Lifestyle Modification as a Primary Intervention

Even as the general population becomes more knowledgeable about healthy eating patterns and physical activity routines, Coronary Artery Disease (CAD) remains the leading cause of morbidity and mortality worldwide. Key risk factors for CAD include high cholesterol, high blood pressure, obesity, and diabetes. Unsurprisingly, the first and third most commonly prescribed medications in the US are a blood pressure-lowering drug and a cholesterol-lowering drug, respectively (4). What may come as a surprise, however, is that lifestyle modifications are often the recommended first-line treatment.

A number of studies have looked into the specifics of these lifestyle modifications, and I’ve highlighted some of them specifically in the paragraphs below.

Diet

Many a bright mind has looked into the best nutritional elements to make up a healthy diet. Before jumping into that research, a quick crash course on nutrition:

Of the six classes of nutrients, three are considered energy nutrients: carbohydrates, fats, and proteins. Each plays an essential role in our diet when portioned correctly.

Carbohydrates can be simple or complex, and while it’s commonly thought that complex carbs are healthier than simple carbs, this is not always the case. But that’s a topic for a different day.

Fat can also be broken down further into saturated and unsaturated fat, based on the structure of the molecule. Low-density lipoprotein (LDL) and high-density lipoprotein (HDL) are molecules made up of fat and protein that carry cholesterol. While LDL carries cholesterol to be stored in our bodies, HDL carries it away from storage to be metabolized and/or excreted. For this reason, LDL is considered “bad” cholesterol while HDL is considered “good” cholesterol. Cholesterol itself is made up of lipids and can be considered in the fat category. It is found naturally in the body and is necessary for the production of hormones and vitamin D. However, too much cholesterol can result in plaques, atherosclerosis, and ultimately heart attack and/or stroke.

Similar to carbs and fats, protein can also be analyzed by its parts. Amino acids, which make up proteins, can be essential (meaning our body does not produce them and it is essential that we get them from our diet) or non-essential. A healthy ratio of essential to non-essential amino acids is desirable—a good thing to consider when looking at protein supplements in addition to natural protein-containing foods.

Now that we’re armed with some basic nutritional knowledge, let’s tackle these findings. While there are technical differences among different studies, the general consensus is the following:

The best dietary patterns are those that are high in vegetables, fresh fruits, whole grains, low-fat dairy products, poultry, fish, legumes, nuts, and non-tropical vegetable oils. Limit intake of red meats and sugary foods, including sugar-sweetened beverages. Reduce the consumption of saturated fats and trans fats. The DASH diet, which is one diet that encompasses the guidelines described above, was found to lower blood pressure as well as LDL levels (3).

Studies also found that reducing daily sodium lowers blood pressure, and that combining limited sodium intake with the DASH diet results in an even greater reduction in blood pressure (3). In fact, higher dietary sodium intake has been associated with greater risk of stroke and cardiovascular disease (3). Taking this a step further, reducing sodium intake by approximately 1000mg/day has been shown to reduce cardiovascular events by a staggering 30% (3)! Luckily, little sodium is found naturally in food (3), indicating that simply reducing the amount of salt we add to our food can have a huge impact on our cardiovascular health.

Omega 3 fatty acids have also been found to have cardioprotective effects (7). In fact, it has been demonstrated that a diet rich in fish oil halves triglyceride levels, and that fish oil supplements decrease the incidence of cardiovascular events such as heart attacks and stroke (7)!

A linear relationship has been found between cholesterol levels and coronary artery disease mortality (7). Accordingly, reducing cholesterol levels will reduce the risk of coronary artery disease. Lower cholesterol levels can be achieved without medication by eating a healthy, balanced diet (such as the DASH diet or Mediterranean diet), incorporating regular physical activity into your daily routine, and quitting smoking (2).

Probably nothing mentioned so far has been especially surprising, but there have been some lesser known findings as well. One such finding is that soy proteins are associated with reducing cholesterol, and consequently reduce the risk of coronary artery disease (7). While there is insufficient evidence to suggest entirely replacing other proteins with soy, soy products do have a role in a balanced diet. Cocoa products have also been shown to reduce blood pressure, as well as reduce risk of cardiovascular disease due to their high composition of flavonoids. We all knew that dark chocolate was good for the soul, but dark chocolate and cocoa products have also been demonstrated to reduce the LDL/HDL ratio (7). Green tea may be a little less surprising, but it has been shown to reduce total cholesterol as well as LDL, without affecting HDL (7). Almonds may also play a role in lowering cholesterol, as well as virgin olive oil and a Mediterranean diet (7).

The main points here? Replace processed high sodium foods with fresh fruits and vegetables. Swap out the steak for some lean poultry, fish, or tofu. Use whole grain bread for that avocado toast you were planning to have for breakfast—avocado deserves better company than a slice of white toast. Snack on a low-fat yogurt or some trail mix instead of that bag of chips. Leave the soda on the shelf, even if it’s diet (there’s no such thing as guilt-free soda)—water is your best friend.

Physical Activity

There is a great deal of evidence demonstrating that higher levels of physical activity are associated with an enhanced life expectancy and lower rates of many chronic diseases, attributed to the beneficial effects of physical activity on blood pressure and on lipid levels (3). Engaging in aerobic physical activity has been shown to reduce LDL and non-HDL cholesterol.

Based on the studies surrounding physical activity, the 2013 Lifestyle Work Group has recommended 2 hours and 30 minutes of moderate intensity physical activity per week or 1 hour and 15 minutes of high intensity aerobic physical activity per week (3). This can be broken down into 3-4 30 to 40 minute sessions per week on average.

Regular physical activity has been shown to reduce VLDL (very low-density lipoprotein, similar to LDL) and raise HDL, as well as lower blood pressure and decrease insulin resistance (7). Interestingly, the amount of exercise is more important than the intensity of the exercise as far as cholesterol levels are concerned.

You might be wondering what type of exercise is best. In terms of cardiovascular benefit, both aerobic and resistance training have been shown to be beneficial. Regardless of what your daily routine looks like, find 30 minutes to take a walk—maybe even a run if you’re feeling spicy. If you don’t have a gym, there are plenty of free online resources for at-home workout routines. Take the stairs when you get to work. Take them again on your way out.

Physical inactivity is the new smoking—that’s not a joke, friends.

Smoking

While a sedentary lifestyle is the new smoking, that doesn’t make the original beast any less deadly.

Smoking negatively affects cholesterol levels, and the adverse outcomes are surprisingly worse in younger smokers—an important reminder that young people are not invincible. The poison of smoking affects all of us.

“Smoking cessation is possibly the single most significant lifestyle change an individual can make as it is a major modifiable risk factor for CVD” (7).

A powerful message here: making the decision to stop smoking may be the biggest factor in improving your health! Not to mention it is also associated with a number of ocular diseases, most notably macular degeneration.

This one is simple: stop smoking. It’s a longer and harder road for some of us than others, but it’s a chance to take control, a chance to make a difference. Here’s a chance to prove ourselves, to ourselves.

If that’s not empowering, I don’t know what is.

Eyes Are The Window to the Soul (And Body)

While you’re enjoying your newly balanced diet and regular physical activity regimen, ponder this: our eyes mirror our bodies. When your eye doctor looks in the back of your eye, she sees the same blood vessels that traverse the rest of your body.

She sees bleeding in cases of uncontrolled high blood pressure and/or diabetes. She sees plaques in cases of poorly controlled cholesterol. She sees areas of poor blood flow and unhealthy blood vessels. And if she sees all those things, these changes likely exist in your heart and brain too.

By taking care of our bodies, we take care of our eyes as well. We can have blockages in our eyes by the same processes that result in heart attacks. We can have bleeding in our eyes by the same mechanisms that result in strokes. Add loss of vision to the list of evils associated with an unhealthy lifestyle. And in some cases, that vision loss is permanent.

The Moral of the Story

The key risk factors of CAD include high cholesterol, high blood pressure, diabetes, and obesity—these risk factors can be modifiable, meaning you are in control! In fact, hypertension is considered one of the most important preventable contributors of disease and death (6).

The first line management of these conditions is non-pharmacological, including lifestyle modifications such as a balanced diet, regular physical activity, and smoking cessation. These lifestyle modifications target controlling weight, improving lipid profiles, and reducing blood pressure.

There is no doubt that making a drastic lifestyle change is hard, but you can make changes day by day, setting short-term and long-term goals. Hold yourself accountable and find a balance.

Take control of your health.

Resources

1. Battista RL, Mayol ML, Hargens TL, Everett KL. ACSMs Resources for the Personal Trainer. 5th ed. Philadelphia: Wolters Kluwer; 2018.
2. Cholesterol. MedlinePlus. https://medlineplus.gov/cholesterol.html. Published March 9, 2020. Accessed March 23, 2020.
3. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk. Circulation. https://www.ahajournals.org/doi/full/10.1161/01.cir.0000437740.48606.d1. Published November 12, 2013. Accessed March 19, 2020.
4. Fuentes AV, Pineda MD, Venkata KCN. Comprehension of Top 200 Prescribed Drugs in the US as a Resource for Pharmacy Teaching, Training and Practice. Pharmacy (Basel). 2018;6(2):43. Published 2018 May 14. doi:10.3390/pharmacy6020043
5. Hypertension Guideline Resources. www.heart.org. https://www.heart.org/en/health-topics/high-blood-pressure/high-blood-pressure-toolkit-resources. Accessed March 23, 2020.
6. James PA, Oparil S, Carter BL. 2014 Guideline for Management of High Blood Pressure. JAMA. https://jamanetwork.com/journals/jama/fullarticle/1791497. Published February 5, 2014. Accessed March 18, 2020.
7. Mannu GS, Zaman MJ, Gupta A, Rehman HU, Myint PK. Evidence of lifestyle modification in the management of hypercholesterolemia. Curr Cardiol Rev. 2013;9(1):2–14. doi:10.2174/157340313805076313