Avoiding Heart Disease

This summer my uncle went to see a doctor after complaining about experiencing shortness of breath. He's an officer in the Indian army and has a regular medical checkup every six months so he wasn't expecting to hear anything too shocking. This time, after some prodding from a cardiologist family friend, the doctors did a more extensive checkup. They told him that four of his coronary arteries were severely blocked. It was amazing he hadn't already had a heart attack. He underwent a quadruple bypass and thankfully is recovering well now.

I happened to be traveling in India at the time and learnt from my family that my grandfather had a fatal heart attack around the same age my uncle was now (mid 50's). He was also an officer in the army and seemingly in good health. I began wondering if a similar fate lies in store for me. The more I considered it, the more ridiculous it seemed. How could someone spend years thinking they're in good health with no idea that they're actually a ticking time bomb?

I decided to be proactive about managing this risk. I wanted to know what data I should be looking at and tracking over time so I could avoid being completely blindsided one day. I went to see a doctor and explained everything above. Her response, "you're young and healthy, come in for a physical once a year to check your cholesterol numbers and don't worry about it - just eat well and exercise regularly". I found this quite frustrating for two reasons:

  1. My cholesterol numbers came back fine (just like they were last year) but I knew cholesterol couldn't be a sufficient indicator of a healthy heart. My uncle had cholesterol numbers that were fine too.
  2. The advice to "eat well and exercise" didn't seem particularly insightful. To me it felt a lot like saying "don't worry about things for now, come back in 20 years when you have some actual symptoms".

So I started doing my own research into predictors of heart disease risk beyond monitoring cholesterol numbers. I came across three blood tests that seemed important; Apolipoprotein_B (ApoB), High Sensitivity C-Reactive Protein (hs-CRP) and Lipoprotein(a) (Lp(a))[1]. There appeared to be evidence[2] that all three taken together could provide a more accurate overview of heart disease risk than cholesterol alone.

I ordered these tests[3] and found that my levels for all three were elevated and fell into the "at risk" category.  There were a few conclusions I drew from my results:

  • While it's not exactly good news discovering that you have an elevated risk of heart disease, it made me feel better that I wasn't flying totally blind anymore. My mind immediately switched to researching ways to improve these numbers.
  • There seem to be fairly clear guidelines on how to go about reducing Apo(B) and hs-CRP numbers e.g. exercising reduces Apo(B) (though interestingly not LDL ("bad") cholesterol) and eating omega-3 fatty acids reduces inflammation.
  • Lp(a) seems trickier to manage. It appears to be mostly hereditary and I can't find a clear consensus on how to reduce it. It occurs to me that while I thought I wanted to gather data on every aspect of my heart, perhaps what I actually wanted was just the data about the things I can control.
  • My cholesterol numbers were checked again during these tests, in just two weeks my total cholesterol had dropped 14%. It seems incredible that such an important number can fluctuate so much over a couple of weeks and yet most people only measure it once a year, at best.

I've been thinking about whether taking this approach to managing my health is a good idea or not. It's certainly a slippery slope. There's always a new study to read indicating some additional marker or factor that should be taken into account. After a while it can seem somewhat overwhelming. I've been wondering though why didn't I have this level of discussion with my doctor? There are of course the obvious practical reasons. Doctors are busy and explaining heart disease risk to a healthy 28 year old isn't  viewed as a priority. Also running blood tests costs money and it's hard to see the insurance companies being willing to foot the bill for tests that aren't deemed necessary.

Ignoring these for a moment though, I've been thinking about the possible philosophical objections to treating managing your health as a data project. Here's what I've come up with so far:

Heart disease is complex and there's still debate about the validity of these additional markers
There's also debate about how useful linking cholesterol with heart disease risk is and yet that's still a standard test. There certainly appear to be enough studies and trials arguing that hs-CRP, ApoB and LP(a) are important so surely these numbers can't be completely irrelevant. If I want to take a proactive and preventative approach to managing my health, surely gathering the most information possible to form a plan of action seems reasonable?

The advice i.e. manage diet/exercise/stress is still the same. You should be doing it anyway.
True but I find that tying actions to specific numbers/metrics is better e.g. it's easier to lose weight if you weigh yourself regularly. Generic advice to eat well and exercise is not as effective as having a specific number you're trying to improve on e.g. lowering your ApoB count. Being specific also allows you to create a more personalized plan of action.

Optimizing for specific factors before fully understanding them can have unforeseen consequences
An example would be the conclusion by Ancel Keys in the 50's that animal fats caused heart disease, resulting in the American Heart Association pushing the idea of low fat diets to the public. By promoting fats as evil, the real danger of sugar and refined carbohydrates were ignored[4].

I'm not advocating pushing any particular theory or medical opinion on people. What I want is a system where I can choose to have access to my data with the explicit acknowledgement that the behaviour of the human body is inherently complex and uncertain. It's then my decision what course of action I want to take, taking the informed opinion of my doctor into account.

Numbers are constantly fluctuating, monitor them too frequently and you'll get stressed
This is actually a direct quote from my doctor. In my opinion it's still not a reason to ignore the numbers. I can opt out of knowing them if I wish but if I want access to that data, why should anyone but me have the right to make the decision? The role of a doctor should include telling me what fluctuations are normal and which ones aren't, rather than just checking in with me once a year.

I'd really like to hear more about what people think about this. Am I missing other major downsides to taking a more proactive approach to managing my own health?  Are there other things I should consider looking at to get a complete picture of my health?

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[1] ApoB: This is a protein found on the surface of LDL ("bad cholesterol") particles. A regular cholesterol test tells you how much cholesterol is contained within the LDL particles but doesn't tell you either the number or size of these particles themselves. Each particle contains one molecule of ApoB i.e. ApoB count == the number of LDL particles you have. This means you can also make an inference as to their size. If you have a high ApoB value, your LDL particles are likely to be small and dense which are believed to be a stronger indicator of heart attack risk. There seems to be some debate both for and against the importance of ApoB as a heart disease risk indicator that's more valuable than just measuring LDL. The existence of the debate alone seemed reason enough for me to add it to my list of data to track.
hs-CRP: This is a protein found in the blood and its presence is a sign of inflammation in the body, which is a risk factor for heart disease.  While testing for hs-CRP alone isn't more predictive of heart disease than a regular cholesterol test, it does provide valuable additional information. If your hs-CRP level is higher than 3.0mg/L you're at high risk for cardiovascular disease, according to the American Heart Association.
Lp(a):This is a different form of LDL (Low Density Lipoprotein - also known as "bad" cholesterol) which attaches to a protein called Apo A. It's apparently unclear what Lp(a) actually does but if your level is greater than 30mg/dL it's deemed an increased risk factor for heat attack.

[2]http://www.lipidjournal.com/article/S1933-2874(11)00606-4/abstract, http://circ.ahajournals.org/content/108/12/e81.full, http://www.medscape.com/viewarticle/714264

[3] I looked into how I'd get these tests ordered myself and found these options:

  • WellnessFX: A nice looking website that has various packages of tests you can run. The cheapest package that included hs-CRP, ApoB and LP(a) was their Baseline (http://www.wellnessfx.com/baseline), priced at $149. It also includes a variety of other tests
  • Directlabs: A dated looking website but offering the option of a la carte tests. Total cost for these three tests: $205
  • Health Tests Direct: Another dated looking website, again with the option of a la carte tests. Total cost: $115.50
I decided to go with WellnessFX since for marginally more money I could get a variety of other tests too.

[4] The opening chapters of Good Calories, Bad Calories contain a detailed explanation of the history involved.

Comments

a plant based diet is known to reverse heart disease http://www.heartattackproof.com/
Lp(a) is hard to manage as well. I had to point this indicator to my doc back in India and it turned out to be the culprit for me. South Asian population seems to have higher levels of Lp(a) Niaspan/Niacin is the most recommended.
You could try to switch to a Paleo diet for a couple of months and see how these numbers change. Just try to balance the macros of every meal at 40-30-30 (carb-protein-fat) to have a healthy Paleo.
Although we'd all like to live forever, it's a sad fact that most of will die at some point (the exceptions are the immortals, are you one?). Anything past 75-80 is overtime. Given the choice, cardiac death might be the best choice, as compares to for example cancer. Certainly take care of yourself, but lead with the heart.
Cholesterol isn't the problem-- eating too many refined carbs and Atherosclerosis is. Don't want to have heart problems-- animal fat isn't the problem. Simple solution--STOP EATING SO MUCH SUGAR/CARBS.
I have to agree with Lorenzo and William, try a low carb diet, eliminate sugar and refined carbs for a couple months, then check your triglycerides and ApoB. I think you'll be pleasantly surprised. It sounds like you are already aware of this approach since you cited the bad science of Ancel Keys. I encourage you to run a brief clinical experiment.
I have to agree with Lorenzo and William, try a low carb diet, eliminate sugar and refined carbs for a couple months, then check your triglycerides and ApoB. I think you'll be pleasantly surprised. It sounds like you are already aware of this approach since you cited the bad science of Ancel Keys. I encourage you to run a brief clinical experiment.
Harj, Much respect for doing your own research. We as consumers each benefit from our own involvement in our well being. Unfortunately you have been dealt the genetic cards of being at significant risk for cardiovascular disease which I see as very prevalent in Punjabi's in the US and even my own relatives in India. I agree with a low carb / low calorie intake diet. Try to eliminate processed carbohydrates. This in turn will decrease glycogen storage in your liver which slows conversion to fat. The increase in central or peritoneal fat as well as whole body fat tends to increase the secretion of estrogen and a variety of inflammatory chemicals. I suggest you read the book by Dr. Caldwell Esselstyn - "prevent and reverse heart disease". He builds on Paleo, Low-carb, South Beach and Atkins in a thoughful whole body way. I am a physician, Punjabi and have lost grandparents, uncles and aunts to heart disease. I practice what I preach. I dropped my weight from 215 to 170, dropped my body fat percentage significantly. My vision and memory improved, my exercise tolerance improved and my "numbers" improved. I did this at age 40 looking at my father who had coronary artery disease and had a minor stroke and then myself. It took 3 years but I am a lot healthier and feel much better.
Good post, Harj. I am in the same boat. It is frustrating that in this 21st century, we still don't know if we should even eat eggs. Some prominent MDs on the paleo diet have measured their LDL-P (currently, one of the leading indicators), and found it to be off the charts (bad). Particle size and count are currently the best indicators. Exercise, low carbs, fish (or krill, or flaxseed) oil. Perhaps dark, dark chocolate, wine (resveratrol). Have been charting my numbers since 1990. Statins give me pretty numbers, but serious muscle aches and memory loss. They are poison to me. Keep us posted! Thanks.
Stop worrying about your cholesterol or fat intake - this is not where the problem is. Regulate your sugar (primarily fructose) intake instead, because the problem is high insulin secretion.
I understand that the factors that you cite are correlated with an increased risk for heart disease. But is there any evidence that these factors are directly or indirectly causing heart disease? In other words, has it ever been shown that reducing these factors will reduce your risk for heart disease? I'd recommend you consult the Cochrane database (http://www.thecochranelibrary.com/view/0/index....) before starting any diet or treatment. Cochrane reviews are unaffected by financial interests or publication pressure.
In terms of other things that can indicate heart disease/getting a more complete picture of your health 1) CT scan of heart to obtain calcium score. Of course, this isn't going to be reimbursable if it's simply preventative, but calcium buildups do play a large role in heart disease and can be discussed with your doctor. 2) Blood glucose/diabetes risk. Diabetes and heart disease are correlated to an alarming extent: can your diabetes indicators also indicate heart disease? I think they're worth monitoring. 3) Prehypertension: check your blood pressure. Preventing/lowering high BP is pretty much done through the DASH diet. 4) Did you get your triglyceride levels measured during your lipid panel? You mentioned cholesterol, but triglycerides are very different. They're definitely indicators of heart disease risk. If you're really really interested in getting an optimized workup and have the cash to spend, get an executive health package at the Mayo Clinic. Leading provider of the highest quality care in the US. The most important part of all of this is interpreting all of these things in conjunction with one another. Can you lay your lipid panel, activity level, waist circumference, diet, fam history, and BP data together and view them as a comprehensive picture? That's when you really begin to understand your risks for disease. WellnessFX makes consumer lab testing available, which is vital, but what we really need is not more data points...but more knowledge from them.
If you want to deal with someone that is concerned about your longterm health, buy a life insurance policy. They perform all these tests when they are evaluating you for coverage. The interests of a life insurance company are much more aligned with yours than you doctor might be. If everybody stayed healthy and never had to see him, he'd be in trouble. I think the original intent of HMO was to reduce your need for services by keeping you healthy, but it instead devolved into avoidance of delivering services. I suppose if compensation were dependent on good test results it might have turned out differently.
Another good marker to follow is waist to hip ratio (target
You should also get your blood tested for liver function, non-alcoholic fatty liver disease (NAFLD) is sneaky you can have it and be thin and a non-drinker. It doubles your risk (if I recall my my Dr. said) of heart attack and stroke.
Harj, I have gone down the exact same path - im Indian, parents have had heart disease and a high stress lifestyle (chronic entrepreneur) - perfect recipe for an early heart attack. I am also a bit of a hypochondriac and im based out of India so medical tests are pretty cheap and i have done my fair bit. This is what I have come up with: 1. Medical science knows very little about the functioning of the human body. You can't pick up a number and optimize on that - because that will screw something else. Case in point - I went for Paleo for about a month and it screwed up my testosterone levels - i came back to a normal diet and it screwed up my blood sugar levels. 2. The regular indian vegetarian diet is the 'best' diet for heart disease (apart from white rice) and broadly keeping you away as much as possible from most illnesses. Yoga is the best form of exercise - especially for the heart as it is known to reduce cortisol levels in your blood. Add to it occasional cardio and a very small amount of strength training and you can't do much better. 3. The mind affects the body more than we can know(check out the book 'the mind-body perspective'). The mind works best when it is 'purposed' and makes the body align as well. Fundamentally what all of this has meant to me is that focus on your work, eat healthy, exercise a bit and deal with that heart attack when you come to it.
Hi Harj, Looks like we southasians have a predisposition to 2 of the worst. CAD and diabetes. Have you consulted the South Asian Heart Center ? (http://www.southasianheartcenter.org/). They advocate an advanced lipid panel test (similar to BerkeleyHeartLab) and you get a follow up visit with a specialist. Was very insightful when I took the test couple of years ago.
This post brings Ray Kurzweil to mind.
I think your point about having specific metrics to improve is underappreciated by doctors. When you're doing frequent tests on your own, it's easy to continually try small experiments to find out what works for *you*, with minimal overhead. In my case, I found that improving my thyroid function dramatically improved most of my problematic bloodwork. I might never have found that out in a standard doctor-patient setup, with the doctor trying to address problems in the most direct and traditionally-accepted way. On a related note, I know enough people doing frequent blood testing that I've started collecting data on test providers and their prices (http://www.testproviders.com). I welcome feedback, the site's still pretty experimental.
Here's a crazy idea: Just take your doctor's advice! While it may gain you some miniscule advantage to spend all of this time pre-optimizing, just following the advice of people (medical professionals) who spend their entire working lives trying to help people live healthier is probably a much more efficient use of your time. I mean, there may be medical doctor or two who has written an in between parser, but I'm guessing it's not gained wide acclaim on github.
Hi Harj, I've thought about these issues too. I spend my life with data, but I have learned that when it comes to my health I am much happier not knowing. Ignorance really is bliss, at least for me. The uncertainties in current medical knowledge, especially for anything long-term like heart disease, are still too large to make a lot of decisions in any reasonable way. Dig into the medical literature on practically any question, and very soon it's conflicting studies and "maybe this, maybe that". It's kind of alarming how even very simple questions can't be answered, but it does seem like in most cases there really isn't any high-confidence recommendation beyond "eat sensibly and get exercise". Also, I found that spending time thinking about these issues was probably actually bad for me. It might sound flippant when a doctor says "you'll only stress yourself", but I think this is basically quite wise. I have a theory that this is particularly true for entrepreneur/investor types. We tend to have long time horizons (aka low discounting factors), so probabilities of events far in the future have a bigger impact on present happiness than for most people. A worry about future health can really rob the present of happiness. So although it seems irrational, I found the best policy was essentially to do nothing. The state of medicine is still frustratingly primitive. Far too much craft and far too little engineering. And far far too little data. I hope we'll change this in the next few decades. But for now, I think the usual platitudes are actually good advice. Mark
Wow, the comment regarding the colesterol: Hell, i'd checked that the last time two years ago! Sure, its not something that most medics do in "prophylaxing", maybe you should ask for measuring the value every time you visit him...
The simplicity of "switch to a whole foods, plant-based diet and you simply won't die from heart disease" has eased my similar anxieties. http://www.heartattackproof.com/ I urge you to look at Dr Esselstyn's book. See also the related documentary, http://www.forksoverknives.com/.
I agree with what some people have said about sugar and refined carbs. I'm not sure how this equates to a low-carb diet being remotely reasonable though. There are about a million intermediate levels between low-carb and SAD sugar junky, some of which approach sanity. I went through a stage of "researching" about health. What I found is that the Internet is full of ludicrous junk science and shills. This is one case where a large grain of salt, taken with every claim, "fact" and study reference you see about diet X improving your health, may actually lower your blood pressure.
Very interesting read. I too am very interested in getting more "data" out of the body and your post put many "puzzle pieces" together for me. Thank you. You might be interested in reading my idea at Brightloops regarding getting these data through blood analysis (http://brightloops.org/idea/view/143/). I recently discussed the idea with a doctor at a blood bank who addressed that while the innovation height is quite high and it could be applied in many scenarios, the actual production would demand some serious disruptions in the way we extract and analyze blood samples today. But hey, challenges are to be overcome. ;) Again, a very good read, I'll definitely recommend it to others.
Indian diets (lots of grains and pulses and sweets) are really bad for you. Good Calories (and the rest of Taubes' writing) is an excellent book. Dr Eades has a great blog as well. Besides HsCRP you should also get your HBA1c checked (3 month average blood sugar result). There are simpler tests you can perform[1] to find out your actual risk status: they're called the carotid ultrasound and the calcium risk score. It's basically an indicator of how supple (non-sclerotic) your arteries are. [1] http://www.esmil.com/heart-vascular-scans/ about 160$
It's amazing how varied the opinions are on diet. I've been through this for a decade, had bad indicators of heart disease, finally got it under control with diet. Tried Paleo for 3 years. My cholesterol rocketed, as it does for most people on a meat-heavy, fiber-light diet. Then read The China Study. I think that's the second-most authoritative and defensible book. It's been higher than #200 on Amazon for like 6 years, not via promotion, but because its research is so respected. Then Caldwell Esselstyn's book, Preventing and Reversing Heart Disease. He has huge cred. Clinton's cardiologist after the quadruple bypasses and South Beach Diet were not working. Then Eat to Live, My Beef with Meat, and The Engine 2 Diet. Me and probably 100 of my friends had our lives changed by those books.
"High dietary glycemic load is associated with a higher risk of CHD and stroke, and there is a linear dose- response relationship between glycemic load and CHD risk." Fan J, Song Y, Wang Y, Hui R, Zhang W. Dietary Glycemic Index, Glycemic Load, and Risk of Coronary Heart Disease, Stroke, and Stroke Mortality: A Systematic Review with Meta-Analysis. Ning Y, ed. PLoS ONE. 2012;7(12):e52182. Available at: http://dx.plos.org/10.1371/journal.pone.0052182. Accessed December 4, 2013. "Several decades of epidemiological and clinical research have identified physical inactivity, excessive calorie consumption, and excess weight as common risk factors for both type 2 diabetes mellitus and coronary heart disease... Recent data suggest that a high intake of rapidly absorbed carbohydrates, which is characterized by a high glycemic load (a measure of carbohydrate quality and quantity), may increase the risk of coronary heart disease by aggravating glucose intolerance and dyslipidemia." Liu S, Manson JE. Dietary carbohydrates, physical inactivity, obesity, and the “metabolic syndrome” as predictors of coronary heart disease. Curr Opin Lipidol. 2001;12(4):395–404. "This meta-analysis suggests that a low-GI diet may help lower total and LDL cholesterol." Fleming P, Godwin M. Low-glycaemic index diets in the management of blood lipids: a systematic review and meta-analysis. Fam Pract. 2013;30(5):485–491. "Postprandial events have been recognized as potential risk factors for cardiovascular disease (CVD). Raised postprandial glucose and insulin levels as markers of increased insulin resistance are two such risk factors, and in turn may relate to other risk factors, especially those associated with metabolic syndrome, including elevated blood pressure [1–5]. Studies have tended to show that low-GI diets may reduce the risk of heart disease by reducing the total (TC) and LDL cholesterol concentrations [34, 35, 36] and, at the same time, they may also raise HDL-C [37], although not all studies show this response. Furthermore, some low-GI diets, especially those containing beans, may reduce systolic blood pressure  38]. Low-GI diets have been associated with lower high- sensitivity-CRP [39] and PAI-1 concentrations as markers of inflammation and thrombosis risk [40], respectively."  Mirrahimi A, Chiavaroli L, Srichaikul K, et al. The role of glycemic index and glycemic load in cardiovascular disease and its risk factors: a review of the recent literature. Curr Atheroscler Rep. 2014;16(1):381. "In summary, our findings in this large and multinational cohort further confirm and substantially extend our knowledge regarding an overall benefit of a low-fat, low-glycemic- index food pattern. High-protein intake did not elicit relevant unfavorable effects on cardiovascular risk markers. However, a low-glycemic-index diet supported by a low-protein diet appears to further reduce hsCRP, and as such low-grade inflammation, even after a substantial reduction due to weight loss. These data therefore provide an important argument in favor of low-glycemic-index diets in obese healthy individuals. The present systematic review provides evidence for beneficial effects of long-term interventions administering a low glycemic index/load diet with respect to fasting insulin and pro-inflammatory markers such as C-reactive protein which might prove to be helpful in the primary prevention of obesity-associated diseases." Schwingshackl L, Hoffmann G. Long-term effects of low glycemic index/load vs. high glycemic index/load diets on parameters of obesity and obesity-associated risks: a systematic review and meta-analysis. Nutr Metab Cardiovasc Dis. 2013;23(8):699–706.
I feel the simplest, most reliable guide is to eat foods with lots of fiber. They are naturally low glycemic index because fiber slows digestion. They fill you up. Fiber is the #1 thing associated with cancer, heart disease, and diabetes. It naturally moves you away from processed and animal foods, because they have no fiber. http://nutritionfacts.org/video/fiber-vs-breast...
I have very little natural interest in diet, but since I have lived with Type 1 diabetes for the past decade I know an awful lot about sugars. I have to test my blood sugar a dozen times every single day. I am also a geek so I've read up. I strongly suspect that your diet was useless due to carbs. I quickly learned from my experience as a diabetic that refined grains are like poison. A single piece of toast raises my blood sugar about the same as a candy bar. A bowl of cereal raises my blood sugar by around 10x normal levels. Yes, 10x! Additionally, your avoidance of meat is misguided. Eating meat != gaining fat. Eating carbs and sugars == gaining fat. Check out Sweden as an example of a country which is reacting to real research, instead of corruption due to the ag industry. Also, I find myself refusing to be impressed at all with the fixation on LDL. We're still in the dark ages. Measuring LDL is a great way for the medical and pharma industry to get paid. Considering they pushed low-fat for so long, I am pretty cynical about the fixation on cholesteral, which they keep adding caviets too. Starches and sugars, on the other hand... you won't find much research that shows they are healthy. If I were you, I'd do the diet over, but cut out any and all wheat, and any and all sugar.

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