How to avoid a heart attack

How big of a problem is ischemic heart disease – which often leads to heart attack – among Poles?

It is a sneaky and dynamic disease. We often diagnose it only when a coronary episode, commonly known as the heart attack, has already occurred. We do not have detailed statistics, but the condition is estimated to affect about 1.6 million people. We also have data on the risk factors of ischemic heart disease. One of them is dyslipidemia, i.e. abnormal cholesterol levels – present in over 60% of Poles, or about 18 million people! Arterial hypertension affects about 11 million people in Poland. And another issue: alcohol consumption. An average Pole drinks a bucket (or nearly 11 liters) of spirit a year. Smoking – about 30% of Poles are addicted to cigarettes. The lack or insufficient amount of physical activity affects 70% of Polish population, who leads a sedentary lifestyle and does not exercise. And excessive body weight – more than half of us are overweight or obese. Such a lifestyle leads to diseases related to atherosclerosis. These in turn account for 180,000 deaths per year in Poland. This is a very serious problem, and it will continue to get worse, because our lifestyles do not improve, and our society is ageing. 

The risk factors you have mentioned are related to lifestyle. Does this mean that genes are unimportant?

We have data on this topic from various studies, e.g. the EPIC (European Prospective Investigation into Cancer and Nutrition) study. They show that we may reduce the risk of myocardial infarction by as much as 81% if we make our lifestyles healthier. What does “healthier” mean? Avoiding alcohol and smoking, having a balanced diet and exercising regularly – walking briskly for about half an hour every day is best. And of course, do not allow obesity to develop. 
These factors account for 81% of the risk, which leaves 19% for genetics. Or even less, as those 19% also cover such risk factors as pollution or loneliness.

Is ischemic heart disease rightly called a civilization disease?

I would say it is a condition that depends on your lifestyle. Referring to civilization is not exactly accurate. For example: I live in Warsaw, which is a big city. So you could say that because this is a civilization disease, I am at a higher risk of developing hypertension. And yet, the situation could be exactly the opposite. Living in Warsaw may actually reduce the risk of hypertension for me, because I have access to quality food, walking grounds, bike paths, education, I can climb up the social and economic status ladder, and so on… Living in a big city may actually help prevent the disorder. Of course, those who live in Warsaw may also eat fast food only, and spend their evenings on the couch, drinking alcohol – but this is your choice rather than the impact of the city. 

Since so much depends on our choices, let’s look at the details: what should we eat and what should we avoid to reduce the risk of atherosclerosis?

With the right diet, not only can you reduce the risk of atherosclerosis, you can stop or even revert its progression! This was proved by Dean Ornish of University of California, San Francisco. In 1998, he published a study in one of the high-impact journals in cardiology. In his study, he proved that patients who followed a nutritional regime based on balanced plant-based products, the volume of atheroma decreased, which in turn improved blood flow through vessels and removed the complaints related to atherosclerosis. So your diet does not only work as prevention, it may also be a form of treatment. 
But going back to your question about the details. Dr Ornish proposed a lacto-ovo vegetarian model. The only animal products allowed in it are skim milk and yoghurt, and egg whites, with no restrictions on plant products such as vegetables, fruits, legumes, nuts, or whole grains. But it must be noted that this kind of diet may be a big challenge for most people. If a plant-based diet is not well-balanced, it leads to deficiencies, mostly of calcium. So it should not be recommended to everyone.
Another recommended model is the Mediterranean diet. It is often recommended by cardiologists. Unfortunately, in my practice I often see that patients define such a diet based on the menu at Italian restaurants, which means spaghetti alla carbonara and a bottle of red wine. Which is completely wrong.
One diet that is easier for patients to understand is the DASH diet. Its crucial guideline is that you include 400 g of vegetables in your meals every day. They will work like a hypotensive drug, lowering your blood pressure if it is too high. But that is not everything, as you may reduce your blood pressure as if you were taking two hypotensive drugs. In order to achieve this, you need to reduce the amount of sodium in your diet. This is more challenging, as all highly processed foods contain a lot of sodium. So it is not enough to quit adding salt, you also need to eat unprocessed foods. If you manage to implement these two recommendations, you get two benefits. On the one hand, you are adding the healthy foods, i.e. vegetables, and on the other, you are getting rid of the “junk”, i.e. all fatty and salty foods.  

You have talked about the diet, but what other aspects of lifestyle are significant in preventing ischemic heart disease?

The short answer is “all of them”. On a more serious note, though, the most significant elements are those that are missing in your lifestyle. For instance, if you do not get enough sleep but otherwise eat a healthy diet and stay active, then the most important thing will be to take care of sleep hygiene.

I thought you would point to exercise straight away.

Exercise is very important, but you need space for it. Life is hectic for many people. Our workdays are very intensive, so in the evening we try to relax fast, e.g. by watching movies on streaming platforms, drinking alcohol or having fatty dishes for a late dinner. This takes up the space needed for exercise and badly affects sleep. And sleep is what tips the balance when it comes to our shape and willpower, and thus our daily choices. It is also extremely important when you want to change something in our lifestyle for the better. When you have not slept enough, you are unlikely to go to the gym. When you are tired, you look for instant gratification. And you find it in fatty, sweet foods, which give you a boost of happiness hormones. To my patients who try to lose weight, I often say: “Wait with the gym, get a good night’s sleep first.” When you have slept well, you are more likely to stick with your diet; the time for exercise will come, when the patient has gotten used to eating healthy.

You have mentioned weight loss. Why does obesity affect the heart so badly? 

In short: atherosclerosis is an inflammatory disease of the arteries, and fatty tissue generates inflammation. Increased cytokine levels and hormonal imbalances lead to the release of fatty acids. These, in turn, “wrapped up” in proteins to form lipoproteins, form plaque in vessels if not metabolized. This in turn triggers our immune system, as the lipoprotein deposits need to be cleaned up – and this exacerbates the inflammation in the arteries. They become stiffer and pose more resistance. Apart from that, additional kilograms are an additional burden for the heart. And this creates a vicious cycle that may lead to the ischemic disease and ultimately to a cardiovascular incident or stroke.

Speaking of obesity, it is worth mentioning some interesting studies. They show that obesity may be infectious. Their results indicate that if you are surrounded by obese people, the risk of developing obesity rises by 57%. This is easy to explain. When your friends like fast food, then you are more likely to go out with them to get a hamburger rather than salad. This turns into a routine over time, and you take over their bad habits.

But human relationships are very important, as loneliness contributes to the development of disease.

Of course, they are fundamental. Research has shown that the lack of relationships with other people carries the same risk of disease as smoking 15 cigarettes a day. When you have good relations with others, on the other hand, and you know that there is someone who cares for you, then your mood will be better, you will be more open and take better care of your health. Physical contact is also important in human relationships, e.g. hugging. This directly influences your vegetative system and releases tension. 

Alcohol and smoking rank high as risk factors. Should we quit them altogether?

When we smoke and drink alcohol, we poison our bodies. This leads to inflammation at the level of individual cells, which is the royal road to a heart attack and some other conditions. Many patients ask me how much alcohol is safe. That amount is 4 g of pure ethanol, i.e. a teaspoonful of vodka, or 30 ml of wine, or 150 ml of beer – a day. Yet, as I have said, Poles drink much more, and the problem is getting worse. But alcohol is a very challenging substance. If you get addicted to it, you may need specialist treatment. If you already “use” alcohol, it is very important to be highly responsible about it, and check your relationship with alcohol from time to time, e.g. using the AUDIT test. It is a multiple-choice test that verifies whether your drinking is already risky or not. 
It is easier with nicotine addition. You can often deal with it yourself, or with the help of a pharmacist, i.e. by using over-the-counter remedies. But I would like to caution you against alternative tobacco products. They are advertised as better, more interesting, less harmful. Yet there is research that shows that when it comes to the risk of cardiovascular disease, it is high both for people who smoke traditional cigarettes, and for users of alternative tobacco products.

We recommend lifestyle changes, but it is very difficult to achieve, as we need to change habits that have been reinforced for years. How do you do that? 

Step by step. A good place to start is to do a health check once a year. No one lives an ideal life. Take a look at yourself. Note down your body weight, BMI, and waist measurement in a given year. Then look at the risk factors: do I drink alcohol, and if so – how much per week? Do I smoke, and if so, how many cigarettes per day? How do I see my relationships with others? Do I wake up feeling rested? Do I feel stressed? How much vegetables do I eat every day? Do I exercise? When you have identified the factors that are worth changing, start with the one that appears the easiest to change. Let’s say you want to improve your diet. Add 400 g of vegetables every day – those that you like. This does not take a lot of self-denial. Or, for example, if you drink sweet drinks, replace them with unsweetened ones, and in the next step – with water. Reinforce the change for 6 weeks, tick it off, and then move on to deal with the next one. Success boosts motivation. Over time, tackle the changes that appear slightly more and then even more difficult. You have more chance of success when you work step by step.
 

Interview by: Iwona Kołakowska
Photo: Michał Teperek
Communication and Promotion Office WUM