What causes heart disease part XL (part forty)
27th October 2017
As readers of this blog will know, for many years I have pursued the idea that ‘stress’ was the primary cause of cardiovascular disease. Actually, it is strain. Stress is the force applied, strain is the effect that stress produces. For the sake of simplicity, I will just use the word stress.
This journey started when I began to take an interest in the rate of heart disease death in Scotland and France. Being Scottish born and bred, (OK, my father was English, but I forgive him) I felt I knew a bit about the lifestyle of the average Scot, aye Jimmy.
I had also travelled to France many times, so I felt I knew a bit about the French as well. The other reason for looking at France and Scotland was that, in my formative years, Scotland had one of the highest rates of heart disease in the world, perhaps the highest. I am talking primarily about death from myocardial infarction here. On the other hand, the French rate was very low, perhaps the lowest in the world, and has since then got lower.
Why such a massive difference? The conventional explanation was that the Scots had such a terrible diet. The famed deep-fried Mars bar is oft quoted. ‘How can a country that deep fries a Mars bar expect anything less.’ As if everyone in Scotland does nothing but stuff their faces with deep-fried Mars bars, all day, every day.
I do not have the statistics to hand, but I would be very surprised to find that even fifty per cent of Scots have eaten even one. Indeed, if you have made the mistake of eating a deep-fried Mars bar, you will never (unless very drunk) eat another. However, the Scottish ‘unhealthy diet’ meme is so firmly embedded in most people’s brain that it cannot be removed.
Ironically, a Mars bar contains almost no fat at all, it is made almost entirely from sugar a.k.a. carbohydrate. If you wrap it in batter, and stick it in a deep fat fryer full of vegetable fats, you have, according to current thinking, just made it significantly healthier. More carbs wrapped round the outside, and now dripping with vegetable/polyunsaturated fat. Mmmmm … you can just feel your arteries unclogging.
In reality, as with most other well-known facts about heart disease, when I started to look closely, the only significant difference that I could find about the diets in France and Scotland, was that the Scots ate slightly less saturated fat. They also ate fewer vegetables.
On the other hand, the French smoked more, took a bit less exercise and, at the time, had an identical BMI and blood pressure to the Scots. Rates of diabetes were also identical, as were average total cholesterol levels.
In short, I could find no significant difference in ‘classic’ risk factors. If anything, they slightly favoured the Scots over the French. Yet, and yet, age-matched, the French suffered one fifth the rate of deaths from heart disease. If you open up a risk calculator designed for a UK population, and use it to calculate risk for the French, you still have to divide the answer you get, by four. [Which might suggest that risk calculators are not capturing the major causes of CVD].
This gave me to think that there may be something else going on. Other than diet.
What? There have been many papers written about the ‘French Paradox’. The paradox being that they eat masses of saturated fat (highest consumption in Europe, probably the world), they have average to high cholesterol levels and a vanishingly low rate of heart disease.
Scientifically the French paradox should really be called the ‘French refutation of the diet-heart hypothesis and the LDL hypothesis, and all other hypotheses about cardiovascular disease you can think of’. Instead, a range of protective factors have been proposed. Eating garlic, drinking red wine, lightly cooked vegetables, and suchlike. But if you chase them down, and I have, they explain nothing – at all. Primarily, because they are just not true a.k.a. unsupported by evidence.
So, what was going on? What was the key thing that caused the Scots to die of heart disease in great numbers? One obvious and outstanding difference between the Scots and French was not what they ate, but the way that they ate. Scots saw, and in many cases still see, eating very much as a refuelling exercise. On the other hand, mealtimes, and eating, is a massive part of French life. Time is taken, food is appreciated, families tend to eat together – and suchlike.
Could it be, I thought, that the way food is eaten is more important that what is eaten?
If you eat whilst you are relaxed and socialising with friends and family, will your body deal with food in a different way? The answer is, of course, yes. Just to put it in the most basic terms. If you are highly stressed, either physically or psychologically, your fight or flight system will be activated. The sympathetic nervous system will be directing blood from the digestive system, to muscles, acid production in the stomach will be down, the heart rate will be up – and suchlike.
At the same time the stress hormone: adrenaline (epinephrine), growth hormone, glucagon, and cortisol levels will be high and surging round your bloodstream. This will be activating catabolism – the breakdown of energy stores – sugar levels will be up, free fatty acids circulating, blood clotting systems activated, insulin levels down, and on and on. This is not, it should be added, the perfect metabolic situation in which to eat food.
If you look at most animals, after they have eaten they like to lie down, relax and fall asleep. This allows the food that has been eaten to be digested. Humans seem happy to leap to their feet and rush about after eating. I started thinking about the fast food culture of the US. They began the trend for fast eating, fast living, eating and driving. Rush, rush, busy, busy, work, work, bang, bang. They were first to suffer a high rate of heart disease.
I began to study the effect of stress on metabolism. I looked at a condition known as post-aggression metabolism. The state the body finds itself in after trauma such as a car crash or major operation. In such cases the stress hormones are sky high, blood sugar moves into the diabetic level, insulin cannot achieve anything as it is battling against a catabolic system on full throttle. Not a good time to be eating food.
Then I looked at less dramatic situations. My attention drifted onto Cushing’s disease. A condition where the stress hormone cortisol is over-produced by the adrenal glands. Usually because of a cortisol secreting tumour. Cushing’s disease represents a form of chronic ‘fight or flight’, constant stress.
I discovered that, in Cushing’s there is a spectrum of metabolic, and other physiological, abnormalities such as:
- High blood sugar level
- High insulin level
- High clotting factors
- High VLDL (triglycerides)
- Low HDL
- High blood pressure
- Abdominal obesity.
I also noted that, Cushing’s increases the risk of CVD by, at least, 600%.
I then realised that Cushing’s syndrome and the metabolic syndrome shared exactly the same set of metabolic and physiological abnormalities. So I began to think. ‘This is beginning to look interesting.’ Actually, I was thinking this before the term metabolic syndrome existed. At the time is was called either Reaven’s syndrome, or syndrome X. The term “insulin resistance syndrome” is now popular.
Then I was pointed to the work of Per Bjorntorp, who had been looking at the Hypothalamic Pituitary Adrenal axis (HPA-axis). This is the central control system for the stress/flight of fight response. It links together the sympathetic and parasympathetic nervous system, with the actions of the stress hormones, the adrenal glands, thyroxine, glucagon, insulin etc. etc. A complex beast of a thing.
Bjorntorp established that chronic psychological stress (chronic strain) creates a dysfunction of the HPA-axis that can be monitored, most easily, by looking at twenty-four-hour cortisol secretion. A dysfunctional HPA-axis leads to a flattened and unresponsive (burnt-out) cortisol release during the day. This does not mean cortisol levels are high, or low, they just flat-line.
He studied various populations e.g. Sweden and Lithuania, and found that the Lithuanians (at the time) were far more likely to have a dysfunctional HPA-axis than the Swedes, and their rate of CVD was four times as high as that in Sweden. A study done only on men at the time. I then started to look at other conditions where the HPA-axis is damaged. Depression, schizophrenia – in fact almost all psychiatric illness – PTSD, survivors of childhood abuse. In all cases the same pattern emerged. HPA-axis dysfunction, greatly increased risk of metabolic syndrome/insulin resistance syndrome and greatly increased risk of CVD death.
I detoured round spinal cord injury. Most people are probably unaware that spinal cord injury is associated with a very much higher rate of CVD. People who suffer spinal cord injury also have a damaged HPA-axis. Some more than others. It depends on the level of the damage, and whether or not the autonomic nervous system is damaged. [The autonomic nervous system is the name given to the network of nerve fibres that make up the sympathetic and parasympathetic nervous system. It travels down the spine, but not in the spinal canal].
I then had a look at corticosteroids. These are the drugs used in many diseases as anti-inflammatory agents. They are used in diseases such as asthma and rheumatoid arthritis and Crohn’s disease and systemic lupus erythematosus (SLE), all ‘auto-immune’ diseases where the body attacks itself. Corticosteroids dampen down the ‘inflammatory’ response.
Corticosteroids are synthesized from cortisol, which is one of the body’s own steroid hormones. Which is why they are called corticosteroids (steroids manufactured in the cortex of the adrenal gland). They are fantastic drugs, and widely used. However, if you take corticosteroids for a long time you will end up with the metabolic syndrome, and a greatly increased risk of CVD, around a 400% increase.
The more I looked, the more it seemed very clear that the unconscious neuro-hormonal system was the key player in CVD, both heart attacks and strokes. It also seemed that cortisol was probably the lynch pin. It still does. Which is why my favourite graph on CVD comes from Lithuania. I have used it before, and I make no bones about using it again.
The rate of heart disease in Lithuania was gradually falling during the 1980s, until the year 1989. At which point the Berlin wall came down, the Soviet Union broke apart and the structure of society was torn apart. It was a very, very, stressful time.
What happened to the rate of heart disease in men, under 65.
Latvia and Estonia showed the same pattern, as did Russia three years later when Gorbachov was deposed by Yeltsin. In non-Soviet European countries, nothing happened. Heart disease rates continued their gentle fall.
I had been looking for evidence that abrupt social disruption leads to stress which leads to CVD. The problem is that, normally, gigantic social disruption = war. During war medical statistics tend to get overlooked, or other causes of sudden death distort the picture.
For the first time in history, a gigantic social upheaval occurred right in front of our eyes. It was not war, and the WHO was there, recording away, as part of the MONICA project. [Myocardial infarction and coronary deaths in the World Health Organization]. Cause, and effect? I believe so.
Which takes me back to Scotland. Glasgow was a very big city, then it shrank. It shrank because social engineers decided to move people from the tenements, which were considered crowded and unhealthy, to wonderful new towns, and high-rise flats. Such as these shown below.
As you can imagine people very much enjoyed living in these inhuman monoliths. A great sense of community and fun developed. So much so that they have now all been demolished.
Whilst this great forced location of people was taking place, the rate of CVD in and around Glasgow exploded. Yes, Scotland as a whole had a high(ish) rate, but greater Glasgow, whilst all this was going on, had by far the highest rate of all. Cause, and effect?
So, my thought experiment that started in Scotland, ended up back in Scotland. I then looked around the world for populations with extraordinarily high rates of CVD. I hypothesized that populations that had suffered enormous social stress would have high rates. So I looked at Australian aboriginals, Maoris, migrant populations, native Americans, and suchlike.
What did I see. Well, pretty much the same things everywhere. Social upheaval followed by high rate of CVD. At present Australian aboriginals have, I believe, the highest rate of CVD in the world. A population where lifestyle and culture has been shredded. If you use a CVD risk calculator on a young aboriginal woman, you have to multiply the predicted ten-year risk by thirty.
Exceptions, of course, exceptions. The Rosetta community of Pennsylvania US. An immigrant population that had moved from Rosetta Italy to Rosetta US – en masse. They became famous for a very, very, low rate of heart disease. What made them different? Here is a section from a Huffington Post article:
‘What made Rosetans die less from heart disease than identical towns elsewhere? Family ties. Another observation: they had traditional and cohesive family and community relationships. It turns out that Roseto was peopled by strongly knit Italian-American families who did everything right and lived right and consequently lived longer.
In short, Rosetans were nourished by people.
In all ways, this happy result was exactly the opposite expectation of well-proven health laws. The Rosetans broke the following long-life rules, and did so with a noticeable relish: and they lived to tell the tale. They smoked old-style Italian stogie cigars, malodorous and remarkably pungent little nips of a cigar guaranteed to give a nicotine fix of unbelievably strong potency. These were not filtered or adulterated in any way.
Both sexes drank wine with seeming abandon, a beverage which the 1963 era dietician would find almost prehistoric in health value. In fact, wine was consumed in preference to all-American soft drinks and even milk. Forget the cushy office job, Rosetan men worked in such toxic environs as the nearby slate quarries. Working there was notoriously dangerous, not merely hazardous, with “industrial accidents” and gruesome illnesses caused by inhaling gases, dusts and other niceties.
And forget the Mediterranean diets of olive oil, light salads and fat-free foods. No, Rosetans fried their sausages and meatballs in…..lard. They ate salami, hard and soft cheeses all brimming with cholesterol.’ 2
The tenements of Glasgow were filthy and rat infested and crowded and had poor sanitation. But if you speak to those who lived in them, their memories were of close family ties, strong community support, fun, playing football in the street. Then they were shifted to the Brave New World of sterile social engineering. Isolation, loneliness, breakdown of community. Death.
You want to know one of the most important ways to avoid dying of CVD?
2; https://www.huffingtonpost.com/dr-rock-positano/the-mystery-of-the-roseta_b_73260.html