As my 30-plus years as a faculty member at the University of Maryland School of Medicine and Medical Center has drawn to a close, I fondly recall 10 heart-related findings/discoveries and newsworthy events that gained worldwide attention, ending with the first genetically altered pig heart transplanted at UMMS last week. Here they are in no special order.
While the holiday season is jovial and celebratory for the majority of Americans, it can also be a source of despondency and despair for others. This is especially true for those afflicted with seasonal affective disorder or have great fear and anxiety leading to self-imposed travel restrictions in the midst of the COVID pandemic.
Fortunately, as of this writing, the most recent evidence suggests that if you’ve been vaccinated and “boosted”, the latter should be less of an overriding concern.
Nevertheless, as compared to the pre-COVID pandemic era, levels of depression and anxiety have also risen to unforseen heights. With the Holiday Season upon us, presented below is a heart healthy selection of foods/drinks proven to enhance mood and combat/limit depression and make your holiday season a more enjoyable one.
Mushrooms: A new study of nearly 25,000 men and women found that compared to non-consumers, those who ate mushrooms on a regular basis were less likely to experience signs of depression. Mushrooms are an excellent source of ergothioneine (ERGO), an amino acid with antioxidant properties shown (in rodent studies) to alleviate symptoms of depression. Other good food sources of ERGO are beans (black, kidney) and oat bran.
Cranberries: Cranberries are also rich in antioxidants and in the brain protective and anti-inflammatory compound ursolic acid. Ursolic acid not only reduces growth of certain tumors but has also been shown to improve memory and reduce mood disorders, especially anxiety and depression. Try a handful of cranberries or 4 ounces of pure cranberry juice each day to reap the benefits.
It is well established that cardiovascular disease is disproportionately higher in blacks than in whites, Asians and Hispanics. In fact, death from heart disease is 1.7 to 2-fold higher in black men compared to white men 45 years and older. Similarly in women, cardiovascular events are also elevated in blacks compared to whites with an approximate 2.5-fold risk beginning in middle-age (45+ years).
According to the American Heart Association, 7 core health behaviors/risk factors shape the likelihood of developing a heart attack or stroke. They include: blood pressure (BP), body mass index (BMI), cholesterol level, dietary habits, glucose control, physical activity and smoking history. In an otherwise healthy individual, “ideal” cardiovascular health would be defined as optimal core health behaviors/risk factors such as 1) BP less than 120/70; 2) BMI between 18-24.9 kg/m2, 3) LDL cholesterol levels less than 100 mg/dL, 4) a diet low in animal based saturated and trans fats, 5) fasting blood glucose less than 100 mg/dL, 6) being physically active (at least 150 minutes of mild-moderate activity [such as brisk walking at 3-5 mph] per week) and 7) not smoking cigarettes. Unfortunately, less than 1 in 3 adult men/women exhibit ideal cardiovascular health led by Asians (29%) and Whites (19%) while Hispanics and Blacks (14% and 10%) lag well. behind this milestone. For a more comprehensive review on this topic, check out our recent paper led by my colleague, Dr. Penny-Kris Etherton.
Listed below are further insights into the barriers, challenges and opportunities for implementing change to reduce disparities in diet-related heart disease based upon the publication in the Journal of the American Heart Association.
Food deserts are areas that lack access to affordable foods that comprise a healthy diet (e.g., fruits, vegetables, low‐fat milk, whole grains). In Baltimore, high availability of healthy foods was only present in 19% of predominately black neighborhoods compared to 68% of white neighborhoods.
A study conducted in Atlanta found that individuals in food deserts were more likely to be black, less likely to be college graduates, and had lower income compared with individuals in nonfood deserts.
Access to supermarkets stocking affordable healthy foods is associated with greater likelihood of fulfilling healthy dietary recommendations. For each supermarket present in a census tract, the intake of fruits and vegetables rose by 32%.
Large disparities exist in supermarket access in predominately black communities. There are 5 times more supermarkets in census tracts where whites live compared to where blacks reside.
Approximately 3.5% of the US population live in a food swamp, defined by the ratio of fast-food outlets and convenience stores to supermarkets and grocery stores in a given area.
Financial incentives to encourage purchasing of healthy foods and/or disincentives or restrictions on purchasing of unhealthy foods improves diet quality, especially in low‐income groups. A 10% reduction in the price of healthy foods increased consumption by 12%.
An increase in the cost (tax) of unhealthy foods decreased consumption by 6%. This approach reduced intake of sugar‐sweetened beverages (9%), fast food (3%), and other unhealthy beverages (5%).
In our 3rd installment on “Trending Nutrition Controversies” by the American College of Cardiology’s Nutrition Workgroup and led by Dr. Monica Aggarwal, we describe some of the popular dietary-related controversies in 2021. For a link to this publication, press here.
Below are highlights of this review and the evidence for or against the use of these products and development/progression of cardiovascular disease.
Artificial and Non-Nutritive Sweeteners: Whether they contain aspartame (Equal), saccharin (Sweet & Low), sucralose (Splenda) or stevia (Truvia), the artificial sweetener franchise has been stirred into a frenzy as several large studies have linked the frequency of these sweeteners to weight gain, increased risk of Type 2 diabetes and cardiovascular disease. Consequently and until new studies suggest otherwise, we recommend limiting the use of artificial sweeteners. Instead, consider adding unsweetened vanilla/ cocoa extract and/or a cinnamon stick to your morning Java.
Cocoa/Cacao: As a rich source of antioxidants, studies have shown that 1-2 tablespoons of cocoa/cacao daily is associated with 10-15% lower risk of heart disease compared to non-consumers. Minimize use of chocolate-containing products that are highly processed (e.g., sugar and corn syrup) to maintain the benefits.
Soy: Isoflavones (e.g., genistein, daidzein) present in soy are powerful antioxidant and anti-inflammatory mediators. Substitution of soy in place of animal based protein has been associated with reductions in LDL cholesterol (3-5%), systolic blood pressure (5-7 mmHg) and overall improved survival from heart disease and cancer.
Plant-based Meats and Substitutes: Despite the recent hoopla surrounding the alternative meat craze for the plant-based Beyond Burger (mung bean/pea) and Impossible Burger (soy), both products also add saturated fat (coconut oil) and sodium to enhance flavor and texture. While these substitutes may be viewed as “healthier” compared with animal sources of protein, they are viewed as less healthy choices when compared to minimally processed proteins, such as lentils, peas and beans.
Dietary Nitrates: Foods such as beet root, celery and dark green vegetables are high in dietary nitrates. Plant based nitrates promote the production of nitric oxide that in turn improves vascular health, reduces insulin resistance and improves exercise capacity. Supplementation with beetroot juice (high in dietary nitrates) was shown to reduce systolic blood pressure by 8 mmHg (the near equivalence to a single BP medication). After nitrates are converted to nitrites, the antioxidants contained within plant but not animal based products also protect against the formation of carcinogenic nitrite (N-nitroso) compounds.
Grass-Fed versus Grain-Fed Meats: Grass-fed beef has a lower fat content with a more favorable saturated fat profile than consumption of grain-fed meat. However, both grass-fed and grain-fed meats contain trans-fats that promote heart disease and studies to date have not shown differences between the two in cholesterol levels, triglycerides, blood pressure or insulin sensitivity. In case you missed highlights of our 2nd Nutrition Controversy paper press here and see below:
Added Sugars: Individuals should limit added sugar to less than 10% of calories and preferably less than 100 calories daily for women and less than 150 calories daily for men.
Legumes: Consuming 3.5 ounces of legumes (such as beans, chickpeas, lentils and peas) at least 4 times each week is associated with ~15% reduction in the risk of heart disease.
Tea consumption: Daily consumption of any tea is associated with an 8-10% reduced risk of heart attack or stroke.
Kimchi: In a 2-week study in overweight/obese men and women consumed 3 servings (3.5 ounces) of kimchi daily, significant decreases in weight (3.3 lbs), fasting glucose (100to 94 mg/dl), and systolic BP (126 to 121 mm Hg) were observed.
Folic Acid & Vitamin B12: Although folic acid and vitamin B12 supplements lower homocysteine levels, results from large clinical trials studies have failed to demonstrate reduction in cardiovascular events.
Probiotic yogurt: Diabetic patients randomized to probiotic yogurt containing Lactobacillus acidophilus (300 g daily) for 8 weeks experienced a 23% reduction in LDL-C and 15% increase in HDL-C compared with baseline. And for some of the highlights of our 1st Nutrition Controversy paper press here and see below:
Green Leafy Vegetables: For each oz of green leafy vegetables consumed daily, there is a 13% lower risk of developing T2DM.
Southern Foods: A Southern pattern of eating consisting of fried foods, egg dishes, processed meats, and sugar-sweetened drinks is associated with a 50-60% increase in cardiac events over a 6-year period compared to a primarily plant-based pattern.
Cholesterol: For each 300-mg increment in dietary cholesterol (~2 egg yolks), blood cholesterol levels rise 6-7 mg/dL
Blueberries: Consuming ~1 cup of blueberries per day is associated with blood pressure reduction of 7 mm Hg systolic and 5 mm Hg diastolic.
Anthocyanins: A 32% lower risk of a heart attack was observed in those with the highest compared to the lowest quintile of anthocyanin intake (e.g., blueberries and strawberries).
Mixed Nuts: A Mediterranean diet supplemented with a 1 ounce serving of mixed nuts daily for 5 yrs was associated with a 30% lower risk of cardiac events compared with a lower-fat control diet.
Plant-based diet: A study conducted in Tarahumara Indians consuming a plant-based diet (e.g. corn and beans) did not identify a single overweight or hypertensive man during the 4-yr follow-up period.
Vegetable Oils: A study conducted in Costa Rica found that the saturated fat, palm oil used for cooking was associated with 25-30% higher risk of heart disease compared to use of less saturated vegetable oils (soybean and sunflower).
The new study was conducted in mice that were genetically modified to release the peptide, NaKtide, in fat cells. NaKtide is a direct inhibitor of Na,K+ATPase signaling. The authors found that compared to a control diet, a Western diet (greater than 40% of calories derived from fat) resulted in Na,K+ATPase -mediated cellular inflammation and altered levels of brain biomarkers that affect memory and cognition. These proinflammatory effects were abolished when NaKtide was activated, thereby resulting in improved function of regions that include the brain’s memory center (hippocampus).
The bottom line is that in a mouse model, Na,K+ATPase signaling in fat cells promotes memory loss and neurodegenerative changes. They raise the possibility that a similarly operative signaling -pathway in humans might lead to adverse long-term neurologic consequences under certain conditions (such as repeated exposure to a high fat diet). Finally, they suggest that effective therapies directed against this proinflammatory signaling pathway could offset cognitive decline.
Of course, the most effective and currently available approach to reduce cognitive decline as related to this pathway would consist of reducing daily intake of highly saturated, processed and deep-fried foods!
Listed below are additional features related to diet, physical activity, obesity and brain health.
A new study out this week has found that being diagnosed with elevated blood pressure at a young age, is associated with risk of early dementia.
The study published in the American Heart Association journal, Hypertension analyzed 11,399 Chinese adults who were diagnosed with hypertension at 3 age groups: 1)when they were younger than age 35; 2) between ages 35 to 44 and 3) aged 45 to 54 years. Another 11,399 men and women without a history of high blood pressure served as the control group. Brain MRI scans were performed in all participants. The results of the study indicated that in all 3 comparator age groups, those with hypertension exhibited smaller brain (volume) sizes with the largest difference observed in the group under age 35.
Among the subjects who developed any type of dementia during the study period, the risk was 61% higher in men and women 35-44 years of age who had been diagnosed with hypertension compared to similar aged normotensive controls. In addition, vascular dementia was increased 45-69% when hypertension was diagnosed between ages 35-54 years. To review this paper, click here.
The study supports early identification and treatment of high blood pressure – it stands to reason that control of hypertension at a young age would reduce development of dementia.
High blood pressure can occur under a variety of circumstances and may be associated with the following:
A new paper out this week led by my colleague, Dr. Teo Postolache raises the intriguing question as to whether patients prescribed statins have lower rates of psychiatric based hospital admissions as compared to non-statin users. The rationale for this study was based on prior work suggesting that statins not only slow cognitive decline and reduce the risk dementia but also decrease hospitalization rates as much as 25% in men and women with a history of major depression. Additional support for statin use includes inherent beneficial effects on oxidative stress, neuroinflammation and immune function, all of which that are commonly aggravated in psychiatric illnesses.
In the current study of ~680,000 Veterans with a history of schizophrenia or bipolar disorder studied, statin use was associated with a 15-30% lower likelihood of psychiatrically based hospitalization and emergency room visits. While this study cannot prove cause-effect (that is, statin use being directly implicated in lowering hospitalization rates) it does support further investigation testing various statins -including those that dissolve in fat (lipophilic) or do not (hydrophilic) – and monitoring hospitalization rates between randomization of assigned statin and the prespecified follow-up period.
Listed below are additional considerations related to psychiatric illness and cardiovascular disease.
Observant physicians can identify important clues about the heart (and overall) health of their patients simply by being attentive to physical appearance and interactions. While telemedicine has provided an invaluable service during the COVID19 pandemic, many, if not most of us have missed the informative “personal touch” we have with our patients.
Perhaps the first clue we receive when patients walk through the door is through a simple handshake. While some of my patients continue to feel more comfortable with a fist/elbow bump greeting since COVID-19, a sizeable proportion have returned to handshakes following vaccination.
Bilateral carpel tunnel syndrome: While carpel tunnel syndrome can occur with repetitive motion/ overuse of a wrist such as from continuous typing/surfing the internet, the development of carpel tunnel syndrome in both hands especially in the absence of repetitive motion/overuse may be due to transthyretin cardiac (hATTR) amyloidosis. This disorder results from the accumulation of abnormal (amyloid) proteins that deposit in various organs and tissues. Fortunately, treatment is now available for this condition.
Blueish Tint of Eye Whites (sclera): In adults, the appearance of blue sclera may be indicative of Ehlers Danlos Syndrome, a connective tissue disorder characterized by joint hypermobility (“double jointed”), skin that is easily stretchable (and susceptible to bruising) and heart involvement (e.g., aortic dilation).
Painful Mouth Sores: Consider Behcet’s disease in someone with a history of recurrent (painful) mouth sores and new onset heart failure.
Large Tongue: In addition to amyloid, a large tongue (macroglossia) may be observed with an underactive thyroid (hypothyroidism) especially when accompanied by high levels of (LDL) cholesterol.
Split Uvula: A split or bifid uvula is seen in the Loeys-Dietz Syndrome, a disorder affecting connective tissue and associated with aortic enlargement/dissection. The disorder is named after Dr. Bart Loeys and my colleague, Dr. Hal Dietz.
Yellowish-Orange Tonsils: Yellowish-orange tonsils is a classic feature of Tangier Disease, a disorder characterized by extremely low levels (e.g., less than 10 mg/dL) of HDL (the good cholesterol).
Nodules on the legs: Clues to the diagnosis of sarcoidosis are tender raised reddish bumps (nodules) on the front of the lower legs (Erythema nodosum) combined with heart-related symptoms such as palpitations, dizziness or progressive shortness of breath.
Itchy Rash on Chest, Back & Arms: Very high levels of triglycerides (e.g., greater than 1000 mg/dL) may be associated with a yellowish-red (papular) rash on the chest, back and arms and is often due to poorly controlled diabetes.
There are numerous excellent contributions encompassing plant-based, Mediterranean and other popular diets, intermittent fasting/restrictive feeding, dietary recommendations for diabetes, metabolic syndrome, heart failure, atrial fibrillation and many other cardiovascular/inflammatory disorders.
Our contribution entitled, “Lifestyle Approaches to Lowering Triglycerides” was led by Dr. Stephen Hankinson (former University of Maryland medicine resident, currently affiliated with Brigham & Women’s Hospital).
Listed below are some of the numerous “pearls” throughout the book. It is a superb resource for anyone interested in evidence-based medicine as it relates to nutrition and cardiovascular risk reduction.
Overwhelmingly, consumption of whole foods enriched in dietary macronutrients have a more pronounced benefit on heart disease risk factors (such as high blood pressure/ cholesterol) than dietary supplements, for whom minimal if any such evidence exists.
For decades, triglycerides (TGs) took the proverbial back seat in the lipid/lipoprotein hierarchy. In recent years, however, TGs have gained increasing traction as a bonafide and independent biomarker of cardiovascular risk based on a series of well conducted epidemiologic and genetic (Mendelian randomization) studies.
Earlier this month, the American College of Cardiology released a new document that systematically outlines a series of decision trees that clinicians and health care professionals might consider when treating patients with elevated TG levels. It was a great privilege to work with colleagues and “lipid luminaries” in an highly engaging effort spearheaded by Drs. Salim Virani and Pam Morris.
Listed below are some of the highlights of the document that can be accessed by clicking here.
Lifestyle interventions should be initiated in adults with fasting triglyceride levels of 150 mg/dL or non-fasting triglycerides of 175 mg/dL or higher.
Among lifestyle recommendations for treating high triglycerides, weight loss is among the most robust (10-20% reductions on average) with up to 70% reductions potentially achievable.
Dietary recommendations to lower elevated triglyceride levels include switching from a low-fat, high carbohydrate diet to a higher-fat (predominantly mono/polyunsaturated) and low-carb diet (30-40% of calories).
In men and women with the metabolic syndrome, a high protein/weight loss diet (greater than 25% of energy intake/500 calorie per day deficit) is associated with ~35% reduction in triglycerides.
Physical activity and exercise may contribute up to a 30% reduction in triglyceride with both resistance training and aerobic activity contributing to these effects.
Excess alcohol consumption, especially with pre-existing high triglyceride levels can precipitate pancreatitis.