Michael Ozner, MD
Reducing The Risk Of Heart DiseaseFebruary 2018
Michael Ozner was named one of the top cardiologists in America, and has written multiple books including the best-selling The Complete Mediterranean Diet and Heart Attack Proof.
Dr. Ozner has focused his career on eradicating heart disease, America’s number one killer. His research on the benefits of the Mediterranean diet and his emphasis on prevention first has saved millions of lives. In this interview, Dr. Ozner gives an assessment of our next steps in conquering heart disease.
LE: Heart disease is still the number-one killer in America, even with all the billions spent on cardiac prevention and medications. What is the next step for reducing this devastation?
MO: Our priority needs to be how we can prevent heart disease in the first place, instead of focusing on treatment of existing disease. By the time a patient is referred for cardiac catheterization or open-heart surgery, there has already been a failure in the system. We need to focus much earlier, when the disease process is silent and the damage cascade has yet to begin. If we can do this, we can finally notch significant victories in the battle against cardiovascular disease—including heart attack and stroke. Cardiovascular disease remains the leading cause of death in the United States, but it’s also largely preventable. We’re only going to prevent this disease if we start early enough.
LE: Where do we begin?
MO: It’s amazing how much of our current thinking on lipid control is based on outdated science. The problem is that the approach of current medicine misses the boat when it comes to diagnosis of those at risk of heart attack. We’ve had a major shift in our recent cholesterol guidelines, toward risk and away from cause. This was not a move in the right direction, because it’s better to go after the cause, not just try to reduce the risk when disease becomes entrenched. You have to identify the enemy as early as possible to get at the root of the matter. The enemy in this case is not actually cholesterol—which is vital for health—but the type and number of cholesterol-carrying particles, called lipoproteins, floating in the bloodstream. If the bloodstream is laden with an increasing number of atherogenic (atherosclerosis-producing) lipoproteins, eventually these lipoproteins may infiltrate the artery wall, setting off an immune-system response that can lead to arterial disease and possibly heart attack and stroke. If we want to get to the root cause, we need to reduce the number of atherogenic lipoproteins.
LE: Most people would assume that their physician is requesting this type of information in their annual blood tests during their physical.
MO: Well, they’re not. Most physicians order a basic lipid panel that includes total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides. Although this basic panel is helpful in evaluating risk, we need to dig deeper and look at the number of potentially harmful (atherogenic) particles. The good news is that we already have the technology to accurately measure the number of dangerous lipoproteins—even if it’s not in wide use. The apolipoprotein B (apo B) blood test is used to measure the number of potentially dangerous particles that can lead to the atherosclerotic process. A second test, the LDL-P test, can also be used since it measures the total number of LDL particles. Either of these two relatively inexpensive tests provides a much more accurate assessment of cardiac risk than our current focus on LDL cholesterol.
LE: Can you tell us more about the importance of testing for apo B?
MO: Because of the obesity epidemic, insulin resistance and diabetes, there’s often discordance between LDL cholesterol numbers and apolipoprotein B levels. If your LDL cholesterol (LDL-C) is perfectly normal, but you have too many apo B particles crashing the artery wall, you can still drop dead of a heart attack. Multiple large scale clinical trials have shown that measurement of particle number (apo B or LDL-P) is superior to total cholesterol or LDL-C in predicting heart-attack risk. Once we accept that measuring apo B gives a better indication of cardiac risk we can then take the next logical step: driving those numbers down to prevent heart disease in the first place. The good news is that we are able to lower elevated cholesterol and apo B levels with a healthy lifestyle and medications (if necessary) and thereby reduce the risk of heart attack and stroke.
LE: Besides particle numbers, what role does high blood pressure play as a risk factor for heart disease?
MO: High blood pressure is an important risk factor for cardiac health, but again, there’s significant controversy over the current guidelines.
LE: Have there been studies supporting the reduction of blood pressure levels below these guidelines?
MO: The recent SPRINT trial showed that getting blood pressure lower than current guidelines translates to decreased overall cardiovascular mortality, mainly driven by a significant reduction of stroke risk.
The SPRINT trial was published in the New England Journal of Medicine. This rigorous study compared the rate of cardiac events among almost 10,000 nondiabetic patients with high blood pressure who were separated into two treatment groups. The first group was aggressively treated, with a treatment goal of reducing blood pressure to 120 mmHg, while the second group followed the current guidelines of aiming for 140 mmHg. At the end of the five-year follow-up period, the conclusions were clear. SPRINT showed that among adults with hypertension but without diabetes, lowering systolic blood pressure to a target goal of less than 120 mmHg resulted in significantly lower rates of fatal and nonfatal cardiovascular events and death from any cause. This remains controversial within the cardiology community—with many cardiologists continuing to aim for the older standards. However, during my recent symposium (Cardiovascular Disease Prevention 2017), a general consensus emerged that a target goal of systolic BP less than 130 mmHg was acceptable, until further trials confirm the SPRINT conclusions.
Note: Based upon published population-based data on cardiovascular outcomes, Life Extension® believes an optimal blood pressure target is 115/75 mmHg. However, rapid and aggressive blood pressure reduction in patients with kidney disease, as well as older patients, should be avoided. Older patients usually do not tolerate rapid, aggressive blood pressure reduction, and may require higher blood pressure for optimal organ perfusion (e.g. kidney, brain). Frequent monitoring, including blood tests for kidney function and electrolyte levels (e.g. potassium), should accompany aggressive blood pressure control with prescription Rx medications.
Once again, we know how to reduce and prevent elevated blood pressure through a combination of diet, exercise, stress management, weight control, proper sleep and medications. The challenge is getting the medical community to accept that previous guidelines aren’t stringent enough and help educate patients about getting dangerously elevated blood pressure under control long before a heart attack, stroke, or heart failure occurs.
LE: What role do certain supplements, such as fish oil or omega-3 fatty acids, play in achieving heart health?
MO: Omega-3 fatty acids reduce inflammation, lower blood pressure, lower resting heart rate, reduce triglycerides, improve insulin sensitivity, and reduce the risk of arrhythmias and sudden cardiac death. You need only look at Japan for proof, where people eat much more coldwater fish on average and have higher blood levels of omega-3 fatty acids and much lower levels of cardiac disease.
Ultimately, it’s important to test your blood for omega-3 fatty acid levels using the omega-3 index, which measures for the levels of EPA and DHA in red blood cells. We need to do better in spreading the message on the importance of omega-3 fatty acids. The average American has an omega-3 index of 4% to 5%, compared to an average omega-3 index of 9% to 10% in Japan. I recommend aiming for an omega-3 index of 8% to 10%.
LE: We are in the middle a diabetes epidemic, which is a direct path to heart disease. What role does insulin resistance play in the prevention strategy?
MO: Numerous clinical studies have been published in prominent medical journals showing a clear link between insulin resistance and cardiometabolic disease. Even with this increased awareness, we’re still doing a poor job of recognizing insulin resistance. Once again, the issue is that we aren’t catching this insidious disease process early enough but waiting until it’s already advanced. Many people go to the doctor and get a fasting blood glucose level test, and if it’s normal, they think they’re fine. We know that’s not necessarily true. In fact, a normal blood glucose reading might actually mean that the pancreas beta-cells, where insulin is produced, are working overtime to produce enough insulin to clear excess glucose from the blood. This can lead to “beta-cell strain” and, if left unchecked, can result in beta cell dysfunction and ultimately beta-cell failure, which can lead to insulin-dependent type II diabetes.
Prediabetes is generally diagnosed when the fasting blood-glucose measures between 100 mg/dL and 125 mg/dL. Readings over 125 mg/dL indicate type II diabetes.
If you wait until you have prediabetes, you have done harm to your insulin-producing beta cells. It only makes sense to catch people before they have prediabetes. To identify issues before blood glucose levels starts to rise, you can measure fasting insulin levels. If they’re elevated, it suggests the pancreas is overproducing insulin to maintain normal blood glucose levels. The earlier we intervene with lifestyle changes (diet and exercise) to prevent the progression to diabetes, the better.
LE: Right along with insulin resistance is the obesity epidemic that carries risk factors for so many diseases. Aside from being unattractive, excess weight, especially belly fat, is extremely harmful. Can you discuss this connection?
MO: The issue of insulin resistance is closely related to an area of intense interest among cardiovascular researchers: adiposopathy, or the accumulation of “sick fat.” This condition starts with a flawed lifestyle—especially a diet high in sugar and refined starches, saturated and trans fats, and highly processed food. This unhealthy dietary pattern combined with a lack of exercise results in excessive fat production in the liver. This excess fat is then carried to the fat (adipose) cells for storage.
As people eat a high-fat and high-sugar diet, their triglycerides often rise. Elevated triglycerides are stored in fat cells (adipocytes) and as these cells begin to swell and increase in size, adipocyte dysfunction and insulin resistance result. Over time, this leads to increased mobilization of free fatty acids that are released into the bloodstream and have a harmful effect on the liver, pancreas, arteries and other organs.
We know adiposopathy often begins in the belly, with accumulated belly fat. So one of the best diagnostic tests is measurement of waist circumference. Men with a waist circumference greater than 40” and women with a waist circumference greater than 35” are at greater risk. Like so many of the issues we have discussed, the best approach to adiposopathy is to prevent it in the first place. And lifestyle is always the first and most important step.
LE: Increasingly, we are seeing products in the supermarket that are labelled with “plant sterols” that claim to lower cholesterol. What are your thoughts on this?
MO: This is a very controversial topic. Consumers need to be aware of the science and not fall for the hype. You are correct, plant sterols (phytosterols) occur naturally in plants and have become increasingly popular as a way to lower cholesterol. They are added to certain foods (e.g. margarine, yogurt, fruit juices) which advertise plant sterols as a natural way to reduce harmful cholesterol levels.
It turns out that for many people, plant sterols can be toxic and actually promote heart disease over the long-term. The issue is the function of two sterol transporters called ABCG5 and ABCG8. These two transporters work to transport plant sterols out of the cells that line the gut and back into the gut lumen so they can be excreted. If there is a genetic defect in ABCG5 and ABCG8, these plant sterols can enter the bloodstream and have a potentially devastating effect on the arteries, including accelerated atherosclerosis and premature heart attack.
This disease was already well known in children who were born with significant defects in the transporters. Children with this condition often develop premature heart attacks as teenagers and young adults. The discovery that many adults also have a mild mutation, however, expanded the universe of people who could be adversely affected by sterol accumulation.
This doesn’t mean people should avoid eating a wide variety of fruits and vegetables, which naturally contain a small amount of plant sterols. The consensus among many sterol researchers is to avoid excess plant sterols added to food or supplements for the purpose of cholesterol lowering.
LE: This seems like an extremely clear road map for avoiding heart disease. Both physicians and the public need to be partners in this endeavor.
MO: That’s absolutely correct. We already know much of what we need to know to prevent millions of Americans from suffering and dying of heart disease. The sad truth is that our lifestyles are killing us. We don’t get enough exercise, our diets are highly processed, calorie-dense and nutrient-depleted. We’re stressed out and often suffer from sleep disorders, and we are suffering from epidemic rates of metabolic disorders like insulin resistance and diabetes.
We need to become proactive in our battle against heart disease. Everyone should develop a heart disease prevention strategy with their personal treating physician—don’t wait until cardiovascular disease strikes and then hope that medications or surgery can bail you out. The second major step is convincing the medical community to emphasize the role of therapeutic lifestyle intervention in maintaining heart health. In addition, clinicians need to use the proper blood biomarkers to identify metabolic derangements that can be corrected before disease becomes established.
Considering the high cost of surgery and expensive invasive procedures, prevention is extremely cost effective, both for individuals and medical systems. When I see the work Life Extension is doing by educating the population, that is an enormous step forward and a great contribution.
There is currently a revolution in medicine among the lay public. People want to know how they can stay healthy without having to take multiple pills every day or undergo risky and expensive surgical procedures. And we know how. It’s about prevention. This is evidence-based medicine. It’s not hype. It works. We know how to keep people out of the hospital.
For further information and videos on heart disease prevention, visit Dr. Ozner’s website at www.drozner.com
Michael Ozner, MD, FACC, FAHA, is one of America’s leading advocates for heart disease prevention. Dr. Ozner is a board-certified cardiologist, a fellow of both the American College of Cardiology and the American Heart Association, medical director of Wellness and Prevention at Baptist Health South Florida, a well-known regional and national speaker in the field of preventive cardiology, and a member of Life Extension’s Scientific Advisory Board. He is symposium director for Cardiovascular Disease Prevention, an annual international meeting dedicated to the treatment and prevention of heart attack and stroke. He was the recipient of the 2008 American Heart Association Humanitarian Award and was elected to Top Cardiologists in America by the Consumer Council of America. Dr. Ozner is also the author of The Great American Heart Hoax, Heart Attack Proof, and The Complete Mediterranean Diet.
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