BODYHEART is interested in various aspects of health, wellness and lifestyle. Our goal is to promote products, processes and interactions that reduce morbidity and mortality, as well as improve mental and physical health, fitness and daily life.
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Cardio-respiratory Fitness:
Cardiorespiratory fitness: It’s important. So what else is new?
I recently read an article that gave a brief overview of Dr. Robert Ross’ research regarding exercise. Dr. Ross, professor of exercise physiology in Ontario, Canada, has studied cardiorespiratory fitness throughout his career. In 2004, Dr Ross and others determined that cardiorespiratory fitness is a more important marker then BMI for overall health. People with improved cardiorespiratory fitness had lower abdominal fat independent of BMI. Also, for given BMI, those with better cardiorespiratory fitness had a significantly lower waist circumference as well as lower total abdominal tissue. Larger studies then provided compelling evidence that waist circumference is connected with diabetes and cardiovascular disease beyond what can be explained by BMI alone. This is independent of gender or age. Dr. Ross and others think that exercise should be viewed as a cost effective medication for all patients at risk for or with cardiovascular disease. While this appears obvious to all of us, our societal lack of motivation to improve cardiorespiratory fitness persists—not for all but certainly for the majority. The cost to our healthcare system is enormous.
Eat Your Vegetables: European Heart Journal, 2016.
Eating healthy food is good for you. That is not news but a recent study in the European Heart Journal added some credence to the thought that the Mediterranean diet is truly heart healthy. This study also looked at what you eat that is good and what you do not eat that is bad and showed that eating the good is actually more important than not eating the bad. This study focused on patients with known stable coronary artery disease and was questionnaire based. A Mediterranean diet score was calculated based on increasing consumption of grain, fruits, vegetables, legumes, fish, alcohol, and less meat. A Western diet score was calculated based on consumption of refined grains, sweets, dessert, sugar drinks, and fried food. Notably, the main outcome of interest was the standard outcome used in heart studies, “major adverse cardiac events” (MACE). MACE events include cardiovascular death, nonfatal myocardial infarction or nonfatal stroke. More than 15,000 patients were enrolled from 39 countries. The average age was 67. People were followed for almost 4 years:
There was no association with an increased Western diet score and MACE but there was an association with the Mediterranean diet score and MACE. The higher the Mediterranean diet score, the lower the cardiac risk. MACE for Western diets did not improve based on a lower score and did not get worse with a higher score. These observations suggest that guidelines should focus more on greater consumption of healthy foods.
HDL cholesterol: Another example of nothing is easy.
A new study using an increasingly popular analytical approach that looks at huge databases reviewed the relationship between HDL cholesterol and mortality. What was once a given — the higher the HDL the better off you are/the lower the HDL, the worse — is not necessarily the case. It appeared that both low and high HDL levels (at the spectrum edges) are associated with elevated mortality but for different reasons. HDL cholesterol elevation is not necessarily a good thing. Numerous studies looking at various drugs that increase HDL level have never shown life benefit. In other words, if you have a relatively high HDL cholesterol level, that is good but if a drug brings you to that level, it has never been shown that doing that pharmaceutical intervention is helpful. This study is useful in considering very high HDL, very low HDL and the basic science involved in atherosclewosis production. For most people, the basic principle– that relatively higher HDL levels are relatively better and relatively lower HDL levels are relatively worse–is true. Very high HDL levels tended to be associated with alcohol use and this likely contributes to the results. Also, high HDL levels were not associated with cardiovascular mortality while low HDL levels were. This remains true: Levels above 40-50 in men and 50-60 in women remain associated with decreased risk of mortality from cardiovascular disease. Common sense steps to increase HDL levels still remain common sense.
SLEEP DISORDERED BREATHING — IT FEELS LIKE GLOBAL WARMING: We say it causes many medical issues
A small-single center study in the journal Stroke this year reports that 90% of acute ischemic stroke patients were found to have sleep-disordered breathing and a third had severe versions of this problem. Sleep apnea was diagnosed using a portable system after the diagnosis of stroke was made. 43 patients were part of the study. 86% had some level of obstructive sleep apnea and 32% had severe sleep apnea. Because the sleep-disordered breathing was not formally assessed or diagnosed before the hospitalization for stroke, this is a limited study, but it is good to consider how sleep apnea and cerebrovascular events interact. Further study will help. The authors write that the findings of high prevalence of sleep-disordered breathing with evidence of the associated elevation of inflammatory and procoagulant biomarkers stress the importance of this pathophysiology in stroke development.
Sleep Disorders and Heart Disease
Connections exist between the two but it is hard to know if the cardiovascular disease itself or overweight or diabetes cause obstructive sleep apnea or whether the sleep apnea is just a bystander that is coincidentally seen with the other diseases. Common-sense and past clinical experience suggests overweight as the primary driver but prudent thinking has been wrong in the past and that is why research must always be rigorous. More study is needed regarding this question. We know that about 40% of an average cardiologists population has sleep apnea. Treating obstructive sleep apnea improves hypertension. Less is known regarding other types of heart disease. Currently the best way to treat sleep apnea aside from weight loss and exercise is CPAP. For those intolerant people who did not tolerate CPAP, there are newer forms of CPAP and for people who are intolerant of any CPAP, there are alternative, albeit less tested, therapies. For the moment, the best way to treat sleep apnea may not be the easiest way—that is weight loss.
Zetia is just not a great drug.
Ezetimibe (Zetia) is a drug that is really good at lowering LDL levels. It impairs dietary and biliary cholesterol absorption at the intestine without affecting the absorption of triglycerides or fat soluble vitamins. One of the mainstay thoughts regarding cholesterol therapy is that lower LDL levels help prevent first-time and recurrent heart attacks. This is why statins are prescribed. Somehow, however, the way statins lower LDL cholesterol is better than the way other drugs lower LDL cholesterol. Ezetimibe has been around for years and is very effective at lowering LDL cholesterol levels. We have been prescribing it in conjunction with statins when people do not reach their goal LDL level on one drug alone and Ezitimibe is marketed with simvastatin in combination pill form (Vytorin) . While Zetia helps reach goal LDL level, it has never been proven to lower heart attack or mortality rates. Another study designed to show that it does have significant clinical endpoints once again showed that it had only modest effect and the FDA, based on this most recent study, voted against approving an expanded indication for ezetimibe in combination with simvastatin therapy. Zetia remains a third line agent.