21-Day Plan

Principle #5

Principle #10

Principle #10--Reduce elevated triglycerides. Promote HDL cholesterol.

“Most doctors believe the misinformation they were taught in medical school—that triglycerides levels of 250 to 500 mg/dl are perfectly normal. They’re wrong, and their ignorance could kill you. Even 200 mg/dl is too high. As a matter of fact, you need to worry about your heart health when your triglycerides are anything above 100 mg/dl.”—Robert C. Atkins, M.D.

“People with very high triglycerides levels and very low HDL levels—another pattern characteristic of Syndrome X—are 16 times more likely than normal people to have a heart attack.”—Burton Berkson, M.D., Syndrome X

Long ignored by the medical establishment, elevated triglycerides have become a leading predictor of heart disease. Simply stated, the higher your triglycerides, the greater your risk of a heart attack. As triglycerides go up, protective HDL goes down.

Our 21-Day Plan objective: Triglycerides under 100 and HDL over 60 for men and over 70 for women. Taken together, the 21-Day key principles reduce blood sugar, spare insulin, reduce triglycerides, boost HDL, promote healthy blood vessels, reduce the risk of deadly blood clots, and extend life. Drugs and low-fat diets can’t do that.

Summary of 21-Day Plan benefits:

1. Untamed emotional stress (like anger and road rage) increases blood sugar, circulating insulin, stress hormones and triglycerides—and lowers protective HDL and DHEA. Low HDL and low DHEA are associated with diabetes and coronary heart disease.

2. Eating high quality eggs for breakfast - instead of highly processed box cereal - will prevent blood sugar elevations, spare insulin, lower triglycerides, and boost HDL. Eggs are a complete protein and provide a wide range of naturally occurring vitamins and minerals. Eat as many as you like – fried slowly in butter, lard or bacon fat. Free range small producer eggs are best – containing 10 times more lecithin and vitamin E.

3. Small amounts of red wine (one or two glasses a day) boosts HDL. A glass or two of beer may also have a beneficial effect on HDL. Excess alcohol, however, stresses the liver and impairs blood sugar metabolism. Replacing excess coffee with antioxidant rich green tea, the national beverage of Japan, will reduce triglycerides and promote beneficial HDL cholesterol.

4. Replacing refined foods with whole unprocessed, low glycemic carbohydrates and properly raised animal foods will reduce homocysteine and triglycerides while promoting HDL cholesterol. In short, an Atkins style diet is heart healthy for most people.

5. A complete lipid evaluation is needed to accurately assess your risk of heart disease. (See complete discussion in Diet Heart News.)

6. Pasteurized low-fat milk contains oxidized dry milk powder and homogenized milk contains oxidized fragmented fat particles (xanthine oxidase) that damage arteries and increase the chance of deadly blood clots. If you can’t find whole raw milk, it may be best to avoid milk altogether. You don’t need milk for cereal because you shouldn’t be eating cereal if you are prone to Syndrome X.

7. Magnesium and trace minerals promote the generation of energy in the mitochondrial cell furnaces throughout the body, enhancing the uptake of insulin, lowering triglycerides, and increasing protective HDL. Magnesium – not calcium – is the number one mineral deficiency among people over forty.

8. Fasting blood sugar near optimum (87.1) is associated with reduced triglycerides (below 100) and protective levels of HDL cholesterol (above 60 for men and above 70 for women).

9. Excess carbohydrates produce elevated triglycerides. Elevated triglycerides are associated with low HDL cholesterol. Moderate exercise and animal foods increase HDL.

10. Low levels of HDL cholesterol are one of the most significant warnings of a future heart attack.

11. Activity, exercise, and relaxation lower triglycerides and promote HDL cholesterol and healthy hormone levels. Extreme exercise causes heart attacks and coronary heart disease.

12. The grain-based Food Guide Pyramid promotes high triglycerides and low HDL. The Pyramid recommends that all of us consume 6 to 11 servings of grain each day. This dietary advice is an underlying explanation for the explosive growth of Syndrome X and diabetes during the last 20 to 30 years.

13. The traditional, healthy cooking fats—butter, coconut butter, lard, olive oil, palm oil and palm kernel oil—raise protective HDL cholesterol and reduce triglycerides. They are heat-stable and safe for cooking and baking.

14. Regular use of herbs such as cayenne, ginger, garlic, onion, hawthorn, American ginseng, Siberian ginseng, gotu kola, and valerian root stimulate, cleanse, and nutritionally support healthy blood circulation, reducing fibrinogen, and the chance that a deadly blot clot will block blood flow in a coronary artery.

15. Excess omega-6 fats found in commercial vegetable oils, margarine, partially hydrogenated fat, vegetable shortening, and from strictly grain-fed animals inflame arterial tissue, promote blood clots, increase blood pressure and arterial tension and reduce the ability of red blood cells to carry insulin.

16. Omega-3 rich milled flaxseed is nutritionally dense—an excellent source of minerals, fiber, and cancer-fighting plant lignans. Daily flaxseed helps promote a favorable 1:1 or 2:1 balance of omega-6 and omega-3 essential fats.

17. Optimum protein, especially protein from grass-fed animals, is needed to build and maintain structure throughout our bodies. Dietary protein promotes HDL cholesterol and reduces triglycerides.

18. Eating cold water fish like Norway sardines and Alaskan salmon reduces inflammation and promotes healthy free-flowing blood.

19. Balanced and physiologically beneficial levels of DHEA, progesterone, and pregnenolone promote optimum body functioning and extend longevity.

20. In both supplement form and food (lamb and beef), carnitine will lower triglycerides and promote beneficial HDL cholesterol. Carnitine burns fat and provides optimum energy for the heart and muscle tissues.

21. Vitamins C (mineral ascorbate form and E (emphasizing Gamma Tocopherol) are the base of the antioxidant pyramid. Antioxidants work in team fashion to strengthen blood vessel walls and prevent LDL cholesterol from oxidation. Alpha Lipoic Acid, grape seed extract, green tea, NAC (n-acetyl-l-cysteine), and Pycnogenol further enhance antioxidant defenses.

Principle #5--Ask your doctor for a complete lipid evaluation.

"It's a national scandal. I'd estimate that only 5 percent of doctors in the United States are using these specialized blood tests."-Thomas Yannios, M.D.

"Lab test results by themselves are useless, however; you must have them analyzed by a doctor who recognizes that there are many paths to heart disease."-Robert C. Atkins, M.D.

Summary CHD Risk Factors

Risk Factor	Optimum	Risk	Serious Risk
C-reactive Protein	<1	>2	>3
Fasting Glucose	87	>100	>110
Fibrinogen	<235	>235	>350
Homocystine	<8	>8	>12
Lipoprotein(a)	<20	>25	30
HDL (men)	>60	<60	<40
HDL (women)	>70	<70	<50
Triglycerides (TG)	<100	>100	>150
TG/HDL ratio	1:1	2:1	4:1
LDL Cholesterol	-	>240	-
Total Cholesterol	-	>350	-

Normal blood cholesterol ranges from 180 mg/dl to 350 mg/dl. Blood cholesterol increases naturally as we age or suffer stress. LDL over 240 and Total Cholesterol over 350 is a warning signal - especially in people under 50 - that something is wrong. Usually these people also have other risk factors like elevated fasting glucose that signal Metabolic Syndrome.

The above tests can be ordered during "blood work." Costs vary. If your insurance company will not pay for all tests, discuss the relative importance of each one with your doctor. You may have to consider paying for a test or two. If you only get one test, make it fasting glucose. Why? Because by itself it is a reliable predictor of both diabetes and heart disease.

"Cholesterol is overemphasized to the point where the other risk factors are too often ignored," wrote the late Dr. Atkins. This hurts two groups of people: Those with high cholesterol who are over treated with dangerous drugs, and those with low and average cholesterol who mistakenly are not treated at all.

In the Cardiovascular Health Study (Chapter 11, 21 Days to a Healthy Heart), we learned that high fasting glucose is "significantly and independently associated with mortality" and high blood cholesterol is not. In fact, in the study, people with higher LDL cholesterol (more than 153 mg/dl) had just two thirds the mortality risk of those with so-called desirable levels-less than 96 mg/dl.

In the long-term Framingham Heart Study (Chapter 4, 21 Days to a Healthy Heart), we learned that declining cholesterol over time was the best predictor of overall mortality. "For each 1 mg/dl drop of cholesterol, there was an 11 percent increase in coronary and total mortality." For people over 50, declining cholesterol over time is a risk factor for all causes of death!

Only excess carbohydrates raise blood sugar and fasting triglycerides. Please note: There are triglycerides made in the gut from dietary fat, and triglycerides made in the liver from dietary carbohydrate. When you fast for 12 hours, only the liver-made triglycerides remain. Triglycerides made in the gut from dietary fat are cleared within 2 hours by cells hungry for the nutrients they carry.

When your doctor tests for triglycerides, she is looking at fasting levels that reflect your body's carbohydrate load. Throughout 21 Days to a Healthy Heart, we're going to learn that it's primarily your carbohydrate load that initiates diabetes and coronary heart disease. High blood sugar or fasting glucose levels are associated with elevated triglycerides and low HDL cholesterol (explained in detail in Chapter 10).

Schedule your blood work or lipid evaluation in the morning. In order to get valid baseline values, you must fast at least 12 hours before blood is drawn. You can drink water. If you have a family history of premature coronary heart disease or diabetes, evaluating your risk at a young age is especially important.

Otherwise, by your fortieth birthday, make sure you get a complete lipid evaluation. Tell your doctor you need as much information as possible in order to (1) learn what is going on in your arteries and (2) to take preventive measures to protect yourself. Knowing these values is the beginning of your 21-Day Plan.

There is no free cholesterol floating in your blood; strictly speaking, you do not have a "cholesterol level." All measurements of "cholesterol" are actually measurements of lipoprotein. Lipoproteins are the buses that transport cholesterol and triglycerides (fat) through the body.

Total cholesterol is actually a composite number that includes VLDL (very low density lipoprotein), IDL (intermediate density lipoprotein), LDL (low density lipoprotein), and HDL (high density lipoprotein). The liver sends the lipoprotein known as VLDL into the bloodstream. As it travels, cells snatch what they want and VLDL turns into IDL, then into LDL. Once VLDL has reached LDL size, it is reabsorbed by the liver or absorbed by other cells that need cholesterol.

HDL cholesterol is made separately and acts as a cholesterol mop, scavenging loose cholesterol and transporting it back to the liver. HDL cholesterol is most important. HDL is associated with protection from heart attacks. You want as much HDL as possible. HDL is reverse transport-garbage trucks hauling cholesterol back to the liver for recycling. HDL of 60 or more protects men-70 or more protects women. Men with readings below 40 and women with readings below 50 are at much greater risk of heart disease.

In The Heart Disease Breakthrough, Dr. Thomas Yannios wrote, "In the Physicians' Health Study…though heart attack victims were found to have the same cholesterol levels as the control population, people developing heart attacks were distinguishable by their low HDL levels. Yet most therapy for heart disease prevention is directed at lowering LDL-rather than raising HDL."

Ideally, triglycerides are under 100 mg/dl. Triglycerides are made in the liver from your carbohydrate load. Readings above 100 signal increased risk of heart disease. Risk is linear-the higher the number, the greater the risk, especially for women. Readings above 150 for both men and women signal serious increased risk of coronary heart disease (see Chapter 10).

As we will learn, the ratio of triglycerides to HDL (TG/HDL) is the most reliable predictor of your risk for heart disease. You can calculate your TG/HDL ratio by dividing your triglycerides by your HDL. If your triglycerides are 80 and your HDL is 80, your TG/HDL ratio is 1:1, which is ideal.

If your triglycerides are 180 and your HDL is 60, the ratio is 3:1. If your TG is 207 and your HDL is 44, the result is 4.7 (nearly 5:1). A ratio this high represents serious increased risk of heart disease. In fact, a ratio of 2:1 or higher means you have a greater than average risk of dying from heart disease.

In most people, a high-carbohydrate, low-fat diet will increase triglycerides and reduce HDL. Like a teeter-totter, when triglycerides go up, HDL goes down. As you will learn in Chapter 10, this is one of the most consistent findings you will find in blood work.

If you have high triglycerides and low HDL, you can assume that LDL cholesterol in your body-regardless of the level-is more likely to oxidize (become rancid or damaged). Once oxidized, LDL is 30 times more likely to contribute to plaque, according to Dr. Yannios.

Currently, there is no test for oxidized cholesterol, but the presence of high triglycerides signals the increased risk of oxidized LDL whether LDL is high or not. Elevated TC and elevated LDL are not major independent risk factors for heart disease. Don't let your doctor focus on lowering total cholesterol and then ignore your overall lipid picture.

You can die of heart disease with high or low LDL. In Heart Disease Breakthrough, Dr. Yannios wrote, "In other studies of people who developed heart disease, 46 percent had LDL levels below 160-the level at which the National Cholesterol Education Program recommends no further intervention beyond a prudent diet."1

Many doctors are saying that healthy people should simply ignore total cholesterol if it's below 300 mg/dl. "In the case of older people, there is absolutely no relevant study concerning cholesterol as a factor for heart and circulatory problems," wrote Christiaan Barnard, M.D., in his book, 50 Ways to a Healthy Heart.

Thoroughly discussed in Chapter 18, C-reactive protein (CRP) is produced by the liver in response to inflammation in the arteries. If monitored early enough, elevated CRP can be an early warning of heart attack risk-6 or more years in advance. A faulty diet can damage or "inflame" arterial tissue, weaken the immune system, and make the body vulnerable to bacterial or viral infections.

The late Dr. Robert C. Atkins recommended low-dose aspirin (81 mg) to lower dangerously high CRP. Eating deep sea fish and using fish oil supplements can also reduce inflammation in the heart and arteries (see 21-Day Plan #19).

Aspirin may be recommended to help prevent blood clots in late stage active heart disease or to lower elevated CRP, but the scientific evidence in support of daily aspirin is inconclusive. According to Dr. John G. F. Cleland, "All the large long-term trials of aspirin after myocardial infarction show no effect on mortality." Dr. Cleland states that aspirin may simply change the way vascular events present themselves; i.e., a reduction in non-fatal events and an increase in sudden death.2

The aspirin component of the Physicians' Health Study is most often cited as a reason to take daily aspirin. It was widely reported that "Aspirin decreased the number of heart attacks in healthy male physicians by 40 percent." Virtually overnight, aspirin became the most inexpensive drug in history to prevent heart attacks.

In this landmark study, about 11,000 physicians took Bufferin (aspirin coated with magnesium) and 11,000 received a placebo. Five years later, 44 from the Bufferin group and 44 from the placebo group had died. The Bufferin group did suffer fewer deaths from heart attack, but this reduction in mortality was offset by a higher incidence of deaths from stroke, sudden cardiac death, and other cardiovascular events.3

When we take a closer look at the "40 percent reduction in the number of heart attacks," we discover the medical profession's clever use of relative risk statistics. There were 100 fewer nonfatal heart attacks in the Bufferin group. In the Bufferin group, 100 out of 11,000 physicians apparently benefited from taking Bufferin-that's less than 1 percent. But when the researchers divided 100 by 239, the number of heart attacks in the placebo group, they arrived at a 40 percent relative risk reduction!4

Aspirin works by destroying or interfering with both good and bad hormone-like substances (prostaglandins) for a period of about 6 hours. In doing so, aspirin interferes with the function of vitamin C in the body and increases the risk of internal bleeding, ulcers, and hemorrhaging-type strokes.

Diets emphasizing high quality protein, natural fat, and nutritional supplementation are a better way of protecting ourselves from heart attacks-fatal or nonfatal. On a regular basis, use healthy natural foods like avocados, flaxseed or flax oil, cold water deep sea fish or fish oil, magnesium and trace minerals, cayenne, ginger, garlic, onion, and vitamins C and E.

These nutrients promote free flowing blood and provide a wide range of other nutrients. As we know, aspirin has no nutritional value. If you decide to take aspirin (81 mg) for periods of time, at least understand the risks involved.

Fasting glucose is a measurement of how well your body is managing glucose or blood sugar. Ideal fasting glucose is 87.1. High normal (between 100 and 109) represents significant increased risk of heart disease. Impaired blood sugar control leads to diabetes. More than 80 percent of Type II diabetics die of heart disease (see 21-Day Plan #10).

Fibrinogen is the protein molecule that traps red blood cells and locks them into a blood clot. Elevated fibrinogen means thicker blood. Thicker blood flows less easily, especially through partially blocked arteries. Fibrinogen in combination with other risk factors is a predictive risk factor for coronary heart disease.

Blood platelets are tiny cells that are attracted to injured tissue of any kind. They accumulate to stop the flow of blood and then chemically stimulate the blood clotting process. Multiple clotting factors are then activated sequentially to convert circulating fibrinogen into the web of fibers called fibrin.

Testing for fibrinogen is easy and inexpensive, but your doctor may hesitate to order the test because fibrinogen levels fluctuate a lot-rising and falling rapidly in response to many stimuli. Stress, trauma, infections, and recent heart attacks all cause fibrinogen to increase.

But consistent elevated fibrinogen-the highest third in the range-conveys a 250 percent increased risk of heart disease compared to people with levels in the lowest third. People with active heart disease and high levels of fibrinogen are in danger of disease instability and a dramatically increased chance of repeated clotting and blockages.5

Lipoprotein(a) has been called the "heart attack" cholesterol. Lipoprotein(a) is actually a sticky protein that attaches to LDL and accumulates rapidly at the site of arterial lesions or ruptured plaque. Readings of 30 or more indicate serious increased risk of heart disease, especially in the presence of elevated fibrinogen (>350).

Lipoprotein(a) promotes blood clotting and inhibits plasminogen, your body's natural clot-dissolving enzyme. Eating large amounts of margarine and partially hydrogenated fats are known to increase lipoprotein(a). Butter and saturated fats reduce lipoprotein(a) (see 21-Day Plan #14).

Homocysteine, a by-product of amino acid metabolism, is normally cleared rapidly from the bloodstream. Elevated homocysteine is a result of vitamin deficiency, especially folic acid and vitamins B-6 and B-12. Elevated homocysteine damages arteries and dramatically increases the risk of heart attack and stroke. Levels greater than 8 micomoles per deciliter signal increased risk of heart disease (see 21-Day Plan #4).

LDL Particle Size is beyond the scope of this discussion. For a detailed analysis of all 7 sub-fractions of LDL and 3 sub-fractions of HDL, I strongly recommend The Heart Disease Breakthrough by Thomas Yannios, M.D. Understanding and testing these sub-fractions is critically important for patients who have "normal lipid values" but persistent aggressive coronary heart disease.

Dr. Yannios goes beyond "good" and "bad" cholesterol and describes genetically determined LDL and HDL particle characteristics. While I do not endorse his recommendations regarding dietary fat, his work in The Heart Disease Breakthrough is must reading for the serious student of heart disease.

LDL is a particle that consists of cholesterol and varying amounts of triglycerides. Steering the LDL is a protein called "Apoprotein B." Because each LDL particle has an Apoprotein B marker, the number of LDL particles can be counted in a laboratory test. The cholesterol level in routine tests-milligrams of cholesterol in a given volume of blood-does not reveal the number or size of the cholesterol particles.

At the same cholesterol level in the blood-say 220 mg/dl-a person can have a different distribution of LDL particle count and particle size. LDL "B" particles, for example, are smaller, denser, and contain more triglycerides, which induce chemical changes that make the LDL more much more likely to oxidize and damage artery walls.

If your triglycerides are low (below 75), your LDL is most likely larger subclass A. If your triglycerides are high (over 180), your LDL is most likely small, dense subclass B. High triglycerides are a warning sign that you may have this more oxidized-prone form of LDL-regardless of the level of cholesterol circulating in your blood.

Once oxidized, LDL is more likely to attract foam cells, clotting factors, and develop into atherosclerotic plaque. While elevated triglycerides suggest the presence of these more malignant "B" particles, only further laboratory testing can document their presence and exact number.

As Dr. Yannios points out, "Many of the people with the most aggressive heart disease have total cholesterol under 200. They could more accurately assess their risk by carefully scrutinizing glucose and triglycerides levels or, even better, by testing specifically to identify LDL subclass B."6