The best way to evaluate the presence or state of CVD is by a thorough workup. A history will describe any possible symptoms tied to circulatory compromise or blockage, the result of atherosclerosis. A physical exam will not usually tell much unless there is some heart abnormality, poor circulation, or elevated blood pressure. The blood pressure (BP) should ideally be under 120/80 in adults and 110/70 in children. Any elevation puts a patient at higher risk, and calls for closer follow-up. The BP can go up just from the nervousness of being in a doctor?s office, so it needs to be checked under more normal circumstances if it is abnormal. However, if it goes up under the stress of visiting a doctor, it likely goes up with other stress also.

An electrocardiogram, or EKG, is a measurement of the heart rhythm and electrical activity. This is positive only after problems already exist. Neither an EKG nor a chest x-ray is preventive; they simply show the presence of disease after it occurs and offer very few cues that would point out potential future problems, as can the blood pressure or blood level of cholesterol, HDL, and LDL. Many doctors are encouraging patients to treat cholesterol levels over 200 mg./dl. with diet, exercise, and even drug therapy. Increased blood levels of triglycerides, sugar, and uric acid are also of concern. A more extensive test for the heart is an echocardiogram using ultrasound, which can pick up more subtle changes in the heart muscle and its internal valves. Angiography, the injection of dye into the blood to study the circulation through the heart or any area of the body, is done more commonly these days to measure the circulatory status. It is performed before cardiac bypass surgery and is itself very risky, expensive, and possibly painful.

The best approach to cardiovascular disease is, of course, prevention. To prevent CVD, our overall plan includes not smoking; preventing and/or controlling obesity, high blood pressure, and diabetes; exercising and staying fit; eating a low-fat, more vegetarian diet; and monitoring and keeping our levels of cholesterol low, both in our diet and in our blood. For high-risk people, the program needs to be more vigorous. They need clear dietary guidelines and good follow-up care if they are to have a good chance of reducing development of CVD potential and its associated morbidity and mortality of later years. Not smoking, more aggressive control of obesity, hypertension, or diabetes, and a more strict low-fat diet are really mandatory.

Much research is being conducted to investigate whether atherosclerosis is reversible. There is no question that its progress can be slowed through diet and exercise. However, whether it is possible to actually reverse it and clear the vessels of plaque is still questionable, although many authors, including myself, feel that it is possible and recent studies suggest this. Some studies show that a low-fat, low-cholesterol diet can result in increased cardiac output and a reduction of blood fats, which it is thought will decrease fatty plaques over time. A comprehensive research experiment conducted by, among others, Dean Ornish, M.D. and discussed in Stress, Diet and Your Heart suggests that exercise, stress reduction, and better diet result in marked improvement in almost all patients with CVD, in terms of both symptom reduction and enhanced performance ability. This is now proven in his new book, Dr. Ornish?s Program for Reversing Heart Disease.

Many of the significant risk factors contributing to CVD can be lessened through dietary influences. These risks include high blood pressure, high cholesterol, (especially high LDL levels), high triglyceride levels, and obesity, as well as many cases of diabetes. High fat consumption, low fiber intake, and excess salt and sodium intake are influential nutritional risks. Proper diet alone can decrease cholesterol levels by 30 percent or more, although this usually requires some radical dietary shifts. Smoking and lack of exercise, the main nondietary habits (cardiovascular risk factors) involved, often require similar changes of willpower as does diet; and furthermore, we need a feeling of positive self-worth to even gather the force to make these successful changes.

The primary dietary focus of the cardiovascular disease prevention diet is fat intake. The diet should be low in fat in general and particularly low in saturated fats (animal fat plus coconut and palm oils) and the hydrogenated fats (all margarines) and oils such as used for frying foods. These are mainly poor-quality vegetable oils used so commonly in commercial food preparation and restaurant cooking. Avoiding these oils is highly recommended. It is clear that a diet high in saturated fats and cholesterol leads to increased blood cholesterol levels and increased atherosclerosis. In my clinical experience, homogenized, pasteurized milk and dairy fats seem to drive cholesterol to high levels. A quart or more of whole milk daily or regular intake of ice cream can lead to cholesterol levels over 300 mg./dl.; and thus, going off these foods can dramatically lower the cholesterol.

To prevent atheroschlerosis, a low-fat, low-cholesterol, and high-fiber diet is recommended. Fiber reduces CVD risk in many ways. It binds cholesterol and fats and lessens their absorption. It subsequently decreases blood cholesterol and LDL and increases protective HDL cholesterol. Increased fiber levels?and we are talking about 20?30 grams daily, which often requires supplemented fiber?will also help reduce blood pressure levels in those with elevations.

Fat intake should be reduced from the average 40?45 percent to a maximum of 25?30 percent of total calories; even lower levels, 15?20 percent, are suggested. With supplemental fatty acids or the use of good-quality cold-pressed vegetable oils to obtain our necessary linolenic acid, even lower fat intake can be consumed safely. This, however, is very difficult unless we eliminate a wide variety of common foods, including all fried foods, meats, milk products, butter, cheese, eggs, nuts, and seeds, which also clearly reduces protein intake.

Currently, the average American fat intake ranges from about 100?150 grams per day. Of course, men usually consume more than women, and many people with some food awareness consume less. In diet analyses, however, I commonly see this range, even up to and over 200 grams daily. At 9 calories per gram, 125 grams means 1,125 calories per day of fat. If that represents the average of about 40 percent of total calories, it would mean a diet of about 2,800 calories a day, which would add weight to most folks other than athletic men. If we eat 100 grams (900 calories) of fat daily, and that is one-third of our total calories, that means a total of 2,700 calories a day; if fats are a more healthful 25 percent of the diet, that means a total of 3,600 calories, more than most people consume. Realistically, fat intake levels must be no higher than 50?75 grams a day to create a calorie range of 1,800?2,700 with a diet containing 25 percent fat.

The types of fat consumed are also important. More unsaturated (poly- and monounsaturated) than saturated fats are suggested; that means a higher intake of vegetable oils and polyunsaturated-fat-containing foods. Beef, for example, has a ratio of saturated to polyunsaturated fat (S:P) of around 15:1, whereas the ratios in poultry and fish are closer to even. Vegetable fats found in nuts or seeds have an even lower S:P ratio. The polyunsaturates tend to be more beneficial to our levels of fat and cholesterol than the saturated fats found in milk, eggs, and meat. However, the polyunsaturated fats are unstable and not only lower total cholesterol but may also reduce the important HDL; the monounsaturated fats are probably better. Be careful of the hydrogenated polyunsaturates (many margarines and cooking oils); they have increased saturated fats and unusable, trans-fatty acids (mirror image molecules of the natural cis-fatty acids), and are even less desirable than the fats from butter, milk, or meat. Excess polyunsaturates also have added cancer and heart disease risks, possibly because of oxidation and the potential formation of free radicals. Overall, a minimum of fats is suggested, with avoidance of many of the less healthful unsaturated fats, such as refined cooking oils, margarines, mayonnaise, and artificial dressings and creamers, which also contain questionable chemicals. It is fairly clear that the total fat intake has an important influence on blood cholesterol as does the proportion of saturated fats or cholesterol-containing foods, so this needs to be an important area of focus.

Particularly helpful oils are contained in the coldwater fish such as salmon, mackerel, sardines, and herring. These contain EPA (eicosapentaenoic acid) and DHA (dicosahexaenoic acid), which have a positive effect on lowering cholesterol and triglycerides. It is now considered that these are CVD-prevention nutrients and that consuming these oil-containing fish two or three times a week will be to our cardiovascular benefit. EPA can also be used as a supplement to the diet.