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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Lipoprotein testing

19. October 2007 William Davis (5)
This is an update of a post I made about a year ago. However, I'm reposting it since the question comes up so often.


How can I get my lipoproteins tested?
This question came up on our recent online chat session and comes up frequently phone calls and e-mails.

If lipoprotein testing is the best way to uncover hidden causes of coronary heart disease, but your doctor is unable, unknowledgeable, or unwilling to help you, then what can you do?

There are several options:

1) Get the names of physicians who will obtain and interpret the test for you. That’s the best way. However, it is also the most difficult. Lipoprotein testing, despite over a decade of considerable scientific exploration and validation in thousands of research publications, still remains a sophisticated tool that only specialists in lipids will use. But this provides you with the best information on you’re your lipoproteins mean.
2) If you don’t have a doctor who can provide lipoprotein testing and interpretation, go to the websites for the three labs that actually perform the lipoprotein tests: www.liposcience.com (NMR); www.berkeleyheartlab.com (electropheresis or GGE); www.atherotech.com (ultracentrifugation). None of them will provide you with the names of actual physicians. They can provide you with the name of a local representative who will know (should know) which doctors in your area are well-acquainted with their technology. I prefer this route to just having a representative identify a laboratory in your area where the blood sample can be drawn, because you will still need a physician to interpret the results¾this is crucial. The test is of no use to you unless someone interprets it intelligently and understands the range of treatment possibilities available. Don’t be persuaded by your doctor if he/she agrees to have the blood drawn but has never seen the test before. This will be a waste of your time. That’s like hoping the kid next door can fix your car just because he says he fixed his Mom’s car once. Interpretation of lipoproteins takes time, education, and experience.

3) Seek out a lipidologist. Lipidologists are the new breed of physician who has sought out additional training and certification in lipid and lipoprotein disorders. Sometimes they’re listed in the yellow pages, or you can search online in your area. One drawback: Most lipidologists have been heavily brainwashed by the statin industry and tend to be heavy drug users.

4) Contact us. I frankly don’t like doing this because I feel that I can only provide limited information through this method and, frankly, it is very time consuming. I provide a written discussion of the implications and choices for treatment with the caveat to discuss them with your doctor, since I can’t provide medical advice without a formal medical relationship. We also charge $75 for the interpretation. But it’s better than nothing.

5) Make do with basic testing. Basic lipids along with a lipoprotein(a), C-reactive protein, fibrinogen, and homocysteine would provide a reasonable facsimile of lipoprotein testing. You’ll still lack small LDL and postprandial (after-eating) information, but you can still do reasonably well if you try to achieve the Track Your Plaque targets of 60-60-60. It’s sometimes a necessary compromise.

Our discussions on the Track Your Plaque Forum have impressed me with the difficulty many people encounter in getting lipoproteins drawn and interpreted. Some of our Members have been very resourceful identifying blood draw laboratories around the country, such as Lab Safe, that will at least provide the blood draw service.

I wish it was easier and we are working on some ideas to facilitate this nationwide. It will take time.

In 20 years, this will be a lot easier when doctors more commonly use lipoprotein testing. But for now, you can still obtain reasonably good results choosing one of the above alternatives.

Is it exercise or diet?

18. October 2007 William Davis (7)
Wayne, a 61-year old retired school superintendent, had been an exercise fanatic all his adult life. If not running long distances and occasional marathons, he'd bike up to 70 miles a day. He did this year-round. In cold weather, he set his bicycle up on an indoor device and also ran on a treadmill and added weight training.

That's why it was kind of surprising that he sported a large belly. At 5 ft 8 inch and 190 lbs, that put his Body Mass Index (BMI) also high at 28.8 (desirable <25). You'd think that vigorous, almost extreme, exercise like this would guarantee a slender build.

Wayne also had lipoproteins to match: triglycerides 205 mg/dl, LDL 176 mg/dl but LDL particle number much higher at 2403 nmol/l (an effective LDL of 240 mg/dl); 75% of LDL particles were small.

I asked Wayne about his diet. "I eat healthy. Cheerios for breakfast usually. Some days I'll skip breakfast. Lunch is almost always a sandwich: tuna, turkey, something like that on whole wheat bread or a whole wheat bagel. Chips, too, but I guess that's not too healthy. Dinners vary and we eat pretty healthy. Almost never pizza or junk like that."

"Pasta?" I asked.

"Oh. sure. Two or three tiems a week. Always whole wheat. With a salad."

Wayne was well aware of the conventional advice for whole grains and, indeed, had been trying to increase his intake, particularly since his basic cholesterol numbers had been high in past. To his surprise, the more he tried at diet, the more LDL seemed to go up, as did triglycerides.

I see this situation every day: The obsession with processed carbohydrate foods, worsened by the message perpetuated by the American Heart Association, the USDA Food Pyramid, Kraft, Kelloggs, Post, etc. Eat more fiber, eat whole grains.

NY Times columnist, Jane Brody, chronicles her (embarassing) mis-adventure following the same mis-guided advice in Cutting Cholesterol, an Uphill Battle.

According to the USDA Food Pyramid, Wayne is not getting enough grains and whole grains, particularly since he is highly physically active. Consistent with the message given by the food industry: "Eat more!"

The food industry-supported Whole Grain Council advises:

Whole Grains at Every Meal
The US Dietary Guidelines recommend meeting the daily requirement by eating three "ounce-equivalents" of breads, rolls, cereals or other grain foods made with 100% whole grains. A slice of bread or a serving of breakfast cereal usually weighs about an ounce.

Want an easier way to think about it? Just look at your plate at each meal, and make sure you've included some source of whole grains. That's why our slogan is "Whole Grains at Every Meal."


By this scheme, if you are overweight, it's because you lack fiber and you're too inactive. "Get up and go!" It's not the diet, they say, it's you!

See through this for what it is: Nonsense. Wayne was overweight, packing 20 extra pounds in his abdomen from his over-dependence on processsed carbohydrates--"whole grains"--not from inactivity.

Instant heart disease reversal

17. October 2007 William Davis (16)

What if reversal of heart disease--regression of coronary atherosclerotic plaque--were achievable instantly? Just add water and--voila!!

To my knowledge, it is not--yet. But I sometimes play with this idea in my head. I could imagine that such a program would consist of a few essential elements:

--A fast or semi-fast, or at least a very spare diet, over a period like 10 days to promote net catabolism. It is also supremely anti-inflammatory to restrict calories.

--High-dose vitamin D, e.g., 20,000 units per day of D3 to fully replenish depleted stores and achieve all the metabolism-correcting effects of D3 restoration.

--EPA + DHA at a higher than usual dose with frequent throughout-the-day dosing to encourage replacement of cellular lipid constituents with the more stable omega-3 fraction of fatty acids.

Beyond this, I'm uncertain. What role l-arginine, statins, niacin . . . conjugated linoleic acid? ApoA1 Milano infusions?

This is simply whimsical at this point. I don't know if such an approach would work. But if it did, you might imagine that it would offer an opportunity--for the properly motivated--as an alternative treatment for angina, advanced coronary disease, a means to pull someone back from the brink.

With the insights gained from our slow-but-powerful Track Your Plaque approach, perhaps we will also gain insights into how to accelerate such a process of reversal so that it is achievable in days, rather than months or years.

The small LDL epidemic

16. October 2007 William Davis (24)
Ten years ago, small LDL was fairly common, affecting approximately 50% of the patients I'd see. For instance, an LDL particle number of 1800 nmol/l would be 40-50% small LDL in about half the people.

But in the last few years, I've witnessed an explosion in the proportion of people with small LDL, which now exceeds 80-90% of people. The people who show small LDL also show more severe patterns. 80-90% small LDL is not uncommon.

Why the surge in the small LDL pattern? Two reasons: 1) The extraordinary surge in excess weight and obesity, both of which favor formation of small LDL particles, and 2) over-reliance on processed carbohydrates, especially wheat-based convenience foods.

The constant media din that parrots such nonsense as the report on CNN Health website, Healthful Breakfast Tips to Keep You Fueled All Day, helps perpetuate this misguided advice. The dietitian they quote states:

"If you don't like what you're eating, you won't stick with it. If your choices aren't the most nutritious, small tweaks can make them more healthful. For example, if you have a sweet tooth in the morning, try a piece of nutty whole-grain bread spread with a tablespoon each of almond butter (it's slightly sweeter than peanut butter) and fruit preserves instead of eating foods that offer sweetness but little nutritional benefit, like doughnuts or muffins. If you enjoy egg dishes but don't have time to prepare your favorite before work, try microwaving an egg while toasting two slices whole wheat or rye (whole-grain) bread. Add a slice of low-fat cheese for a healthful breakfast sandwich that's ready in minutes. And don't overlook leftovers. If you feel like cold pizza (which contains antioxidant-filled tomato sauce, calcium-rich cheese, and lots of veggies), have it. It's a good breakfast that's better than no breakfast at all."

It sure sounds healthy, but it's same worn advice that has resulted in a nation drowning in obesity. The food choices advocated by this dietitian keep us fat. It also perpetuates this epidemic of small LDL particles.

If you have small LDL and its good friend, low HDL, it's time for elimination of wheat products, not some politically-correct silliness about increasing fiber by eating whole grains. Whole grains create small LDL! Or, I should say, what passes as whole grains on the supermarket shelves.

For some helpful commentary on this issue, see Fanatic Cook's latest post, Playing with Grains.

Mini-dose CTA?

15. October 2007 William Davis (11)
I caught this little news report in the online edition of Canyon News , an LA paper, under the title Cedars-Sinai Develops Test to Prevent Heart Attacks .

They report that Dr. Daniel S. Berman M.D., chief of Cardiac Imaging and Nuclear Cardiology at Cedars-Sinai, reports that a new method of performing CT coronary angiography, "mini-dose CTA," has been developed that allows both coronary calcium scoring as well as CT coronary angiography (CTA) at a dose as low as 10% of standard dose. No technical details were provided.

Now, that may be worth knowing more about. If this is true, then CTA may indeed be useful as a "screening" procedure. However, we are going to need to know more: What devices are capable of doing this, what settings on the devices were used, etc. It does indeed come from a reputable source in Dr. Dan Berman, who is well known in nuclear cardiology circles.

We will try and dig for info. Stay tuned.

Wheat-free and weight loss

13. October 2007 William Davis (14)
With a heart scan score of 1222, Leslie could be in deep trouble in short order.

At 64 years old, Leslie had gained nearly 40 lbs since she'd given up a lot of her activities caring for a husband who'd developed psychological difficulties and stopped contributing to the household duties. A tall woman at 5 ft 9 inches, she held her 202 lbs well, but her lipoprotein patterns were a disaster:

--LDL particle number 2482 nmol/l--an equivalent LDL cholesterol of 248 mg/dl (drop the last digit)
--HDL 38 mg/dl
--Triglycerides 241 mg/dl
--90% of LDL particles were small
--Lipoprotein(a) 240 nmol/l

Blood sugar was in the pre-diabetic range at 112 mg/dl, C-reactive protein was high at 3.0 mg/l, blood pressure was somewhat high at 140/84.

Now, with the exception of lipoprotein(a), these patterns are exquisitely weight-sensitive. A reduction in weight would yield effects superior to any medication I could give her.

Processed wheat products were a big problem for Leslie: whole wheat bread, pretzels for snacks, whole wheat pasta. Yes, they sound healthy, even endorsed by the American Heart Association, often bearing "heart healthy" labels on the packages. Don't you believe it.

In particular, Leslie had the number one cause for heart disease in America: small LDL particles, a pattern that is magnified 30-70% by wheat products. Endorsed by the Heart Association? (As I often tell people, if you want heart disease, follow the diet advocated by the American Heart Association.)

Leslie was skeptical, worried that she would be hungry all the time and would have virtually nothing left to eat. Instead, when she returned to the office three months later, she reported that eating was easy, finding healthy foods not containing wheat was easier than she thought, she felt great, finding more energy than she'd had in years.

She'd also shed 30 lbs.

Leslie's lipoprotein patterns also reflected the weight loss. She achieved her 60:60:60 Track Your Plaque lipid targets, small LDL shrunk dramatically, blood sugar and blood pressure were back in normal ranges.

I see results like Leslie's several times every week. For those of us with patterns like Leslie's, or just obesity that accumulates in the abdomen, going wheat-free is among the most powerful single strategies I know of.

If you need convincing, try an experiment. Eliminate--not reduce, but eliminate wheat products from your diet, whether or not the fancy label on the package says it's healthy, high in fiber, a "healthy low-fat snack", etc. This means no bread, pasta, crackers, cookies, breads, chips, pancakes, waffles, breading on chicken, rolls, bagels, cakes, breakfast cereal. I find elimination of wheat easier than just cutting back. I believe this is because wheat is powerfully addictive. It's very similar to telling an alcoholic that a drink now and then is okay--it just doesn't work. They need to be alcohol-free. Most of us need to be wheat-free, not just cut back.

You won't be hungry if you replace the lost calories with plenty of raw almonds, walnuts, pecans, sunflower and pumpkin seeds; more liberal use of healthy olive oil, canola oil and flaxseed oil; adding ground flaxseed and oat bran to yogurt, cottage cheese, etc.; and more lean proteins like lean beef, chicken, turkey, fish, and eggs.

The majority of people who go wheat-free lose weight, sometimes dramatically. Most people also feel better: more energy, more alert, better sleep, less mood swings. Time and again, people who try this will tell me that the daytime grogginess they've suffered and lived with for years, and would treat with loads of caffeine, is suddenly gone. They cruise through their day with extra energy.

Even without weight loss, going wheat-free usually raises HDL, reduces the dreaded small LDL dramtically. It also reduces triglycerides, blood sugar, C-reactive protein, blood pressure. Blood sugar control in diabetics is far easier, with less fluctuations and sharp rises in blood sugar.

Success at this also yields great advantage for your heart scan score control and reversal efforts.

Collective wisdom

12. October 2007 William Davis (5)

As public consciousness and knowledge about health issues grows, thanks to the internet and other media, I predict that:

1) Hospitals will recede into a role of acute and catastrophic care ONLY, dropping the charade of providing health, which they do NOT.

2) Doctors and other health professionals will begin to see themselves as providers of acute and catastrophic care, also. They will stop providing day to day care, such as treating high blood pressure, cholesterol, breast exams, and other preventive maintenance.

3) Instead, preventive care will be self-provided. The public will have acquired sufficient savvy and know-how to manage issues like blood pressure themselves. They will need the assistance of helpful information resources, web-based for the most part. Much preventive care can, in fact, be algorithm-driven, just like following a simple recipe.

All the worries about runaway health care costs will be much reduced, since excessive testing driven by liability worries will disappear, repeated office visits for day-to-day issues will go away. Yes, you will need a doctor and hospital for a broken leg, car accident, unexpected cancer, or non-compliance or neglect of prevention.

But osteoporosis, high blood pressure, nutrition, weight loss, hormone management, cholesterol issues, minor complaints will all be managed by people themselves with the assistance of web-based knowledge systems.

I already sense this sort of phenomeonon developing, though in its infancy, in venues like the Track Your Plaque Forum and other health portals, places where the information being discussed exceeds the quality of information you can obtain from your doctor. Over and over again, for instance, the sophistication and knowledge demonstrated by our Track Your Plaque Forum discussions shows that the public is capable of far more understanding of health issues than many previously believed. Most of our members could carry on a credible conversation with trained lipid experts. The knowledge base of our members exceeds that of 98% of most of my colleagues when it comes to heart scans, lipoproteins, and nutrition.

I am in awe of Wikipedia, the popular online encyclopedia. Five 20- and 30-somethings have created a knowledge base that has now eclipsed Encyclopedia Britannica in size and scope, with equivalent accuracy, and relatively little cost. I'd like to see the same phenomenon occur in health care information, helping to usurp the current paternalistic "I'll tell you what to do" model.

Success--Slow but sure

12. October 2007 William Davis (5)
John is a gentleman.

At age 76, he continues to teach at a local college. He's a delight to talk to, having written several scholarly books on religious topics. He's a fountain of knowledge on religious history and the roots of faith.

John is one of those incurably optimistic people, always greeting me with a smile and a warm handshake. I can't help but linger for a hour or so to talk with John, unfortunately disrupting my office schedule miserably.

John is another Track Your Plaque success story. Though he didn't set any records in reduction of his heart scan score, he did it simply by adhering to the program over a period of two years, succeeding slowly but surely.

John's first heart scan score: 1190, a score that carries as much as a 25% annual risk for heart attack. Among the list of causes was an LDL cholesterol in the 170 mg/dl range, along with an LDL particle number that verified the accuracy of LDL.

Among John's suggested treatments was a statin drug, since I was not confident he could reduce LDL with diet and nutritional modifications sufficiently to safely reduce both LDL and his risk for heart attack. But he proved terribly intolerant to any dose of any statin, with incapacitating and strange side-effects, like head-to-toe itching, abdominal cramps and diarrhea. It was clear: John needed to do the program without benefit of a statin drug.

I therefore asked John to maximize all efforts that reduce LDL, 70% of which were small LDL paricles despite his very slender build. He used oat bran and ground flaxseed daily, raw nuts, a soy protein smoothie every morning, and eliminated wheat and other high-glycemic index foods (including the Oreos he loved to snack on). Because the mis-adventures with statin drugs wasted nearly a year, I asked John to undergo another heart scan. Score 2: 1383, a 16% increase.

I asked John to keep on going. Thankfully, he did manage to tolerate fish oil, niacin (though it required over a year just to get to a 1000 mg per day dose), and vitamin D. With all these efforts, he did reduce LDL to the 80-90 mg/dl range. Of course, John's unflagging optimism was crucial. He did express his occasional anxiety over his heart scan score, but dealt with it in a logical, philosophical way. He understood that there was no role for prophylactic stents or bypass, and he accepted that much of his program rested on his ability to adhere to the strategies we advised.

Another year later, a 3rd heart scan: 1210, a 12% reduction.

I'm very proud of John and his success. When you think about it, he succeeded in conquering heart disease with some very simple tools, minus statin drugs. It can be done, but requires consistency and patience--and an optimistic outlook.

Vitamin D and octagenarians

10. October 2007 William Davis (28)
Roger practically bounced in his chair vibrating with energy.

"It must be the vitamin D! I haven't felt like this in years. I can work around the yard all day and still have energy left over."

At age 84, Roger started out with pretty good health, despite a prosthetic valve and bypass surgery 5 years earlier. He looked 74, perhaps younger.

I've seen this effect now in about 20 octagenarians. A Track Your Plaque Member mentioned this same effect in his father-in-law in a discussion in our Forum. Most are taking around 6000-8000 units per day (gelcap, of course). The average dose of vitamin D tends to be higher in this age group, since by age 80, you've essentially lost the capacity to convert 7-hydrocholesterol to active vitamin D3 in the skin. Most octagenarians start with 25-OH-vitamin D3 levels of 10 ng/ml or less--profound deficiency.

I believe the effect is real, having now witnessed it multiple times. Unfortunately, my observations are too informal to qualify as a study. (I wouldn't even know how to quantify this. I suppose some sort of muscle and coordination testing might yield quantifiable measures.) However, there are some data emerging that show less fractures, falls, improved coordination, and perhaps improved memory and mentation with vitamin D supplementation, though doses often used in studies tend to be lower than what we are using in practice.

I haven't been so excited about the effects of a nutritional supplement in a long time. Vitamin D continues to yield surprises every day in its array of positive and powerful effects.

Could we say that vitamin D restores youthfulness?