Why do the Japanese have less heart disease?

24. April 2011 William Davis (49)
We should look to the Japanese to teach us a few lessons about preventing heart disease. A Japanese male has only 65% of the risk of an American male (despite 40% of Japanese men being smokers), while a Japanese woman has 80% less risk than an American woman. While the U.S. is near the top of the list of nations with highest cardiovascular risk, Japan is the lowest.

What are they doing right?

There is no one explanation, but several. Genetics probably does not play a substantial role, by the way, as demonstrated by observations of Japanese people who emigrate to Western cultures. People of Japanese heritage living in Hawaii, for instance, develop the same cardiovascular risk as non-Japanese living in Hawaii. They also develop obesity and diabetes.

Among the factors that likely contribute to reduced risk in Japanese people:

--A style of eating that does not include a lot of sweet foods. No breakfast cereal or donuts for breakfast, for instance, but miso soup with tofu, fish, green onions, and daikon (as takuan, or pickled radish).
--Seaweed--It's probably a combination of the green phytonutrients and iodine. Typical daily iodine intake is in the neighborhood of 5000 mcg per day from nori, kombu, wakame, and other seaweed forms. (The average American obtains 125 mcg per day of iodine from diet.)
--Seafood--Fish in many forms not seen in the U.S. are popular.
--Green tea--Consumption of green tea has been confidently linked to reduced cardiovascular risk, probably via visceral fat-reducing, anti-oxidative, and anti-inflammatory effects. Although tea in Japan is often the less flavonoid-rich oolong tea, softer benefits from this form are likely.
--Soy--Tofu, miso, and soy sauce are staples. It's not clear to me whether soy is intrinsically beneficial or whether it is beneficial because it serves to replace unhealthy alternatives. (Genetic modification may change this effect.)
--Reduced exposure to cooked animal products (except seafood). This is not a saturated fat issue, but probably an advanced glycation end-product/lipoxidation issue that result from cooking.
--The lack of a "eat more healthy whole grain" mentality, the advice that has plunged the entire U.S. into the depths of a diabetes and obesity crisis (along with high-fructose corn syrup and sugar). Noodles like udon and ramen do have a place in their diet, as do some dessert foods. But the overall wheat exposure is less--no bagels, sandwiches, and breakfast cereals.
--Less overweight and obesity--The above eating style leads to less weight gain.

Japanese foods have a unique taste, consistency, and mouth-feel that go well with saltiness, thus the downside of their diet: salt consumption. On a broad scale, high salt consumption has been associated with hypertension and gastric cancer. But the tradeoff has, on the whole, been a favorable one.


One study trying to find some answers:

Dietary patterns and cardiovascular disease mortality in Japan: a prospective cohort study.

Shimazu T, Kuriyama S, Hozawa A et al.
Division of Epidemiology, Department of Public Health and Forensic Medicine, Tohoku University Graduate School of Medicine, Japan.


We prospectively assessed the association between dietary patterns among the Japanese and CVD mortality. Dietary information was collected from 40 547 Japanese men and women aged 40-79 years without a history of diabetes, stroke, myocardial infarction or cancer at the baseline in 1994.
During 7 years of follow-up, 801 participants died of CVD.

Factor analysis (principal component) based on a validated food frequency questionnaire identified three dietary patterns: (i) a Japanese dietary pattern highly correlated with soybean products, fish, seaweeds, vegetables, fruits and green tea, (ii) an 'animal food' dietary pattern and (iii) a high-dairy, high-fruit-and-vegetable, low-alcohol (DFA) dietary pattern. The Japanese dietary pattern was related to high sodium intake and high prevalence of hypertension. After adjustment for potential confounders, the Japanese dietary pattern score was associated with a lower risk of CVD mortality (hazard ratio of the highest quartile vs the lowest, 0.73; 95% confidence interval: 0.59-0.90; P for trend = 0.003). The 'animal food' dietary pattern was associated with an increased risk of CVD, but the DFA dietary pattern was not.

The Japanese dietary pattern was associated with a decreased risk of CVD mortality, despite its relation to sodium intake and hypertension.
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Comments (49) -

  • Anonymous

    4/24/2011 3:50:12 PM |

    they also drink alcohol daily

  • Anonymous

    4/24/2011 5:36:40 PM |

    I wouldn't entirely dismiss genetic factors to.

    I believe the Japanese apo e profile may be better than caucasian (on average) --

    A racial difference in apolipoprotein E allele frequencies between the Japanese and Caucasian populations

    http://onlinelibrary.wiley.com/doi/10.1111/j.1399-0004.1986.tb01901.x/abstract

    A bad Western diet may trump this genetic profile, hence why those who leave Japan/eat poorly still get heart disease.

    But there could be some genetics in play too.

  • Anonymous

    4/24/2011 6:04:33 PM |

    Bear in mind that the soy they consume is typically fermented, including natto, which is extremely high in vitamin K2 - MK7.

  • Anonymous

    4/24/2011 7:37:04 PM |

    I just returned to the US after having spent the last 10 years there.  Some observations:

    (1) While it is true that consumption of breakfast cereal or donuts for breakfast is exceedingly rare, virtually nobody under the age of 70 eats miso soup with tofu, fish, green onions, etc. for breakfast.  The typically breakfast for younger people nowadays is a fried egg, white toast, and coffee.  And lunch and dinner often includes white rice and/or wheat noodles.

    (2) Contrary to what the first anonymous said, the typical Japanese does NOT drink alcohol everyday.

    (3) Contrary to what the third anonymous said, most soy is consumed in the form of tofu, and only a relatively small percentage of Japanese eat natto on a regular basis.

    (4) The amount of refined wheat products consumed by the average Japanese is large and growing.  For example, you will see a huge number of bread, cake, pastry, etc. shops in virtually every neighborhood in Japan nowadays.  Take a stroll down a supermarket aisle in Japan and you will see large amounts of goods made from refined wheat products (bread, cookies, etc).

    (5) US fast food chains are ubiquitous and always packed with young people.

    Based on the eating habits among young people I've observed there, my guess is that we'll be seeing an increase in heart disease to rival that of the US.

  • majkinetor

    4/24/2011 8:02:53 PM |

    If Japanese consume K2 a lot, this might be big part of the solution to this enigma (since natto is the best source of K2 in the world). Calcification of soft tissues is one of the major CV problems and eliminating it from equation changes the scene.

    I wonder what is the reference for "less sugary foods" claim.

    It was the main issue in Alan Aragon's bashing of "Sugar: The bitter truth" video by Lustig. While I think that Alans review is junk, it has some interesting points, among others, the suspicious claim that Japanese people don't consume suggary food.

  • Might-o'chondri-AL

    4/24/2011 8:39:56 PM |

    Japan Public Health Center 1990 dietary highlights for 40,000 men and women +/- 48 - 50 years old. All were without cardio vascular disease and had BMI of +/- 23.5.

    The women:
    calories/d = 1,227-1,491
    rice gr/d  = 164-182
    fish gr/d  = 31-54
    % miso 3x/d= 18-33% did

    The men:
    calories/d = 1,910-2,344
    rice gr/d  = 294-336
    fish gr/d  = 38-66
    % miso 3x/d= 23-46% did

    Nationwide for Japan in 1990 3% of adults had a BMI of 30 or more (obese); and at that time, 20% of women plus 24% of men had a BMI of 25-29 (overweight).

    Compared to 1960 statistics by 1994 there were 4 times the number of overweight adults; and the increase in overweight adults was higher among the rural population.
    A Japan National Survey (exact year not in my notes) stated the average adult protein intake was +/- 60 grams of protein per day; with 1/2 of that protein coming from rice.

  • Gretchen

    4/24/2011 9:32:43 PM |

    1. Re salt. I read an article recently showing that in people with diabetes, the higher the salt intake, the lower the overall mortality. This is only one study and might be a fluke, but it's interesting.

    2. Re sugar. This is annecdotal. Many moons ago, in early 1960s when I was in college, I lived in a Coop dorm where we did all the cooking. One night a friend and I were trying to make a casserole that ended up bland, so we kept adding things to improve the taste. It got worse and worse, and there was no time to start over again.

    Finally, when the rest of the dorm was nagging us to get the food on the table, we threw in a can of pineapple.

    A student then said to us, "I hope dinner is extra good tonight, because I have a friend from Japan visiting, and I want to impress her." We were very embarrassed.

    Afterward the Japanese woman came up and asked if we'd cooked the meal. We had to say yes. She said, "Oh thank you so much! This is the first food I've had in America that was sweet enough."

    Now, maybe she was unusual. Maybe her family was adopting American tastes. But it's made me question comments about Japanese not eating sugar.

    I suspect the key may be the amount of food consumed in meals. Those beautifully displayed boxes of food don't actually contain a lot. Maybe they like sweet things but don't eat a lot of them.

  • Might-o'chondri-AL

    4/24/2011 9:33:59 PM |

    Natto is said to be more popular in the east of Japan, like Tokyo; and less popular in Osaka & Kobe regions. Here's the average natto consumption for select decades I have:

    1960 =  0.45 kg/yr/person
    1970 =  1.1 kg/yr/person
    1980 =  1.3 kg/yr/person

    Natto generally is sold in +/- 40 gram unit packets; so 365 days in a year x 40 gr. natto = 1.46 kg/yr/person , which would be the contemporary natto eaters intake. One gram of Natto +/- =  0.17 gr. protein + 0.14 gr. carbohydrate + 0.108 gr. total fat (0.016 gr. saturated fat) + 10 mcg. Mk-7 + 0.84 mcg. Mk-8 + 0.0072 gr. nattokinase +  0.55 gr. water.

    By mid 2000s there were Japanese newspaper reports that the natto consumption was trending downward.
    Apparently, the natto industry response was to make hybrid natto food products to attract the younger Japanese market.

  • Kurt

    4/24/2011 10:33:38 PM |

    I agree with Anonymous. Japanese people have begun eating lots of puffy white bread/pastries. It will take some time for this to be reflected in the heart disease stats.

  • Anonymous

    4/24/2011 11:39:33 PM |

    I've lived in Japan for the past three years in southern Osaka. The claim that Japanese people (below, say the age of 60 or so) don't eat many sweet things is patently false.

    There, I think, has been a huge shift in diet trends over the past generation or two, with the older generation still eating mostly as the article suggests, and the younger generations eating progressively more and more like westerners.

    Most people I talk to consider fluffy white sweet bread (lots of sweetener in the dough itself) topped with extra sweet jam or jelly with some orange juice or heavily sweetened coffee breakfast.

    Even some slightly more traditional dishes like sukiyaki are cloyingly sweet as prepared by most people, or if made from packaged mixes (fewer people can / are interested in cooking, especially from scratch, nowadays).

    Another example that comes to mind is Kimchi. That Korean stuff is a tangy, spicy, fermented delight, white most of it found in Japanese supermarkets is filled with sugar -- sometimes even as the second or third ingredient after hakusai!

    It's true, however, that the "heart healthy whole grains" message is largely absent here, and that there is really no fear of fatty meat (yakiniku!).

    Regardless, the article flies in the face of what contemporary Japan actually eats; the article sounds more like a stereotype of what people ate just before or just after WW2.

    Besides, the Okinawans have (or rather had) the longest life expectancy of all, and they practically revered pork fat! Pork, fish, sea vegetables, tubers, and veggies, is what their traditional diet is purported to be.

    (end ramble)

  • Dr. William Davis

    4/25/2011 12:23:38 AM |

    Several commenters make the crucial point that the Japanese diet is changing. I agree: Western influence, from Dunkin Donuts to McDonalds, has infiltrated their culture. I expect that we will see the cardiovascular advantage of the Japanese erode over the coming decades. But the point remains: At least at one time, they followed a diet that likely provided at least part of the reason for their reduced risk for heart disease.

    I am Japanese and, when we were kids, we lived on tofu, taukuan, rice, omeboshi, natto, and all the other foods from Japan that we could get from shops in New York. We did eat rice cakes containing sweet beans, but sweet was simply, at least in that period, not a prominent part of the diet. Salt was, however.

  • Anonymous

    4/25/2011 12:50:15 AM |

    I would be interested to know what this dietary pattern consisted of since it was also associated with an increase in CVD:  "The 'animal food' dietary pattern was associated with an increased risk of CVD"

    Stephanie A.

  • Chooky F.

    4/25/2011 12:55:32 AM |

    I have heard that they have a much higher incidence of stroke.  I'm not sure if this is true or not but I have seen data suggesting it is 5X as likely in Japan as it is in the U.S.  I have also heard that dying from heart disease is considered less honorable than dying from stroke.  There is some speculation that the Japanese diagnose death due to stroke at higher rates.  The two can be difficult to diagnose correctly.  Stroke and heart disease are the same problem.  I think their diet in general is less stroke/heart prone than the US but their arteries may not be as unclogged as the heart disease numbers suggest.

  • Boo

    4/25/2011 1:08:31 AM |

    I'm another long-time Japanese resident. While taking care of my wife in the hospital here, I noticed what seemed like an epidemic of diabetes. So even without massive obesity, and without the same level of heart disease, the modern Japanese diet (toast for breakfast, lots of white rice) is having its effects.

  • Adam Michael

    4/25/2011 1:38:30 AM |

    Once again, I really believe it comes down to eating as many whole foods as possible while reducing the amount of processed products.  This article on the Japanese lifestyle coincides with my conviction.

    We do not necessarily have to adopt the exact regimens they follow, but understand that the closer we align ourselves with whole, natural foods, the closer we will be to improving health.

  • Might-o'chondri-AL

    4/25/2011 1:46:45 AM |

    "It's the small things in life"; seems worth noting, since we in the west overlook what we don't have a frame of reference for. A Japanese meal is traditionally accompanied by things we don't think much of.

    Old style pickles ("Nukazuke") were food items embeded (buried) in a rice bran medium; the "bed" innoculated the pickles with micro-organisms. It could be interpreted to be a pro-biotic dietary practise. (I have an easy rice bran pickle recipe if anyone wants.)

    Miso's many substrates, and some pickles (ex: eggplant; recipe on request) are made by embedding the substrate in Koji. Koji is usually rice innoculated with a fungus strain of Aspergillus oryzae.

    Soybean miso is the most commonly known miso,in one form or another, in the west; people attribute it's benefit to what they know (the soy). Actually the koji is what lowers the per-oxidation of linoleic acid; and it is the koji fraction that provides the beneficial scavenger activity against our cell oxidants.

    Koji in miso is infused with the fungal (A. oryzae's) tri-acyl-glycerol lipase gene and gluco-amylase pro-chymosin gene. It can make some of the miso substrate's medium chain fatty acids into a form we can absorb (ie: esterified); with  attendant anti-oxidant properties.

    Oh, and those lectins in grains and beans people seem to disparage these day? Well fungi, like A. oryzae, have enzymes to break lectins down; so koji fermented foods enhance mineral bio-availability.

    For east coast USA Koji and Natto contact "Katagiri" Japanes Grocery in N.Y.C. (on an east 70+ street, near Bloomingdales). For west coast USA bulk (35 lbs. box or six 1 lb. tubs box) white rice Koji contact producer  "Miyako" Oriental Foods in Baldwin Park (near L.A.). For Japanese cultures to make your own contact "G.E.M." Cultures, now in Wash. state. I have no financial interest in any venture; gotta go check on today's natto batch....

  • Anonymous

    4/25/2011 4:06:51 AM |

    Why is more Iodine helpfull?

  • Might-o'chondri-AL

    4/25/2011 4:27:18 AM |

    edit needed for my last comment above, see the 6th paragraph (next to last)....
    Replace the word "lectin" with "phytates" ; and then the enzyme which fungi have are going to be a "phytase", the type of enzyme with ability to break down "phytates".

  • LifeCoachAndy

    4/25/2011 6:41:00 AM |

    Rice consumption cited in one comment above clearly indicate that rice consumption has inverse association to increasing cvd. It again sugggest that increased consumption of other foods such as more animal foods, more fat, junk, McDOnalds, sugar etc, which probably replaced rice therefore increasing incidence of CVD.

  • rhc

    4/25/2011 12:47:27 PM |

    @ Might-o...where can I get instructions. Do they come with the order? Or are you offering some here? I'd love to make some. Great post...again.

  • Fuel Rest Motion.

    4/25/2011 12:59:35 PM |

    I have been here 10 plus years and even in that time I have seen a  visible increase  in the number of overweight and the recent  "Metabo"  metabolic syndrome craze.

    Go to any supermarket: it's aisle of processed grains, snacks, cookies and cakes for miles.
    Go to any convenience store and see one whole aisles of "Snack pun" - snack bread. This stuff is hideous. 400-600 calories of bleached white bread,  margarine and sugar rich fillings. Its essentially mostly sugar and this  kind of thing is replacing the fish and  miso breakfast. A staggering  large percentage of teens and young adults consider this a decent  breakfast or lunch.
    As a teacher I frequently see  students buying two snack puns at the cafeteria  and that's their lunch.  1000  calories of basically sugar.
    Instant Noodles are hugely popular and not helping either.
    This current generation is going to  seriously dent  the  precedent of statistics their grandparents and great grandparents.

    As for the good stuff, yes still more fish consumed on the whole than  elsewhere but huge amounts of grain fed overproceesed meats.
    Seaweed- yes still about and definitely  beneficial and the ubiquitous onigiri is still popular, though  at the convenience store  the snack breads seem to rule in terms of selection these days.
    An for grains have you seen the standard food pyramid in Japan? or the spinning top as it's called.
    Very grain heavy.

    http://www.mhlw.go.jp/bunya/kenkou/pdf/eiyou-syokuji5.pdf

    More walking - much much more walking in Japan compared to the  USA has more to do with it I suspect!

  • Peter

    4/25/2011 1:19:54 PM |

    The Japanese used to eat a lot less than us. I bet eating 2700 calories a day average of any diet ups your cvd risk.

  • Anonymous

    4/25/2011 1:56:48 PM |

    What about chlorine in the Japanese water supply - do they use as much chlorine as we do in the US?

  • Fuel Rest Motion.

    4/25/2011 2:20:31 PM |

    chlorine? A heavily industrialized nation like Japan? you better believe it! but it  does vary to place to  place.
    Some cities  it's like the water is coming straight out of a swimming pool.
    The tap water is ok to drink after some basic filtration.

  • Might-o'chondri-AL

    4/25/2011 3:56:23 PM |

    Hi rhc,
    I am not selling anything; the sources for specialty items are all places I have bought from. If you can't track them down online then I'll get you contact details; assuming Doctor Davis doesn't object.

    To make your own Natto it is really easy. Koji making involves more steps, but there are a lot of different things you can do with it.

    Rice bran pickles are the simplest of all to crank out daily, once your rice bran "bed" builds up it's microbial flora. The rice bran "bed" needs to be stirred (ideally)daily to keep funky microbes from taking over; but if you put some (say)veggies in the rice bran bed you can hand stir it then and enjoy those "pickles" later the same day. Sacks of rice bran are sold in many Japanese groceries (like Katagiri) and I've used "Bob's Red Mill" brand rice bran (health food store/mail order).

    G.E.M. Cultures is now run by Gorden E. McBride's daughter up in Washington state. They mail order the pure Japanese Natto spores I've used for years and send instructions a novice can follow. (I have some incubating now at +/- 105* Farenheit in a covered dish set up over a scrapped food dehydrator's heat coil base.)

    G.E.M. also provides the culture for making Koji; they actually have several Koji strains, depending on what end product you want to make - instructions always are included. To make white rice  Koji from scratch you want to be able to get "sticky" white rice (ex: "Hakubai" or "Wel-Pac" Sweet Rice, from JFC International) and steam cook it.

    G.E.M. also sells the already innoculated Koji and a little bit doesn't really go very far except for experimenting. Miyako Oriental Foods is a modern Koji "factory"; they sell rice Koji (and Miso) to places like Katagiri in individual tubs under the label "Cold Mountain". Koji has a very long shelf life (dry stored, no direct heat), so refrigeration is not absolutely essential.

  • Anonymous

    4/25/2011 5:54:03 PM |

    For those who have lived in Japan, do the Japanese do any formal exercise? walk a lot?

  • steve

    4/25/2011 6:27:14 PM |

    It would be interesting to hear your thoughts on French diet as they too have a much lower incidence of heart diseas( not as low as Japanese), but their diet is western oriented.  My guess would be lack of sugar, junk food, and minimum Omega 6 intake.  They do eat wheat, but not in quantities similar to those in U.S.

  • rhc

    4/25/2011 6:56:12 PM |

    @ might-o... Thanks so much for the additional info. I've printed it all out and will start investigating the sources and processes.

  • Anonymous

    4/25/2011 10:51:33 PM |

    @ Steve:

    http://wholehealthsource.blogspot.com/2010/11/observations-from-france.html

    http://wholehealthsource.blogspot.com/2010/05/does-red-wine-protect-cardiovascular.html

    http://www.vinopic.com/index.php/roger-corder/roger-corder-intrinsic-quotient#red-wine-quality

    Cheers!

  • Might-o'chondri-AL

    4/26/2011 1:14:02 AM |

    The body's internal ratio of Magnesium (Mg) to Calcium  (Ca) in East Asia and the USA
    typically differ; with African Americans having even lower Mg % than their caucasian countrymen. Specificly the East Asians statisticly have/had more Mg relative to Ca; and conversely Americans had less Mg relative to Ca in their bodies.

    The Japanese living outside of Japan (or those eating more like the west inside) Japan could be having less Mg %; this could explain several things. Low Mg is implicated in inflammation, insulin resistance, metabolic syndrome & Type II diabetes; 2000 data for U.S.A. showed 79% were below MDR Mg.

    In other words the American diet supplying much more Ca in relation to more sparse Mg creates a ratio, that in the body is involved in the dynamic of pathological development. Ca is not "bad" in itself, but in the context of too little Mg the inflammatory underpinning of many diseases wrecks havoc (ex: coronary heart disease, insulin resistance, Type II diabetes, etc.).

    Ca has systemic roles in signalling for various cell cycles. Mg plays a role in (among other things) DNA repair and lowering insulin levels. Special gut ion uptake channels  with the gene TRPM 7 (transient receptor potential melastatin) regulate Mg.++ balance; shear volume of Ca++ can interfere with that ion channel taking up the Mg (Ca & Mg ion charges tend to compete).

    One researcher thinks the really low Mg to strong Ca ratio explains the African American susceptibility to more coronary events. Maybe this Mg:Ca ratio explains some (not all) of the  data showing Japan has/had less heart disease; and also a big factor why Japanese in the west are/were relatively more prone to heart disease.

  • Dr. William Davis

    4/26/2011 1:16:50 AM |

    Might--

    Fascinating detail on the organisms used to ferment!

    I'm also quite impressed that you can actually eat natto. Even though I was exposed to it by my Mom as a kid, I still can't stomach the stuff.

  • Sue Ek

    4/26/2011 3:08:19 AM |

    The Birth Control Pill only recently became legal in Japan. To me it points to the sudden increase in heart disease among Japanese women.
    ~ Sue Ek, BOMA-USA

  • Bob

    4/26/2011 3:36:21 AM |

    Physical activity is more fundamental than diet.

  • Might-o'chondri-AL

    4/26/2011 3:44:07 PM |

    East Asia = 1 Magnesium  per 1.6 Calcium
    U.S.A.    = 1 Mg. per 2.8 Ca
    Of course, those are statistical generalizations of vast regions of people. One researcher speculates the "American Heart Healthy" diet benefit, of eating more whole grains, might be due to their extra Mg.

    Meta-analysis of adult women taking Ca supplements may provide another clue. For every 1,000 women taking Ca supplements over 5 years time there were 6 extra heart problems (strokes and infarctions); while for the same scenario (1,000 over 5 years) the Ca supplementing only prevented 3 fractures.

    That analysis went on to speculate it is not the exact dose of Ca that mattered; since the risk factor went up whether taking less than 500 mg. Ca or 1,000 mg. Ca. daily. The theory proposed was that it was the 5 years of abrupt blood Ca loading that created the risk.

    Data was that (with Ca pill) the risk of myocardial infarction
    rose 25 - 30 % and the stroke risk rose 15 - 20 %; with obese women having less fatal events than their non-obese counterparts (more tissue mass to stash the Ca load ?). If wondering, the addition of vitamin D to the Ca supplement seemed not to be a factor in mitigating or increasing the risk.

    If the Ca supplement implications
    (women only studied) are suggestive and we add to the body equation a poor base line Mg ratio to Ca maybe this explains some of the historical pattern of heart disease. America went in big for non-whole grain food and favored dairy (ie: Ca)in the post-wars 1900s; Japan during that same epoch wasn't big on milk and had (in theory?) better Mg. intake ratio.

  • Renfrew

    4/26/2011 8:11:38 PM |

    Interesting how many readers have lived in Japan. My wife is Japanese, so I have some first hand experience, besides living there for a ferw years.

    Not mentioned so far is the close and cohesive social network that most Japanese enjoy. While in Okinawa I saw lots of old people gathering daily, doing things together, playing games, ball, eating together and generally share the news and gossip. This kind of social web is heart-protecting. We know from studies that loneliness and hostility is detrimental to cardiac health. Possible physiological mechanism: Stress hormone Cortisol would go down, Oxytocin would go up.
    Another factor: "Hara hachibu", this means literally "Stomach 80%".
    It refers to the habit of filling your stomach only 80% and not 100%. Thus eating less and therefore practicing a mild form of caloric restriction, which we know, is clearly life extending.  
    In all, I think it is a mix of everything mentioned here and each part is contributing.
    Renfrew

  • Marc

    4/27/2011 2:27:56 PM |

    Might-

    I couldn't agree with you more about the calcium/magnesium link to heart problems.  I've thought that for years after doing a minor study of magnesium related issues.  In fact the clear implications of magnesium deficiency is astonishing. When you consider the large number of processes that it is responsible for and the lack of it in the American diet it becomes increasing obvious that it has a very important part to play in all of this.

    Marc

  • Anonymous

    4/27/2011 4:37:17 PM |

    My sister lives in Japan, and she sent my kids some Japanese Chocolates for Christmas. The Japanese Chocolate was not nearly as sweet as American Chocolate. I think Americans have a problem with moderation. We want to much of a 'good' thing. The sugar in Japanese chocolate is just a small example, but could be an indicator that there are small differences in everything they do that add up to make a difference. Smile

  • Diana

    4/27/2011 8:49:28 PM |

    Dr. Davis,

    I note that in your post you OMIT the fact that the staple food of the Japanese is rice, and that carbs traditionally comprise 80% of the Japanese diet.

    Stop lying to and misleading people about carbs and weight gain.

    You and I are on the same side about sugar and refined junk carbs.

    OK?

  • Kevan

    4/28/2011 5:55:11 PM |

    Diana, I note that in your post you OMIT any links or proof that the Japanese eat an 80% carb diet. If you are going to make statements and claim them as "fact", you need to prove them. Otherwise, it's just your opinion.

  • Peter

    5/7/2011 6:33:47 PM |

    If I eat much rice my blood sugar goes way up.  Did that happen to Japanese on the traditional diet?

  • sally

    5/14/2011 7:44:20 PM |

    The Japanese eat seaweed.

  • Tom

    5/15/2011 11:15:50 PM |

    It can't even be said with 100% certainty that the high amont of salt they may consume is bad.

  • Laura

    5/17/2011 2:12:57 PM |

    Very interesting point! Yes, he did not mention rice, but the other components are all very good for you. Great posting, Dr.

  • Gabby

    7/10/2011 10:49:40 AM |

    Gosh, I wish I would have had that infrmoation earlier!

  • King

    7/10/2011 11:07:37 AM |

    And I was just wnodeirng about that too!

  • Frenchie

    7/10/2011 10:01:51 PM |

    IJWTS wow! Why can't I think of thgins like that?

  • Fanni

    7/11/2011 1:59:42 PM |

    To think, I was confused a mtinue ago.

  • J Diz

    2/28/2012 3:32:55 PM |

    In visiting France (Cannes and Paris), I noticed that there is a focus on fresh (whole) foods everywhere, and I mean EVERYWHERE.  Only in highly populated urban areas did I see availability of processed snacks and junk food.  Fresh vegetables and free-range meats were what i found.  Most importantly, the portion sizes were small (similar to Japanese).  Though they did eat numerous times through the day, portions were small.  Sweets are big in France, but no one ever over-indulges.  They take the time to savor and enjoy their sweets from a patisserie or cafe.  It''s their food culture from the ground up that has led to their long lives and, quite frankly, very attractive frames.

  • Patricia Arland

    6/16/2012 10:27:37 AM |

    I am a bit confused by the mention of soy sauce......Kikkoman ingredients read, "Water, WHEAT .........."  thought the idea was to stay away from wheat

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Do stents prevent reversal?

27. January 2007 William Davis (3)
I've seen this phenomenon several times now: A highly-motivated Track Your Plaque participant with a stent in one artery will do all the right things--lose weight, achieve 60:60:60 in basic lipids, identify and correct hidden lipoprotein disorders, take fish oil, correct vitamin D, etc.

Follow-up heart scan shows dramatic reduction in scoring in the two arteries without stents--30% per artery. But the artery with the stent will show marked increase in scoring above and/or below the stent. (It's impossible to tell what happens in or around the stent itself from a calcium scoring standpoint, since steel looks just like calcium on a CT heart scan.) In other words, there is marked plaque growth in the vicinity of the stent, despite the fact that dramatic reversal of atherosclerosis has occurred in other arteries without stents.

Should we take this to mean that a stent destroys the opportunity for atherosclerotic plaque reversal in the stented artery? I don't know, but I fear this may be true. What dangers does this different sort of plaque pose? Is it the result of the injury imposed at time of stent implantation, some modification of flow or biologic responses as a result of the presence of the stent?

These are all unanswered questions. But I believe that it is yet another suggestive piece of evidence that the best stent is no stent at all.

At what score should I have a heart cath?

25. January 2007 William Davis (0)
This question comes up frequently: At what specific heart scan score should a heart catheterization be performed? In other words, is there a specific cut-off that automatically triggers a need for catheterization?

In my view, there is no such score. We can't say, for instance, that everybody with a score above 1000 should have a catheterization. It is true that the higher your score, the greater the likelihood of a plaque blocking flow. A score of 1000 carries an approximately 25-30% likelihood of reduced blood flow sufficient to consider a stent or bypass. This can nearly always be settled with a stress test. Recall that, despite their pitfalls for uncovering hidden heart disease in the first place, stress tests are useful as gauges of coronary blood flow.

But even a score of 1000 carries a 70-75% likelihood that a procedure will not be necesary. This is too high to justify doing heart catheterizations willy-nilly.

Unfortunately, some my colleagues will say that any heart scan score justifies a heart cath. I believe this is absolutely, unquestionably, and inexcusably wrong. More often than not, this attitude is borne out of ignorance, laziness, or a desire for profit.

Does every lump or bump justify surgery, radiation, and chemotherapy on the chance it could represent cancer? Of course not. There is indeed a time and place for these things, but judgment is involved.

In my view, no heart scan score should autmatically prompt a major heart procedure like heart catheterization in a person without symptoms.

Niacin makes NY Times

24. January 2007 William Davis (0)
In the wake of the crash and burn of Pfizer's torcetrapib, media attention has turned up the miracles of . . .good old niacin. The NY Times carried a well-written report on niacin in its recent report, An Old Cholesterol Remedy Is New Again.


(Read the entire report at http://www.nytimes.com/2007/01/23/health/23consume.html?em&ex=1169701200&en=670fa84ae2ea648c&ei=5087%0A)

Among their comments:

...torcetrapib worked primarily by increasing HDL, or good cholesterol. Among other functions, HDL carries dangerous forms of cholesterol from artery walls to the liver for excretion. The process, called reverse cholesterol transport, is thought to be crucial to preventing clogged arteries.

Many scientists still believe that a statin combined with a drug that raises HDL would mark a significant advance in the treatment of heart disease. But for patients now at high risk of heart attack or stroke, the news is better than it sounds. An effective HDL booster already exists.

It is niacin, the ordinary B vitamin.

In its therapeutic form, nicotinic acid, niacin can increase HDL as much as 35 percent when taken in high doses, usually about 2,000 milligrams per day. It also lowers LDL, though not as sharply as statins do, and it has been shown to reduce serum levels of artery-clogging triglycerides as much as 50 percent. Its principal side effect is an irritating flush caused by the vitamin’s dilation of blood vessels.

Despite its effectiveness, niacin has been the ugly duckling of heart medications, an old remedy that few scientists cared to examine. But that seems likely to change.

“There’s a great unfilled need for something that raises HDL,” said Dr. Steven E. Nissen, a cardiologist at the Cleveland Clinic and president of the American College of Cardiology. “Right now, in the wake of the failure of torcetrapib, niacin is really it. Nothing else available is that effective.”

In 1975, long before statins, a landmark study of 8,341 men who had suffered heart attacks found that niacin was the only treatment among five tested that prevented second heart attacks. Compared with men on placebos, those on niacin had a 26 percent reduction in heart attacks and a 27 percent reduction in strokes. Fifteen years later, the mortality rate among the men on niacin was 11 percent lower than among those who had received placebos.

'Here you have a drug that was about as effective as the early statins, and it just never caught on,' said Dr. B. Greg Brown, professor of medicine at the University of Washington in Seattle. 'It’s a mystery to me. But if you’re a drug company, I guess you can’t make money on a vitamin.'


Of course, you and I don't have to wait for the media to endorse something. I'm nonetheless thrilled that this hugely helpful vitamin is gaining greater recognition. My preferred form nowadays is over-the-counter SloNiacin (Upsher Smith). Weve seen no liver side-effects and a minimal quantity of flushing. It's also reasonably priced, $13.99 for 100 tablets of 500 mg at Walgreen's. That's a lot cheaper than prescription Niaspan at $130 for 60 tablets.

Perhaps the notoriety will cut back on the silly responses from some physicians that I still hear about from patients: "My doctor said to stop the niacin because it's going to destroy my liver."

Wheat: the nicotine of food

24. January 2007 William Davis (1)
Yes, we know that wheat contributes to creating small LDL, drops HDL, raises triglycerides, and VLDL. We also know it indirectly slows the clearance of after-eating fats from the blood (curious, I know). Wheat products also increase inflammation (C-reactive protein), raise blood sugar, and contribute tremendously to diabetes.

What many people don't know is that wheat products also have an addictive quality: have one donut and you want another. It's true for bread, breakfast cereals, pretzels, cookies, etc. How many times have you had just one Oreo cookie?

Curiously, elimination of wheat products, unlike elimination of nicotine, usually causes the cravings to disappear. In other words, if you stop smoking cigarettes, the desire to smoke doesn't go away. With wheat products, the often overwhelming desire for more wheat products often just goes away.

But most people are simply unable to dramatically reduce or eliminate wheat products from their daily diet and therefore struggle each and every day with excessive cravings for bagels, donuts, cookies, breads, etc.

Try this useful experiment: Eliminate wheat products for a month and see what happens. Most people drop blood pressure, lose the tummy excess, feel more alert, see a drop in blood sugar, experience improvements in lipoproteins, and regain control over appetite.

Good time for a heart attack?

22. January 2007 William Davis (0)
Man Has Heart Attack At Right Place, Right Time

If Robert Ricard had picked the wrong restaurant for lunch, he might have died.

The 71-year-old Michigan man suffered a heart attack shortly after ordering a glass of wine with friends at Bentley's Roadhouse on Saturday.

Luckily, a disaster medical team was sitting nearby.


A TV station in Michigan reported the above story. You've heard these "if it wasn't for ___, so and so would have died" stories. They're reported in all cities at one time or another.

What amazes me about these common local stories is that they're accepted at all. The question that comes to my mind is "Why couldn't the heart attack have been averted in the first place?" Early identification then, as close as humanly possible, elimination of risk would have been a preferable path.

Of course, it may not be the role of the media to cast judgement on why and how the entire episode could have been completely prevented from occurring. But you shouldn't fall into the same trap of complacency. We cannot expect others to save us when the "big one" hits. Your best assurance is to never have one in the first place.

How good is the South Beach Diet?

21. January 2007 William Davis (2)
I'm a fan of the South Beach Diet.

Though it is billed as a program for weight loss (for which it is very effective), it is really a program for health. The basic approach of South Beach involves:

Eat good fats — Choose good fats from olive oil, canola oil, peanut oil, flaxseed oil, walnut oil, avocados, nuts, and fish. Omega-3 (fish oil) supplements are also fine.


Eat good carbs — Good carbs include high-fiber, nutrient-dense fruits, vegetables, legumes, and whole grains.

Eat lean protein — Good sources include eggs, low-fat dairy, nuts, seeds, legumes, skinless white-meat poultry, fish, shellfish, lean cuts of meat, and vegetarian options such as tofu.

(From The South Beach Diet, Dr. Arthur Agatston)


There's no doubt that South Beach can yield dramatic weight loss. In my experience, the success in weight loss depends on 1) how unhealthy your diet was in the first place, and 2) how long you can stick to Phase I, the inital phase during which weight loss is most dramatic. Some people have to periodically cycle back to Phase I to break a "plateau" or to lose faster.

But South Beach is also healthy. It has all the ingredients of a healthy eating program: Low saturated and hydrogenated fats, rich in monounsaturated fats, high fiber, low- to moderate- glycemic index, vegetables and fruits, lean proteins.

The Atkins' diet, in contrast, while very effective for weiglht loss, is an unhealthy process. I've seen lots of bladder infections, constipation, skin rashes, and kidney stones. That's just in the short term. If you stick to the "induction phase" (the no carbohydrate, low fiber, indiscriminate fat initial phase) for an extended period, I suspect that other adverse internal phenemena also develop that might not show for years, like cancer. But--it does work for weight loss!

South Beach's Phase I is also carbohydrate restricted, but steers you towards healthier foods, such as healthy oils from olive and canola, raw or dry roasted nuts, and lean proteins and vegetables.

What really makes South Beach special, however, are its clever recipes. Dr. Arthur Agatston (the author) involved chefs from the restaurants in the South Beach area of Miami to help create healthy yet delicious recipes. We've tried many of them and, while they are different from traditional fare, are delicious and satisfying for the most part.

Criticisms? None, really. But, when my patients choose South Beach (which I often encourage), I often have to impress on them that the Track Your Plaque program is not about weight loss. It is about seizing control of a potentially life-threatening disease. It is a far more important goal with greater implications. Weight loss is just one aspect of a coronary plaque control effort. For this reason, we sometimes have to make changes in the South Beach program to allow for correction of specific lipoprotein patterns.

The most common modification is in people with small LDL particles. This pattern often does indeed respond to weight loss and/or niacin. However, it occasionally persists despite these efforts. We then will ask the patient to continue to restrict the re-introduction of wheat products, though it is allowed after Phase I in South Beach. In other words, for this specific and sometimes difficult to control lipoprotein pattern, a spedific modification of the off-the-shelf South Beach program is sometimes necessary. Of course, the diet is created to suit everybody. Lipoprotein analysis permits detailed insight into your patterns and it's only to be expected that specific modifications might be needed.

But, as written, you can do quite well in your plaque control program by sticking to South Beach.

Be patient with niacin

19. January 2007 William Davis (0)
Mel's HDL started at 37 mg/dl one year ago. Mel had several other abnormal lipoprotein patterns along with his HDL (inc. small LDL and Lp(a)), but HDL was clearly a crucial factor in his panel.

With a heart scan score of 1166, we needed to raise Mel's HDL to the Track Your Plaque target of 60 mg/dl. So Mel started niacin, our number one method to raise HDL, in addition to reducing his exposure to wheat products and other high glycemic index foods; increasing his physical activity; trying to reduce his excess tummy fat; fish oil; dark chocolate (2 oz per day) and red wine (1-2 glasses per day, preferably dark French reds). The form of niacin we often choose is SloNiacin (Upsher Smith), available over-the-counter for about $12-14 per 100 tablets.

Mel started out with niacin 500 mg per day at dinner, increased to 1000 mg at dinner after four weeks. Although this is usually too soon to reassess HDL, Mel insisted. His HDL 41 mg/dl. Mel's disappointment was palpable. He was the usual type A personality: he wanted his HDL higher--now! So Mel insisted that we increase niacin to 1500 mg per day. (We never go higher than this if low HDL or small LDL is the indication for niacin; only when Lp(a) is present do we go higher.)

Six months into this process, HDL: 45 mg/dl. Still a sluggish response.

One year later, HDL: 68 mg/dl. Finally!

That is typical for niacin, as well as combination of lifestyle changes Mel made. None of them result in an immediate rise in HDL; all take months to 1-2 years to exert full HDL-raising effect.

Think of HDL as the 82-year old grandma who takes a long time to cross the street-she does get there!

Note: Doses of niacin >500 mg per day should be taken with medical supervision.

Can vitamin D be a SOLE risk factor?

18. January 2007 William Davis (6)
Here's a crazy question. It occurred to me as I was talking to Drew, a slender, active 54-year old dentist with no bad habits including no smoking.

Drew's heart scan score was 222. His lipoprotein analysis mostly revealed a lot of nothing, which is unusual. The only pattern that showed up was a modestly high LDL of 122 mg/dl with a very slight excess of small LDL. That's it. I would not be satisfied that these were sufficient cause for Drew's level of coronary plaque.

Drew's 25-OH-vitamin D3 level: 15 ng/ml--severe deficiency--despite the fact that his doctor had suggested that he take a vitamin D2 preparation. In other words, Drew had been profoundly deficient, probably for years.

Given the unimpressive cholesterol and lipoprotein values, could vitamin D serve as a trigger for coronary plaque all by itself?

I don't have an answer and know of nobody else who does. However, my opinion is that vitamin D is indeed a potent risk that can cause heart disease as a sole risk factor.

Perhaps it's another piece of circumstantial evidence suggesting that vitamin D has an enormous influence on health, including coronary plaque. Interestingly, the only other health problem Drew has had is prostate cancer, treated a few years ago with prostate removal and radiation. Good evidence suggests that vitamin D deficiency escalates risk of prostate cancer substantially.

By the way, I've seen people taking vitamin D2 preparations, called "ergocalciferol," who are every bit as deficient as those who take no vitamin D at all. Avoid D2 or ergocalciferol preparations: they're worthless.

Does fish oil raise LDL cholesterol?

17. January 2007 William Davis (1)
Katie had an LDL (conventionally calculated) of 87 mg/dl, HDL of 48 mg/dl.

She added fish oil, 6000 mg per day. Three months later her LDL was 118 mg/dl, HDL 54 mg/dl. In other words, LDL increased by 31 mg. What gives?

Several studies have, indeed, shown that fish oil raises LDL cholesterol, usually by 5-10 mg/dl. Occasionally, it may be as much as 20-30.

Unfortunately, many physicians often assume that it's the (minor) cholesterol content of fish oil capsules, or some vague, undesirable effect of fish oil. It's nothing of the kind.

Since we based Katie's program on (NMR) lipoprotein analysis, not conventional lipids (HDL, calculated LDL, triglycerides, total cholesterol), I knew that Katie also had a severe excess of intermediate-density lipoprotein, or IDL, and very-low density lipoproteins, VLDL. This signifies that after a meal, dietary fats persist for 12, 24,or more hours. Fish oil is a very effective method to clear IDL and VLDL, though sometimes it also causes a shift of some IDL and VLDL into the LDL class. Thus, the apparent increase in LDL.

Another contributor: Conventional LDL is a calculated value, not measured. The calculation for LDL is thrown off by any reduction in HDL or rise in triglycerides. In Katie's case, the rise in HDL from 48 to 54 means that calculated LDL is becoming more accurate and rising towards the true measured value. At the start, Katie's true measured LDL was 122 mg/dl, 35 mg higher than the calculated value. Calculated LDL is therefore approximating measured LDL more accurately as HDL rises.

The most important lesson to learn is that, if LDL rises significantly on fish oil and you haven't had lipoproteins formally measured, there may have been a substantial postprandial abnormality like IDL that was unrecognized.

Heart disease is everywhere

16. January 2007 William Davis (0)
If you ever need convincing that heart disease is everywhere, you should do what I do: subscribe to Google Alerts and have them forward news anytime the search phrase "heart attack" crosses the web. (Just go to Google, click on "more" to the right of the search bar, and follow the links.)


Some recent samples:


Workmates resuscitate driver after heart attack

A woman coal mine truck driver had a heart attack and required resuscitation with a defibrillator 3 times on the way to the hospital.





Heart attack kills groom at reception
A 34-year old man died during his wedding reception, leaving behind his 26-year old new wife.






Heart attack ruled as cause of crash

An Alabama man drove his pick-up truck into oncoming traffic while suffering a heart attack.






Heart-attack victim to return to Hamburg stage


Country music artist, Michael Harding, suffered a heart attack and cardiac arrest during a performance. He is apparently recovered and returning to the stage.



That's just a sample from the last two days. While you and I are carry on a conversation on reversal of heart disease, our neighbors and friends drop over every day. Even though I witness successful heart disease reversal routinely, the rest of the world is not participating.

Pass it on: Coronary disease is identifiable, preventable, controllable, and reversible.