school and therefore, unless a health professional is interested (and self-taught) in this area, emotional health is unlikely to be sufficiently incorporated in clinical practice.  Amazingly, even well-educated men and women don’t appreciate the relationship between chronic stress and heart disease.  Having given the lecture “Heal Your Heart” to many groups, including newly appointed Judges, the one consistent response has been a lack of awareness of this relationship.  In other words, if health professionals are insufficiently trained and unable to proactively address this issue, how can strategies be initiated to improve emotional health for our patients at increased cardiovascular risk?

Second, we have no point-of-care measure to effectively evaluate emotional stress, unlike measures available for cholesterol, glucose and other heart-risk biomarkers.  Identifying high blood pressure solely in the physician’s office (i.e, white coat hypertension) is not in itself a sensitive measure to gauge emotional health.  In fact, many of my patients with transient elevation in blood pressure readings at the office do not describe feeling overly stressed out on a regular basis.

Finally, major medical organizations have expended minimal effort in this arena…until now.  A long-awaited and newly published American Heart Association scientific statement that deals exclusively with mind-heart-body connections can be found here.   Please also check out our accompanying commentary entitled, “Stressing the Cardiovascular Implications of Mind-Body Heart Connections”.

The importance of this AHA scientific statement cannot be overstated.  First, they point out that anxiety, depression and work-related stress raises the risk of a cardiovascular event (or death) by 30-40%. By contrast, a growing body of evidence demonstrates that factors promoting emotional factors, such as optimism, sense of purpose, mindfulness and well-being may reduce risk by a near similar percent!  Taken together, emotional health should be incorporated in medical education and residency training as part of a comprehensive program aimed at optimizing heart disease prevention.

Wishing you positive emotional health and a Happy VD weekend!



The 2 Faces of High HDL


Recently, my former college classmate and long-standing colleague, Dr. Annabelle Rodriguez, published an intriguing review on the paradox of high HDL that details her elegant work.  She found specific genetic variants associated with high HDL (equal to or greater than 60 mg/dL) to be linked to increased (rather than decreased) risk of heart disease.

These insights fall flatly on the face of earlier studies.  That is, between the 1970s into the late 90’s, we were taught that high levels of HDL (“the  good cholesterol”) protect the heart.  The body of work that originated in the U.S. was largely conducted in Framingham, MA where an inverse association between HDL cholesterol and risk of heart disease was uncovered.  With respect to high levels of HDL, each 5 mg/dL increment above the median (45 mg/dL for men and 55 mg/dL for women), corresponded to a 10-15% lower risk of heart disease.  Other studies not only found high HDL to be inherited but also associated with longevity as reported by the Cincinnati group led by Dr. Charles Glueck, my mentor during medical residency.

Because high levels of HDL cholesterol were seemingly protective to the heart, studies were then designed to determine the extent to which raising HDL might reduce the risk of future cardiovascular events.  Unfortunately, the two potent HDL compounds tested, niacin and cholesteryl ester transfer protein (CETP) inhibitors both failed. In other words, raising HDL cholesterol with these agents did not translate into reduced cardiovascular risk.  Around this time, other observational studies found very high HDL (~80 mg/dL and higher) to be associated with increased cardiovascular risk, as elaborated upon by Dr. Rodriguez…hence “the HDL paradox”.

So how might we resolve this discrepancy?  First, let me provide full disclosure as we have done considerable work in this area. For one, not all genetic cases of high HDL correlate with increased risk of heart disease.  Notwithstanding the genetic variants described by Dr. Rodriguez found to be associated with elevated risk (e.g., SCARB1, LAG3),  we and others have recently identified families with extremely high HDL (greater than 100 mg/dL) to be at low cardiovascular risk.  And even though CETP inhibitors do not effectively reduce risk, there are individuals with CETP deficiency who appear to be protected as we’ve  reported.

With respect to recent observational studies suggesting that high HDL may be problematic rather than protective, I have 2 comments.  First, one should interpret these data very cautiously because they do not adequately account or adjust for “confounders” such as excessive alcohol intake and chronic hormone/steroid use, both of which may significantly raise HDL cholesterol levels.  Unfortunately, alcohol intake, especially when excessively used, is notoriously underreported in clinical practice as well as in observational studies.

Secondly, after revisiting the Framingham Study, we found that high HDL was indeed cardioprotective.  This was provided that levels of other risk factors including lipoproteins/lipids such as LDL (“the bad cholesterol”) and triglycerides were normal.

Bottom Line: There are 2 faces of high HDL. If you have high HDL (60 mg/dL and greater) with a family history of longevity OR If your HDL cholesterol levels are higher than 60 mg/dL AND you don’t smoke, are physically active, do not have a history of hypertension or diabetes, do not take steroids/hormones (that artificially raise HDL) and do not excessively consume alcohol (no more than 1 ounce on an average day), put on a HAPPY face as your heart is likely to be protected.  For all others with high HDL, a more subdued face may be in order until risk factors for heart disease are under more optimal control.  

Dr. Michael Miller is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland.