A new study, presented at the American Society of Hypertension meeting in San Francisco this month, looked at how the risk of suffering a stroke or heart attack varied with blood pressure in a group of 10,001 coronary heart disease patients.

The researchers found that those with a systolic blood pressure below 110 mmHg were 3.1 times more likely to suffer a stroke or heart attack compared to those with a blood pressure of between 130 and 140 mmHg. Those with a diastolic blood pressure below 60 mmHg were 3.3 times more likely to suffer a heart attack or stroke compared to those with a diastolic blood pressure between 70 and 80 mmHg.

The blood pressure associated with the lowest overall risk of coronary heart disease was calculated to be 140.6/79.8 mmHg, significantly higher than the 120/80 mmHg level recommended by the American Heart Association.

The researchers noted that the findings did not necessarily mean that low blood pressure causes cardiovascular disease. It is possible that low blood pressure is caused by some other factor that is in turn responsible for increased cardiovascular disease risk. Congestive heart failure for example can lead to low blood pressure due to the inability of the heart to pump sufficient blood around the body.

The research backs up the findings of similar studies that have found an increased risk of cardiovascular events in patients with low blood pressure who are already suffering cardiovascular disease. On the other hand, healthy individuals with low blood pressure who are free from cardiovascular disease do not appear to be at an increased risk of heart disease and stroke.

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The research, conducted by Canadian scientists, involved the comparison of a diet rich in foods known to reduce cholesterol with a popular statin known as lovastatin.

34 participants who were suffering from high cholesterol completed the study which consisted of three one month phases. The first phase was a whole-wheat based diet (control diet), the second phases was the same whole-wheat diet plus 20mg per day of lovastatin, while the final phase consisted of a diet based on four cholesterol lowering components: 1g/1000kcal of plant sterols, 10g/1000kcal of soluble fiber which came from oats, barley, and psyllium, 21.4g/1000kcal of soy protein, and 14g/1000kcal of almonds.

The researchers found that LDL cholesterol was reduced by 29.6% for the cholesterol lowering diet compared to 33.3% for the statin diet. 27 of the 36 participants reduced their cholesterol levels to within the safe range on the statin compared to 24 participants on the cholesterol lowering diet. Nine of the participants achieved better results on the cholesterol lowering diet than from the statin alone. The researchers also calculated that participants dropped their 10 year risk of coronary heart disease from 11.4% to 8.4% on the cholesterol lowering diet and from 11.6% to 7.7% on the statin.

Cholesterol is thought to be one of the most important risk factors for coronary heart disease. Researchers have calculated that a 1% reduction in LDL cholesterol levels results in a 1.5% decrease in the risk of coronary heart disease.

Components of the cholesterol lowering diet were only included if they had a scientifically verified mechanism of action. Plant sterols reduce the absorption of cholesterol in the intestines. Soluble fiber increases the excretion of bile acids from the body leading to an increase in the production of bile acids in the liver. Bile acids are produced by the oxidation of cholesterol so an increase in bile acid production increases the rate of cholesterol metabolism. Soy protein increases the function of LDL receptors in hepatic cells leading to an increase in the uptake of LDL cholesterol by the liver. Almonds contain numerous cholesterol lowering substances including plant sterols, fiber, and mono-unsaturated fat which increases HDL cholesterol levels while lowering LDL cholesterol.

Rich sources of soluble fiber include peas, beans, oats, barley, pears, broccoli, Brussels sprouts, carrots, and psyllium. Sources of plant sterols include margarines, most vegetable oils, peanuts, blueberries, broccoli, Brussels sprouts, and cauliflower.

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The researchers used data from the Framingham Heart Study (FHS) to determine how total cholesterol levels influence overall heart disease risk. More than 7,000 men and women were studied of which 1,120 developed coronary heart disease during the 25 year study period.

The researchers calculated that at the age of 40, men in the highest group for total cholesterol (greater than 240mg/dL) had a 57% probability of developing coronary heart disease by age 80. In contrast, men in the lowest group for total cholesterol (less than 200mg/dL) had a 31% probability of developing coronary heart disease. In women, the risks of developing coronary heart disease by age 80 were 33% and 15% for the high and low cholesterol groups respectively.

The full results of the study are presented in the graph below.

The American Heart Association (AHA) recommends individuals maintain a total cholesterol level below 200mg/dL. Total cholesterol is made up of two components: LDL and HDL. LDL makes up the larger proportion of of total cholesterol and is the type that is detrimental to heart health. An LDL cholesterol level of 100mg/dL or lower is considered optimal however further reductions in heart disease risk are seen at levels as low as 60mg/dL. HDL cholesterol is the other component of total cholesterol and is considered to be beneficial to heart health. It is recommended that an individual aims for a HDL to total cholesterol ratio of 5:1 with a ratio lower than 3.5:1 considered ideal.

The percentage of Americans with high cholesterol is currently decreasing with just 16% of men and 18% of women having total cholesterol levels greater than 240mg/dL. In 1975 the numbers were 26% and 28% for men and women respectively.

Despite these reductions in total cholesterol, heart disease remains the most common health problem facing the western world. In the United States, 49% of men and 32% of women will develop heart disease during their lifetimes. By comparison, cancer carries a 44% and 37% lifetime risk for men and women respectively, diabetes carries a 33% and 39% lifetime risk for men and women, while the lifetime risks for Alzheimer’s disease are 7% for men and 13% for women.

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The study, conducted by Canadian scientists, involved analyzing 262 previous studies on heart disease involving a combined 29,000 individuals from 52 countries. The researchers attempted to isolate the risk factors thought to have the greatest impact on an individuals probability of suffering a heart attack.

The researchers found that nine modifiable risk factors accounted for more than 90% of all heart attack cases. The risk factors were (in descending order to importance):

• A high ApoB/ApoA-1 ratio
• Current smoking
• Psychosocial factors (e.g work stress)
• Diabetes
• Hypertension (high blood pressure)
• Abdominal obesity
• Poor fruit and vegetable intake
• Lack of physical activity
• Little or no consumption of alcohol

The ApoB/ApoA-1 ratio is similar to the LDL/HDL ratio but is thought to be a better overall predictor of heart disease. The odds of suffering a heart attack were 3.25 times greater for individuals with an ApoB/ApoA-1 ratio in the top 20% compared to the bottom 20% and were 2.87 times greater for current smokers compared to former or non smokers. The full odds ratios for each of the factors are shown in the graph below (an odds ratio greater than one indicates an increased risk of heart attack while an odds ratio less than one indicates a reduction in heart attack risk).

The two greatest risk factors, a high ApoB/ApoA-1 ratio and smoking, were calculated to be responsible for a massive 67.3% of all heart attacks worldwide. The nine factors combined were responsible for 90% of all heart attacks in men and 94% of heart attacks in women.

According to lead researcher Dr. Salim Yusuf of the Michael DeGroote School of Medicine in Ontario, Canada: “…most people believe that only half the risk of heart attacks can be predicted. This study convincingly shows that 90% of the global risk is preventable.”

The researchers added that while obesity was an established heart attack predictor, it was not included as one of the risk factors because it performed relatively poorly compared to abdominal obesity. This is because fat located around the central organs appears to be much more problematic for the heart than fat located in other areas. The authors recommend people place less emphasis on BMI and instead use  a measure of central obesity such as waist size or the waist to hip ratio to more accurately gauge heart disease risk.

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Recent scientific studies point instead to two specific types of fat, trans fats and saturated fats, which are thought to increase the risk of cardiovascular disease.

The largest study on the effects of fat intake on heart disease was published in The New England Journal of Medicine in 1998. The research was conducted at the Harvard Medical School and involved more than 80,000 women from the Nurses’ Health Study (NHS) who were followed over a 14 year period.

Over the course of the study, 939 of the women developed heart disease. The researchers found that both saturated and trans fats led to an increase in the risk of heart disease while polyunsaturated and mono-unsaturated fats both reduced heart disease risk.

The researchers calculated that a 5% increase in calories increased heart disease risk by 17% (relative to carbohydrate calories). A 2% increase in energy due to trans fats was calculated to increase heart disease risk by 93%. This means calorie for calorie, trans fats have almost ten times the impact on heart disease compared to saturated fats.

In contrast, a 5% increase in energy due to mono-unsaturated fat and poly-unsaturated fat was found to decrease heart disease risk by 19% and 38% respectively.

The authors also found that animal fats as a whole increased heart disease risk while fat from plant sources reduced risk slightly. A small positive trend was observed between dietary cholesterol and heart disease however the relationship was not statistically significant.

Trans fats are produced in an industrial process where unsaturated fats are partially hydrogenated in order to increase their melting point. Both saturated and trans fats are thought to increase heart disease risk by increasing levels of LDL cholesterol. Trans fats are further thought to lower levels of the beneficial HDL cholesterol. It is thought that trans fats are responsible for more than 35,000 heart disease deaths each year in the United States.

Trans fats are not widely found in natural foods but are common in processed goods such as french fries, spreads, dips, biscuits, pies, and other snack foods. A small amount of trans fat is also present in animal milk and fat. Foods high in saturated fat include beef, pork, coconut oil, palm oil, full-fat milk, butter, cream, eggs, and bacon.

Mono-unsaturated and poly-unsaturated fats on the other hand are thought to increase HDL cholesterol while decreasing LDL cholesterol levels. Rich sources of unsaturated fats include avocados, seeds, nuts, soybean oil, canola oil, olive oil, and most varieties of oily fish.

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The researchers looked at a group of almost 72,000 middle aged women from the United States who were initially free of heart disease.

The study, which began in 1984, continued for ten years. During the study period 934 cases of coronary heart disease were observed. The researchers found that the women who slept for 5 or less hours a night were 39% more likely to develop coronary heart disease during the study than women who slept for 8 hours a night. Those who slept for 6 and 7 hours a night were 18% and 10% more likely to develop heart disease respectively.

The researchers also found that too much, as well as too little sleep, increased heart disease risk. Nine or more hours of sleep a night was associated with a 37% increase in the risk of coronary heart disease.

The optimal amount for adults is thought to be between 7.5 and 8.5 hours a night however less than a quarter of adult Americans are thought to get this amount of sleep.

Short term sleep deprivation is known to cause many adverse effects on the cardiovascular system such as disturbances in the rhythm of the heart, higher blood pressure, impaired glucose tolerance (a precursor to diabetes), and higher cortisol levels - a stress hormone that has been implicated in heart disease.

Lack of sleep was also more common amongst overweight individuals and it is possible that some of the observed relationship between sleep and heart disease was due to weight rather than a lack of sleep however even after the results were adjusted for confounding factors such as BMI, depression, and snoring the relationship still existed.

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Over an average follow up period of 2.5 years, 62 new cases of coronary heart disease were documented. The researchers found that women in the highest quartile for soy protein intake were 75% less likely to develop coronary heart disease over the study period compared to women in the highest quartile for soy protein intake.

The risk of subsequently dying from coronary heart disease did not appear to be as strongly linked to soy protein intake however deaths from coronary heart disease were still lower amongst those who consumed high amounts of soy. Women in the highest quartile for soy protein intake were 27% less likely to die from coronary heart disease than those in the lowest quartile.

The full results of the study are presented in the graph below.

The authors concluded that: “Our study provides the strongest argument to date for the recommendation made by the American Heart Association to increase soy food intake to promote heart health.”

There are several mechanisms that are thought to explain the beneficial effects of soy on the heart. Soy protein is known to positively influence several risk factors for heart disease. Studies have shown a reduction in total cholesterol levels and LDL cholesterol levels, an increase in beneficial HDL cholesterol, and reduced blood pressure in individuals who consume large amounts of soy products.

One study, published in the American Journal of Clinical Nutrion in 2005, found that diets high in soy protein reduced total cholesterol levels by 3.8%, reduced LDL cholesterol levels by 5.25%, and increased LDL cholesterol levels by 3.0%.

Another study, also published in The American Journal of Clinical Nutrition, found that women who consumed 25g or more of soy protein a day had on average 1.9 mmHg lower systolic blood pressures and 0.9 mmHg lower diastolic blood pressures than women who consumed little or no soy.

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The study, conducted by researchers from the Department of Medicine at the Harvard Medical School in Boston, involved 75,521 women aged between 38 and 63 who were followed over a 10 year period. The researchers looked at the impact of glycemic load and carbohydrate intake on the risk of myocardial infarction.

Glycemic load is similar to the glycemic index in that both are a measure of how a certain food affects blood sugar levels with high values indicating a greater effect on blood sugar. The difference between the two is that the glycemic load takes into account the amount of carbohydrate present in the food item. For example two foods may have the same glycemic index however one might contain twice the proportion of carbohydrates than the other, this item would therefore have twice the glycemic load as the other item.

During the 10 year study period, 761 of the women suffered a myocardial infarction of which 208 were fatal and 553 were non-fatal. After adjusting the results for factors such as BMI, smoking, and alcohol intake, the researchers found that the women in the highest quintile for dietary glycemic load were at a 98% increased risk of suffering a myocardial infarction.

Total carbohydrate intake also showed a modest association with myocardial infarction. Those in the highest quintile for carbohydrate intake were 23% more likely to suffer a myocardial infarction than those in the lowest quintile.

The major findings of the study are presented in the graph below.

The researchers also found that the increased risks of myocardial infarction associated with a high glycemic load diet were greatest in women with a BMI greater than 23. In contrast, glycemic load showed little association with myocardial infarction in women with a BMI lower than 23.

The researchers concluded that: “our findings suggest that a high intake of rapidly digested and absorbed carbohydrate increases the risk of CHD independent of conventional coronary disease risk factors”.

Foods that have a high glycemic load include refined breakfast cereals, white bread, white rice, baked or mashed potatoes, potato chips, most fruit juices and soft drinks, pasta, and raisins.

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The study, conducted by Dutch researchers, used data from the Zutphen study to assess whether cocoa could reduce blood pressure and improve cardiovascular health. In total, 470 elderly men aged between 65 and 84 were used in the 15 year study which began in 1985.

The men were divided into three groups according to chocolate intake with the highest group averaging at least 2.25g of cocoa per day while the lowest group consumed less than 0.5g per day on average. After adjusting for other factors such as BMI and age, the researchers found that compared to men in the lowest group for cocoa intake, the men in the highest group had systolic and diastolic blood pressures that were 3.1 and 2.0 mm Hg lower respectively.

The researchers also found that regular chocolate eaters were much less likely to die from cardiovascular causes such as heart disease and stroke. Men in the highest group for cocoa intake were half as likely to die during from cardiovascular disease during the study than men in the lowest group for cocoa consumption.

Interestingly, after adjusting these results for blood pressure, the men who ate the most cocoa were still less likely to die from cardiovascular disease meaning that the lower risk of cardiovascular death was not due to the lower blood pressures observed in the regular cocoa eaters but by some other mechanism.

It is thought that the flavanols found in chocolate are responsible for the cardiovascular benefits of cocoa. In particular, catechins and epicatechins which are found in cocoa, wine, and green tea leaves, are thought to be the most beneficial compounds. It is believed that catechins and epicatechins reduce the build up of plaques in the arteries and improve the function of the cells lining the blood vessels known as endothelial cells. Flavanols are also thought to reduce LDL cholesterol levels and improve blood flow throughout the body.

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The study, conducted by researchers from the Paul Brousse hospital in France and the Department of Epidemiology and Public Health in London, focused on 10,308 middle-aged participants from the Whitehall II study. The participants, initially aged between 35 and 55, were followed from 1985-1988 up to the conclusion of the study in 2002-2004.

The participants completed six tests of cognitive ability. The tests were on reasoning, phonemic and semantic fluency, memory, vocabulary and a mini-mental-state-examination (MMSE). The MMSE is a 30 point test that is often used to screen for Alzheimer’s disease and other dementias. The researchers standardized the results of the tests to T-scores (mean score standardized to 50 with standard deviation of 10).

The researchers found that men with a history of heart disease performed significantly worse in reasoning, vocabulary, and MMSE. Furthermore, T-scores for men became progressively worse the longer they had been suffering from heart disease.

Amongst women, a history of heart disease was associated with lower performance scores in the phonemic and sementic fluency tests.

The authors of the study believe that heart problems in mid-life may be a precursor for dementia in later life, underlining the importance of maintaining a healthy heart. According to lead researcher Dr Archana Singh-Manoux: “Our results should give an added incentive to reduce the risk factors for coronary heart disease (CHD), as by so doing we could also be reducing the chances of cognitive decline.”

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The research, conducted by Marc McRae of the National University of Health Sciences in Illinois, involved the analysis of results from 13 trials on the effects of vitamin C on cholesterol levels. The minimum dosage of vitamin C taken across the studies was 500mg/day for a period of between 3 and 24 weeks.

When the data from all the studies was pooled, vitamin C supplementation resulted in an average reduction of 7.9mg/dL for LDL cholesterol levels while HDL cholesterol levels increased by 1.1mg/dL. LDL cholesterol is the so called “bad” cholesterol because high LDL cholesterol levels are associated with an increased risk of heart disease. HDL cholesterol on the other hand appears to have preventative effects on heart disease.

The study also found that vitamin C reduced triglyceride levels in the blood by 20.1mg/dL. High levels of triglycerides in the blood leads to atherosclerosis (the hardening of the arteries) and an increased risk of heart disease and strokes.

McRae added that the 7.9mg/dL reduction in LDL cholesterol levels was equivalent to around a 6.6% reduction in coronary heart disease risk while the 20.1mg/dL reduction in triglyceride levels corresponded to a 2.4% reduction in coronary heart disease risk.

While the minimum dosage of 500mg per day is quite high and would be difficult to achieve through diet alone, most vitamin C supplements contain at least this amount. Vitamin C is also well tolerated in the body and no short or long term adverse effects have been observed from the use of vitamin C supplements.

It is believed that vitamin C reduces LDL levels by increasing the ability of the liver to transform cholesterol into bile acids. Vitamin C may also reduce the oxidation of LDL cholesterol and increase the number of LDL-receptors thus increasing the rate of removal of LDL cholesterol from the blood.

A desirable LDL cholesterol level is less than 100mg/dL while a desirable HDL cholesterol level is greater than 60mg/dL. Triglyceride levels lower than 150mg/dL are considered optimal.

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More than 35% of adult Americans are known to suffer from hypertension and this figure rises to more than 60% in people older than 55.

Fortunately high blood pressure can largely be controlled through lifestyle and diet changes. Here are eight of the easier ways to lower blood pressure without the use of prescription medication.

1. Take A Fish Oil Or Omega 3 Supplement Daily

The largest study on the effect of fish oil on blood pressure was published in the journal Circulation which is published by the American Heart Association (AHA). The study found that 15 grams of fish oil a day lowered systolic blood pressure by 8.1 mmHg and diastolic blood pressure by 5.8 mmHg. Overall, the study found that each 1 gram per pay increase in fish oil lowered systolic blood pressure by 0.66 mmHg and diastolic blood pressure by 0.35 mmHg.

It is believed that the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which are found abundantly in fish oil, are responsible for its blood pressure lowering effects.

2. Reduce Salt Intake

Scientific evidence suggests that a 2.3 gram per day reduction in sodium intake can cut systolic blood pressure by 6-10 mmHg and diastolic blood pressure by 3-5 mmHg.

The current maximum recommended intake of sodium is 2.4 grams of sodium per day which is the equivalent of a teaspoon of table salt. The average daily intake of salt in the United States is more than twice this amount. Around 12% of sodium in the average American diet is due to salt being directly added to food while more than three-quarters of sodium intake is through the consumption of processed foods which tend to be high in salt.

3. Consume A Diet Rich In Potassium

Potassium appears to reduce blood pressure levels, particularly in those who consume a high sodium diet or who suffer from hypertension. Studies indicate a reduction in systolic blood pressure of up to 6 mmHg and diastolic blood pressure of up to 4 mmHg in people who consume a potassium rich diet. Potassium appears to work by increasing the rate that sodium is excreted from the body.

The recommended daily intake of potassium is 4.7 grams per day however the average daily intake in the United States is just 2.5 grams per day. Potassium is found abundantly in fresh fruits and vegetables. Potassium rich foods include (potassium per serving in brackets): bananas (0.6g), tomatoes (0.5g), cucumbers (0.4g), pears (0.3g), baked potatoes (0.9g), and orange juice (0.5g).

4. Reduce Intake Of Caffeine

A high intake of caffeine is associated with a significant increase in blood pressure. Interestingly, when caffeine is consumed through natural sources such as coffee, tea, and chocolate the effect on blood pressure appears to be much smaller. The amount of caffeine in three cups of coffee is enough to increase short term systolic blood pressure by 8mm Hg and diastolic blood pressure by 5 mm Hg.

Caffeine has a relatively short half life of 3 to 4 hours meaning its effects on blood pressure are relatively short lived although regular caffeine consumption throughout the day can result in a sustained increase in blood pressure. People looking to reduce their blood pressure levels should limit their intake of caffeine, particularly from sources where caffeine is not naturally present such as energy drinks and caffeine pills.

5. Reduce Abdominal Fat Levels

Body fat, particularly around the abdominal area, is strongly correlated with blood pressure. One study, published in the Journal of Human Hypertension in 1999, found that waist size, a measure of central obesity, was strongly correlated with the risk of developing hypertension. Individuals in the highest quartile for waist size were almost six times more likely to have hypertension than individuals in the lowest quartile for waist size.

6. Increase Intake Of Dietary Fiber

A study, published in the Archives of Internal Medicine in 2005, found that an increase in fiber of 11.5 grams per day resulted in a reduction in systolic blood pressure of 1.13 mmHg and a reduction in diastolic blood pressure of 1.26 mmHg. The effect was greatest amongst people aged over 40 years and in those with hypertension.

7. Increase Intake Of Vitamin C

A high intake of vitamin C appears to reduce blood pressure in hypertensive individuals. A study, published in the journal Lancet in 1999, found that taking 500mg of vitamin C a day for a month reduced overall blood pressure by 9% in hypertensive individuals.

8. Increase Intake Of Magnesium And Calcium

Both magnesium and calcium appear to reduce blood pressure by a small, but statistically significant amount. Magnesium rich foods include beans, broccoli, fish, prunes, almonds, brazil nuts, tofu, and spinach. Calcium is found abundantly in dairy products, fish with edible bones, tofu, peas, broccoli, spinach, and almonds.

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The study, conducted by Norwegian researchers, involved the study of around 25,000 people from Norway who were initially free of heart disease, diabetes, and thyroid problems. The participants were followed for an average of 8.3 years during which 410 people died from coronary heart disease.

The researchers found that levels of thyrotropin were much lower in those who had died of coronary heart disease (CHD). Thyrotropin is produced in the pituitary gland and stimulates the growth and function of the thyroid gland. Thyrotropin levels are considered to be an accurate marker of thyroid function

Women with the lowest thyrotropin levels were 41% more likely to die from CHD than those with average thyrotropin levels and 69% more likely to die from CHD than the women with the highest thyrotropin levels. Although low thyrotropin levels were linked to a higher CHD risk in men, the association was not statistically significant.

An under-active thyroid is known to lead to weight gain, an increase in blood cholesterol levels, and hypertension (high blood pressure) which are all significant risk factors for heart disease. Extremely low thyroid function can lead to bradycardia (extremely low heart rate), depression, fatigue, muscle wasting, hair loss, and even death in rare cases.

Hypothyroidism is generally treated through the administration of the thyroid hormones thyroxine and/or triiodothyronine.

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One of the largest studies on the effects of exercise on heart disease prevention was published in The New England Journal of Medicine in August of 1999. The study consisted of 72,488 females from the Nurses Health Study (NHS). The participants were 40 to 65 at the beginning of the study in 1986. The study continued for eight years during which 645 coronary deaths (475 deaths from heart attacks and 170 from other coronary heart disease) were observed.

The researchers found a strong association between total physical activity and the risk of developing coronary heart disease. After adjusting for factors such as BMI, smoking status, and alcohol consumption, those in the top 20% for total exercise were 34% less likely to have a coronary disease event than those in the lowest 20% for total exercise.

The researchers found that their was little difference in terms of heart disease reduction between those who exercised vigorously compared to those who got their exercise from walking. Those who exercised vigorously for 7 or more hours per week were 24% less likely to develop heart disease than those who did not. Those who walked for 7 or more hours per week were 26% less likely to develop heart disease. Those who both exercised vigorously and walked for more than 7 hours each were 30% less likely to develop coronary heart disease than those who did neither.

The researchers did however find that brisk walking at a speed of 3 mph or greater was more beneficial than easy-paced walking at a speed of less than 2 mph. Those who did their walking at a brisk pace were 36% less likely to have a coronary event than those who did their walking at an easy pace.

Exercise has numerous benefits on the heart - it both raises HDL levels and reduces LDL levels, it also reduces body fat levels and blood pressure levels which are major heart disease risk factors. Exercise is also thought to improve the elasticity of the arteries which helps in the prevention of atherosclerosis.

Doctors generally recommend 30 minutes of exercise a day in order to receive the full heart benefits of exercise however studies show that less than a quarter of adult Americans get this amount of daily exercise.

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One of the largest studies on the relationship between heart disease and height was published in the American Journal of Epidemiology in 1995. That study involved 119,741 women from the Nurses Health Study (NHS) who were initially free of heart disease and ranged in height from 56 inches (1.42m) to 77 inches (1.96m).

The researchers found that shorter women were more likely to be obese, have high cholesterol levels, and be diagnosed with diabetes while taller women were more likely to consume alcohol and smoke cigarettes.

From 1976 to 1990, 3,638 cardiovascular events were observed including 1,304 heart attacks and 1,343 cases of angina.

After adjusting the results for known cardiovascular risk factors such as BMI, smoking, serum cholesterol levels, and hypertension the researchers found that women who were 67 inches (1.70m) or taller were 27% less likely to suffer from coronary heart disease and 23% less likely to suffer from a heart attack than women who were less than 62 inches (1.57m) in height.

A study of 22,071 male physicians in the United States published in the journal Circulation in 1993 yielded similar results.

That study found that men who were 73 inches (185cm) or higher were 35% less likely to suffer a heart attack than men who were 67 inches (170cm) or shorter.

While the precise reasons why shorter people are more likely to develop heart disease are unknown there are several possible mechanisms. One is that taller people tend to have lower levels of fibrinogen in their blood. Fibrinogen is involved in the blood clotting process however high levels of fibrinogen has been associated with increased coronary heart disease risk.

Shorter individuals are also more likely to be overweight and develop diabetes which are two established risk factors for heart disease however even after these are taken into account, tall people still tend to be less susceptible to heart disease.

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Nitric oxide signals the smooth muscle in the blood vessels to relax which improves blood flow Nitric oxide has beneficial effects on many heart disease risk factors. Several studies have demonstrated a link between hypertension and low levels of nitric oxide in the blood. It is thought that nitric oxide widens the blood vessels and arteries which reduces the pressure exerted by the blood on vessel walls. Nitric oxide may also play a role in preventing the hardening of the arteries (atherosclerosis).

While high levels of nitric oxide in the blood are thought to be associated with a lower risk of heart disease only a few lifestyle and dietary factors have been shown to influence nitric oxide production in the body.

It is believed that a diet rich in arginine increases the production of nitric oxide however studies have produced mixed results as to whether arginine can reduce the risk of coronary heart disease.

Arginine rich foods include dairy products such as milk, yogurt, cheese, meats such as beef, pork, chicken, turkey, tuna, salmon and lobster, bread - particularly whole grain breads, seeds, and nuts.

One study found that a high salt intake is associated with lower levels of nitric oxide in the blood. It is thought that salt impairs the ability of enzymes to convert arginine into nitric oxide.

A recent study found that nitrate and nitrite rich foods such as fruits, vegetables and cured meats can improve a patients outcome following a heart attack. Nitrites and nitrates are converted to nitric oxide during periods of oxygen deprivation such as during a heart attack, this in turn helps open clogged or closed arteries improving recovery after a heart attack.

High levels of exercise are thought to encourage the endothelium to produce more nitric oxide while diets high in saturated fat are thought to damage the endothelium and reduce nitric oxide production. Mediterranean style diets, which are both high in mono-unsaturated fat and low in saturated fat, are thought to improve both endothelial function and nitric oxide production.

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One study, published in the journal Archives of Internal Medicine in February 2004, looked at data from 10 previous studies in order to determine the effects of dietary fiber intake on the risk of heart disease.

In total the 10 studies included a combined 91,058 men and 245,186 women over study periods of 6 to 10 years. Over that time 5,249 cases of heart disease were observed with 2,011 deaths due to heart disease occurring. The researchers found that a 10 gram per day increase in dietary fiber intake was associated with a 14% decrease in the incidence of heart disease and a 27% decrease in death due to heart disease.

The study found that both fiber from cereal, which resulted in a 25% reduction in coronary deaths, and from fruit, which led to a 30% reduction in coronary deaths, were beneficial however no association was found between fiber from vegetables and a reduction in heart disease.

A second study, published in the journal Circulation in 1996, found that the risk of dying from a coronary event was 29% lower for those in the highest 20% of fiber intake compared to those in the lowest 20%. The results of that study are presented in the graph below.

It is believed that fiber has positive effects on several heart disease risk factors, high fiber intake can lead to a reduction in LDL cholesterol levels, reduced weight and body fat, lower blood pressure, lower triglyceride levels, and improved blood sugar control. Fiber has also been implicated in a reduction in the risk of certain cancers such as colo-rectal cancer.

Fiber comes in two forms: soluble fiber and insoluble fiber and both are believed to have similar heart health benefits. Most health professionals recommend that individuals get between 25 and 40 grams of fiber each day. Most people fall far short of these levels however with the average American consuming just 15g per day.

Excellent sources of fiber include (percentage of fiber included in brackets): lentils (30.0%), almonds (11.8%), oats (10.6%), bran cereal (10.0%), peanuts (9.5%), dates (7.5%), prunes (7.1%), cooked peas (5.2%), avocados (4.9%), apples (3.9% with skin on), broccoli (3.0%), carrots (3.0%), spinach (2.7%), and bananas (2.4%).

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Researchers at the National Institutes of Health and Harvard Medical School in Boston analyzed 44,636 women who were part of of the Nurses Health Study. At the beginning of the study in 1976, the average age of the women was 50. The participants were followed up every two years for the duration of the 16 year study. The researchers looked for associations between a large waist size and an increased risk of death from cardiovascular disease, cancer, and total mortality.

Over the entire study period, 3,507 deaths were observed with 1748 caused by cancer and a further 751 due to cardiovascular diseases such as heart disease and stroke. The main findings of the study are presented in the graph below.

The women with the largest 20% of waists (a waist size of 35 inches or more) were found to be 79% more likely to die from all causes of mortality at a given age compared to women in the lowest 20% of waist sizes (28 inches or less). Women in the highest quintile of waist sizes facing a 99% increased risk of dying from cardiovascular disease at a given age compared to women in the lowest quintile. Cancer mortality risk was found to be 63% higher for women in the highest quintile of waist sizes compared to the lowest quintile.

The link between waist size and cardiovascular disease existed even in women within the healthy BMI range. Women with a normal BMI (between 18.5 and 25) and a waist size greater than 88cm were three times more likely to die of cardiovascular disease than women with a normal BMI and a waist size of 88cm or lower.

The researchers concluded that measures of abdominal fat such as waist size and the waist to hip ratio are strong predictors of cancer mortality, cardiovascular mortality, and total mortality. Although the study consisted only of women, the authors believe that similar patterns exist in men.

A study published in 2005 in the same journal had found that a large waist size (greater than 88cm), combined with elevated triglyceride levels increased the probability of developing metabolic syndrome by 370%. Metabolic syndrome is associated with a large increase in the probability of an individual developing heart disease and/or diabetes.

The research comes on the back of a recent study suggesting that a large belly in mid-life increases an individuals risk of developing Alzheimer’s disease and other dementias. These studies emphasize the importance of maintaining a healthy waist size throughout life.

An ideal waist size is less than 30 inches (76cm) for women and 35 inches (89cm) for men.

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The researchers looked at data from 1,739 offspring of the Framingham Heart Study with an average age of 59 years. The participants had their blood levels of Vitamin D recorded in 1996, as well as their blood pressures, current smoking habits, diabetes status, cholesterol levels, and physical activity levels. The participants were free of heart disease and other cardiovascular problems at the beginning of the study.

After an average follow up period of 5.4 years, 120 (6.9%) of the participants had developed some form of cardiovascular disease, with 65 of the patients suffering from coronary heart disease, 19 suffering from heart failure and 28 suffering cerebrovascular events such as strokes.

The researchers found that after adjusting for age and sex, the risk of developing cardiovascular disease was 2.04 times higher in the group that had vitamin D levels less than 15ng/mL compared to those with vitamin D levels greater than 15ng/mL. Furthermore, the group with vitamin D levels less than <10ng/mL had 2.63 times greater risk of cardiovascular disease than the group with vitamin D levels greater than 15ng/mL.

After adjusting the results for other cardiovascular disease risk factors such as blood pressure, diabetes status, cholesterol levels, and BMI, the relative risks of cardiovascular disease dropped slightly to 1.62 times and 1.80 times greater for the <15ng/mL and the <10ng/mL groups respectively.

The researchers also found that in participants with hypertension, vitamin D deficiency increased cardiovascular risks by an even greater amount while in individuals without hypertension, vitamin D deficiency led to only a small, non-significant increase in cardiovascular disease risk.

The research authors concluded that: “These prospective, community-based data suggest that vitamin D deficiency is associated with increased cardiovascular risk, above and beyond established cardiovascular risk factors. The higher risk associated with vitamin D deficiency was particularly evident among individuals with hypertension.”

The study also found that vitamin D levels across the participants were quite low with less than 10% of the participants having levels of vitamin D in the blood greater than 30ng/mL which is considered optimal. Vitamin D deficiency is relatively common, particularly in the winter months and in people living in very high or very low latitudes were sunlight exposure is insufficient to allow the body to synthesize vitamin D. In these people vitamin D must be consumed through dietary sources such as fortified milk and cereals, fatty fish and fish oils, mushrooms, and eggs.

The researchers added that: “Low levels of vitamin D are highly prevalent in the United States, especially in areas without much sunshine, 20 to 30 percent of the population in many areas has moderate to severe vitamin D deficiency.”

Vitamin supplementation is another way to increase vitamin D levels however experts urge caution as in people without a vitamin D deficiency, additional vitamin D will not necessarily improve cardiovascular health and in some recent studies, high doses of some vitamins have actually been shown to increase mortality.

The research appears in the American Heart Association’s journal, Circulation.

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Smoking has many effects on the body that lead to increased coronary heart disease risk. First, toxic substances in cigarettes such as carbon-monoxide, nicotine, and aromatic hydrocarbons lead to inflammation of the arteries and blood vessels in the body. The build up of plaque in the arteries and scarring of the arterial walls due to this inflammation leads to atherosclerosis which is a strong risk factor was heart disease.

Nicotine in cigarettes also causes an increase in blood pressure and heart rate as well as increasing LDL (the “bad” cholesterol) and decreasing HDL (the “good” cholesterol). Smoking also reduces the bloods ability to transfer oxygen to and from the heart which results in reduced aerobic fitness.

Studies estimate that smokers have between two and four times the risk of developing heart disease than those who have never smoked. Smokers also have around three times increased risk of other cardiovascular diseases such as strokes, peripheral arterial disease, and aneurysms.

The good news is that within two years of stopping smoking, a third of the excess risk of coronary heart disease attributed to smoking is eliminated. For the average smoker, after 15 years without smoking, the risk of coronary heart disease is almost the same as for someone who has never smoked. The longer the duration of smoking and the earlier an individual begins smoking, the longer it takes for the increased cardiovascular risks to disappear.

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