How should you protect your heart? When it comes to diet vs drugs, which do you choose?
How Effective Are Drugs for the Heart?
Drug companies get excited when their medications reduce the risk of something (heart attacks, strokes, death) by 30% or 40%. When they accomplish a relative risk reduction in that neighborhood, the FDA frequently approves the drugs and the companies advertise them like crazy on TV and in magazines. As a result, doctors prescribe such drugs in huge quantities and patients think of them as a lifeline to good health.
When a diet performs equally well, it is often ignored or forgotten because there is no one to beat the drum for food as medicine.
The Story of a Statin:
If you don’t believe us, just get inside our time machine. Several years ago the maker of the best-selling drug in America (Lipitor, AKA atorvastatin) created ads that proclaimed:
“In patients with multiple risk factors for heart disease, LIPITOR REDUCES RISK OF HEART ATTACK BY 36%*…”
On the surface, this seemed fabulous. A lot of people would love to reduce their risk of a heart attack by a third. They might interpret this to mean that out of 100 people, Lipitor would protect 36 from having a heart attack. Those would indeed be impressive odds.
But the asterisk told a different story. In fine print the ad went on to explain:
“That means in a large clinical study, 3 percent of patients taking a sugar pill or placebo had a heart attack compared to 2 percent of patients taking Lipitor.”
What this means is that if 100 people took the drug and 100 people took the placebo, there would be 2 heart attacks among Lipitor users and 3 among placebo takers-just 1 fewer heart attack over the course of the study (which actually had many more people and ran longer than a single year). In other words, 99 people out of 100 who took the drug did not get any obvious heart attack protection. All of a sudden, the odds don’t seem as appealing as a 36 percent relative reduction in risk.
Diet vs Drugs:
Around the same time there was a book review published in the New England Journal of Medicine (“Nutrition in the Prevention and Treatment of Disease,” May 30, 2002) that noted:
“two fish meals a week are as effective as statins in preventing death among patients with cardiac disease.”
We’re not sure how many doctors prescribed fish instead of statins, but during the last two decades more than $130 billion has been spent on Lipitor alone (not counting lovastatin, pravastatin or simvastatin, and several other statin-type cholesterol-lowering drugs).
The Mediterranean Diet:
What if we told you that the Mediterranean diet is just as good? Would you believe us? Would you believe the research?
A study published in the New England Journal of Medicine (Feb. 25, 2013) reports that people at high risk for heart disease can lower their likelihood of having a heart attack, stroke or dying prematurely from cardiovascular causes by switching from their “normal” diet to a Mediterranean diet. The relative risk reduction was about 30%. The investigators were so impressed with the results that they stopped the study after nearly five years (one year earlier than planned). The results were so beneficial that they felt it would be unethical to keep people on their normal diets instead of the Mediterranean diets. They also felt compelled to announce their findings to the world.
The PREDIMED Trial:
Here is what they did. Roughly 7,500 people in Spain were recruited to participate in the PREDIMED trial (PREvencion con DIeta MEDiterranea). Although none had clear signs of cardiovascular disease at the start of the study (Oct. 1, 2003), they were all at substantial risk. They were between 55 and 80 years of age and had at least three of the following problems: type 2 diabetes, hypertension, high LDL cholesterol levels, low HDL cholesterol levels, overweight or cigarette use.
At the start of the study the subjects were randomized to either:
- A Mediterranean diet with lots of extra-virgin olive oil (a minimum of 4 tablespoons daily, up to a liter weekly). It also included fish (3 times/wk) and legumes (3 times/wk). Drinkers were allowed at least a glass of wine a day. Carbs from baked goods were discouraged.
- A Mediterranean diet as above, but instead of olive oil the volunteers were instructed to eat a large handful of nuts a day (30 grams of nuts daily containing 15 g of walnuts, 7.5 g of hazelnuts & 7.5 g almonds)
- A low-fat control diet that allowed carbohydrates like sodas and baked goods
Here are the conclusions of the authors in their own words:
“Our results compare favorably with those of the Women’s Health Initiative Dietary Modification Trial, wherein a low-fat dietary approach resulted in no cardiovascular benefit. Salient components of the Mediterranean diet reportedly associated with better survival include moderate consumption of ethanol (mostly from wine), low consumption of meat and meat products, and high consumption of vegetables, fruits, nuts, legumes, fish, and olive oil. Perhaps there is a synergy among the nutrient-rich foods included in the Mediterranean diet that fosters favorable changes in intermediate pathways of cardiometabolic risk, such as blood lipids, insulin sensitivity, resistance to oxidation, inflammation, and vasoreactivity [blood vessel flexibility].”
Lowering fat consumption does not improve health outcomes. In fact, the advice of the American Heart Association to reduce fat and substitute polyunsaturated vegetable oils (such as safflower oil) may be counterproductive (see this link to a previous post to understand why).
Consuming more olive oil and nuts were among the most likely causes for the improved outcomes of the Mediterranean diet.
This was a primary prevention trial. That means that none of the participants had diagnosed heart disease at the start of the study. Statins have not been shown to lower heart attacks, strokes or prevent death in a similar population.
More Evidence on Diet vs Drugs for Heart Disease:
Statins are effective in lowering such events in people who have already experienced a heart attack (a secondary prevention trial), but the drugs have not performed as well as the Mediterranean diet in otherwise healthy people who are at high risk for problems down the road.
We’re not in any way discouraging people from taking statins if their physicians insist that they are necessary. They do help prevent second heart attacks! What we are sharing, however, is the good news that a Mediterranean diet is at least as good, if not better, than statins in the primary prevention of heart attacks, strokes or premature death in high-risk individuals.
Since the first results of the PREDIMED trial were reported, there have been many other studies showing benefit from the Mediterranean diet. People following this eating pattern reduce their chances of breast cancer, retinopathy, cognitive decline, depression and diabetes. Recent research from Italy showed that those whose diets were closest to the traditional Mediterranean pattern were 37 percent less likely to die of heart disease than those whose diets were less healthful.
How Can You Eat Mediterranean Style?
Would you like to know more about the “nuts and bolts” of a Mediterranean diet? We have included the nitty-gritty details in our book, Quick & Handy Home Remedies from The People’s Pharmacy. You will learn about the best protein sources (besides fish) and which vegetables and fruits are ideal. You will also get practical low-carb dietary suggestions that will be very helpful in planning your grocery shopping expeditions. In addition, there are breakfast, lunch and dinner recipes that follow a Mediterranean diet approach.
Should you desire even more recipes for good health, you may want to take a look at our book, Recipes and Remedies from The People’s Pharmacy. We asked some of the country’s leading nutrition experts to share their recipes with our readers and radio show listeners.
Walter Willet, MD, DrPH, is Chairman of the Department of Nutrition at Harvard School of Public Health. He sharesd his wife’s “Lentil Nut Loaf with Red Pepper Sauce.” Lentils are legumes, highly valued in the Mediterranean Diet.
Christopher Gardner, PhD is a Stanford University nutrition guru. He also offered a great legume recipe: “Lentil and Roasted Bell Pepper Salad.” (You’ll find more great lentil recipes here. And you can listen to our radio show on healthful vegetarian eating here.)
Have you incorporated the Mediterranean diet into your daily meal plan? If so, share your favorites in the comments below. Do you consume 4 tablespoons of olive oil a day? Do you consume a handful of nuts? Let us know your secrets to good health!
This article was updated on 11/22/2016