In our increasingly obese and aging population, the prevalence of a variety of cardiovascular disease risk factors (CVDRF) has risen like a hot stock’s share value. The good news is that there are a number of excellent drugs available, with acceptable safety, modest costs, and minimal side effects. The bad news, of course, is that the majority of patients won’t take these medications as prescribed: any number of publications document far less than acceptable levels of adherence.
Several new developments and some not so new studies have demonstrated that there are a few delicious, healthy, and inexpensive nutritional choices, as well as some sensible lifestyle choices that are associated with a reduction in the risks for cardiovascular disease.
Few of us can resist dark chocolate—a delicacy once reserved for the royal taste buds . . . now an everyday reward and a quick pick-me-up during a tough workweek.
A recent meta-analysis of 13 publications including those available on Medline, Cochrane, and other registries noted a significant blood pressure (BP)-reducing effect of cocoa-chocolate compared with a control.1 Systolic BP mean change was −3.2 mm Hg, (P = .003), diastolic BP −2.0 mm Hg (P = .003). White chocolate without cocoa was used as a control. The treatment interventions ran for 2 to 18 weeks. Daily flavanol dosages ranged from 30 mg to 1000 mg in the active-treatment groups.
The authors concluded that dark chocolate was superior to placebo in reducing systolic hypertension. However, it did not lower BP in normotensive individuals below 140/80 mm Hg. Other investigators combined dark chocolate with added sterol esters and examined the effects on CVDRF.2 The study included 49 adults who followed an AHA-style diet and were then randomized to either 2 cocoa flavanol-containing dark chocolate bars a day for 4 weeks or a placebo. Consumption of the chocolate reduced systolic BP at 8 weeks by 5.8 mm Hg (P < .05).
Chocolate has other benefits, including evidence for cognitive improvement (it causes vasodilatation in peripheral vasculature and the brain), and BP reduction. A recent article in The New England Journal of Medicine suggests that there is a statistically significant relationship between per capita ingestion of chocolate and the number of Nobel prizes won in that country.3 Of course, this does not prove causation, but there may be a benefit from the cognitive improvement associated with chocolate.
Once considered to be poison by some Europeans, tomatoes and their salubrious effects have recently become an important topic of study. High plasma concentrations of lycopene and beta-carotene found in tomatoes have been associated with reduced prevalence of cardiovascular disease.
The effects of tomatoes and beta-carotene on asymptomatic carotid atherosclerosis has been studied in Italy.4 One hundred sixty-five subjects with and without ultrasonographic evidence of asymptomatic carotid atherosclerosis were followed; 80 had evidence of carotid atherosclerosis (carotid intima-media thickness greater than 0.80 mm); 85 did not.
Participants with carotid atherosclerosis demonstrated significantly greater BMI, significantly higher total and LDL cholesterol levels, and lower plasma concentrations of lycopene and beta-carotene. Patients with the higher levels of carotid atherosclerosis had higher levels of LDL cholesterol and lowered levels of HDL cholesterol. Overall, there appears to be beneficial effect of antioxidants and lycopene on cardiovascular disease events.
One tasty and readily available treat has been produced for hundreds of years as edible oil. Said to be sponsored by Charlemagne who sought to reduce the cost of imported Italian olive oil, grapeseed oil has been the subject of recent study.
In an abstract presented in 1990 at the American Association of Cardiovascular and Pulmonary Rehabilitation, 33 subjects on a low-fat diet ingested 30 g of grapeseed oil in their daily diet for 4 weeks. Their HDL levels rose from a baseline level of 32.8 mg% to 37.6 mg%—an increase of 14.6% (P < .01).
In a larger study published in 1993, a group of 56 men and women and ingested 45 mL of grapeseed oil in their daily diet. Their HDL levels rose from a baseline value of 31.6 mg% to 35.6 mg% (P < .001). There were no adverse effects and the material was well tolerated.
Grapeseed oil has been available for hundreds of years and no untoward effects have become apparent.
This general statement usually holds true: for every 1% reduction in LDL cholesterol, there is a 1% reduction in cardiovascular adverse events. For every 1% rise in HDL levels, a 3% reduction in adverse events is usually cited.
Other natural approaches to risk reduction
Dark chocolate, tomatoes, and grapeseed oil are not the only natural approaches to cardiovascular risk reduction. Patients with hypertension have been treated with an herb Orthosiphon stamineus, with a significant reduction in mean systolic and diastolic blood pressure. The studies are small, and larger, longer-duration studies will be required to identify the proper role of this new therapeutic modality.
Data from the Nurses’ Health Study of 71,000 women identified 5 factors that could reduce the risk of stroke, now the third leading cause of death and permanent disability in this country:
• Not smoking
• Drinking a glass of wine a day
• Maintaining a BMI below 25 in middle-age
• Eating a diet rich in fruits, vegetables, whole grains, nuts, and lean meats, and taking a daily multivitamin.
If all these lifestyle measures were followed, stroke risk fell 80%.
A more recent publication examined ideal cardiovascular health in a multiethnic population in the South Bronx. Almost 3000 subjects with a mean age of 69 ± 10 years were prospectively followed for a mean of 11 years. There was a strong gradient relationship between the number of ideal health metrics and CVD endpoints, including stroke.
The 7 CVD factors included:
• Not smoking
• BMI below 25
• Physical activity 150 min/d
• Diet rich in whole grains, fish
• Total cholesterol level < 200 mg/dL
• Blood pressure < 120/80 mm Hg
• Fasting blood glucose level < 100 mg/dL
Individuals with all the ideal metrics had about half the number of strokes as those with the lowest levels.
While reducing the risk of strokes and other adverse events is of primary importance, even individuals who avoid such serious endpoint events are not free of significant risk.
A low HDL has been determined to be a significant risk factor for defect and decline in memory in midlife. The Whitehall II study followed almost 3700 British civil servants aged 35 to 55 years and demonstrated that a low HDL level was associated with poor memory over a 5-year period.6 Even those who did not have a cardiovascular event still paid a price.
If interventions as simple as ingesting grapeseed oil and increasing exercise can reduce the risk of a life-altering cardiovascular event, this is a win-win approach to prevention.
1. Zomer E, Owen A, Magliano D, et al. The effectiveness and cost effectiveness of dark chocolate consumption as prevention therapy in people at high risk of cardiovascular disease: best case scenario analysis using a Markov model. BMJ. 2012;344:e3657.
2. Allen RR, Carson L, Kwik-Uribe C, et al. Daily consumption of a dark chocolate containing flavanols and added sterol esters affects cardiovascular risk factors in a normotensive population with elevated cholesterol. J Nutr. 2008;138:725-731.
3. Messesrli FH. Chocolate consumption, cognitive function, and Nobel laureates. N Engl J Med. 2012;367:1562-1564. http://www.nejm.org/doi/full/10.1056/NEJMon1211064
4. Riccioni G, D’Orazio N, Speranza L, et al. Carotenoids and asymptomatic carotid atherosclerosis. J Biol Regul Homeost Agents. 2010;24:447-452.
5. Nash DT, Nash SD. Grapeseed oil, a natural agent which raises serum HDL levels. J Am Coll Cardiol. 1993;21:318-320.
6. Brunner E, Stallone D, Juneja M, et al. Dietary assessment in Whitehall II: comparison of 7 d diet diary and food frequency questionnaire and validity against biomarkers. Br J Nutrition. 2001;86:405-414. http://discovery.ucl.ac.uk/26129/1/download14.pdf