1MEN’S AND WOMEN’S HEALTH – NOVEMBER 27TH, 2007

HEART DISEASE AND ASSOCIATED RISK FACTORS

LECTURE 23

• Underlying cause of Metabolic Syndrome: obesity.

• 70% of adults projected to be obese by 2007.
• Supposed to use lifestyle change to try to reduce LDL for 12 weeks before prescribing statins.
• Plant sterols: therapeutic dose is 1500mg

Despres: Pfizer-funded study: they expected him to find that LDL was the most important factor
• High LDL: 50% increase in risk of disease. HDL seems to be more predictive than LDL in isolation. If HDL is bad, this
is worse than bad LDL.
• Acknowledges that LDL plays a role, but concludes that obesity plays a role.
• BMI study: looks at BMI 21 as standard, compares other to it. Increased risk even within normal BMI range.

Portfolio diet: Almonds, plant sterols, very high fibre, low glycemic foods, viscous fibre: okra, eggplant, oatmeal, low
saturated/trans fats. NO WEIGHT LOSS, NO EXERCISE, intentionally, to isolate effect of food. 30% reduction in LDL.
Varady: exercise, found good results.
Using them in combination would amplify results.

HYPERTENSION
DASH diets: Lower bad fat, recommended fibre, 4 servings of fruit/veg per day.
These diets are all modest changes. We can do much better.

DYSGLYCEMIA
Low fat diet? We don’t like this.

Secondary coronary prevention: people who have already had a heart disease.
Mediterranean diet: modest increase in good fat, modest decrease in bad fat  70% reduction in CAD morbidity

Singh: control diet is REALLY healthy: 26g of fat. You would improve health if you used this as an INTERVENTION.

INTERVENTION
Modest carbohydrate restriction: not ideal, but it helps people comply with the diet.
“prescription foods” and “supplementation”: these are general recommendations.

BASIS:
References for the recommendations made for interventions presented.
AHA: Position paper of American Heart Association

Nuts: positively affects lipids (look it up… can’t remember which one it acts on), increases fibre.

Plant sterols: NFH, Seroyal, Douglas Labs: offer sterols in liquid form (oil base). Don’t use in a powder: it doesn’t work.
References for coffee follow.
Reference for plant sterols. 10-15% reduction of cholesterol as monotherapy.
Fish oil: dose once a day. Better absorption if taken with a meal, best if it contains fat. Sterols: have to be given with
every meal. More likely that patients will comply with therapies that you give once a day.

INTERVENTION:
Caffeine and dysglycemia: body recognizes caffeine as something that impairs blood glucose regulation. Secrete more
insulin.

Khan: lowers blood sugar and cholesterol (powdered).

Mang: Liquid cinnamon: blood sugar only.

Lutein for the eyes.

MEN’S AND WOMEN’S HEALTH, NOVEMBER 26TH 2007 – PAGE 1

Relaxation breathing exercise: FDA approved machine to teach people diaphragmatic breathing. 8 studies showing it
works to reduce blood pressure.
CALORIC RESTRICTION:
See recipes.

Case #1:
Patient meets all 5 criteria for metabolic syndrome. Just started metformin. On 2 BP meds, still has high BP.
One week later: he’s complying with exercise and diet.
Blood sugar NO LONGER DIABETIC after 36 hours on Phil’s treatment.
First week, no readings over 7.
Metformin is only agent you can take if you are normoglycemic. Other hypoglycaemic drugs, have to reduce dose when
you start therapy.

March 21st: lost weight and waist circumference. Now 1 reading over 6 every 7-10 days.
Blood pressure wouldn’t drop.
Single most powerful predictor of heart disease is radio of TC:HDL. Great lipid panel!

June 28th: weight loss has slowed, but benefit persists.

Case #2:
Lipitor: this is a massive dose.
Not morbidly obese, just overweight.
No CoQ10, but on plant sterols, fish oil, almonds
Week 2: High HDL, this is good. Modestly compliant. Doing the exercise, still eating crap but eating less.
After 2 weeks, motivated, doing more. Blood glucose better, losing weight.
Week 12: still losing weight, more compliant. Almost normoglycemic. Blood lipid now parallels what it was on 40mg of
Lipitor.

Case #3
Young man, significantly overweight. On lots of drugs. Dysglycemic despite drugs. Ultra high risk.
Chooses to come off of all of the drugs from day 1.
Modestly compliant, loses a point a week. Blood pressure plummets, off drugs.
“vegetables make me puke”:
B: Veal parmagiana off coffee truck
Had to negotiate! Got him to eat Cheerios (wanted frosted flakes).
Does olive oil and almonds, won’t touch fruit and vegetables.
HBA1C: great reading, but after 6 weeks, wouldn’t expect this to be impacted.
Very favourable panel.
Exercise is covered: foreman, walks a lot.
Dose of fish oil to impact lipid panel is 2000-4000mg/day.
By week 16, he was having a small salad every day.
Went from complete non-compliance to health.

Case #4
Young male, overweight, injecting lots of insulin (70-80mg insulin). Type 1 diabetic: their glucose levels will be different.
HbA1C: Ultra high risk: over 8% (he is 8.7%)
Got into training, joined football team.
His saving grace was SUBWAY! Can promo this to people: at least it is an alternative to McDonalds. Have to negotiate
with patients.
He was willing to do fibre supplement.
Diabetic specialist recommended to take 10% more insulin (his blood glucose was 9)
Takes a bit more, blood sugar comes down.
Over 1 year, have 1% drop in HbA1C: 18% reduction in morbidity.
35 pound reduction: great reduction in risk.

Case #5: brutally difficult case

Some people will not be able to lose much weight: history of extreme crash diet.
Glyburide, avandia: oral hypoglycaemic agents. Avandia: controversy: raises lipid?
Big dose of statin. Diovan is BP drug.
10 years before, had serious bout of Lupus.
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ANA: has started increasing again, she’s ready to listen.
Before she came in to see Phil, got her blood sugar to average 9. She is already making changes.
3 weeks in, 50% dose statin, the lipid panel is dramatically improved. Better than 20mg of provastatin.
Further reduction in statin drug.
Barely lost any more weight. Fight for her to lose weight.
Also having trouble with blood sugar regulation.

Week 12: lipids worse. Doctor wants to put her back on 40mg provastatin. She takes 10mg. Had some trouble with
compliance.
Starts gaining weight again, less compliance.
Doc freaks again, recommends drugs again, but she takes less.
At last visit, the ANA plummeted. After non-compliance, ANA back up again. Gets scared, complies again.
Replaced 30mg of statin with our therapies.

Case #6:
Beta blockers: can’t touch these.
84, very overweight, Type 2 diabetic but insulin-dependent.
Exercise? Get him to the pool!
Will often see massive amount of weight loss in first week.
Didn’t believe he needed to reduce insulin, had VERY low blood sugar (3), hypoglycaemic.
Week 4, fell off the wagon. Checked cholesterol that week, even these measures are good (underestimates actual results
as he was non-compliant that week.) Cholesterol will change in 1 week.

Tell patient to expect that the therapy you are doing with them is going to powerfully reduce their blood sugar. In order to
avoid a hypoglycaemic event, they will need to reduce insulin, probably by 40%. Continue to take insulin! Let MD know
what they are doing: diet and lifestyle protocol.
Diabetics monitoring their blood sugar and adjusting it based on what they are eating, what they are doing (exercise). You
aren’t telling them anything new, they are used to changing their dose. Just warn them about magnitude of change.

SCP=Secondary Coronary Prevention

SCD: sudden coronary death, reduced by fish oil. Anti-arrhythmic.

JELIS studies: no effect because they were done in Japan where EPA levels are already high. Adding more doesn’t
benefit SCD, but reduces the risk of non-fatal events. They are getting 1800 PLUS the 900 they are getting from food.
Dose should be 2000-4000mg/day (EPA/DHA combined). In the world of HEART, the EPA/DHA doesn’t matter. It matters
in psychiatry where bias must be towards EPA.

L-Carnitine:
Reduced CV events in some studies.
L-Carnitine: prescription in Canada.

CoQ10: Cost to patient at this dose = $0.75-$1.00/day.

Also reduces blood pressure.
Depleted by statins.

Thiamine:
Furosemide is thiazide diuretic. Depletes cardiac myocyte levels of thiamine. 100mg was IV, Phil says oral at this dose is
fine too.
Should be given to all patients on Furosemide.

Novel CVD risk markers:

Ratio of TC:HDL was gold standard, but now look at oxidized LDL. Regular LDL isn’t problem, but once it is oxidized, can
be taken up by macrophages.
Much more expensive: lipid panel is $25.

ADMA: by product of protein metabolism. Significant risk factor for heart disease. Nitric oxide is vasodilator.
L-argenine drives the reaction forwards by providing more substrate.

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In-office ECG: come down in price. Looks good to patient! Can learn to read, refer to cardiologist if abnormals. Will pick
up abnormalities. Resting ECG. Good screening test. Can bill for them, make it part of intake, vs. salivary test, VEGA
machine, pendulum… Will see effect of therapies.
Finger prick test, significant cost to strips, but test is done in-office, more quickly.

MEN’S AND WOMEN’S HEALTH, NOVEMBER 26TH 2007 – PAGE 4