Heart disease is a fixture of modern civilization and behavior and therefore can be treated effectively and with dramatic results by making fairly simple lifestyle changes. People in African villages do not need bypass operations. Studies have consistently shown that heart disease rates are higher in Western cultures, that heart disease rates increase in countries that adopt Western diets and lifestyles, and that dietary modifications reduce disease cardiac. Some of the differences may not be attributable to diet per se, but rather to how food is grown and the industrialization of American agriculture (eg, the effects of corn-fed versus grass-fed animals) . However, it is clear that most heart disease is caused by factors associated with Western civilization, such as poor diet and lack of exercise.

There are also “non-medical” factors not directly related to lifestyle that increase the risk of heart disease, such as low income, lack of social support, depression, marginalization in society, and childhood stress. . I can’t fix all these social ills with this book, but I just want you to understand that it’s not as simple as “one disease, one pill.”

Exercising for just 30 minutes a day reduces the risk of developing heart disease by 30%. This can include anything from running, playing tennis, or just walking briskly. And there’s no need to get a minimum heart rate. If you’re older and don’t run or play any sport, you should incorporate a 30-minute daily walk into your routine. That’s better for you than statins by any measure. And there are no hidden side effects of exercise that we don’t know about yet, other than spraining your ankle.

If you have risk factors and don’t already have heart disease, you need to address them. Improving your diet will help you lower cholesterol and prevent heart disease. In fact, following the low-fat diet recommended by the National Cholesterol Education Program lowers LDL cholesterol just as well as statin treatment, without side effects (Jenkins et al 2005).

The so-called Mediterranean Diet (vegetables, legumes, fruits, cereals and fish) reduces the risk of heart disease and prolongs life (Trichopoulou et al 2005). Heart disease patients who followed the Mediterranean diet had a 50-70% reduction in recurrent heart attacks (de Lorgeril et al 1999). These results are twice as good as any drug.

It’s a fairly simple diet to follow long term. Eat at least one serving of fruit every day, which I define as an apple, a banana, a peach, a cup of blueberries, etc. Eat three to four servings of vegetables every day: one cup of broccoli, two to three cups of leafy greens, one cup of tomatoes, etc. Five to seven one-cup or 2-ounce servings of whole grains, beans, and starches such as cracked wheat, whole-wheat pasta, lentils, and sweet potatoes should also be consumed daily. Meat and other animal proteins, such as eggs and dairy, should be limited to once or twice a week. The mortality of people who followed this diet was cut in half over a period of four years. This diet replaces unsaturated fats (olive oils and nuts) with saturated fats (butter, animal fat), and also includes wine and nuts. In fact, olive oil has been shown in laboratory studies to improve endothelial function (Translation: it increases the flexibility of the coronary arteries, which may be beneficial in reducing the risk of heart attacks).

You may have heard of the recent Women’s Health Initiative (WHI) study that showed that a low-fat diet does not reduce heart disease (Howard et al 2006). The problem with that study is that it lumped all the fats together. We now know that some fats are better than others. For example, there are fats in things like olive oil and fish that actually promote good health. As an example of that, WHI’s generic low-fat diet lowered LDL cholesterol by just 10 points, while a diet high in fruits and vegetables, soy and nuts, and low in animal fats, lowered cholesterol by 30%, which was equivalent to the effects found with a statin (33%) (Jenkins et al 2005).

The low carbohydrate diet does not prevent heart disease. Look at the doctor who developed it: he died of a heart attack. Women in the Nurses’ Health Study (82,802) completed dietary questionnaires and were then followed for 20 years. Low carbohydrate intake was not associated with a reduction in heart disease. Eating a diet high in sugar increased the risk of heart disease by 90%. High vegetable intake was associated with a 30% reduction in heart disease (Halton et al 2006).

Eating fish is good for the heart; be careful about eating a lot of fish high in mercury (a contaminant that gets into fish), such as swordfish and tuna, during pregnancy, as it can cause birth defects. Foods that are part of the Mediterranean diet such as fish, olive oil and nuts increase “good” HDL cholesterol and reduce “bad” LDL cholesterol. These foods are high in omega-3 fatty acids (such as docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) and low in omega-6 fatty acids). It is often pointed out that ancient diets had a 1:1 omega-3 to omega-6 ratio, while today’s diets have much higher amounts of omega-6, largely through calorie replacement in form of leafy plants with grains and seeds

When I was a medical student at Duke in 1985, I distinctly remember sitting on the front porch of my home in Durham, North Carolina, reading The New England Journal of Medicine, where an article described how the Arctic Inuit, who had a diet high in fish and low in meat, had much lower rates of heart disease. That observation led to the idea that the omega-3 fatty acids in fish prevented heart disease, which naturally led pushy marketers to try to put it in a pill or bottle and sell it. However, there is a lot going on in fish, and it’s not clear what exactly you get from it in terms of health benefits (or what you avoid by eating fish over other things).

de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N (1999): Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Traffic 99:779-785.

Halton TL, Willett WC, Liu S, et al (2006): Low-carbohydrate diet score and the risk of coronary heart disease in women. New England Journal of Medicine 355:1991-2002.

Howard BV, Van Horn L, Hsia J, et al. e (2006): Low-fat dietary pattern and risk of cardiovascular disease: the Women’s Health Initiative randomized controlled dietary modification trial. Journal of the American Medical Association 295:655-666.

Jenkins DJ, Kendall CW, Marchie A, et al (2005): Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants. American Journal of Clinical Nutrition 81: 380-387.

Trichopoulou A, Orfanos P, Norat T, et al (2005): Modified Mediterranean diet and survival: EPIC prospective elderly cohort study. British Medical Journal 330: 991-998.