The Townsend Letter
Dr. Michael Ozner is somewhat of an iconoclast in the field of cardiology. His practice in Miami, Florida, is dedicated exclusively to cardiovascular disease prevention, eschewing intervention procedures such as stents and coronary bypass surgery. His prescription for cardiac wellness and prevention is quite simple: "Eat a delicious meal of fish, whole grains, and fresh vegetables. Drink a glass of red wine. Take a nice walk, then take a nap. Relax with your family and friends. Do it all again tomorrow, and the next day, and the next, for the rest of your life." The lifestyle prescription Dr. Ozner describes sounds like a vacation. Yet it is indeed a lifestyle and a prescription, one that has been shown to decrease the risk of cardiac events, to control weight, and to make life less stressful for those who choose to follow it.
An American-Style Mediterranean Diet
In his new book, The Miami Mediterranean Diet, Dr. Ozner brings his health prescription to the masses in a palatable form—literally. The book touts the benefits of the traditional Mediterranean diet and shows how it can be adapted to the modern American lifestyle. It is packed with hundreds of patient-tested recipes and easy-to-read health information drawn from years of clinical practice. The book is available fromwww.cardiacoz.com.
While The Miami Mediterranean Diet has won favorable reviews from physicians and patients alike, the book aims to do more than teach people how to reduce their cardiac risk and live longer, healthier lives. It seeks to encourage dialogue among physicians, as well as between doctors and their patients, about a prevention program with substantial evidence to support its efficacy.
"We've known for years that a Mediterranean-type diet will protect us from cardiovascular disease and other disease states," says Dr. Ozner, who serves as medical director of wellness and prevention at Miami Baptist Hospital's Cardiac and Vascular Institute. "It also allows us to lose weight and keep it off. This has been shown over and over again."
Citing the 20-year landmark Seven Countries Study conducted by Dr. Ancel Keys starting in the late 1950s, Dr. Ozner explains that a diet low in processed foods and saturated animal fats was found to produce the longest life expectancy in the world and the lowest heart disease rates in those living in the Mediterranean region. The study tracked more than 13,000 men from Italy, Greece, Yugoslavia, the Netherlands, Finland, Japan, and the US. Among its dramatic findings: Greek men were 90% less likely to die from a heart attack than American men.
"It's rare to see someone overweight in Greece, and they don't restrict carbohydrates there," says Dr. Ozner. "People eat pasta, fresh vegetables, beans, whole grains, cold-water fish, nuts, olive oil, and red wine. They walk rather than drive and are active during the day. In the US, we have fad diets restricting or eliminating carbs, and we still have an obesity epidemic."
On the Path to Prevention
The path that led Dr. Ozner to a prevention-only cardiology practice began more than 20 years ago, when he decided that intervention – namely, bypass surgery and, at the time, balloon angioplasty – was not enough to effectively reverse America's heart disease epidemic. His patients who had undergone such procedures kept returning for a second or third intervention while living in a state of constant stress, waiting in dread for the next cardiac event to occur.
"This is when I got interested in prevention," explains Dr. Ozner. "Heart disease is really a conglomeration of different insults to our bodies, all of which can be controlled by a three-part program of prevention and lifestyle changes: nutrition, exercise, and stress management. Along with smoking cessation, using these prevention strategies in my own practice has resulted in a significant reduction in patients developing heart attacks if they hadn't had one, and those who had were less likely to require repeat intervention."
Today, Dr. Ozner's patients include both those who are at risk for cardiovascular disease and others who have had heart attacks, strokes, or peripheral vascular disease and wish to prevent future events.
Dr. Ozner, who also serves as a clinical assistant professor of medicine and cardiology at the University of Miami School of Medicine, is puzzled as to why more cardiologists do not emphasize prevention when it works so well, though he notes that physicians are becoming more accepting of prevention modalities. His lectures promoting "aggressive prevention with conservative intervention" draw plenty of positive feedback from his colleagues. His annual Cardiovascular Disease Prevention Symposium in Miami has attracted standing room-only audiences of professionals eager to learn about recent advances in prevention.
"Physicians appreciate that the data now support prevention," he notes. "We've shown that proper nutrition and use of supplements that are known to be effective can reduce low-density lipoprotein (LDL) to the low levels now recommended. We can significantly reduce our reliance on intervention this way. I regularly recommend fish oil supplements for all patients who are at increased risk or have inflammatory conditions or elevated lipids, including triglycerides. Beyond that, I make further recommendations based on the individual patient's needs."
Dr. Ozner emphasizes that he is not opposed to intervention when appropriate, particularly with clinically unstable patients. For someone in the throes of heart attack, surgery to open an artery suddenly blocked by a fresh thrombosis is a life-saving procedure. "However, that's a far cry from saying all people who have blockages, including those who are stable, require surgical intervention," he says. "Clearly, that would be inappropriate."
The most exciting advances in cardiology today are in the area of prevention, contends Dr. Ozner. Effective new medications are being developed through genetic engineering and other technological advances. He still believes, however, that the key to beating the nation's number-one cause of death is alerting the American public to the urgent need for health-promoting changes in lifestyle and nutrition.
Trends Fuel Heart Disease Epidemic
Dr. Ozner points to a number of societal trends that he believes contribute to the heart disease epidemic, chief among them the abysmal state of nutrition in America. The public seems hungry only for fad diets that promise much and deliver little, he says. Food manufacturers produce products stripped of nutritional value, a situation he says demands more responsible action. Pharmaceutical companies push pills as the panacea for all our woes. The unrelenting stress of modern life further erodes our health and makes matters worse. "Gulping down processed foods in our hectic environment leaves little wonder why—despite the billions of dollars we spend on intervention— our nation is still the leader in terms of heart attack, stroke, and other diseases," he says. "This is where "lifestyle" clearly comes into play.
"We know what the root of the problem is. We as a nation have stopped exercising—we drive instead of walking, take elevators instead of stairs. We eat processed foods instead of fresh fruits and vegetables. Our lives are filled with enormous amounts of stress, all of which has led to deterioration of our health status. The trillions of dollars spent on health care are bankrupting the country. Society would be much healthier if we returned to a healthier lifestyle."
Dr. Ozner faults the food industry for not providing Americans with healthier food choices. For example, food processing destroys whole grains, ripping out the germ and bran—major sources of nutrients, vitamins, and fiber—leaving only starch stripped of all nutritional benefit. Dr. Ozner notes that per capita consumption of refined sugar has increased exponentially over the past few decades, leading to an obesity epidemic in children and adolescents. He decries cuts in physical education programs in schools and is mystified by the apparent lack of concern for this age group. "One could say, ‘So what?'" he says. "So what is that we have an epidemic today of type II diabetes in children, adolescents, and young adults, which leads to heart attacks."
Trans fats should be banned in the US, Dr. Ozner says, as they are in Denmark. Scientific studies have long linked hydrogenated oils to adverse medical conditions. Trans fats have contributed to thousands of premature deaths from cardiovascular disease. According to Dr. Ozner, "We really need to wake up to the fact that we've been given bad information and led down the wrong path with fad diets such as the low-carb craze. We should insist that the food industry become more responsible with advertising and promoting healthy foods. Much as we've placed sanctions on cigarette manufacturers, we should do the same with the food industry."
Our nation's flawed health care delivery system is also at fault for much of what it attempts to treat, Dr. Ozner says. Physicians are rewarded for treatment procedures instead of for keeping people healthy and out of the hospital through preventive medicine. We are overly reliant on pills and under-reliant on healthy lifestyle choices, he says.
"I've seen people get on prescription medication just so they can abuse diet and lifestyle," Dr. Ozner notes. "The fault here lies with the public for listening to the bombardment of pharmaceutical industry advertising hype. But the pharmaceutical industry is also responsible for pushing these pills on society. COX-2 inhibitors like Vioxx® are a perfect example. We've known for years that one of the best anti-inflammatory substances for arthritis is fish oil, a natural substance containing eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). It makes more sense to use products like that."
The lack of nutrition training in medical schools also contributes to the problem, he says. Many physicians feel nutrition simply is not important, contrary to the growing body of data demonstrating that it is extremely important. It takes time and an inclination to discuss nutritional guidelines with patients, so physicians often find it easier to write prescriptions than to talk about nutrition. Additionally, physicians are wary of sending patients to registered dieticians, fearing the dieticians may tell patients something contrary to what the physician believes. "For all those reasons, it's easiest to give people reading material, whether it's a book like mine or other nutritional guidelines, to educate them on healthy lifestyles and keep them off the fad diets," Dr. Ozner says. "Have them read publications like Life Extension magazine, get people thinking about health and prevention, and they're more likely to stay healthy."
Dr. Ozner believes in putting responsibility for overall health squarely on the patients' shoulders. They must be proactive, Dr. Ozner says, and not sit back and wait for cardiovascular disease, cancer, and other conditions to strike. Patients should embark on effective strategies early in life and discuss all prevention modalities with their doctors. First, they should seek out a physician they can trust. However, he notes, it is prudent to seek second opinions if there is any doubt concerning recommendations for medicine, hospitalization, or procedures.
Building trust calls for returning to the doctor-patient relationship that existed years ago, when patients frankly discussed any troubling topic with their personal doctors. More recently, managed care and other market forces have made medicine more of a business than a professional calling. "The doctor-patient relationship has eroded because physicians must see patients every five minutes to make ends meet," Dr. Ozner notes. "You can't counsel patients with the details of a good preventive program in that short a time."
If physicians do not have time to talk to patients who want to improve the relationship, what is the solution? Be creative, Dr. Ozner says, and find ways to disseminate information: "I give reading assignments, and ask them to write down any questions they have. The patient comes back motivated and educated and, I think, more likely to follow recommendations."
For the physicians' part, Dr. Ozner notes that the word "doctor" actually means "teacher." He says physicians need to get back to the very derivation of what they are by instructing patients rather than quickly scribbling prescriptions. "Doctors need to find resources to teach people how to live a healthy lifestyle," he explains. "I think the Life Extension Foundation does a very good job in helping promote the concept of prevention and a preventive approach to health care. The Foundation is about quality of life. It really has helped educate the public on a variety of disease states and, most important, how to prevent them. I applaud any organization that tries to improve people's health and decrease the likelihood that they will develop disease states."
Beating the heart disease epidemic comes down to changing attitudes all around, says Dr. Ozner. For the health care system, it means redirecting billions of dollars spent on intervention into prevention modalities. For physicians, it means embracing prevention modalities, educating patients, and redeveloping trust. And for patients, it means waking up, taking responsibility for their health, and looking beyond pills.
"In America, we're all looking for a magical pill to solve all our problems, when what will work is changing our attitudes," he says. "You can live a long, happy life that will result in more pleasure from exercise, from eating food that's delicious, and from reducing stress. I'm amazed to see how people who adopt this type of lifestyle honestly feel they're not only healthier, but much happier."
A better remedy
BY MICHAEL D. OZNER
There's an issue in the national healthcare conversation that no one is talking about: excessive spending on unnecessary treatments.
On Wall Street there's a system in place -- albeit a broken one -- for overseeing suspect transactions and sniffing out abuse. But spending in the medical-industry marketplace continues to be largely unregulated, leading to a waste of billions of healthcare dollars.
My field of practice -- cardiology -- provides a dramatic example of the needless hemorrhaging of American medical resources.
Cardiologists perform an alarming number of expensive and high-risk interventional surgical procedures -- namely, coronary artery bypass surgery and angioplasty with stent placement -- in men and women with coronary artery disease whose condition is stable. According to the Agency for Healthcare Research and Quality, one in six American healthcare dollars is spent on these cardiac procedures -- a stunning $60 billion every year.
And yet, there is no scientific evidence that such high-cost surgeries are preferable to low-cost lifestyle intervention and medical therapy in stable patients. In fact, the consensus among the most reputable scientific studies concludes that the majority of coronary bypass and angioplasty surgeries performed on medically stable patients are unnecessary.
Counseling medically stable patients about diet, exercise, stress management and smoking cessation is relatively inexpensive and has been proven in dozens of studies to help prevent a future heart attack and lower the risk of cardiovascular death. Unfortunately this proven treatment approach is rarely reimbursed by insurance. In other words, surgical procedure-oriented modern cardiology and the insurance companies that cover it are pound wise and penny foolish -- and no one is watching the shop.
Three major national studies proved that for the majority of patients, bypass surgery is no more effective than conservative medical treatment. And every major study has shown that putting stents in stable patients is no more protective than following a heart-healthy lifestyle and taking medication to reduce cardiac risk.
The studies have also shown that stents sometimes make matters worse, by increasing the chance that a dangerous clot will form in a coronary artery, thus raising the risk of a heart attack or sudden death, as noted in 2006 by an advisory panel to the Food and Drug Administration. Unless the patient was in the midst of a heart attack, the opening of a blocked coronary artery with an angioplasty catheter resulted in a worse outcome compared to management through lifestyle intervention and medication.
There are exceptions, of course -- patients for whom bypass, angioplasty and stents are necessary and lifesaving interventions. These are patients in the throes of a heart attack and those with disabling chest pain despite medical therapy. But such ``unstable'' patients represent only a minority of those undergoing these costly, sometimes risky procedures.
I am certain that my physician colleagues in other areas of medicine can cite similar examples of wasteful spending caused by the excessive overuse of expensive, unnecessary treatment.
As a physician who has been practicing medicine for almost three decades, I propose the following practical solutions to our current healthcare dilemma.
Rather than the government's instituting universal healthcare and a public option for healthcare insurance, patients and doctors alike should insist instead on a sensible approach to medical care in America, emphasizing preventive care and allowing expensive and high-risk procedures only if there is scientific evidence to support them.
In addition, let's adopt legislation that will eliminate frivolous lawsuits that are holding American medicine hostage, forcing doctors to practice defensive medicine, which subjects Americans to needless tests and interventions to the tune of billions of wasted dollars each year.
We should also adopt prescription-drug reform and allow Americans to purchase prescription medications outside the United States at a substantial savings. This will ultimately lower prescription drug costs in America.
Finally, let us institute controls on the health-insurance industry that will lower the cost of health insurance and still allow the industry to compete in a free-market environment. For those who cannot afford insurance because of economic hardship, let us provide low cost or free medical care at teaching hospitals and clinics as well as not-for-profit hospitals and clinics that enjoy significant tax benefits.
This approach will cost us less in the long run than the universal healthcare/public-option proposal now being volleyed about in Congress. It will allow a robust free-market approach to healthcare to continue and prosper. Just as with Wall Street, we need government oversight, not a government takeover.
Dr. Michael D. Ozner is medical director for wellness and prevention at Baptist Health South Florida and author of The Great American Heart Hoax.
CAR(DIAC) JAM Keping the Freeways of Your Heart Clear
In the race to control heart disease, managing cholesterol has been at the head of the pack. Michael Ozner, MD, renowned cardiologist and author of the best-selling books, The Great American Heart Hoax and The Miami Mediterranean Diet, explains why we need to know more about cholesterol than just our total number to prevent cardiovascular disease.
What do we know today about cholesterol?
We have been led to believe that cholesterol is a villain. But it is necessary for the body to make cell walls, steroid and hormone production, and for other purposes like emulsifying fats as part of the bile system.
In our cardiovascular system, there is an understanding that cholesterol is indisputably linked to atherosclerosis, or the buildup of fatty deposits in the blood vessel wall. Cholesterol comes from two sources: dietary cholesterol from what we eat and cholesterol that is primarily produced in the liver. Cholesterol made in the liver must be transported by lipoprotein particles in the blood, which carry the cholesterol (low-density lipoprotein, or LDL, and high-density lipoprotein, or HDL) and triglycerides to tissues in the body.
What happens to transported LDL?
When LDL cholesterol levels are elevated in our blood, the cholesterol-carrying particles can enter the artery wall. Once there, a network or matrix-like system in the vessel walls traps LDL-cholesterol particles like a spider web traps a fly. Retention of cholesterol particles leads to oxidation, and oxidized LDL particles attract inflammatory cells like sharks sensing blood.
These inflammatory cells identify the oxidized LDL particle as a foreign invader, and take up these particles leading to “foam” cells. The foam cells lead to an atherosclerotic plaque. Inflammation drives this process and contributes to the progression of the plaque, the rupture of the plaque and the clot that forms post rupture that can lead to acute cardiovascular events, such as heart attacks and strokes.
Is knowing your LDL level enough?
Your LDL level is part of the picture. Knowing the number of LDL particles (lipoproteins) transporting the cholesterol is also very important. For example, we can use a traffic jam as an analogy. The car is the LDL particle (lipoprotein) transporting the passenger (cholesterol). It is the total number of passengers (cholesterol) that create a traffic jam moving into the artery wall. So 100 LDL particles are more likely to create a jam than one large particle.
How do we keep the number of total LDL particles low?
Nutrition is the single most important factor. Cholesterol comes from eating animal products, so limit consumption of meat, cheese, milk and eggs. In addition, avoid saturated fat and trans-fat that can also raise LDL-cholesterol levels. A Mediterranean diet has been shown to lower LDL-cholesterol and inflammation. Regular exercise raises our good (HDL) cholesterol. A list of additional measures that lower bad cholesterol and reduce inflammation is outlined in The Great American Heart Hoax.
Enhancing Longevity through the Miami Mediterranean Diet
By Michael Ozner, MD, FACC, FAHA - Feb 20, 2009
While most people relentlessly pursue diet after diet to lose weight, often with mixed results, there is one diet that not only helps you safely lose weight but can also dramatically reduce your risk of heart disease as well. In countless studies, a Mediterranean-style diet has been proven to lower inflammatory markers, reduce metabolic syndrome, eliminate many of the risk factors that contribute to cardiovascular disease, and lower one’s exposure to cancer. In short, this is a diet and a lifestyle that not only can make you look and feel great but can help you live a longer, healthier life at the same time.
In my clinical practice as a preventive cardiologist, I have seen the impressive results of my Miami Mediterranean Diet not only help people lose weight but actually save lives. Characterized by whole grains and legumes, lean protein, fresh fruits and vegetables, and plenty of heart-healthy olive oil, the Mediterranean diet has been clinically proven-again and again-to arrest the degenerative factors that lead to many of our most lethal diseases. The Miami Mediterranean Diet is about preventing cardiovascular disease by reducing inflammation and neutralizing free radicals that lead to heart disease, cancer, and numerous other diseases. Can we defeat cardiovascular disease and its manifestations (heart attack, stroke, peripheral vascular disease)? The answer is yes! And prevention – not intervention – is the key.
The Mediterranean Diet Revolution
As a preventive cardiologist, I have often taken a position that is the polar opposite of many of my colleagues. I firmly believe that we do far too much intervention in this country – invasive procedures like stents, balloon angioplasties, bypass surgeries and not enough prevention. As doctors, if we seriously invested the time in teaching our patients how to prevent heart disease, we could actually see a significant drop in the amount of cardiovascular mortality in this country. And given that every 36 seconds, someone in America dies of an illness related to cardiovascular disease, there’s clearly plenty of need for better prevention. In recent years, I’ve devoted nearly as much time to lecturing as I have to seeing patients. Traveling all over the world, I eagerly spread the word about the benefits of the Miami Mediterranean Diet. The reason is simple: cardiovascular disease prevention is a topic that is near and dear to my own heart.
My “Eureka” Moment
I first became interested in this remarkably healthful diet about a quarter of a century ago. I remember I had just returned home, late one evening, after a full day of performing a half-dozen or so balloon angioplasties on my patients. Exhausted, I sat down to unwind with some reading material, and came across an article written by University of Minnesota scientist. Ansel Keys, PhD.14 15 It described the groundbreaking, Seven Countries Study, which established that the dietary patterns of people living in the Mediterranean region were associated with better health and longer life. A middle-aged Greek man, for instance, was 90% less likely to have cardiovascular disease than a comparable man in the West.
That’s when a light bulb went off for me. I thought, “Wait a minute, this is crazy, we’re doing it all wrong!” I had just done one half-dozen interventional procedures, and here was information that could have prevented the problem with something as simple as diet and lifestyle.
I had always believed that vascular disease – atherosclerosis – was a metabolic disorder. And this suggested that it required a metabolic solution. So I sat down and typed up 20 to 30 pages describing the diet and lifestyle I wanted my patients to follow. It was a simple patient handout. And guess what? I found that it really worked. Ninety-five percent of my patients were losing weight, lowering their blood pressure, reducing their detrimental low-density lipoprotein (LDL), raising their beneficial high-density lipoprotein (HDL), and getting healthier.
Eventually, my intervention-oriented colleagues started asking, “Why aren’t you sending us more cases?” They wondered why I wasn’t sending patients to the cardiac catheterization lab anymore. The simple answer is that my patients were getting better-without invasive procedures like stents, angioplasties, or bypass surgeries. It was revolutionary!
I’ve come to believe that we’re marching down the wrong path in the United States. We have this “quick-fix” attitude. If a patient develops cardiovascular disease, our treatment is to put in a stent, or to do a triple-bypass operation. While emergency coronary intervention with stent placement and other forms of intervention is often appropriate and necessary in unstable coronary syndromes or for patients in the throes of a heart attack, intervention has never been shown to decrease the risk of a future heart attack or prolong life compared with lifestyle changes and medical therapy in stable patients with coronary artery disease. In fact there’s no evidence that putting in a stent or performing a surgical bypass prevents future heart attacks – none. But we keep on doing invasive interventions on stable patients. What we’re doing is wrong. Its much better to put a patient on the Mediterranean diet and lifestyle and medical therapy (as needed) to successfully address the underlying metabolic derangements.
Originally I called my handout the “Cardiovascular Disease Prevention Diet and Lifestyle,” but soon word got out, and people all over the country were calling my office asking for my “Miami Mediterranean Diet.” I gladly sent copies, and the idea for a book was born. It was clear that the information contained in my hand-out was changing people’s lives. In order to provide as much guidance as possible, I decided to write the Miami Mediterranean Diet in order to provide a working blueprint for anyone who wants to lose weight and reduce their exposure to coronary heart disease, hypertension, diabetes, Alzheimer’s disease, and cancer. As I watched people change their eating habits and increase their health, I knew that it was time to update the book and have just released the 2008 expanded edition of the Miami Mediterranean Diet. The benefits of this eating plan go beyond good health, in my experience, if you are healthy on the inside, you are going to look fantastic on the outside, too!
Ancient Traditions, Modern Diet
But what exactly is the Mediterranean diet? At least one researcher has defined it as, “the dietary pattern found in the olive-growing areas of the Mediterranean region, in the late ‘50s and early ‘60s, when the consequences of World War II were overcome, but the fast-food culture had not reached the area yet.”16 But as another leading researcher points out, the term “Mediterranean diet,” implying that all Mediterranean people have the same diet, is a misnomer. The countries around the Mediterranean basin have different diets, religions and cultures.”17 So what I did, in developing the Miami Mediterranean diet, was to combine elements from all the best of those cultures and cuisines, guided by both tradition and modern science. The result is a diet that reflects the ancient dietary traditions of the Mediterranean basin, adapted for a modern American public in desperate need of nutritional guidance. Although I’ve successfully leveraged the principles of the Mediterranean diet in my medical practice for more than two decades, it seems the world has only recently begun to notice what my patients have known for years - this is a diet and lifestyle that works. And scientific validation of the diet’s health claims has accumulated dramatically in the past decade. In the two short years since the publication of the first edition of the Miami Mediterranean Diet, for instance, numerous clinical trials published in the medical literature have confirmed my message - this diet works; this diet saves lives.1,3-13,18-23
Few, if any other diets, can claim as much with equal authority. For thousands of years the people of the Mediterranean region have benefited from this healthful lifestyle. Of course, they didn’t set out to adopt a specific diet with carefully targeted benefits. Rather, they drew sustenance from the land and the sea as their forbears had always done. They cultivated olive and fruit trees and vegetable and herb gardens, raised sheep and goats, and harvested grains and the bounty of the sea. They were only doing what seemed natural, but as it happens, theirs is a uniquely healthful diet and lifestyle. Extra-virgin olive oil, for instance, is remarkably heart healthy since it lowers harm for LDL. It also helps to prevent oxidation of LDL through the action of its abundant polyphenols.5,6,8,24,25 Likewise, fresh vegetables, fruits, nuts, beans, fish, and red wine (consumed in moderation) all contribute to true health benefits of the Mediterranean diet. Red meat is infrequently consumed, and even then, it is ordinarily used simply to flavor dishes such as soups and stews.
Recent rigorous science has proven it. From weight loss to improved lipid profiles and significantly reduced risk of developing a variety of cancers, osteoporosis, stroke, and even Alzheimer’s disease, 3,4,9,11,12,21,26-30 adherents of the Mediterranean diet reap numerous long-term benefits that are virtually guaranteed to deliver longer, healthier life.
Of course, it’s not all due to food alone. My book also emphasizes the importance of exercise and stress reduction for maximum health benefits. The Mediterranean lifestyle includes daily exercise, which is as important to good health as a proper diet. Stress reduction is another integral component of this heart friendly regimen. Exercise, diet and stress reduction are complementary activities in my New World version of this longevity-inducing Old World lifestyle. “The Mediterranean diet and lifestyle can help reduce our level of stress”, I wrote, in the original Miami Mediterranean Diet. “Meals are enjoyed with family and friends in a relaxed fashion, with ample time for friend’s conversation. Often a short nap or ‘siesta’ follows the meal.” And as un-American as a mid-day nap may sound, brief naps may actually improve both productivity and overall health.31, 32
Bountiful Evidence: the Inflammation Connection
Why does the Mediterranean diet work? One theory is that this diet significantly reduces saturated fat consumption and eliminates trans fat intake, thereby reducing atherosclerosis and significantly improving cardiovascular health. Another is that it reduces inflammation. Still another is that it supplies significant quantities of free radical-fighting antioxidants. Perhaps all these factors play a role. Extensive research has certainly demonstrated the role of inflammation in the development and progression of degenerative diseases, such as heart disease, cancer, and diabetes.23, 33-36
Key components of the Mediterranean diet have been shown to be anti-inflammatory. Among these are omega-3 fatty acids from fish.37,38 In contrast, the typical American diet, with its high content of saturated fat, trans fatty acids, and omega-6 fatty acids, is pro-inflammatory. 35, 39-45
The results of such a diet became apparent late last year, when British researches published the findings from a decade-long prospective study on a large sample of the aging US population. By gleaning information about diet and mortality from the National Institutes of Health-AARP Diet and Health Study scientists were able to determine the extent to which conforming to a classic Mediterranean diet influences life span.
They discovered that “the Mediterranean diet was associated with reduced all-cause and cause-specific mortality.” In women, the greater the conformity to the tenets of the diet, the greater the benefits, including, “decreased risks that ranged from 12% for cancer mortality to 20% for all-cause mortality.” 3 This is a remarkable validation of a particular dietary pattern, especially given the study's robust sample size of more than 380,000 American men and women.
Another large study published by Greek researchers last year documented improvements in insulin sensitivity, as well as decreases in cholesterol levels and systolic blood pressure, even among overweight and obese men and women who at least came “close” to sticking to the Mediterranean diet.4 The study yielded data showing that subjects with the greatest adherence to the classic Mediterranean diet were more likely to have normal blood glucose metabolism. This implies that this diet is also protective against type 2 diabetes.
A previous report by the same Greek research team concluded that greater adherence to the Mediterranean diet was associated with a reduced incidence of obesity.12 In other words, the Mediterranean diet is slimming, not fattening. Of course, my patients and I have known that for years.
The traditional Mediterranean diet has long been associated with long life span and a decreased risk of degenerative disease, and modern science now confirms the vast benefits of this style of eating. Now you too can reap the benefits of this traditional diet, using the guidelines and menu plans outlined in the Miami Mediterranean Diet.
Delicious and satisfying, the Miami Mediterranean diet has helped many individuals to improve their cardiovascular health, avoid invasive procedures, lose weight, avert diabetes and metabolic syndrome, and maintain their youthful vitality. I hope you’ll join us in following this healthful diet and lifestyle. It could just save your life.
Read This Before Saying Yes To Bypass Surgery
Michael Ozner, M.D.
Bottom Line Health
The three - year survival rate for most patients who have had bypass surgery is almost exactly the same as it is for patients with heart disease who don’t have surgery.
Good News: With medications and lifestyle changes, the vast majority of patients with heart disease can reduce the risk of a future heart attack by up to 80% - without undergoing expensive and risky procedures.
More than half a million Americans die each year from heart disease. The majority suffer from coronary artery disease (CAD). This is caused by atherosclerosis, a condition in which a buildup of fatty deposits (called plaque) in the coronary arteries causes blockages that restrict blood flow to the heart. The plaque may rupture and result in a blood clot in the artery, which can shut off the blood supply and lead to a sudden heart attack.
Many doctors view CAD primarily as a plumbing problem. When imaging tests reveal blockages in the arteries, their first instinct is to clear out the “gunk”, whether or not a patient is experiencing troublesome symptoms.
This approach is often flawed. Most bypass and stent procedures are the equivalent of cosmetic cardiology. They make blood vessels appear healthy but do little to reduce heart attack risk. In fact, most heart attacks are caused by tiny blockages that can be hard to detect – and these blockages often are not in the blood vessels that triggered all the concern in the first place.
Surgical procedures are risky. The mortality rate from bypass surgery ranges from 3% to 5%. More than 50% of patients may experience cognitive difficulties after surgery, and patients who have bypass surgery are nearly four times more likely to suffer a subsequent stroke. Those are poor odds for procedures that don’t necessarily prolong life or make patients healthier.
Some patients – those with unstable CAD – do require intervention, such as bypass surgery or a stent procedure. Example: A person with critical blockages in multiple coronary arteries and a weak heart muscle.
Most patients with CAD, however, are stable and unlikely to benefit from a bypass or stent. They are the best candidates for what might be called a medical bypass. With medication and lifestyle changes, most of these patients can eliminate symptoms (if any) and reduce heart attack risk. Only in rare cases, if symptoms get worse, would one of these patients need to consider medical intervention.
One key factor in cardiovascular health is to have an ongoing relationship with your doctor – he/she can advise you on the best steps to take to prevent and treat heart disease. He may recommend that you…
Follow a Mediterranean-style diet. Eat lots of fruits, vegetables, whole grains and legumes…olive oil instead of butter or margarine…several servings of fish weekly…and no more than a few weekly servings of lean meats.
The landmark Lyon Diet Heart Study, which followed more than 600 participants for almost four years, showed that people who ate a Mediterranean diet instead of a typical American diet had a 50% to 70% reduction in recurrent cardiovascular disease.
Relax with yoga, meditation, exercise, etc. Doctors don’t always ask patients about stress – which is why it is sometimes called the “forgotten” risk factor for heart disease. People who successfully manage stress can significantly lower blood pressure and the risk of heart disease. Stress management also lowers the risk for arrhythmias (heart rate irregularities).
Exercise daily for 30 to 45 minutes. It is one of the best ways to maintain a healthy weight and prevent or control diabetes and high blood pressure. Regular exercise raises levels of HDL “good” cholesterol. It also can contribute to weight control – which can reduce inflammation in the blood vessels, a risk factor for CAD.
All forms of exercise are beneficial. Aerobic exercise, such as brisk walking, is the best choice for most people because it doesn’t require a high level of fitness to do it.
Get your cholesterol checked – and take cholesterol-lowering medication if necessary. Everyone should have a blood test for cholesterol annually. Research indicates than aggressive lowering of LDL cholesterol helps reduce risk of heart disease and death form CAD. Bonus: Cholesterol-lowering statin drugs also reduce inflammation in the blood vessels.
Take a baby aspirin daily. It helps prevent platelets from clumping together and forming clots that can block blood flow to the heart. The anti-inflammatory effects of aspirin are also beneficial. Since aspirin may cause gastrointestinal upset and/or bleeding, talk with your doctor before initiating aspirin therapy for CAD prevention.
See your dentist twice a year. Studies have shown that patients with periodontal disease – gum inflammation that can results in tooth loss – have a higher risk of heart attack and stroke than those without it.
Get more omega-3s. Most Americans are deficient in omega-3 fatty acids. Omega-3s lower inflammation and triglycerides, a fat that can put you at risk for heart disease. Omega-3s reduce the risk of arrhythmias and heart attack. Sources of omega-3s include coldwater fish, such as salmon, and plant sources, such as walnuts and flaxseed. Or ask your doctor about taking a fish oil supplement
The New York Times
January 6, 2009
More Isn’t Always Better in Coronary Care
By JANE E. BRODY
Ira’s story is a classic example of invasive cardiology run amok.
Ira, of Hewlett, N.Y., was 53 when he had an exercise stress test as part of an insurance policy application. Though he lasted the full 12 minutes on the treadmill with no chest pain, an abnormality on the EKG led to an angiogram, which prompted the cardiologist to suggest that a coronary artery narrowed by atherosclerosis be widened by balloon angioplasty, with a wire-mesh tube called a stent inserted to keep the artery open.
The goal, he was told, was to prevent a clot from blocking the artery and causing a heart attack or sudden cardiac death.
Wanting to avoid an invasive procedure, Ira decided to pursue a less drastic course of dieting, weight loss and cholesterol-lowering medication. But three years later, the specter of a stent arose again. An abnormal reading on a presurgical EKG led to another angiogram, which indicated that the original narrowing had worsened. Cowed by the stature of the cardiologist, Ira finally agreed to have not one but three coronary arteries treated with angioplasty and drug-coated stents, making him one of about a million Americans who last year underwent angioplasties, most of whom had stents inserted.
Being Treated While Healthy
For patients in the throes of a heart attack and those with crippling chest pain from even minor exertion, angioplasty and stents can be lifesaving, says Dr. Michael Ozner, a Miami cardiologist and the author of “The Great American Heart Hoax” (Benbella Books, $24.95). But, Dr. Ozner said in an interview, such “unstable” patients represent only a minority of those undergoing these costly and sometimes risky procedures.
Most stent patients are healthy like Ira, who was experiencing no chest pain or cardiac symptoms of any sort. Yet Ira was afraid not to follow the doctor’s advice, despite the fact that no study has shown that these procedures in otherwise healthy patients can reduce the risk of heart attacks, crippling angina or sudden cardiac death. “We’ve extended the indications for surgical angioplasty and stent placement without any data to support the procedures in the vast majority of patients — stable patients with blockages in their arteries,” Dr. Ozner said.
What the studies do show, Dr. Ozner said, is that putting stents in such patients is no more protective than following a heart-healthy lifestyle and taking medication and, if necessary, nutritional supplements to reduce cardiac risk. The studies have also shown that stents sometimes make matters worse by increasing the chance that a dangerous clot will form in a coronary artery, as noted in 2006 by an advisory panel to the Food and Drug Administration.
Dr. Ozner, medical director of the Cardiovascular Prevention Institute of South Florida, is one of many prevention-oriented cardiologists vocal about the overuse of “interventional cardiology,” a specialty involving invasive coronary treatments that have become lucrative for the hospitals and doctors who perform them.
Even some interventional cardiologists have expressed concern about the many patients without symptoms who are treated surgically. “The only justification for these procedures is to prolong life or improve the quality of life,” said Dr. David L. Brown, an interventional cardiologist and chief of cardiology at Stony Brook University Medical Center, “and there are plenty of patients undergoing them who fit into neither category.”
The treatments — coronary artery bypass surgery, angioplasty and the placement of drug-coated stents — cost about $60 billion a year in the United States. Though they are not known to prevent heart attacks or coronary mortality in most patients, they are covered by insurance. Counseling patients about diet, exercise and stress management — which is relatively inexpensive and has been proved to be life-extending — is rarely reimbursed. In other words, procedure-oriented modern cardiology is pound wise and penny foolish. And in these economic times, it makes great sense to reconsider the approaches to reducing morbidity and mortality from the nation’s leading killer.
Most people mistakenly think of coronary artery disease as a plumbing problem. Influenced by genetics, diet, diabetes, hypertension, smoking and other factors, major arteries through which oxygen-rich blood flows to the heart gradually become narrowed by deposits of cholesterol-rich plaques until blood can no longer pass through, resulting in a heart attack.
In coronary bypass surgery, a blood vessel taken from elsewhere in the body is reattached to a clogged coronary artery to bypass the narrowed part.
However, as Dr. Ozner points out in his book, “three major studies performed in the late 1970s and early 1980s clearly proved that for the majority of patients, bypass surgery is no more effective than conservative medical treatment.” The exceptions — patients whose health and lives could be saved — were those with advanced disease of the left main coronary artery and those with severe crippling, or unstable, angina.
Bypass surgery does relieve the pain of angina, though recent studies suggest this may happen because pain receptors around the heart are destroyed during surgery.
“The studies on angioplasty delivered even worse news,” Dr. Ozner wrote. “Unless the patient was in the midst of a heart attack, the opening of a blocked coronary artery with a balloon catheter resulted in a worse outcome compared to management through medication.” In fact, one trial, published in 2003 in The Journal of the American College of Cardiology, found that balloon angioplasty, which flattens plaque against arterial walls, actually raised the risk of a heart attack or death.
Stents were designed to keep the flattened plaque in place. But studies of stable patients found no greater protection against heart attacks from stents than from treatments like making lifestyle changes and taking drugs to lower cholesterol and blood pressure.
A Small Culprit
A new understanding of how most heart attacks occur suggests why these procedures have not lived up to their promise. According to current evidence, most heart attacks do not occur because an artery is closed by a large plaque. Rather, a relatively small, unstable plaque ruptures and attracts inflammatory cells and coagulating agents, leading to an artery-blocking clot.
In most Americans middle age and older, small plaques are ubiquitous in coronary arteries and there is no surgical way to treat them all.
“Interventional cardiology is doing cosmetic surgery on the coronary arteries, making them look pretty, but it’s not treating the underlying biology of these arteries,” said Dr. Ozner, who received the 2008 American Heart Association Humanitarian Award. “If some of the billions spent on intervention were put into prevention, we’d have a much healthier America at a lower cost.”
Dr. Ozner advises patients who are told they need surgery to get an independent second opinion from a specialist.
This is the first of two columns on preventing heart attacks. Next week: Noninvasive remedies that work
The New York Times
January 13, 2009
New Thinking on How to Protect the Heart
By JANE E. BRODY
If last week’s column convinced you that surgery may not be the best way to avoid a heart attack or sudden cardiac death, the next step is finding out what can work as well or better to protect your heart.
Many measures are probably familiar: not smoking, controlling cholesterol and blood pressure, exercising regularly and staying at a healthy weight. But some newer suggestions may surprise you.
It is not that the old advice, like eating a low-fat diet or exercising vigorously, was bad advice; it was based on the best available evidence of the time and can still be very helpful. But as researchers unravel the biochemical reasons for most heart attacks, the advice for avoiding them is changing.
And, you’ll be happy to know, the new suggestions for both diet and exercise are less rigid. The food is tasty, easy to prepare and relatively inexpensive, and you don’t have to sweat for an hour a day to reap the benefits of exercise.
The well-established risk factors for heart disease remain intact: high cholesterol, high blood pressure, smoking, diabetes, abdominal obesity and sedentary living. But behind them a relatively new factor has emerged that may be even more important as a cause of heart attacks than, say, high blood levels of artery-damaging cholesterol.
That factor is C-reactive protein, or CRP, a blood-borne marker of inflammation that, along with coagulation factors, is now increasingly recognized as the driving force behind clots that block blood flow to the heart. Yet patients are rarely tested for CRP, even if they already have heart problems.
Even in people with normal cholesterol, if CRP is elevated, the risk of heart attack is too, said Dr. Michael Ozner, medical director of the Cardiovascular Prevention Institute of South Florida. He thinks that when people have their cholesterol checked, they should also be tested for high-sensitivity CRP.
The new dietary advice is actually based on a rather old finding that predates the mantra to eat a low-fat diet. In the Seven Countries Study started in 1958 and first published in 1970, Dr. Ancel Keys of the University of Minnesota and co-authors found that heart disease was rare in the Mediterranean and Asian regions where vegetables, grains, fruits, beans and fish were the dietary mainstays. But in countries like Finland and the United States where plates were typically filled with red meat, cheese and other foods rich in saturated fats, heart disease and cardiac deaths were epidemic.
The finding resulted in the well-known advice to reduce dietary fat and especially saturated fats (those that are firm at room temperature), and to replace these harmful fats with unsaturated ones like vegetable oils. What was missed at the time and has now become increasingly apparent is that the heart-healthy Mediterranean diet is not really low in fat, but its main sources of fat — olive oil and oily fish as well as nuts, seeds and certain vegetables — help to prevent heart disease by improving cholesterol ratios and reducing inflammation.
It was not until 1999 that the value of a traditional Mediterranean diet was confirmed, when the Lyon Diet Heart Study compared the effects of a Mediterranean-style diet with one that the American Heart Association recommended for patients who had survived a first heart attack.
The study found that within four years, the Mediterranean approach reduced the rates of heart disease recurrence and cardiac death by 50 to 70 percent when compared with the heart association diet.
Several subsequent studies have confirmed the virtues of the Mediterranean approach. For example, a study among more than 3,000 men and women in Greece, published in 2004 by Dr. Christina Chrysohoou of the University of Athens, found that adhering to a Mediterranean diet improved six markers of inflammation and coagulation, including CRP, white blood cell count and fibrinogen.
The same year Kim T. B. Knoops, a nutritionist at Wageningen University in the Netherlands, and co-authors published a study showing that among men and women ages 70 to 90, those who followed a Mediterranean diet and other healthful practices, like not smoking, had a 50 percent lower rate of deaths from heart disease and all causes.
“The Mediterranean diet is one people can stick to,” said Dr. Ozner, author of “The Miami Mediterranean Diet” and “The Great American Heart Hoax” (BenBella, 2008). “The food is delicious, and the ingredients can be found in any grocery store.
“You should make most of the food yourself,” Dr. Ozner added. “When the diet is stripped of lots of processed foods, you ratchet down inflammation. Among my patients, the compliance rate — those who adopt the diet and stick with it — is greater than 90 percent.”
Among foods that help to reduce the inflammatory marker CRP are cold-water fish like salmon, tuna and mackerel; flax seed; walnuts; and canola oil and margarine based on canola oil. Fish oil capsules are also effective. Dr. Ozner recommends cooking with canola oil and using more expensive and aromatic olive oil for salads.
Other aspects of the Mediterranean diet — vegetables, fruits and red wine (or purple grape juice) — are helpful as well. Their antioxidant properties help prevent the formation of artery-damaging LDL cholesterol.
Several recent studies have linked periodontal disease to an increased risk of heart disease, most likely because gum disease causes low-grade chronic inflammation. So good dental hygiene, with regular periodontal cleanings, can help protect your heart as well as your teeth.
Reducing chronic stress is another important factor. The Interheart study, which examined the effects of stress in more than 27,000 people, found that stress more than doubled the risk of heart attacks.
Dr. Joel Okner, a cardiologist in Chicago, and Jeremy Clorfene, a cardiac psychologist, the authors of “The No Bull Book on Heart Disease” (Sterling, 2009), note that getting enough sleep improves the ability to manage stress.
Practicing the relaxation response once or twice a day by breathing deeply and rhythmically in a quiet place with eyes closed and muscles relaxed can help cool the hottest blood. Other techniques Dr. Ozner recommends include meditation, prayer, yoga, self-hypnosis, laughter, taking a midday nap, getting a dog or cat, taking up a hobby and exercising regularly.
He noted that in a 1996 study, just 15 minutes of exercise five days a week decreased the risk of cardiac death by 46 percent.
Even very brief bouts of exercise can be helpful. A British study published in the current American Journal of Clinical Nutrition found that accumulating short bouts — just three minutes each — of brisk walking for a total of 30 minutes a day improved several measures of cardiac risk as effectively as one continuous 30-minute session.
This is the second of two columns on cardiac care. Last week: The drawbacks to interventional cardiology
The Baltimore Sun
Heart-stent popularity is costly in many ways
January 22, 2010
Did hundreds of patients at St. Joseph Medical Center get heart stents when they weren't called for under accepted medical standards?
That's a disturbing question. But for taxpayers, insurers and most medical consumers, it pales next to this one: Are millions of patients getting stents that are unnecessary even when the rules give doctors a green light?
Accumulating evidence says the answer is yes.
"In many instances we're seeing it overused and in some instances abused," says Dr. William E. Boden, a professor at the University at Buffalo Schools of Medicine & Public Health who led a major study on stent effectiveness. "Surgeons and hospitals get reimbursed handsomely for doing procedures."
Don't let the situation at St. Joseph, where patients received stents when they might have had only slightly blocked arteries, obscure the big picture. Most people getting stents don't need them even if scans show substantial blockage, studies suggest. Stents can be dangerous, too.
"You're trading one disease for another - the disease of having a blockage for the disease of having a metallic stent in your heart. And that is a disease, make no mistake," says Dr. Michael Ozner, medical director of the Cardiovascular Prevention Institute of South Florida. "These procedures are not without risk."
Thanks to extraordinary promotion and advertising, stents have become a multibillion-dollar business, substantially contributing to soaring medical-insurance costs and federal deficits. They're a perfect illustration of why American health care costs more but delivers less.
The popularity of the tiny tubes, intended to prop open clogged heart vessels, took off when companies began coating them with drugs to prevent arteries from reclogging. But the coated versions cost as much as three times more than bare-metal stents.
Dr. Mark Midei, the surgeon associated with the implants questioned by Towson-based St. Joseph, was an early proponent.
"This is the hottest thing in cardiology in years," he told The Sun in 2003, referring to the drug-coated Cypher stent made by Johnson & Johnson's Cordis division.
Cordis turned up the buzz with an expensive TV-ad campaign for Cypher that ran nationwide in 2007 but also aired exclusively in Baltimore in early 2008.
Health-policy professionals were used to companies hawking pills directly to patients. Even so, J&J's "Life Wide Open" stent commercial shocked them because it expanded the pitch to medical hardware.
Baltimore "was apparently a key market for Cordis at the time, given the proximity of a lot of hospitals in that region," said J&J spokeswoman Carol Goodrich.
Boy, was it. Last fiscal year, Maryland hospitals did $222 million in stent-related business, a two-thirds increase from fiscal 2002, just before the launch of the coated stents, according to the Health Services Cost Review Commission. And that doesn't count doctor charges.
Stent business at St. Joseph jumped even higher, going from $22 million to $38 million in the same period, the commission says.
Competition for stent spoils helped set off a bitter split at MidAtlantic Cardiovascular Associates, a big Baltimore cardiology practice. It also prompted a federal investigation that preceded the revelation of alleged clinical irregularities at St. Joseph.
Did patients benefit as much as the medical industry? Nobody suggests stents don't save lives when somebody is having a heart attack. But Boden's study and others show little benefit and lots of risk for patients with partly-blocked vessels who aren't in cardiac distress, doctors say. That's most stent cases.
"There has never been a study showing that people who are stable who get stents live one day longer or have fewer heart attacks" than patients with similarly blocked arteries who don't, said Ozner, author of "The Great American Heart Hoax."
In fact, medicine is revisiting the whole Roto-Rooter model that assumes vessel blockage is the main predictor of a heart attack. The worse culprits are often inflammation and smaller plaques that break off and cause clots.
Numerous patients getting stents would be better off exercising, changing diet, losing weight and taking appropriate drugs, says Boden. That way they won't risk the surgical complications of implants and, in the case of coated stents, won't have to take blood thinners for years.
But nobody makes money giving patients sensible and conservative advice.