The Perfect Storm: COVID-19, Poor Lifestyle Habits, and Cardiovascular Disease
When the pandemic took root in early 2020, we sought to understand as much as we could about COVID-19. We learned fairly quickly that COVID-19 was most likely to affect the elderly and those with pre-existing medical conditions such as lung disease, diabetes, obesity, cardiovascular disease, and weakened immune systems. We completely changed the way we interacted with each other, took care of our children, and went to work. Thankfully, vaccines are now readily available for those that want them and as a result our risk for contracting COVID-19 and experiencing a severe course of the disease are declining. Unfortunately, we are discovering that COVID-19 and the lifestyle changes that resulted from it are increasing our risk for cardiovascular disease, the number one cause of death in the US for the last 30 years.
Two unique pandemic-related circumstances have contributed to our increased cardiovascular risks. First, those of us who contracted COVID-19 have experienced an acute inflammatory event, and our understanding of the impact of this event on our heart and blood vessels will only become more profound in the years to come. Secondary to this risk are the behavioral changes that have taken root during our year in quarantine, including unhealthy eating habits, increased consumption of alcohol, lack of physical activity, and the mental toll of isolation and increased stress. Like many experts around the country, I expect this trend to continue to increase as the long-term effects of COVID-19 and the pandemic evolve.
During the pandemic, we have all become intimately aware of our immune system and the vital role it plays in our health. In the same way, we need to seek to understand all we can about our cardiovascular disease risks and understand conditions involving blood pressure, blood sugar, blood cholesterol, and arterial inflammation, as well as their eventual consequences of heart attacks, strokes, and heart failure. Improving my patients' understanding of their health and body and empowering them to become their own health advocates is one of my most rewarding roles as a doctor. This is especially true with the cardiovascular system, where knowledge of what you face today is vital to your ability to thrive later in life. In today's blog, I'll share how to identify your personal risk for cardiovascular disease and what you can do to reduce that risk.
Investigating Your Personal Risk for Cardiovascular Disease
As we begin to exit from such a historic year in medicine, I look for insights gained from our battle with COVID-19 to shed new light on the dangers of cardiovascular disease. Cardiovascular disease has greatly confounded public health initiatives on how to curtail its increasing presence in our society. Even in 2020, diseases of the heart and circulatory system claimed twice as many lives as cancer, diabetes, Alzheimer's disease, and respiratory illnesses. I recognize that while this has been a pandemic in which the most vulnerable have been our elderly population, the more sinister epidemic of cardiovascular disease is felt across all demographics. Whereas the average age of patients who unfortunately succumb to COVID-19 is 79, the average age for the first heart attack is 65 for men and 71 for women. In fact, cardiovascular disease kills more women than all cancers combined. Increasingly, I am seeing a significant number of patients in their 40s and 50s starting to show signs of coronary heart disease, observing the hallmark indications of plaque and inflammation in their arteries.
What can be done to counter such sobering statistics? Are we simply destined to suffer the burden of cardiovascular illness as we grow older? When is the best time to start proactive healthcare? These are serious and genuine concerns that I hear from my patients which demand honest answers and a determined approach to medicine that is personalized, data-driven, and participatory. Yes, the risks of cardiovascular disease are great, but greater still is the risk of inaction or ambivalence. Knowledge is power, and as we begin to reboot our lives from the pandemic, now is the time to take the power back!
With new patients, this is where I begin: a comprehensive medical and family history, a survey of lifestyle and risk factors, laboratory testing, genetic testing, and/or imaging studies. Together, we gain valuable insights into hidden risks and unique avenues for treatment. With that knowledge, we then collaborate to develop a plan that is realistic and clear and establish follow-ups to make sure we are staying on track as a team.
Evaluating Genetic Risk Factors
Family history can tell us a great deal about your risks of developing heart disease. We find that certain conditions trend within families, especially if you have had a 1st or 2nd degree relative who suffered a cardiovascular event (stroke or heart attack) before age 55. New technologies now also allow us to pursue targeted genetic testing as it pertains to your cardiovascular health. You may have inherited risks from either your maternal or paternal DNA that determine how you form and break up blood clots, cholesterol's effect on the brain, risks of statin medication intolerance, unique nutrient deficiencies, and inflammation.
Ultimately, if you do have a genetic risk, we work on lessening its impact on your health by compensating for any underperforming or overperforming genes in the body. I find genetic testing to be extremely helpful as we stay true to your aim of personalized and preventative medicine. At NaturoMedica, we partner with specialized cardiovascular labs, Boston Heart Lab and Cleveland Heart Lab, to provide our patients with access to this genetic information as well as advanced lipid testing - a blood test that screens not only the quantity of cholesterol in the body, but also the quality, particle size, origin, and inflammatory burden.
Evaluating Non-genetic Risk Factors
There are four areas of concern when I consider how non-genetic cardiovascular disease risks become elevated: blood pressure, blood sugar, blood cholesterol, and arterial inflammation. When we choose to pursue a comprehensive cardiometabolic test like Boston Heart, we unlock definitive insights into these areas and are better able to practice a personalized approach to healthcare.
1. Blood Pressure
For many patients, the blood pressure screening in a medical office is their first indicator of cardiovascular health. The causes of high blood pressure are numerous, which is perhaps why it is generally the first risk factor that elevates for most patients, often first noticeable in their 30s. Stress, sedentary lifestyle, poor diet, poor sleep, alcohol, smoking, lack of sun exposure, and kidney/thyroid disease are just a few of the causes that I see most often. We must work to control blood pressure because persistently elevated pressure will cause hardening of the arteries, damage to the kidneys, eyes, and small blood vessels (stroke and aneurysm). Fortunately, there are many avenues to explore for blood pressure control, including gentle dietary modifications, nutrient therapies, herbal medicine, acupuncture, exercise plans, stress-reduction techniques, and if needed, conventional medications. Often, we will start with the more foundation approaches of diet and lifestyle and work up from there.
2. Metabolic Health and Blood Sugar
You might consider your blood sugar and conditions like diabetes to be separate from the cardiovascular system and risks, but in fact, we see the greatest cardiovascular risks in both men and women with pre-diabetes and diabetes. The inability to control blood sugar in the arteries leads to micro-tears in the walls of your blood vessels, damaging them slowly and requiring plaques of cholesterol to deposit, like a patch, to strengthen the architecture of the area. This leads to inflammation. Preventing diabetes is perhaps the most profound thing you can do not only your cardiovascular health but also for your cognitive health and longevity.
We test both blood sugar and insulin values to understand more about the complex interaction between your dietary macronutrients and how the body and specifically your pancreas is tolerating them. I view elevated insulin levels as the first sign of trouble with blood sugar. To address this, we work together to develop a plan for metabolic health that addresses healthy carbohydrate intake, along with nutrients, herbal medicine, or medications for better control of blood sugar.
Conventional lab work will simply indicate the total amount of cholesterol, the LDL "bad" cholesterol, and the HDL "good" cholesterol. I strongly believe in occasionally going deeper, into the particle sizes of your LDL cholesterol, which determine how much inflammation they cause, and to the lifecycle of the HDL molecules, which can be thought of like vacuums that can clean up after your bad cholesterol. We test to determine how many of the large and hollow versions of your HDL are present. If deficient, we work together on a diet and lifestyle plan for improvement, often relying on increased exercise, omega-3 fish oil consumption, and functional medicine strategies such as bergamot or niacin.
High LDL cholesterol may cause plaquing, narrowing of your arteries, inflammation, and lead to heart attacks or strokes. There are many treatment approaches to the reduction of LDL, most of which rely heavily on a statin medication to slow down liver production of cholesterol. A good percentage of my patients report intolerance to these medications or a philosophical desire to avoid their use. To that end, Boston Heart Lab includes within their advanced lipid test the Cholesterol Balance test, which identifies the distinct origins of your cholesterol, what percentage comes from the liver, and what percentage is directly absorbed from the intestines. Genetically we are all unique in the ability to perhaps over-produce or over-absorb cholesterol. If you have been diagnosed with high cholesterol, it may be from the over-absorption of cholesterol, which is not treatable with a statin medication or their natural alternatives. Being classified as an "over-absorber" of cholesterol requires more focus on diet, fiber intake, and therapeutics such as plant sterols or well-tolerated and cost-effective cholesterol-binding medications such as Zetia.
Inflammation leads to dangerous changes to the architecture of your arteries and is the result of all other cardiovascular risks. As the most accurate indicator in terms of your risk, I often describe inflammation as "where the rubber meets the road". Inflammation develops slowly and is often asymptomatic until it reaches that dangerous threshold, contributing to a cardiovascular event like a heart attack or stroke. Often more concerning is inflammation with concurrent elevations in a particle called Lp(a), which has only recently been established as its own diagnosis - an independent risk factor for atherosclerosis and heart disease.
Lp(a) is genetically inheritable and causes an increase in the calcification of your arteries, leading to hardening and narrowing, putting you at a much greater risk for heart attack. When I discover a patient has Lp(a) elevations, we modify down their target blood pressure and cholesterol numbers and pursue a Coronary Calcium Scan, a specialized X-ray of the heart, which tells us how the native arteries of the heart are circulating blood, what percentage blocked they are, and whether or not my patient is at risk for heart attack. To treat Lp(a) elevations, and inflammation in general, I use a combination of diet and lifestyle, herbal and nutrient therapeutics, and occasionally statin medications if the need is there. If your risk for heart attack is very elevated, we work with cardiologists to determine the right course of action.
NaturoMedica's Approach to Optimizing Health
We have found that patients that seek care from NaturoMedica are looking for a more personalized approach to their healthcare. Often, they are searching for answers that the conventional medical model has been unable to give. They want to focus on the cause of illness and not simply the symptoms. They want someone to believe in them and their ability to do the hard work in behavior change, diet, exercise, and self-care. Creating an integrative medicine plan for our patients means doing just that - treating the cause of illness with both conventional and natural approaches, to best serve the needs of our individual patients today and proactively for the future. It means utilizing specialized testing methods that go deeper into the underlying disease process and risks. It means collaboration, for both the mental and physical wellbeing of our patients.
As we reflect on the Covid pandemic and the call-to-action it has provoked in us to examine our lives and behaviors more closely, I ask that we not forget old truths and realities that while perhaps inconvenient, are more critical than ever—cardiovascular disease is the single greatest threat to our longevity and potential to live happy and healthy lives. I encourage us all to consider what we are doing to understand our hidden risks for cardiovascular disease and safeguard against them, because for some, the first symptom of heart disease may in fact be fatal.