Medical Issues published by the Daily Dish

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I will be adding here those articles published by the Daily Dish concerning health.

The Lowdown on Cholesterol
Learn the differences between 'good' and 'bad' cholesterol.
By Arthur Agatston, MD, Everyday Health heart expert

You may wonder why, if cholesterol is so bad for you, it is present in your body in the first place. The answer is that cholesterol is not all bad and is, in fact, necessary for life. Your liver manufactures cholesterol for a reason: It is essential for the production of cell membranes and sex hormones, such as estrogen and testosterone. Cholesterol is even added to infant formula because it's necessary for normal growth and development. We also obtain cholesterol from animal food sources, such as dairy and meat. (Plant foods like fruits, vegetables, and legumes contain no cholesterol.) Although cholesterol is essential to life, we don't need very much of it to keep our bodies running well. Our cells take whatever cholesterol is necessary for maintenance and cell repair and store the excess for future use. The problem is that many of us eat a diet that is too high in saturated fat and trans fats, and this can stimulate the liver to produce more cholesterol than the body needs.

The connection between high total cholesterol and heart disease was made in 1961 by the Framingham study. Back then, we didn't have the technology to distinguish between different types of cholesterol particles. That gradually changed, and by 1977 the Framingham study had established a link between an increased risk of heart attack and elevated levels of LDL cholesterol. It was also at this time that we began to confuse the public with measures of different cholesterol particles and terms like "good" and "bad" cholesterol.

During a discussion with a patient recently, she asked me, "What's the difference between good and bad cholesterol? Isn't it all the same when it's building up in my arteries?" The answer is that it's not the cholesterol itself that is good or bad, but the particles that carry it. These particles are called lipoproteins (the lipo is short for lipid, which means fat). High-density lipoprotein (HDL) and low-density lipoprotein (LDL) are two of them. It's the protein part of the lipoprotein particle that acts like a shuttle bus, transporting the cholesterol (and other fats like triglycerides) through your bloodstream to where they are used, stored, or excreted by the body. Lipoproteins are necessary for transporting fats because fat is not soluble in water or in blood.

As it turns out, it's LDL, the so-called "bad" cholesterol, that is doing a lot of the shuttle bus driving. You'd think that this job would make LDL "good." But what makes LDL "bad" is that in excess it can cause us trouble. All cells have special receptors, or binders, that latch onto LDL, pulling it into the cells, where it is used as needed. When these cells have had their fill of cholesterol, they stop making receptors, which allows the rest of the LDL to stay in the bloodstream. Some of this excess LDL deposits its cholesterol "baggage" in our artery walls — including those of the heart — resulting in the formation of soft atherosclerotic plaques.

The job of clearing the blood vessels of this excess LDL falls to the HDL particles, which is why HDL is often referred to as "good" cholesterol. The makeup of the cholesterol itself in both LDL and HDL particles is the same; it is the direction in which the lipoprotein shuttle bus is driving that determines whether the particle is considered good or bad. HDL is good because it serves as a scavenger, removing LDL cholesterol from the cells and plaques and carrying it back to the liver for excretion in the bile, which empties into the intestine so it can be flushed out of our bodies in our stool. This is called reverse cholesterol transport.

How Much Cholesterol Is Too Much?
The Standard Lipid Profile, the heart disease screening lab test used by most doctors, measures your total cholesterol, HDL ("good") cholesterol, LDL ("bad") cholesterol, and triglycerides. In the mid-1980s, the federal government and the American Heart Association joined forces to create the National Cholesterol Education Program (NCEP) to educate the public about the importance of maintaining normal cholesterol. Based on the NCEP guidelines, total cholesterol should be 200 mg/dL or less for everyone. What follows are the NCEP guidelines for LDL, HDL, and triglycerides.

THE NCEP GUIDELINES FOR LDL CHOLESTEROL
99 mg/dL or below is optimal.
100–129 mg/dL is slightly higher than optimal.
130–159 mg/dL is borderline high.
160–189 mg/dL is high.
Anything over 190 mg/dL is very high.
I advise my high-risk patients to get their LDL down to 70 mg/dL. There is some evidence, however, that very high-risk people should get their LDL down even lower. Regardless of risk factors, I think it's advisable for everyone to keep their LDL as low as possible.

THE NCEP GUIDELINES FOR HDL CHOLESTEROL
For both sexes, optimal levels of HDL are 60 mg/dL and over. While the NCEP Guidelines do not differentiate HDL levels for men and women, the American Heart Association does, and I agree. It defines an HDL of less than 50 mg/dL as a risk factor for women and an HDL of less than 40 mg/dL as a risk factor for men.

THE NCEP GUIDELINES FOR TRIGLYCERIDES
149 mg/dL or under is normal.
150–199 mg/dL is borderline high.
200–499 mg/dL is high.
500 mg/dL is very high.

Learn how to eat to improve your health.
Last Updated: 11/14/2008
Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735.

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Should You Be Taking Heart Medications?
When diet and lifestyle changes aren't enough to lower your cholesterol, medications may be necessary.
By Arthur Agatston, MD, Everyday Health heart expert

When I tell high-risk patients that I think they should take a statin drug and explain why it will help to improve their cholesterol levels, they usually agree. But it is not unusual to get some resistance from patients who aren't well informed about the potential benefits or side effects of these drugs.

The following are some typical patient reactions:
"No! I don't want to take any medications. I want to lower my cholesterol naturally, without drugs and their side effects. Won't drugs fry my liver?"
"Sign me up! I'd rather take a pill than worry about my diet or bother with exercise!"

In both cases, these patients are just cheating themselves.

Patients who reject medications because they think they're not "natural" are missing out on some of the best tools in aggressive prevention. Statin drugs alone can slash the risk of having a heart attack by more than 30 percent — and by much more than that when taken in combination with other drugs such as niacin, aspirin, and/or certain blood pressure medications.

I am quick to remind patients who make remarks about drugs not being "natural" that there is nothing "natural" about having a sick artery that is burdened with plaque. I also tell them that statin drugs can actually help to restore the artery to its youthful, flexible state — the way that nature intended it to be. And I remind them that a truly "natural" cholesterol level is in the low 100s. At least that is the level found in populations with unprocessed, non-Western diets.

Patients who think that popping a pill renders diet and exercise unnecessary are also making a deadly mistake. Drugs are meant to work together with these lifestyle changes; they are not meant to replace them. Even if a combination of drugs can reduce your risk of having a heart attack by 50 percent, half of all people taking these drugs who were destined for a heart attack will still have one. That's why making lifestyle changes is so essential to further reduce risk.

Although I am a passionate believer in the power of diet and exercise, given what we know today about the effectiveness of statins and other drugs, it makes no sense at all for at-risk patients not to take them. I made this point recently when I was lecturing at a major medical center about the benefits of good fats, good carbs, and lean protein to a group of physicians. At the end of my talk, after having built a strong case for the role of diet in heart disease prevention, one doctor asked if I would be willing to conduct a study that tested the principles of the South Beach Diet as a sole therapy for patients with coronary artery disease. I was adamant that I would not. Using diet alone to treat heart disease would be ignoring 30 years of lifesaving medical advances.

So does that mean that statins should be universally prescribed in a manner akin to adding fluoride to drinking water to reduce tooth decay? That would be going too far. But statins have generally been underprescribed.

Despite numerous excellent studies documenting their effectiveness, millions of people who should be taking these cholesterol-lowering drugs are not. This means that millions of Americans have an unnecessarily high risk of suffering a heart attack, stroke, or sudden death.

A Word of Caution:
Tell your doctor about all the medications and dietary supplements you take regularly, whether they're prescription or over-the-counter. When taken in combination with other drugs, many otherwise safe medications can interact, causing potentially dangerous side effects. Never stop taking a heart medication without consulting your doctor.

Last Updated: 12/01/2008
Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735.

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Your Heart and How It Works
The heart serves a vital purpose in the body.
By Arthur Agatston, MD, Everyday Health heart expert

The heart is not an inanimate pump: It is a living, dynamic community of millions of hardworking cells. Its job is to deliver blood to organs that would die without it. Blood contains oxygen and nutrients necessary for the functioning of every cell in the body, including heart cells.

Everyone's heart beats around 70 times per minute, or 100,000 times per day, or about 2.5 billion times in the average lifetime. This vital organ is programmed to work automatically for every second of every day for as long as you live, no matter what else you're doing mentally or physically. In other words, your heart never rests.

Your heart is located just about in the center of your chest and is divided into four chambers: The two smaller upper chambers are known as the left atrium and right atrium and the two larger lower chambers are the left ventricle and right ventricle. Oxygen-poor blood enters the right atrium and is then pumped into the right ventricle and through the pulmonary artery to the lungs, where it is enriched with oxygen (and loses carbon dioxide).

The oxygenated blood is then carried to the left atrium via the pulmonary veins, from where it enters the left ventricle, the main pumping chamber of the heart. It is the thick, powerful muscle of the left ventricle that pumps blood to all the organs of the body via the aorta. From a cardiologist's point of view, it is the left ventricle that is the most important chamber because it is the area of the heart most likely to be affected by a heart attack.

As blood enters the aorta, some is immediately directed to the coronary arteries. The left main coronary artery divides into two major coronary arteries — the left circumflex artery (LCx) and the left anterior descending artery (LAD). A third major artery, the right coronary artery (RCA), has its own point of origin from the aorta. All of these arteries have branches, which are also known as coronary arteries. They supply the beating heart muscle with blood and oxygen. If anything obstructs the flow of blood through one of these arteries for more than 20 to 30 minutes, the heart will likely not receive enough oxygen, and the part of the heart muscle fed by that artery will die. This is what happens when you have a heart attack.

Heart failure occurs when your heart muscle is damaged to the point that your heart can no longer pump sufficient blood to the rest of your organs. When your heart is damaged and can no longer pump efficiently, blood also tends to back up into the lungs, making them heavier, which results in difficulty breathing.

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Women, Hormones, and Heart Disease
Estrogen provides protective benefits that may help women delay heart disease.
By Arthur Agatston, MD, Everyday Health heart expert
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It may appear as though women don't get heart disease because they tend to develop it later in life than men, largely due to the protective effects of natural estrogen. As long as women are having regular menstrual cycles, they enjoy a significant, although not absolute, level of protection. Naturally produced estrogen is linked with lower levels of LDL ("bad") cholesterol and triglycerides and higher HDL ("good") cholesterol. When a woman's estrogen production plummets in her late forties to early fifties, she begins to lose her hormonal advantage.

Female hormones and heart disease.

For decades, experts advised women to take hormone replacement therapy (HRT) to protect their hearts as well as to relieve menopausal symptoms and strengthen their bones. Estrogen's heart-protective properties looked so promising that nearly half of all postmenopausal female physicians took HRT, a rate higher than that of the general public, according to a 1997 study.

That all changed in 2002, when preliminary results from the Women's Health Initiative, a 15-year research program, caused a dramatic turnaround in the thinking about HRT. Compared with women who did not take HRT, women who took Prempro, a combination of estrogen and progestin, had a startling 29 percent increase in deaths from heart disease, along with a 22 percent increase in total cardiovascular disease. These results stunned the health community and caused a great deal of confusion in the general public.

But as it turns out, the HRT story is probably far from over. A review and analysis of many of the published HRT studies recently appeared in the Journal of General Internal Medicine. The authors pointed out possible explanations for the disparities between the earlier observational HRT studies of women who had chosen, in consultation with their physicians, to be on HRT and the more recent controlled trials. One factor that appears to be important is the timing of when HRT is started. Those women who begin it later appear to be more likely to experience heart attacks than those who begin HRT soon after menopause. In addition, much of the increased risk seems to occur in the first year HRT is started and may be due to an increased tendency to develop blood clots in the first year of HRT use.

I wish I could give women more definitive advice on this subject, but at this time the research is just too inconsistent. Whether beginning HRT earlier after menopause and perhaps at lower dosages is safer is frankly unknown at this time. Therefore, any decision on whether to begin HRT should be made with your physician after careful review of the potential risks and benefits for your particular situation.

JoAnne's Story
"I feel younger now than I did 2 years ago."
I'm 85 years old, and I have pulmonary hypertension (high blood pressure in the arteries that supply the lungs). It can be very serious. When I went to see Dr. Agatston 2 years ago, I wasn't doing well. I couldn't walk across the room without getting out of breath. I was overweight and I felt terrible. He put me on a healthy diet and told me to get some exercise. Thanks to that, I've lost 40 pounds. I breathe a lot better now and I can do a lot more things. I like to walk, but I'm not a youngster. I go to the gym three times a week to walk on the treadmill and do the bike. I do as much as I can. When I get tired, I stop, but I feel much happier and I look much better.

I feel younger now than I did 2 years ago. I used to eat a lot of sugar and a lot of junk. Now I don't eat fried foods, and I don't eat sugar. I don't keep it in my house. If you visit me and you want sugar, you have to bring your own! Now I eat a lot of chicken soup with fresh vegetables. I take care of myself. I do my own shopping and my own cooking. I'm still driving. I never expected to make it to this age. But here I am, thanks to a great lifestyle.


Last Updated: 11/14/2008
Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735.

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Past History of Heart Disease
A proactive approach can reduce the odds of having a second heart attack.
By Arthur Agatston, MD, Everyday Health heart expert

Here's the bad news: If you have had a heart attack, you have a one in five chance of dying within the next 10 years. Now for the good news: You can improve the odds by taking positive steps to protect your heart. My practice is filled with people who came to me after suffering a heart attack and have not gone on to have another. In fact, by following my preventive approach, they improve their heart health over time.

If you have a history of heart disease, getting advanced diagnostic blood testing is not optional, it's a necessity. It's the only way you will be able to find out whether you have the kind of cholesterol-carrying particles in your blood that are good, bad, or really terrible. (The really terrible kind accelerates the accumulation of cholesterol under the protective lining of your artery walls, leading to the buildup of the soft plaque.) Advanced blood testing is also the only way that you will be able to find out whether you have dangerous amounts of other substances in your blood, such as C-reactive protein, a marker for inflammation that can damage the lining of your arteries.

Depending on what type of offending substances advanced testing detects in your blood, your doctor will determine the type of treatment that will be most effective for healing your artery walls and preventing plaque buildup, plaque rupture, and blood clotting — in other words, for preventing future heart attacks. Typically, treatment includes lifestyle changes and medications. If you have a history of heart disease, you must be especially conscientious about making these changes if you want to save your heart and your life. Unfortunately, cardiac care units are filled with people who did not follow a prevention strategy.
Last Updated: 11/14/2008
Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735.

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Diabetes, Prediabetes, and Metabolic Syndrome
Having these conditions could be just as harmful to your health as a prior heart attack.
By Arthur Agatston, MD, Everyday Health heart expert

If you are an American age 40 to 70, the odds are about 40 percent that you've been diagnosed with prediabetes, diabetes, or metabolic syndrome. Shocked by this statistic? You should be! Not long ago, diabetes and prediabetes were rare. Now they are virtual epidemics in the United States, putting tens of millions of Americans at high risk for heart disease. In fact, diabetes is such a strong risk factor for heart disease that medical professionals define it as a "coronary heart disease risk equivalent." This means that a person with diabetes has the same high risk of a heart attack as someone who has already had one. Up to 70 percent of people in coronary care units have prediabetes or diabetes. Women, take note: If you have diabetes and have suffered a heart attack, you have an even greater risk of having another heart attack or heart failure than a man who has diabetes and has suffered a heart attack.

Diabetes is well known as a disease characterized by the body's inability to process sugars and starches. Less well known are the problems that people with diabetes have processing fats in their diet. There are two common types of diabetes: juvenile-onset, or what's now known as type 1 diabetes (which usually appears abruptly before age 30), and adult-onset, or type 2, diabetes. About 90 percent of all those with diabetes in the United States have type 2. Prediabetes, sometimes called metabolic syndrome, insulin resistance, or Syndrome X, will lead to full-blown type 2 diabetes if it goes unchecked. The difficulty with processing fats and the risk of heart attack and stroke begin in the prediabetes phase, which is defined as a blood sugar level of 100 to 125 mg/dL.

The problem with type 2 diabetes and prediabetes is that people who have these conditions process fats abnormally, leading to low levels of good HDL and elevated levels of triglycerides. They also have more small HDL and more small, dense LDL (see the explanation of Question 9, page 51). In addition, they often have high blood pressure and more inflammation in their arteries.

To help reduce these risks, national guidelines recommend that people with diabetes keep their blood pressure below 130/80. Giving up cigarettes is even more important for people with diabetes than it is for others, because smoking and diabetes are a deadly combination. Type 2 diabetes is also closely linked with obesity (see Chapter 5), which explains why, as the American population gets fatter, the rate of type 2 diabetes is soaring. What is even more alarming is that there are millions more "diabetics in training" in our country today. I am speaking of our children, who, as they grow fatter and less fit, are rapidly becoming prediabetic or even diabetic. Type 2 diabetes can no longer be called an "adult-onset" disease.

Luckily, type 2 diabetes is largely a "man-made" disease that we can unmake if we set our minds to it. Exercise, weight loss, and strategic dietary changes — particularly eliminating the highly processed "bad carbs" found in baked goods, breads, snack foods, and other starchy and sugary favorites — are all very effective in reversing insulin resistance.

Last Updated: 11/18/2008
Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735.

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What Your Waistline Says About Your Heart
Carrying excess weight around your middle could have a profound impact on your heart.
By Arthur Agatston, MD, Everyday Health heart expert

There is an important medical condition so obvious that I can diagnose it without performing a single diagnostic test. I can spot it the instant a patient walks into my office. It's so common that I see it everywhere — at malls, in restaurants, on the golf course, and strolling down the street. It has reached epidemic proportions in the United States. I'm sure you've seen it, too, among your family and friends, and maybe when you look in the mirror.

Belly fat, diabetes, and heart disease.

The ailment has many names, including metabolic syndrome, insulin resistance, Syndrome X, and the name I will use, prediabetes. Why is it so easy to diagnose? There's one clue that's a dead giveaway: It's your waistline. One of my colleagues says that when a patient's belly is the first body part to enter his office, the diagnosis is made. If you have gained weight in middle age and most of it is in your belly, you are likely part of the American epidemic of prediabetes. And if you don't start eating better and exercising, full-blown diabetes will almost certainly be in your future.

Why would a cardiologist be so concerned with your waistline? The reason has less to do with how you look on the outside than it does with how you look on the inside. I'm worried about what prediabetes and diabetes are doing to your arteries. Both conditions can injure the lining of your vessels and accelerate the production of plaque, greatly increasing your risk of having a heart attack or stroke.

After a meal, it is the job of insulin to help transport fats as well as sugar from the blood into the tissues. As you develop insulin resistance, fats accumulate in your bloodstream and hang around much longer than usual. During this time, changes in your blood fats occur — your LDL particles and your HDL particles become smaller and your total HDL is reduced. These changes favor the movement of cholesterol from your bloodstream into your artery walls. The smaller and denser the LDLs are, the more likely they are to move into your vessel walls. And the smaller and denser the HDLs are, the less efficient they are at removing the cholesterol from those vessel walls. These changes are also associated with high blood fat levels measured in the form of triglycerides. The fact that these fats are in your bloodstream longer also favors their accumulation in the vessel walls.

So, if you have gained predominantly belly fat as an adult and there is diabetes in your family (even if it occurred in a parent or grandparent late in life), you probably are insulin resistant and have prediabetes. The diagnosis of prediabetes is made if you meet three of the five following criteria:

* Central obesity: A waist circumference of greater than 40 inches for men and 35 inches for women
* Elevated triglycerides: Greater than or equal to 150 mg/dL
* Low total HDL: Less than or equal to 40 mg/dL for men and less than or equal to 50 mg/dL for women
* Elevated blood pressure: Systolic blood pressure of greater than or equal to 130 mm Hg and diastolic blood pressure of greater than or equal to 85 mm Hg
* Elevated fasting glucose: Greater than or equal to 100 mg/dL

Last Updated: 11/18/2008
Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735.

[ami]

Understanding Triglycerides
Triglyceride levels provide insight into your heart disease risk.
By Arthur Agatston, MD, Everyday Health heart expert

Triglycerides are the form in which fat is stored in your body's fat cells. Your triglyceride level is almost always strongly influenced by lifestyle. A low-fat, high-refined carbohydrate actually elevates your triglycerides. Two decades ago, when I first began putting my patients on this type of diet, which was recommended back then, I was often dismayed to see their triglycerides go up. This, of course, was the opposite of what I was hoping to achieve. We now know that it was not the carbohydrates per se that raised the triglycerides, but the bad carbohydrates — sugars and starches devoid of fiber and other nutrients — that did it.

The same thing happened when I experimented with an extremely low fat diet that was also popular at the time. When I put one patient with a moderately high triglyceride level of 220 mg/dL on it to lose weight, he did not lose weight, and his triglycerides soared to over 500. His was just one of many cases like this that made me begin to question the conventional dietary wisdom of the time. Today, I recommend a diet that contains lean protein and moderate amounts of good fats (those found in oily fish, olive oil, and nuts) and good carbs (those found in vegetables, fruits, and whole grains). If patients follow this plan, reductions in triglycerides can be dramatic.

If you have high triglycerides (over 150 mg/dL is borderline high) and low HDL (less than 40 mg/dL if you're a man and less than 50 mg/dL if you're a woman), your risk of heart disease is compounded. To find out if you have this added risk, divide your triglyceride count by your HDL count. Ideally, the resulting number will be 2 or lower. For example, if your triglyceride level is 200 and your HDL is 40, divide 200 by 40 and you get 5. This is much higher than the desirable ratio, and it tells you that you have a heightened risk of a heart attack that will need to be addressed.

Your triglyceride level can also give you insight into your LDL particle size. In general, the higher your triglycerides and the lower your HDL, the smaller and denser your LDL and the greater your risk of heart disease. If your triglycerides are higher than 200 and your HDL is lower than 45, it is very likely that you have too much small, dense LDL.

There are a number of ways to lower your triglycerides. In addition to eating the healthy diet that I describe in Step 1, losing weight and getting more exercise can help. Medications such as niacin and fibrates are also effective at lowering triglycerides, increasing HDL, and enlarging LDL particle size.

THE NCEP GUIDELINES FOR TRIGLYCERIDES
149 mg/dL or under is normal.
150–199 mg/dL is borderline high.
200–499 mg/dL is high.
500 mg/dL is very high.
Last Updated: 11/18/2008
Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735.

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The Diet Debates Are Over
Find what really should be included in a heart-healthy diet.
By Arthur Agatston, MD, Everyday Health heart expert

Today, the diet debates are over. We have moved beyond the confusion of the low-fat versus low-carb battles to an expert consensus on what constitutes a healthy diet. Health-care professionals now agree that our focus should be on nutrient-dense, fiber-rich carbohydrates, healthy sources of unsaturated fats, low-fat dairy, and lean sources of protein, and this is reflected in the new USDA food pyramid. Undoubtedly, ongoing research will continue to add a great deal to our knowledge of the benefits of individual foods, but the basic principles of healthy eating are not going to change.

To better understand how we as a nation got into the health mess we are in and how we have come to the present consensus of opinion, it's important to be aware of some relevant history.

When I began work on the South Beach Diet, the only other diets recommended for heart patients were either the standard low-fat, low-calorie eating plan endorsed by the American Heart Association or the even stricter, extremely low-fat regimens popularized by Dean Ornish, MD, and Nathan Pritikin. At the time, telling patients to eat fat of any sort was medical heresy.

The premise of the low-fat diet was simple. Experts believed that the American diet was too high in fat. They based their belief, in part, on a major study published in the 1970s that compared a society's diet to its rate of heart disease. The study, which was conducted by a brilliant researcher named Ancel Keys, PhD, of the University of Minnesota, identified a direct correlation between fat intake and heart attack. Dr. Keys's study found that residents of the United States and certain countries in Europe had both the highest intake of total fat and the highest rate of heart attack. Countries with lower fat intake had much lower rates of heart disease. It was well known that people in less developed countries with very low fat intakes had almost no heart attacks.

The study identified one exception to the rule. In Crete, people ate a relatively high-fat diet but still had low rates of heart disease. Since the results for Crete were not consistent with the rest of the study, they were discounted. What the researchers did not appreciate at that time was that, although the typical Crete diet was high in fat, the fat was "good" fat from olive oil, fatty fish, and nuts, not the bad saturated fat that was consumed in the countries whose populations had the highest rates of heart attack. What they also didn't understand was the fact that people who lived in countries that consumed the least amount of fat also ate the highest amount of fiber, which we now know is protective against heart disease. In fact, in 1980, when Dr. Keys wrote a book summarizing his research, he suggested that fiber may have been an important variable not taken into account at the time of his study. This was not an oversight, because the role of fiber in nutrition was not known at the time of his study.

But the initial response of the medical community to Dr. Keys's earlier study was to fixate on fat, specifically on how bad it was. The message became "Get the fat out." As a result, people were given advice such as "Avoid oils" and "Eat your salads dry if you can" and "Use only fat-free salad dressings." Moreover, because protein was a major source of fat in the diet, low fat often meant eating less red meat, chicken, fish, and dairy and making up for it with lots of sugary and starchy refined carbohydrates.

The problem with the low-fat, high-carb recommendations was that they did not distinguish between good, high-fiber carbohydrates (such as whole fruits, vegetables, and whole grains) and refined, low fiber, high-sugar carbs (such as white bread and muffins). If the packaging said a food was "low fat," it didn't matter if it had a high sugar or high starch content and virtually no nutrient value; it was considered to be okay.

The war on fat not only kept people away from bad saturated fat but led to the development of trans fats (which, in the form of partially hydrogenated oils, were invented to replace saturated fats like palm and coconut oils but turned out to be much worse). It also prevented them from getting the good, heart-healthy polyunsaturated omega-3 fatty acids found in cold-water fish and flaxseeds, for example, and the good, heart-healthy monounsaturated fats found in foods such as olive oil and nuts.

Through the 1980s and early 1990s, I watched my patients, the country, and frankly myself struggle with the so-called heart-healthy low-fat, high-carb diet. We tried our best to stick with it, but we were always hungry and rarely satisfied. What was even more distressing to me was that I saw problems in my patients' blood chemistries as we began to measure triglycerides and good HDL in addition to total cholesterol and LDL. I observed that some patients' triglycerides rose in response to the strict low-fat, high-carb diet they were following. We now know that a high triglyceride level is often the body's response to excess sugar and starch in a person's diet. But back then, this wasn't well understood. To help my patients, I even tried the then new, magic-bullet statin drugs Mevacor and Pravachol, but the patients' triglyceride levels hardly budged. Furthermore, with the low-fat diet, their LDL cholesterol was also affected: It would go down a few points, which was good, but then it would return to baseline or go even higher. My experience with these patients was corroborated in the clinical trials I was reviewing at the time.

Last Updated: 11/18/2008
Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800)

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How Not to Have a Heart Attack
Advice on heart disease prevention from author and leading cardiologist Arthur Agatston, MD.

A study presented at the American College of Cardiology meeting and published online in the New England Journal of Medicine has raised questions about whether the majority of people treated with a popular invasive procedure to reduce chest pain actually need the surgery. This study is turning up the spotlight on noninvasive prevention rather than surgical intervention, just as Dr. Arthur Agatston, preventive cardiologist and author of The South Beach Diet® does in his book The South Beach Heart Program. According to Dr. Agatston, who has been practicing aggressive prevention for many years, "this study is further evidence that we have been doing too much intervention and not enough prevention."

Following a trial involving more than 2,280 patients, researchers concluded that the use of surgical angioplasty and stenting (coupled with medication) provides no long-term advantage to a patient over a preventive treatment plan that includes appropriate medication, diagnostic testing, and lifestyle improvements. This news has stirred up controversy among the medical community. Over the past three decades the use of invasive angioplasty and stenting — a two-part procedure that involves manually opening a blockage by inflating a balloon at the end of a catheter and then using a wire tube to "prop open" the once-blocked artery — has become the initial strategy in the treatment of stable coronary artery disease. In fact, recent data indicate that more than 1 million coronary stent procedures are performed in this country each year, and nearly 85 percent of these procedures are elective. This finding comes as no surprise to Dr. Agatston, who says that for nearly three quarters of the patients who undergo stenting — those with stable heart disease — it may be unnecessary. According to Dr. Agatston, elective angioplasties and stents almost never prevent heart attacks. Practicing aggressive prevention is the more effective approach.

Dr. Agatston likens this invasive approach for managing heart disease to a plumbing model. In The South Beach Heart Program, he explains that doctors formerly believed that the gradual growth of plaque narrowed the arteries and, thus, reduced blood flow to the heart. Eventually, a clot would develop, resulting in a heart attack. The logical solution seemed to be to open the artery with angioplasty and stenting (or to bypass it) to improve blood flow. But, as Dr. Agatston notes in his book — and as the latest studies confirm — the plumber's approach is outdated and inaccurate.

"While the great majority of patients are presently being treated according to this plumbing model, the treatment of the future belongs to doctors who I characterize as 'healers,'" says Dr. Agatston. "We now know that most heart attacks occur when a soft, cholesterol-rich plaque bursts, resulting in the formation of a blood clot that suddenly blocks the flow of blood to the heart. These soft plaques occur in the lining of the artery wall, not in the artery itself, which is why merely opening up a blocked artery will not prevent a heart attack or stroke," he explains.

"The healer's approach that I present in The South Beach Heart Program is an aggressive prevention model that focuses on reducing the amount of soft plaque in the artery walls and improving the health of the arteries so that plaques do not form in the first place. Doctors who practice the healer's view, myself included, recommend a heart-healthy diet, regular exercise, advanced diagnostic testing to detect heart disease in its earliest and most treatable stages, and lifesaving medications," he says. This noninvasive approach was found to be more effective than stents in the latest study.

"I'll let you in on a big secret," says Dr. Agatston. "Physicians who practice aggressive prevention have seen heart attacks and strokes practically disappear from their practice. It's that simple — this approach can literally prevent heart attacks and strokes and save lives. My goal in writing The South Beach Heart Program was to speed the pace of the cardiac prevention revolution currently taking place in this country." To that end, Dr. Agatston has performed pioneering work in noninvasive cardiac imaging that has resulted in computerized tomography (CT) scanning methods and measures that bear his name: the Agatston Score and the Agatston Method, which are used to screen for atherosclerosis — and are recognized worldwide. The Agatston Score derived from the CT scan is the single best predictor of your risk for a future heart attack.

According to Dr. Agatston, studies like this continue to lend support to a noninvasive, aggressive prevention approach. "All of the latest research and evidence suggests that we already have the tools and knowledge to prevent the majority of heart attacks and strokes. Now we just need to put these methods into practice — and start saving more lives." For more information on Dr. Agatston's life-saving strategies, order your copy of The South Beach Heart Program today, or visit southbeachdiet.com.

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Last Updated: 12/01/2008
This section created and produced exclusively by the editorial staff of EverydayHealth.com. © 2009 EverydayHealth.com; all rights reserved.

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Lipoprotein Tests
These advanced blood test take a closer look at your cholesterol.
By Arthur Agatston, MD, Everyday Health heart expert

Liprotein Subfraction Test
This is an exacting blood test that divides your cholesterol into a variety of subparticles based on their size and density. While the Standard Lipid Profile tells you the quantity of total cholesterol, LDL, HDL, and triglycerides, this test will tell you the quality of your cholesterol. In particular, you will learn whether you have large amounts of small, dense LDL and/or small HDL particles, both of which put you at risk of having a heart attack or stroke.

The rate at which cholesterol gets into your vessel walls depends on the number and size of your LDL cholesterol particles. Small LDL particles containing less cholesterol per particle move into vessel walls more easily than larger particles. The smaller the particle, the more easily it moves in. That's why patients who have low total cholesterol levels and even low total LDL levels can still be at high risk for coronary disease if they have lots of small LDL. Patients with increased numbers of small LDL particles are classified as being pattern B. Those with large LDL particles are classified as pattern A.

Like small LDL, small HDL also has less cholesterol per particle. Patients with predominantly small HDL particles do not clear cholesterol from vessel walls as well as those with larger HDL particles. Small HDL also reduces the total cholesterol number, and this is another reason why patients with low total cholesterol may still be at risk for coronary disease. That's why it is important to know not just your total cholesterol and LDL numbers, but also the size of your particles.

People who have small LDL and HDL along with high triglycerides have what is called the atherogenic lipid profile and must be treated aggressively. These lipid factors are associated with a sedentary lifestyle, obesity, prediabetes, and diabetes — and will accelerate the development of atherosclerosis. A program of weight loss and regular exercise can help to reverse these lipid abnormalities. Taking medications such as Niaspan (prescription niacin), TriCor (fenofibrate), or one of the so-called TZD agents, Avandia (rosiglitazone maleate) or Actos (pioglitazone hydrochloride), can also help.

Lipoprotein (a) Test
Lipoprotein (a), or Lp(a), is a type of LDL particle with a protein called "little a" attached. An increased number of these particles is associated with an increased risk of coronary disease when Lp(a) is greater than 30 mg/dL. (This number could be slightly higher or lower depending on the lab that analyzes the blood test.) This risk is multiplied when Lp(a) is associated with other blood lipid abnormalities, such as elevated LDL.

How Lp(a) actually affects your blood vessels is still not well understood, but you can think of it as making the endothelial lining of the arterial walls more porous to LDL particles. Thus, Lp(a) facilitates the development of plaque, which can lead to heart attacks. Lp(a) is unique in that it does not respond to lifestyle changes. Niacin is the only medication that effectively lowers Lp(a), though it often requires high doses.

Follow-up. When the results of the lipoprotein subclass and Lp(a) tests are abnormal, I treat a patient with lifestyle changes and medications accordingly and repeat the tests every 2 to 6 months depending on the patient's overall level of risk. Once the therapeutic goals are reached, I repeat the tests twice a year.

Last Updated: 11/14/2008
Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735.

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Getting the Right Diagnostic Tests
The right test can determine heart attack risk long before a problem occurs.
By Arthur Agatston, MD, Everyday Health heart expert

Doctors now have the diagnostic tools to detect cardiovascular disease in its earliest stages, years if not decades before a heart attack or stroke occurs. Unfortunately, too few people are taking advantage of these tools. For this reason, I encourage you to read this part of the program and discuss what you learn with your doctor. It describes the most up-to-date tests for predicting whether you're a candidate for a heart attack or stroke, as well as the appropriate follow-up tests.

Although sophisticated tests are becoming more and more widely used, there are still some places in the United States where they may not be available. If so, I recommend contacting the nearest major medical center affiliated with a university to seek a referral to a prevention-oriented physician or a prevention clinic. Because the quality of testing, particularly of the imaging tests, can vary widely from facility to facility, it's important to seek out the best center near you. A well-respected department of radiology will usually have a specialist in the area of cardiac CT. An experienced radiologist or cardiologist is essential for an accurate scan and its proper interpretation.

Why These Tests Are Needed
It's critical to remember that a healthy percentage of all heart attacks occur in people who have none or one of the obvious risk factors for heart disease. These men and women don't smoke, they don't have a bad family history, and even their total cholesterol and LDL and HDL cholesterol levels may be fine by conventional laboratory standards. Some cardiac risk factors can only be detected through the more sophisticated diagnostic tests.

For example, getting advanced blood testing is the only way to find out the size and density of your LDL particles, whether your HDL is the right size, or if you have high levels of lipoprotein (a). Many individuals whose numbers look normal on a Standard Lipid Profile may nevertheless be building up plaque and harboring these potentially dangerous cholesterol particles. Without advanced blood testing, these people would never know they are at risk for a heart attack.

I realize that this involves getting diagnostic tests that may not be covered by your health insurance plan. But to really assess your level of risk for heart disease, you must go beyond conventional testing, even if it means investing some of your own money. While a noninvasive angiogram (heart scan) that includes dye injection, performed with the state-of-the-art 64-slice scanner, can cost about $1,000, you can get your Calcium Score alone for about $400. Advanced blood tests are more likely to be covered but can cost an additional several hundred dollars. I realize that some of you who are already paying hefty insurance premiums may be dismayed by the prospect of having to pay more. However, I believe that getting these tests is one of the best investments you will ever make.
Last Updated: 11/14/2008
Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735.

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Hopping on a bike or treadmill can help your doctor find the source of your symptoms.
By Arthur Agatston, MD, Everyday Health heart expert

An exercise stress test for heart disease.

What is it? The primary purpose of an exercise stress test is to determine your ability to increase blood flow through your coronary arteries to your heart muscle when your heart is beating faster and/or harder, demanding two to five times the blood flow it gets at rest.

If you have been feeling symptoms such as chest pain or shortness of breath with exertion, an exercise stress test will help your doctor figure out whether these symptoms are coming from sluggish blood flow due to a blockage in one or more of your coronary arteries. The stress test will also indicate how severely the blockage is limiting the blood flow, which is crucial information in deciding whether to recommend an invasive or noninvasive approach to treatment.

Doctors also get other valuable information from a stress test. From watching a patient exercise, we get a good sense of whether the person's symptoms are heart or lung related. For instance, some patients complain of shortness of breath even while they are demonstrating outstanding exercise capacity on the treadmill or bike. And yet they don't appear short of breath to me. These people may have the benign "sighing" type of shortness of breath. Other patients demonstrate limited exercise capacity with extreme shortness of breath, and yet they still insist they are doing fine. These are the patients I look at much more closely.

Studies from Steven N. Blair, PED, of the Cooper Institute in Dallas, as well as others, have indicated that overall exercise capacity is an excellent predictor of future health and longevity. The blood pressure response to exercise is a helpful sign of the risk of future complications from hypertension, such as heart attack and stroke. The two most common types of exercise stress tests are the plain EKG test and the nuclear (or thallium) test. During both tests, you walk on a treadmill or ride a bike, which increases in elevation and/or speed every few minutes. In the plain EKG stress test, leads are applied to your chest, as they are for the basic EKG, and tracings are similarly produced. We look for changes on the tracings that indicate compromised blood flow to the heart muscle. This test takes about 20 minutes.

In the nuclear exercise stress test, two sets of images are taken. The first is taken after a small amount of a radioactive tracer (such as thallium) is injected when you are at rest. This is not a dye, so allergic reactions are not a problem. The second set is done after the tracer is re-injected when you are at peak exercise on the treadmill or bike. The radioactive substance travels to the heart muscle in proportion to the flow of blood. If there is a blockage in one or more of the coronary arteries supplying blood to the bottom of your heart, this area will accumulate less thallium during exercise than other areas with normal blood flow. The resting and exercise images are then compared and significant blockage will almost always be apparent.

In younger patients in whom I do not suspect heart disease, I use the plain EKG exercise stress test. In older patients, in those with abnormal resting EKGs, and in patients in whom I strongly suspect coronary artery disease, I prefer the nuclear stress test because it gives a better quantification of heart muscle areas with compromised blood flow. For patients who cannot exercise, there is a third type of stress test called a pharmaceutical stress test. In this test, a drug is injected to dilate the coronary arteries, which allows increased blood flow unless there is a blockage. Nuclear images are obtained in the same manner described for the nuclear stress test to reflect relative blood flow during rest and during exercise.

A stress test is a good indicator of the state of a patient's coronary blood flow at the time of the test. But its ability to predict the future does have limitations. You can accumulate a lot of plaque in your coronary arteries, and even have blockages, yet still maintain normal blood flow at rest and during exercise. This is because your body may have produced the protective network of collateral blood vessels.

While a stress test is valuable for women as well as men, studies have shown that women have more abnormal stress tests without necessarily having obstructive coronary disease. These women may have a disease of their smaller vessels, which can limit blood flow and cause chest pain but not necessarily cause a heart attack. Having a nuclear stress test rather than a plain EKG stress test helps to reduce the number of false positives for women.

Follow-up. If a patient's initial stress test is fine, I normally do not repeat it unless there is a change in the person's symptoms or risk factors. In high-risk patients, including those with known coronary artery disease, I repeat a stress test on a more regular basis.
Last Updated: 11/14/2008
Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735.

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This life-saving test is an essential screening tool for heart disease.
By Arthur Agatston, MD, Everyday Health heart expert
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What is it? A heart scan is a noninvasive procedure that shows the amount of calcified plaque you have in your coronary arteries. Currently, two types of heart scanners are being used. The first is the multislice computed tomography (CT) scanner, which creates an extremely detailed cross-sectional image of your arteries using x-ray cameras. The second is the electron-beam tomography (EBT) scanner, which creates images of the heart using an electron gun. Both types of scanners are excellent, and the one you choose depends on what your doctor recommends and what type of equipment is available at your medical center. It may also depend on how much money you are willing to spend.

There are advantages to each. The advantage of the EBT scanner is that it acquires images faster than a multislice scanner. This is particularly important when imaging a moving organ such as the heart. But while an EBT scan will provide an accurate Calcium Score and show the extent of your coronary disease, it cannot consistently show the presence and extent of soft plaque. That is the true benefit of the state-of-the-art 64-slice scan. Remember, it is the cholesterol-filled soft plaque that can grow, rupture, and cause a heart attack, so it is good to know if there is soft plaque lurking inside the lining of your artery walls.

The 64-slice scanner is simply the latest in a long line of multislice scanners, many of which are still being used. The first multislice scanner was the 4-slice, introduced in the early 1990s. It was followed by 8-, 16-, and 32-slice scanners. Some centers are still using this earlier technology but, while some of these scans can give you an accurate Calcium Score, the 64-slice scan is the best at imaging soft plaque with a dye injection (as I mentioned earlier, this is called a noninvasive angiogram). You may have been told that the 64-slice scanner can actually quantify the percentage of obstruction in your arteries. While it may be able to do this in certain patients, results are often unreliable. The invasive angiogram is still the best technique for determining the percentage of blockage. That said, a noninvasive angiogram is useful for excluding obstruction. In other words, if your scan looks completely normal, you can be confident that it is accurately showing that there are no blockages.

From a patient's perspective, getting a heart scan is quite easy. You lie down fully clothed on an examination table, the scanner passes over you for a minute or two, and then it's over. If a contrast dye is used, you may have to fast beforehand and the examination can take a little longer. One caveat: If you've ever had an allergic reaction to a contrast dye or iodine or have an allergy to shellfish, you should consider a scan that involves contrast dye injection only under special circumstances. Be sure to tell your doctor about any such allergies or reactions. Premedication can be used to minimize an allergic reaction to the dye. Caution must also be used in patients with compromised kidney function (often found in people with diabetes) since the dye can worsen the situation. You should also tell your doctor if you are or might be pregnant; if so, you should not have a scan at all. Once the scanned image of your heart has been analyzed, it's converted into a number ranging from 0 to several thousand. This number is called your Calcium Score. The higher your score compared to others of your age and sex, the more calcified plaque you have in your arteries and the greater your risk for a future heart attack.

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The higher your calcium score, the greater your heart attack risk.
By Arthur Agatston, MD, Everyday Health heart expert

When you have a heart scan, you are given an overall number called the Calcium Score, or Agatston Score, which represents the total amount of plaque in your coronary arteries. The number can range from 0 to 1,000 or more. The higher your number, the more plaque you have in your arteries and the greater your risk. If your score is more than 400, for example, you have an increased likelihood of developing symptomatic heart disease — angina, heart attack, or even sudden death — in the next 2 to 5 years. If your score is more than 1,000, you have a 25 percent chance of having a heart attack within a year without intervention.

Calcium Score for a 55-Year-Old
Man or Woman
Relative Amount of Plaque
0–10 Minimal
11–100 Moderate
101–400 Increased
401+ Extensive
Keep in mind that there's no absolute way to predict who is going to have a heart attack, but your Calcium Score is an excellent way of predicting the likelihood of it happening to you. Of course, when you are trying to predict the future, you must consider other variables beyond your Calcium Score. For example, if you smoke, a low Calcium Score will not protect you. Smokers tend to have very sticky blood. This can result in a much larger blood clot developing after a plaque rupture than would develop in a nonsmoker. On the other hand, someone with a moderately high Calcium Score can forestall a heart attack indefinitely — or even prevent one entirely — simply by controlling risk factors. And even if your Calcium Score indicates a high likelihood for a heart attack in the near future, if you begin an aggressive prevention program immediately, your level of risk can sharply decline within months.
Last Updated: 11/14/2008

Reprinted from: THE SOUTH BEACH HEART PROGRAM by Arthur Agatston, MD. © 2007 by Arthur Agatston, MD. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735.