Suggested Citation: Garko, M.G. (2013, February). Coronary heart disease – Part IV: Modifiable Risk Factors. Health and Wellness Monthly. Retrieved (insert month, day, year), from www.letstalknutrition.com.
Coronary heart disease (CHD) is among the more preventable of the chronic diseases. Yet, “heart disease has been the leading cause of death in the United States since 1921 ….” (Centers for Disease Control and Prevention, 1999, p. 649). Approximately 15.4 million American 20 years of age and older suffer from CHD (Go et al., 2013).
CHD alone accounted for or otherwise caused approximately one of every six deaths in the United States in 2009 (the most recent year reported). In 2009, CHD caused the death of 386,324 Americans. It is projected that by 2030 the prevalence of CHD will increase approximately 18% from 2013 estimates (Go et al., 2013).
Annually, approximately 635,000 Americans will experience a new coronary attack/event, which is defined as either a first/new hospitalized myocardial infarction(MI)/heart attack or a CHD death), with approximately 280,000 having a recurrent coronary attack as defined. Of the 715,000 first and recurrent MI attacks, approximately 21% (150 000) are silent in nature.
Approximately every 34 seconds, one American experiences a coronary event and approximately every single minute an American will die of such an event (see Go et al., 2013).
Contrary to the myth that it is a man’s disease, CHD is the leading cause of death among both men and women. CHD constitutes more than 50% of all cardiovascular events in men and women 75 years of age and older. For men and women, the lifetime risk of developing CHD after age 40 is 49% and 32%, respectively (see Go et al., 2013).
It is not as if efforts have not been made to conquer CHD. On the contrary, since the turn of the 20th century, medical researchers have engaged in a rigorous and sustained scientific effort to figure out the pathogenesis (i.e., the origin and development) of CHD and how to prevent, detect and treat it (Connor, 1999).
Great strides have been made in identifying cardiac risk factors putting people in peril for developing CHD. Significant progress has been made also in treating CHD. For example, a variety of medicines have been developed such as cholesterol lowering drugs, anticoagulants, aspirin, angiotensin-converting enzyme inhibitors, beta blockers, calcium channel blockers, nitoglycerin, long-acting nitrates, glycoprotein IIb-IIIa inhibitors, thrombolytic agents, etc..
In addition, in the effort to help keep CHD patients alive a number of surgical and intervention procedures have been created such as coronary bypass surgery, cardiac catheterization, balloon angioplasty, stents, directional coronary atherectomy or DCA, percutaneous transluminal rotational atherectomy or PCRA, cutting balloon, etc. (see National Heart Lung and Blood Institute, 2006 & Cleveland Clinic, 2006). Yet, the mortality and morbidity statistics associated with CHD remain grim (see Go et al., 2013).
If CHD is not an entirely unexplained or untreatable chronic disease, then why does it remain unpreventable and reign as the leading cause of death in America? Notwithstanding all of the progress in explaining and treating it, no magic pharmaceutical or technological bullets have been discovered to prevent CHD. Ultimately, preventing and reducing the risk of developing CHD begins with health consumers taking personal responsibility to protect themselves from becoming a CHD statistic.
There are at least three actions health consumers can take in assuming personal responsibility for their cardiovascular health or otherwise preventing CHD: 1. Learn about modifiable and non-modifiable cardiac risk factors associated with CHD, 2. evaluate as objectively as possible with the help of a health care professional if they are at risk for CHD and which cardiac risk factors pertain to them and 3. adopt a diet and lifestyle constituted of nutritional, psychological (i.e., attitudes, values and beliefs) and behavioral features which either eliminate or minimize cardiac risk factors and increase the odds of maintaining a healthy cardiovascular system.
The February, 2013, issue of Health and Wellness Monthly will center on the first of the three recommended actions of personal responsibility to prevent CHD. Specific attention will be given to four health-damaging modifiable risk factors of smoking, physical inactivity, poor nutrition and excessive alcohol consumption, which put people at serious risk factor for CHD and are responsible for many of the biochemical-physiological conditions constituting CHD. Having a grasp of these particular cardiac risk factors can help people make informed healthy diet and lifestyle choices to
protect their overall cardiovascular health and prevent and postpone the onset of CHD, specifically.
Modifiable Behavioral Risk Factors
Generally speaking, modifiable risk factors are changeable/controllable lifestyle behaviors and the biochemical-physiological conditions stemming from them, which increase the likelihood of developing CHD.
An underlying assumption of this definition is that preventing or delaying the onset of CHD and its devastating consequences (i.e., disability and death) can be accomplished by lessening or eliminating cardiac risk-prone behaviors and resulting deleterious, biochemical-physiological outcomes, which are presumed to be treatable and controllable. Decades of epidemiological, experimental, clinical and observational research provide convincing support for this assumption.
CHD is a multi-factorial disease that can be caused by the interplay between and among the variables constituting non-modifiable and modifiable risk factors. That is, increasing age, heredity, environment, lifestyle and diet are all factors which can and most often do interact with one another to bear upon the development of CHD. They also drive the rate and severity of cardiac disease progression and create biochemical-physiological conditions putting people at increased risk for CHD. In short, CHD is not caused by one factor. If it were, then researchers would have announced a cure long ago and it would no longer be the leading cause of death among women and men in the United States and around the globe.
The Big Four Modifiable Risk Factors
A host of modifiable risk factors for CHD are identified in the medical/health literature. While not necessarily definitive, the following list contains 20 modifiable cardiac risk factors cited in the literature on cardiovascular health and disease:
- Poor nutrition/diet
- Physical inactivity
- Excessive alcohol consumption
- High stress levels
- High blood pressure
- Elevated LDL
- Low HDL
- Elevated triglyceride levels
- Glucose intolerance
- Iron overload
- Overweight & Obesity
- Metabolic Syndrome
- Left ventricular hypertrophy
- Lipoprotein (a)
- C-Reactive Protein
The above list of cardiac risk factors reflects unhealthy diet and lifestyle factors and biochemical-physiological conditions, which can be brought about by them and lead to the morbidity and mortality associated with CHD.
The four modifiable diet- and lifestyle-related behaviors of poor nutrition, smoking, physical inactivity and excessive alcohol consumption are especially risk-prone for the development of CHD. As it turns out, cigarette smoking and the combination of poor nutrition-physical inactivity are the most common actual causes of death in the United States. In fact, the combination of physical inactivity and poor nutrition is gaining on smoking as actual causes of death (see Centers for Disease Control and Prevention, 2004). Furthermore, the “[f]our modifiable health risk behaviors—lack of physical activity, poor nutrition, tobacco use, and excessive alcohol consumption—are responsible for much of the illness, suffering, and early death related to chronic diseases” (Centers for Disease Control and Prevention, 2012). Not surprisingly, then, they also play a major role in development of CHD.
There is no scientific or practical doubt that lack of physical activity, poor nutrition, tobacco use, and excessive alcohol consumption play a significant role in creating the biochemical-physiological conditions associated with the development of CHD. This is not to say that genetics, environment and non-modifiable risk factors do not play a role in creating these conditions. However, it is to say that the biochemical-physiological conditions of CHD track back in a significant way to the modifiable, risk-prone behaviors of physical inactivity, poor nutrition, tobacco use and excessive alcohol consumption.
Smoking (particularly cigarette smoking) is the single most important preventable cause of death affecting Americans (American Heart Association 2006a; American Heart Association, 2003).
Prevalence among adults. Among adults 18 years of age and older, 21.3% and 16.7% are men and women cigarette smokers, respectively, for the year 2011. Approximately 69.6 million people in the United States 12 years of age and older are current (past month) users of a tobacco product (e.g., cigarettes, cigars, smokeless tobacco, or tobacco in pipes) for the year 2010. Among people 65 years of age and older, 9.4% and 9.1% are men and women smokers, respectively, for the period 2008 – 2010, (see Go et. al, 2013).
Prevalence among youths/students. In 2011, students in grades 9 – 12, 18.1% reported cigarette use (on at least one day during the 30 days before the American Heart Association survey), while 13.1% reported using cigars and 7.7% reported using smokeless tobacco products. Generally speaking, 23.4% of students reported using tobacco of any sort (see Go et. al., 2013).
Gender makes a difference when it comes to smoking/tobacco use among students. Male students (19.9%) are more likely than female students (16.1%) to smoke cigarettes. Male students 17.8%) are also more likely than female students (8.0%) to smoke cigars (compared with using smokeless tobacco products (see Go et al., 2013).
CHD is among the major sequelae (consequences) of smoking in adults (American Heart Association, 2006a; American Heart Association, 1994).
Cigarette smokers run a two to four time greater risk of stroke compared to nonsmokers or people who have quit smoking for more than ten years. Cigarette smoking is an established independent risk factor for sudden cardiac death in those suffering from CHD. Smokers afflicted with CHD have approximately twice the risk of nonsmokers of dying suddenly from a heart attack (American Heart Association, 2006b).
Further, cigarette smokers have a higher risk of developing atherosclerosis, the underlying disease process of CHD. Atherosclerosis is an inflammatory disease resulting in the accumulation of fat-laden plaque forming lesions (atheromas) on the endothelium (inner walls) of the coronary arteries. Atherosclerosis accounts for the alarmingly high number of deaths attributable to smoking.
In addition to contributing to toxins in the blood from cigarette smoking causing atherosclerosis, cigarette smoking causes (1) sudden cardiac death and congestive heart failure, (2) tachycardia (i.e., heart to beat irregularly, (3) high blood pressure, (4) low HDL (good cholesterol) levels, (5) vasoconstriction of coronary arteries, (6) reduction of oxygen levels in the blood, (7) carbon monoxide to bind to hemoglobin in red blood cells, preventing cardiac related cells to have the proper amount of oxygen, (8) an increase in fibrinogen and homocysteine levels, two risk factors for CHD, (9) an increase in chronic inflammation levels, doing damage to the heart from oxidative stress or otherwise promoting atherosclerosis and (10) a decrease in antioxidants produced by the body to repair cells damaged by oxidative stress from inflammation and (11) thrombosis (blood clots) (see American Heart Association, 2006a; American Heart Association, 2003; American Heart Association, 1994; Life Extension Foundation, 2003; U.S. Department of Health and Human Services 2004). Finally, when smokers finish smoking a cigarette it is estimated they lose eight minutes of life (Life Extension Foundation, 2003).
Cigarette smoking is responsible for more than 467,000 adult deaths annually. Approximately one third of these deaths are related to cardiovascular disease (CVD).
During the period of 2000 – 2004, approximately 49, 000 (11.1%) of deaths related to cigarette smoking were attributable to secondhand smoke; smoking during pregnancy resulted in an estimated 776 infant deaths annually; cigarette smoking resulted in an estimated 269,655 deaths annually among males and 173,940 deaths annually among females (see Go et. al., 2013). In terms of gender, male smokers die on average 13.2 years earlier than male nonsmokers, while female smokers die on average 14.5 years earlier than female nonsmokers
It is well established in the scientific literature that engaging in regular physical activity, fitness, and exercise are fundamental to creating, sustaining and reclaiming health, wellness and wellbeing for people of all ages. According to the U.S. Department of Health and Human Services (2002), “[r]esearch has demonstrated that virtually all individuals can benefit from regular physical activity, whether they participate in vigorous exercise or some type of moderate health-enhancing physical activity. Even among frail and very old adults, mobility and functioning can be improved through physical activity. Therefore, physical fitness should be a priority for Americans of all ages” (p.2).
Prevalence of Sedentary Lifestyle
Yet, the prevalence of a sedentary lifestyle in the United States is astounding. There are some grim statistics showing the dominance of a sedentary lifestyle over a physically active lifestyle. For example, more than 60% of American adults are not regularly active, with 25% of the adult population being totally sedentary during their leisure time. Only approximately 15% of U.S. adults are involved regularly (i.e., three times a week for at least 20 minutes) in vigorous physical activity during leisure time. About 22% of adults engage regularly (i.e., five times a week for at least 30 minutes) in sustained physical activity of any intensity during their leisure time (U.S. Department of Health & Human Services, 1996). The statistics for children and adolescents are not any better. Nearly 50% of American youths 12-21 years of age do not engage in regular, vigorous activity, with physical activity declining dramatically during adolescence. Twenty-five percent of young people report that they are not involved in any vigorous physical activity during their leisure time (see U.S. Department of Health & Human Services, 1996).
The following findings on Leisure-time Physical Activity Status from the Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2011, provides a recent and specific portrait of America’s sedentary lifestyle in terms of aerobic activity, strengthening activity, gender and race differences, education and living in a metropolitan statistical area (MSA):
- According to the 2008 federal physical activity guidelines for aerobic activity only, 32% of adults were inactive, 19% of adults were insufficiently active, and 49% were sufficiently active based on their participation in leisure-time physical activity.
- According to the 2008 federal physical activity guidelines for aerobic and strengthening activity combined, 48% of adults met neither the aerobic nor muscle-strengthening guideline, 4% met the muscle-strengthening guideline only, 28% met the aerobic guideline only, and 21% met the full guidelines for both aerobic and muscle-strengthening activity, based on their participation in leisure-time physical activity.
- Women were more likely than men to be inactive or insufficiently active and less likely to be sufficiently active in terms of aerobic leisure-time physical activity. Men were more likely than women to have met the full guidelines for both aerobic and muscle-strengthening activity based on their participation in leisure-time physical activity.
- When leisure-time physical activity is considered by single race and ethnicity, non-Hispanic white adults were more likely to have met the full guidelines for both aerobic and muscle-strengthening activity based on their participation in leisure-time physical activity than Hispanic adults or non-Hispanic black adults.
- As level of education increased, the percentage of adults who were sufficiently active based on their participation in aerobic leisure-time physical activity also increased.
- Adults living in an MSA were more likely to have met the full guidelines for both aerobic and muscle-strengthening activity based on their participation in leisure-time physical activity than adults who did not live in an MSA (U.S. Department of Health and Human Services, 2011, pp. 37-39).
Morbidity and Mortality
There are serious cardiovascular consequences with being physically inactive. For example, “physically inactive people are almost twice as likely to develop CHD as persons who engage in regular physical activity” (U.S. Department of Health and Human Services, 2000, p.22-3). Adults who tend to be less active and less physically fit have a 30% to 50% greater risk of developing high blood pressure (Haskell, et al., 1992), a serious risk factor for CHD. Physically inactive people also run the risk of becoming overweight or obese, dying prematurely of heart disease and developing diabetes. Physical inactivity represents a risk comparable to other CHD risk factors, such as cigarette smoking, high blood pressure and high blood cholesterol (see U.S. Department of Health & Human Services, 1996; U.S. Department of Health & Human Services, 2002).
Despite the increasing evidence showing the increased health risks associated with being physically inactive, the United States still remains a predominantly sedentary society.
Physical Activity and Cardiovascular Health Benefits
On the flipside of the cardiovascular coin, it is also firmly established in the literature that almost everyone can gain substantial health and cardiac benefits from regular physical activity. According to the U.S. Department of Health and Human Services (2002), “regular physical activity has beneficial effects on most (if not all) organ systems, and consequently it helps to prevent a broad range of health problems and diseases” (p.8).
Physically active people tend to outlive inactive people (American Heart Association, 2006; U.S. Department of Health and Human Services, 2000). Furthermore, regular physical activity improves cardiovascular health by reducing the risk of suffering from high cholesterol levels, high triglyceride levels, diabetes, high blood pressure (even those who already have it), Type II diabetes, metabolic syndrome, overweight and obesity, all established risk factors for CHD.
Although vigorous physical exercise improves cardio-respiratory fitness, studies show that even a moderate amount of physical activity for at least 30 minutes a day provides health benefits, including reducing the risk for CHD (American Heart Association, 2003; U.S. Department of Health and Human Services, 2000). The United States Department of Health and Human Services (2002) proposes that “participation in regular physical activity— at least 30 minutes of moderate activity on at least five days per week, or 20 minutes of vigorous physical activity at least three times per week—is critical to sustaining good health” (p. 8).
Insight into the cardiovascular benefits of regular physical activity can be gleaned from the American Heart Association’s summarization of important findings from studies focusing on the link between physical activity and risk reduction for CHD:
- The death rate for heart attack patients who participated in a formal exercise program was reduced by 20 percent to 25 percent.
- Walking briskly for three hours a week, or exercising vigorously for 1.5 hours, will reduce coronary heart disease risk in women by 30 to 40 percent. New England Journal of Medicine, 1999
- A person’s fitness level was a more important predictor of death than established risk factors such as smoking, high blood pressure, high cholesterol and diabetes.
- Becoming more active can lower your blood pressure by as much as 4 to 9 points. That could mean the difference between having high blood pressure and not having it. And it’s the same reduction in blood pressure delivered by some antihypertensive medications — without the side effects. Three 10-minute periods of activity are almost as beneficial to your overall fitness as one 30-minute session. Mayo Clinic
- A U.S. National Institute of Health Diabetes Prevention Program study showed that people at high risk for diabetes and heart disease who underwent intensive lifestyle change including 150 minutes a week of moderate physical activity (such as walking) lowered their cardiovascular disease risk factors more than those taking the diabetes drug metformin. High blood pressure, triglycerides and cholesterol levels all decreased significantly, and HDL “good” cholesterol rose. American Diabetes Association
- Moderately active people had a 20 percent lower risk and highly active people had a 27 percent lower risk of stroke or stroke death than low-active people. Stroke Journal Report, 2003 (American Heart Association, 2006c, p.1)
Besides lowering high blood pressure, triglyceride and cholesterol levels (all recognized risk factors for CHD), decreasing death rates due to heart attacks and lowering the risk for CHD, regular physical activity helps with weight management. Weight management is an important issue when it comes to reducing the risk for CHD because it is a primary strategy for people to prevent two of the major risk factors for the development of CHD, overweight and obesity.
The American Heart Association (2006c) summed up the highlights of the National Heart, Lung, and Blood Institute’s (NHLBI) 2004 Studies of Targeted Risk Reduction Interventions through Defined Exercise (STRRIDE), an eight month study confirming the extent to which physical activity assists in managing weight and, thereby, helping to prevent overweight and obesity:
- Walking 30 minutes a day or 12 miles a week at 40–55 percent maximum heart rate: Lost 1 percent of body weight, lost 1.6 percent of waist measurement, lost 2 percent of body fat and gained 0.7 percent lean muscle.
- Jogging at 65–80 percent of maximum heart rate for 12 miles a week: lost 1 percent of body weight, lost 1.4 percent of waist measurement, lost 2.6 percent of body fat and gained 1.4 percent lean muscle.
- Jogging at 65–80 percent of maximum heart rate for 20 miles a week: lost 3.5 percent of body weight, lost 3.4 percent of waist measurement, lost 4.9 percent of body fat and gained 1.4 percent lean muscle.
- Non-exercise control group: Gained 1.1 percent weight, gained 0.8 percent waist measurement and gained 0.5 percent body fat. (American Heart Association, 2006c, p.2).
These findings are important because they underscore the important role weight management plays in the prevention of overweight and obesity, recognized risk factors for CHD. Thus, one path to preventing or delaying CHD is that of engaging in physical activity to manage weight in order to avoid overweight and obesity so as to reduce the risk of prematurely dying from or being debilitated by CHD.
In summary, regular physical activity improves cardiovascular health by reducing the risk of dying prematurely from CHD. It also helps to prevent (1) high blood pressure, (2) elevated cholesterol and triglyceride levels and (3) overweight and obesity, all of which are major modifiable risk factors for CHD.
Unhealthy Diet and Poor Nutrition
One would be hard pressed to find someone who would disagree with the idea that good nutrition is fundamental to staying healthy and preventing CHD. There is a preponderance of scientific-based research showing that poor nutrition promotes CHD and that healthy nutrition promotes overall health, wellness and wellbeing and lowers the risk for CHD (e.g., see U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2005).
Nevertheless, poor nutrition is one of major causes of ill-health and cardiovascular morbidity and mortality in the United States. Poor nutrition has also been associated with other modifiable risk factors for CHD such as overweight and obesity, Type 2 diabetes, high blood pressure, elevated triglyceride levels, high homocysteine levels, elevated LDL (bad) cholesterol, low HDL (good) cholesterol, glucose intolerance, metabolic syndrome.
Nutrient Deficient Foods
One of the main reasons Americans suffer from poor nutrition is that their daily diet is made-up of nutrient deficient foods, which exist for at least two reasons. First, the harmful methods of industrialized farming have changed the composition of food, decreased the variety of foods, exhausted the soil of essential minerals (e.g., calcium, chromium, magnesium, manganese, molybdenum & zinc) and contaminated the soil with pesticides and other toxic chemicals.
Second, food has become nutritionally devitalized due to harmful food manufacturing methods such as 1. refining techniques (e.g., grinding wheat into white flour & modifying sugar cane into white sugar), 2. preserving methods (e.g., canning, freezing & using chemical additives in the form of artificial colors, flavorings, stabilizers & preservatives), 3. chemical alteration techniques (e.g., hydrogenation process creating trans-fats) and 4. pressing techniques to create vegetable oils (upsetting the proper type and amount of fats to be consumed daily).
Because of these harmful farming and food manufacturing methods most traditional grocery stores are stocked with nutrient deficient fruits and vegetables and packaged-processed foods containing chemical preservatives and coloring agents, saturated and trans-fats, excess sodium, stripped down refined white flour and white sugar and “empty” calories. Such unhealthy foods create nutritional gaps in the daily diet of Americans and are major nutritional causes of CHD and other chronic diseases.
Over consumption of calories. For example, a diet made-up of nutritionally deficient, packaged-processed foods and calorie-laden beverages such as sodas and juice drinks helps to create (along with physical inactivity) an energy imbalance (i.e., consuming more calories than expended), resulting in an over consumption of calories. More calories are consumed than necessary because it takes more of them to create a feeling of satiety or fullness, potentially leading to the cardiac risk factors of overweight and obesity.
The greater the consumption of nutrient deficient foods the more difficult it becomes to consume enough nutrients without the consequence of gaining weight or becoming obese, especially in the case of physically inactive people (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2005). In contrast, nutrient-rich dense foods provide substantial levels of vitamins and minerals (i.e., micronutrients) and fewer calories by comparison. Nutrient deficient foods supply the calories but come up short on the necessary amounts of vitamins and minerals so essential in the digestion and assimilation/absorption of protein, carbohydrates and fats (i.e., macronutrients).
Over consumption malnutrition. One consequence of the long term consumption of a diet consisting of devitalized foods is the development of CHD. Stockton (2000) asserts that the prevalence and dramatic increase in degenerative diseases such CHD is attributable directly to over consumption malnutrition, a condition in which the body is malnourished but simultaneously overfed. She points out that “the amount of nourishment a meal provides is not measured by the quantity of food but rather by the quality of it. We can eat tremendous quantities of food and still be malnourished (and therefore still hungry) when the quality of the food is substandard” (Stockton, 2000, p.18). The Standard American Diet (SAD) is substandard because it is composed of processed, refined, preserved, enriched or otherwise devitalized nutrients, which are at the root cause of CHD and other degenerative diseases (Stockton, 2000).
Unhealthy Dietary Patterns
There are dietary patterns or habits that people should avoid if they want to reduce the risk of developing CHD.
High intake of unhealthy saturated fats, trans fats and cholesterol. The high consumption of saturated fats, trans-fats and cholesterol increase the risk of unhealthy blood lipid levels (i.e., high LDL & low HDL), which, in turn, increases the risk of CHD (American Heart Association, 2003; U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2005).
High intake of sodium. The high intake of sodium raises blood pressure. The higher an individual’s salt intake, the higher his/her blood pressure becomes. Maintaining blood pressure in the normal range reduces the risk of CHD and congestive heart failure.
High intake of manufactured, processed, refined foods. The regular consumption of devitalized foods created by the manufacturing methods of milling and refining can put a person’s overall health and cardiovascular health in jeopardy. Specifically, foods are stripped of vitamins, minerals, enzymes, fiber, bran, protein and other nutrients vital to cardiovascular health when milling and refining techniques are used to convert cane sugar and beet sugar into white sugar (i.e., refined sucrose or table sugar), corn syrup into high fructose corn syrup (HFCS), whole grain wheat into white flour and whole grain rice into white rice.
For example, refined, processed white sugar is devoid of such nutrients as vitamins, B, C and D and such minerals as calcium, phosphorous, iron, selenium, zinc and chromium, needed to metabolize sugar. The deficiency of these nutrients ends up with them being leached from the body so that the sugar can be metabolized. The more sugar that is consumed the more the body becomes depleted of metabolizing nutrients, resulting in a slower metabolism and an inefficient biochemical breakdown of the cardiac culprits of fat and cholesterol. The failure to metabolize the cholesterol and fat contributes to an increase in cholesterol levels, the storage of fat and weight gain, which are recognized risk factors for CHD.
However, it is not only the over consumption of white sugar (i.e., table sugar) that is deleterious to cardiovascular health. An effort should be made to avoid the over consumption of all refined sugars (e.g., brown/raw turbinado sugar, molasses, syrups of different kinds (especially corn syrup in the form of HFCS) and concentrated sweeteners (e.g., dextrose/glucose, fructose, galactose, maltose, lactose, etc.) because they create similar biochemical conditions as refined white sugar.
The nutritional issue with sugar in all of its various forms is that the body metabolizes it rapidly and converts it into saturated fatty acids and cholesterol, which contributes to the development of CHD. Furthermore, a high intake of sugar causes high blood glucose levels putting a strain on the pancreas to produce insulin and causing hyperglycemia.
Alcohol is a rather paradoxical risk factor for CHD. Over the past three or so decades studies have shown that the moderate consumption (30 grams of alcohol or about two standard drinks, per day) of alcohol confers coronary-related benefits or is otherwise inversely associated with incident myocardial infarctions (i.e., heart attacks) for men and women. In other words, studies reveal that moderate drinkers tend to experience a lower risk of myocardial infarctions. Furthermore, previous research indicates that moderate alcohol consumption increases serum HDL-cholesterol concentrations, reduces the incidence of type 2 diabetes mellitus, increases insulin sensitivity, lower levels of inflammatory and hemostatic markers, lower levels of fibrinogen, and lowers the prevalence of metabolic syndrome, all of which lowers the risk for CHD and heart attacks (see Freiberg & Samet, 2005; Mukamal & Rimm, 2001; National Institute on Alcohol Abuse and Alcoholism, 1999).
However, Freiberg & Samet (2005) caution that the “abundance of evidence supporting the hypothesis that alcohol itself leads to lower incident coronary heart disease (CHD) events is not, however, definitive. Because the majority of the data describing the relationship between alcohol and CHD risk comes from observational studies, albeit well-established cohorts, the possibility that confounding may be partially or even entirely responsible for these observed effects remains controversial” (p. 1379).
What is not in scientific-medical question is that heavy drinking and binge drinking are associated with an increased risk for CHD, generally, and increased risk for type 2 diabetes, higher triglyceride levels, higher levels of inflammatory markers such C-reactive protein and metabolic syndrome, all risk factors for CHD (see Freiberg & Samet, 2005; Mukamal & Rimm, 2001; National Institute on Alcohol Abuse and Alcoholism, 1999).
The goal of the February, 2013, issue of Health and Wellness Monthly was to provide the reader with insight into modifiable risk factors associated with CHD. Attention was devoted to the deleterious features and effects of smoking, excessive alcohol use, physical inactivity and poor nutrition. These four major modifiable lifestyle factors put people at especially high risk for CHD by creating deleterious biochemical-physiological outcomes (e.g., Diabetes, overweight and obesity, high blood pressure, high LDL levels, low HDL levels, increased fibrinogen, homocysteine levels and C-reactive protein levels, etc.),which help bring about the morbidity and mortality associated with CHD.
CHD is preventable. One of the best prescriptions to prevent CHD is to take the personal responsibility for learning about modifiable cardiac risk factors, followed up by an objective evaluation of your individual level of risk and adopt a lifestyle that reduces or eliminates the major risk factors found to be associated with developing CHD. This is of course easier said than done. However, dying from or being permanently disabled by CHD is not a good alternative. Given the gruesome morbidity and mortality statistics of CHD, experiencing such an alternative is more of a fact than it is a fiction.
If you smoke, consume excessive amounts of alcohol, live a sedentary life or your day-to-day diet is characterized by poor nutrition in the ways described, then you are at great risk for developing CHD and becoming a sudden death cardiac statistic. Any one of these factors alone puts a person in serous peril. Having two or all four exponentially increases the odds of suffering from CHD sooner rather than later and reducing the chances of treating it effectively.
Preventing CHD is a more preferred health approach than is treating it. It is not being suggested that treating CHD is inappropriate, not useful or not recommended. Instead, it is being contended that prevention should be the priority. If it were, then perhaps CHD would move further down the list of leading causes of death in the United States and other many countries around the world. Pushing it down to even second place would be a victory. Not smoking, avoiding the excessive consumption of alcohol, being physically active and eating a healthy, nutrient rich diet are four preventative measures that can save your life and the life of those you care about and love.
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Suggested Citation: Garko, M.G. (2013, February). Coronary heart disease – Part IV: Modifiable Risk Factors. Health and Wellness Monthly. Retrieved (insert month, day, year), from www.letstalknutrition.com.
 The November, 2012, issue of Health and Wellness Monthly discussed non-modifiable risk factors for CHD.
 Although they are for different years, the statistics reported are the most recent on the prevalence of smoking/tobacco use among adults and youth.
 See the September, 2012, issue of Healthful Hints for a discussion on atherosclerosis and its role in the development of cardiovascular disease, including CHD.
 A sedentary lifestyle is when there is no engaging in leisure-time physical activity such as exercises, sports, physically active hobbies in a two week period (U.S. Department of Health and Human Services, 2002).
 The United States Census Bureau (2013) defines a metropolitan statistical area in the following way: “The general concept of a metropolitan area is that of a large population nucleus, together with adjacent communities having a high degree of social and economic integration with that core. Metropolitan areas comprise one or more entire counties, except in New England, where cities and towns are the basic geographic units” (p.1).