Avoiding a heart attack: diet, drugs ... or both?

Why bother eating a healthy diet when you can take a drug that slashes your cholesterol level? Millions of American are pondering that question. Here's how Frank Sacks answers it.

Sacks is an associate professor of nutrition at the Harvard School of Public Health and a practicing physician at Brigham and Women's Hospital in Boston. He just finished a major clinical trial on the drug Pravachol (which was funded by its manufacturer, Bristol-Myers Squibb) and a diet study on hypertension, funded by the National Heart, Jung and Blood Institute. Sacks spoke to Nutrition Action's Bonnie Liebman by phone.

Q: Do people ignore advice about diet because we have powerful drugs to lower cholesterol? A: Yes. Some physicians have asked me why they should bother with diet when we have such effective drugs. The answer is: These drugs do not wipe out coronary disease.

The drugs reduce coronary rates by 25 to 40 percent, reduce strokes by 30 percent, and improve survival. However, that's not 100. percent. A lot of people who take the drugs still die of heart attacks. And we have controlled clinical trials that show that diet prevents coronary heart disease.

Q: Do people think: "I'll have a piece of cheesecake, then I'll take a pill and be fine"? A: Yes, and it's wrong. You're going to benefit from the drug, but you'll get even more benefit if you make the dietary changes, too.

In one small study of people using diet and drugs to lower cholesterol, 80 percent of the patients on a low-fat diet -- but only 50 percent of those on a high-saturated-fat diet -- got their LDL ("bad") cholesterol levels down to the recommended range.(1)

Q: What if your LDL is low enough on drugs and a high-fat diet? A: Unlike drugs, diet lowers the risk of heart disease in several ways. It works by lowering LDL cholesterol, but it also reduces body weight if you're overweight.

And it works by supplying nutrients that have other benefits. For example, the antioxidant vitamins -- C, E, and several carotenoids -- may prevent coronary disease by inhibiting the oxidation of LDL cholesterol. And the B-vitamin folic acid and vitamin B-C may prevent heart disease by reducing homocysteine levels.

Q: What kind of diet are you talking about? A: Several diets have reversed coronary disease or lowered the risk of heart attacks. They all cut saturated fat and cholesterol. [See "The Sat Fat Switch," pp. 6 & 7.] Some also increased the amount of fruits and vegetables and unsaturated fats like olive oil.

WHO NEEDS DRUGS?

Q: Do doctors give diet a fair test before putting people on drug? A: No. A lot is left up to the patient, and many patients need supervised programs that are often not paid for by insurance companies or HMOS. So patients are left to their own devices, and most have trouble making the dietary changes they intend to make.

I think that the reflex is to treat with a drug, when it should be diet and exercise, and then, if necessary, drug therapy.

Q: So no one should start off with drugs? A: If a person has had a heart attack, I usually recommend drug therapy right off the bat. It's partly logistical, because a treatment plan is put together soon after a heart attack or bypass, and that's when the patient is open to making changes. And most heart attack patients are going to need drugs.

Q: When don't they? A: Our Cholesterol and Recurrent Events (CARE) trial studied over 4,000 people who had already had a heart attack. Those who entered the study math LDL cholesterol over 125 received benefit from the cholesterol-lowering drug Pravachol. Patients with LDL under 125 did not benefit.(2) But the average LDL in our study was 140, which is also the average in the population. Only 20 percent of the population has an LDL of 124 or lower, so most heart attack patients will need drugs. Yet national surveys show that they're not being prescribed to patients who need them.

Q: Why not? A: With all of the educational efforts since the National Cholesterol Education Program started ten years ago, it's inexplicable. For a while, there was a concern that lowering cholesterol could cause cancer or depression or violent deaths, but that bugaboo has been put to rest.

I feel frustrated that physicians aren't prescribing cholesterol-lowering drugs like Pravachol (pravastatin) and Zocor (simvastatin) to more patients. These are members of a class of drugs called "statins." They block the liver's synthesis of cholesterol.

Aspirin is used more frequently, yet aspirin can cause cerebral hemorrhage and serious gastrointestinal bleeding.

Q: But they act differently? A: Yes. Aspirin prevents the blood clots that can precede heart attacks. Statins prevent heart attacks by preventing cholesterol buildup in plaque.

Q: Should people take aspirin? A: In patients who have had a heart attack or who have atherosclerosis, we know that aspirin is beneficial. About 85 percent of them take it, which is good.

In a large study of men who hadn't had a heart attack -- studies on women are under way -- those who took aspirin were less likely to die of heart attacks, but were more likely to die of cerebral hemorrhage.

So that's a little worrisome for the patient who doesn't have heart disease in the first place. It's important to consult math your physician to weigh the benefits and risks of aspirin.

Q: How much aspirin did they take? A: In that study, the men took 325 mg of aspirin every other day. It's possible that if they had taken 60 or 80 mg a day -- or even 80 mg a week -- that might have given them all the benefit and none of the risks. But that hasn't been studied yet.

Q: What about side effects of the statin drugs? A: Very rarely the statins can cause myositis, an inflammation of the muscle tissue. But when it occurs, patients really complain about it, because they're in pain and they're weak. If they stop the drug, it gets better in a couple of days.

If it's ignored, myositis can progress into full-blown rhabdomyolosis, which is a breakdown of the muscle cells to the extent that myoglobin in the blood clogs up the kidneys and causes kidney failure.

Q: Aren't some researchers concerned that the statins cause liver cancer or lymphoma in animals? A: There's a lot of dispute about whether the doses used in the animal studies were realistic. Overall, the trials have not found that the cholesterol-lowering drugs cause cancer, though the trials have lasted only about five years, and, theoretically, you'd need a longer time to definitively investigate cancers. But remember: These drugs are only recommended for people at high risk of heart disease.

RAISING HDL 

Q: Will diet help if you have low HDL ("good") cholesterol? A: If someone is overweight, losing weight can help raise HDL. But other than that, there's not much you can do with diet. A Mediterranean diet that's low in saturated fat, but high in monounsaturated fats like olive oil, will raise HDL slightly.

Alcoholic beverages raise HDL, but more than one or two drinks a day could cause other problems that begin to outweigh the benefits.

Q: Do the statins raise HDL? A: Only by about five percent. Niacin raises it 15 to 35 percent. But no one has done a trial to see if niacin lowers the risk of heart disease in otherwise healthy people math low HDL. We're guessing that it does, but it's a reasonably good guess.

Regular-release niacin lowered the risk of a second heart attack in the one large study that used it on men who had already had one.(4) Timed-release niacin hasn't been studied in a large trial.

Q: Does niacin have side effects? A: Yes. The bothersome side effects are itching and flushing -- a sudden sensation of heat and sometimes sweating caused by dilation of the blood vessels. Timed-release niacin can lessen the flushing and itching, but it doesn't prevent the serious side effects.

Any niacin can raise uric acid levels, sometimes enough to cause gout. It can activate an ulcer or gastritis, and it can exacerbate diabetes.

And in rare cases, people taking timed-release niacin have gone into liver failure. But checking liver enzymes can prevent that. If the physician keeps the dose at 1.5 to 2 grams a day, the timed-release niacin can be used safely.

TAKE YOUR PICK

Q: Are some statins better than others? A: All four of the approved statins are effective in lowering LDL. Like Pravachol, Zocor also prevents coronary events and improves survival, and both have been proven safe in long-term monitoring.(5,6) The other two statins, Mevacor (lovastatin) and Lescol (fluvastatin), have not had similar testing in a major long-term trial. For this reason I recommend either Pravachol or Zocor.

Q: what about cost? A: They are expensive, because they're all still covered by patents. The high doses used in most studies -- about 40 mg a day -- cost $800 to $1,000 a year. But I start my patients with 10 or 20 mg of Pravachol or 5 to 10 mg of Zocor, so it's much cheaper -- about $300 a year. Also, the pricing isn't proportional, so if you buy a large dose and break it in half, you can get a real bargain.

Q: Should anyone with a high LDL be on one of the statins? A: No. You can't just look at LDL. You have to look at the likelihood that someone is going to have a heart attack. Do they have high blood pressure or diabetes? Are they overweight or sedentary.

If someone has an LDL of 140 and has never had a heart attack but is overweight, sedentary, and hypertensive, that raises the level of risk dose to that of a patient who's had a heart attack. So I'd probably prescribe a statin.

If the patient has an LDL of 140 and maybe only one other risk factor, I wouldn't go for drugs, but I would go for diet therapy.

Q: For everyone, regardless of their LDL or HDL? A: Yes. What gets lost in the equation is that the diet recommended to prevent coronary heart disease is also recommended by the American Cancer Society and the American Diabetes Association. The same diet can reduce the risk of most of the major causes of death and illness in our population.

So if someone says, "Oh, the patient has such a low risk of getting a heart attack," I say, "Okay, what's their risk of getting heart attack, stroke, diabetes, or cancer?"

Q: What are some pitfalls of following diet advice? A: Many of the foods labeled "low-fat" are high in sugar, and they're doing more harm than good. They're mostly empty calories, they lead to weight-gain, they raise blood sugar levels, and they don't contribute the protective vitamins, minerals, phytochemicals, and unsaturated oils.

When Dean Ornish says that on his diet you could eat more and weigh less, he may be right. But not with a low-fat supermarket diet.

On a very-low-fat diet like Ornish's, people eat whole grains, fruits, and vegetables. It's not just that they're not getting the bad nutrients, they're also getting beneficial nutrients. Calling his diet a low-fat diet is only half the story. It's as much a fruit-vegetable-whole-grain diet.

(1) J. Amer. Med. Assoc. 265:997, 1991.

(2) New Eng. J Med. 335:1001, 1996.

(3) J. Amer. Med. Assoc. 275:55.67, 1996.

(4) J. Amer. Coll. Cardiol.8:1245. 1986.

(5) Lancet 344:1383, 1994.

(6) New Eng. J Med. 333:1301, 1995.

The Sat Fat Switch

It doesn't matter if you've got high ("bad") LDL or low ("good") HDL. It doesn't matter if you're taking cholesterol-lowering drugs, aspirin, vitamin E, or nothing at all. Experts agree that everyone should be eating a diet that's low in saturated fat.

You should also:

* cut back on cholesterol and tram fats (which clog arteries), sodium (which raises blood pressure), and excess calories, especially from fats and sugars (which add pounds), and

* eat more fruits, vegetables beans, and whole grains (to cut your risk of cancer as well as heart disease and stroke).

But one thing at a time.

Here are some simple switches to help you cut saturated fat. Shoot for no more than 20 grams a day. Check the "%DV" on food labels. It will tell you how much of a day's sat fat the food uses up.

Switch From

Meat, Poultry, Seafood

Hamburger, meatloaf T-bone, rib eye, prime rib, etc. Pork chops, ribs Regular hot dog, bologna,

sausage, etc. Poultry with skin Fried chicken or fish Chicken thigh, wing

Daft Products

Whole or 2% fat milk Regular cheese Regular ice cream Regular cream cheese

Sweets & Desserts

Cheesecake, cheese danish,

croissant, cinnamon roll, brownie,

pie, regular or gourmet ice

cream, fudge brownie sundae,

doughnut, pound cake

Snacks

Chocolate bar, sandwich

crackers, ice cream, Bugles, popcorn

popped in coconut oil

Fast Food

Hamburger, cheeseburger, french fries, pizza fried chicken,

regular milk shake, pot pie, beef taco, beef burrito, taco salad

Restaurant Sandwiches

BLT, chicken salad, corned beef, egg salad, grilled cheese, ham,

tuna salad

Dinner Houses Hamburger, cheeseburger, baby back ribs, chicken fingers, steak

fajitas, bacon & cheese grilled chicken sandwich, french fries,

loaded potato, onion rings, buffalo wings, fried mozzarella sticks,

stuffed potato skins

Chinese Restaurant Food

Moo shu pork, sweet b sour pork, kung pao chicken, General Tso's

chicken, orange (Crispy) beef

Italian Restaurant Food

Lasagna, manicotti, eggplant or veal parmigiana, fettuccine Alfredo,

fried calamari

Mexican Restaurant Food

Taco salad, enchilada, beef chimichanga, chile relleno, cheese

quesadilla, beef A cheese nachos, beef burrito

Seafood Restaurant Food

Seafood casserole, any fried seafood, baked stuffed shrimp

Restaurant Breakfast

Belgian waffles, biscuits & gravy, ham &

cheese omelette, sausage,

egg-pancake-sausage-bacon platter

Condiments

Butter or margarine, sour cream

Switch To

Meat, Poultry, Seafood

Ground Turkey breast, veggie burger Round steak, sirloin Pork tenderloin Fat-free or low-fat hot dog, bologna,

sausage, etc. Skinless poultry Broiled, grilled, or roasted chicken or fish Chicken breast, drumstick 

Dairy Products

1% fat or skim milk Reduced-fat or low-fat cheese Low-fat or fat-free ice cream or frozen yogurt Light or fat-free cream cheese

Sweets & Desserts

Fruit or small serving of a low-fat sweet

(muffin, cake, cookie, pie, pastry, ice

cream, frozen yogurt, sherbet sorbet, etc.)

Snack

Fruits, vegetables, whole-grain crackers,

"light" popcorn,pretzels, baked potato

chips, corn chips, rice cakes

Fast Food

Grilled chicken sandwich, salad with light

dressing, chili, plain baked potato, bean burrito,

"light" chicken taco or burrito

Restaurant Sandwiches

Turkey (sliced), roast beef, grilled vegetables,

grilled chicken, hummus 

Dinner Houses

Grilled chicken or seafood, chicken or vegetable

fajitas, Gardenburger, grilled chicken or salad

with light dressing, pasta with chicken or

shrimp or vegetables in any non-cream sauce,

baked potato (with a tablespoon of sour

cream), vegetable of the day

Chinese Restaurant Food

Stir-fried vegetables, shrimp or chicken with garlic

sauce, Hunan or Szechuan shrimp or chicken

or tofu 

Italian Restaurant Food

Spaghetti with tomato or meat sauce, linguini with

red or white dam sauce

Mexican Restaurant Food

Chicken or vegetable fajitas, chicken or bean

burrito, chicken taco

Seafood Restaurant Food

Any broiled, grilled, blackened, or steamed

seafood

Restaurant Breakfasts

Hot or cold cereal, scrambled egg substitute,

hash browns, ham, pancakes (if they hold the

margarine), toast or bagel with preserves or

marmalade, fresh fruit or juice

Condiments

Whipped fight butter, lower-fat tub margarine,

fat-free or low-fat sour cream