By Katie Clark, MPH, RD

The South Beach Heart Program stresses the need for prevention in heart disease management, and you are a preventive cardiologist.  How does this preventive approach to medicine and heart disease differ from that of your colleagues?

The Holy Grail of cardiology has been too much to look for the so-called seventy percent to eighty percent blockages, and then perform angioplasty or bypass surgery.  We look, first of all, for preclinical disease with imaging the heart and at the calcium score.  In the early stages of disease, we do conventional blood testing as well as advanced blood testing. We treat most of the targets, and we monitor the subclinical diseases. With this preventive approach and early targeting, we really are seeing heart attacks and strokes disappearing from certain clinical practices.

A nice component of The South Beach Heart Program is its straightforward description of recommended diagnostic tests.  While most readers are likely familiar with the traditional lipid panel and CT scans, you emphasize the need for determining the calcium score, also call the Agatston Score.  Can you explain what this test analyzes, and why it is important in determining heart disease risk?

The calcium score quantifies the amount of calcified plaque in the coronary artery.  And, there is also fibrous tissue, and cholesterol, or soft plaque.  The calcium score reflects the total amount of atherosclerosis, which is hardening of the arteries, and it's the number one predictor of future heart attack and stroke.  It's better than Framingham Score and all the risk factors put together.

You also recommend advanced blood testing, which includes a high-sensitivity C-reactive protein test.  What do elevated CRP levels indicate, and is there any relationship between particular foods in the diet and elevated CRP?

The CRP indicates a measure of underlying inflammation, non-specific inflammation that is often associated with real belly fat. This is an independent risk factor for heart attack and stroke.  And we, as a society, are really hyper-inflamed. Our CRP is about 20% higher than those in the UK, and a lot of it comes from our diet.  As we have more trans fat in our diets, more bad fat in general, and less good fats like omega-3 fatty acids and less pure antioxidants from fruits and vegetables...all of this seems to be associated with the increased inflammation, which is a risk factor for heart disease and stroke, as well as many forms of cancer, macular degeneration, Alzheimer's... it is really a reflection of lot of the worst things about western society, including low levels of exercise.

You mentioned antioxidants, and the diet portion of the book did focus on the antioxidant content in various foods and the USDA's ORAC scale. You assert that certain fresh fruits and vegetables are no doubt higher in antioxidant content than others. Do you think there is substantive scientific evidence that warrants recommending certain high antioxidant fruits & vegetables over others? Or is increasing total fruit and vegetable intake across the board more important?

Well, we are really recommending antioxidants across the board, there are biologic reasons and logical reasons why maybe you would want to eat more blueberries, which are high in antioxidants.  But, you know as far as absolute studies go, our philosophy is more of a general recommendation to eat more fruits and vegetables rather focus exclusively on the antioxidant content. And, when it comes to fruits, we also recommend those fruits that are lower on the glycemic index scale.

I liked the anecdote about the man who rationalizes his multiple walks each day saying, "I figure that if I keep moving, they can't bury me." For a middle-aged person at risk for heart disease, how much exercise do you recommend each day, and would you say your recommendations are in line with national guidelines or do you advocate for more or less exercise?

Well, we are a little bit more focused depending on what a patient is doing.  At a minimum, we are saying twenty minutes to thirty minutes per day, five days a week. But, if somebody is doing nothing to start with, then his or her improvement starts with almost any exercise at all. I hate to give specific cut-offs, like if you're a minute under this amount, you're not getting any benefit for what you are doing--that is not realistic.

In The South Beach Heart Program, you recommend taking prescription form niacin as an HDL elevator and to lower LDL and triglycerides. Are there any over-the-counter supplements that you regularly recommend for the prevention of heart disease?

The only over-the-counter supplement I recommend is omega-3 fatty acid fish oil capsules. As far as niacin goes, we want that done in consultation with the physician and don't want patients doing their own dosing. Low dosages of supplemental niacin won't do anything, and I recommend people get most of their vitamins and minerals from fruits and vegetables and real foods. If people don't eat any fish, then fish oil supplements are appropriate. And prescription-strength niacin is indicated in certain cases.

It is no surprise that a heart program book with a diet component contains recommendations regarding the benefits of moderate alcohol consumption. How are red wine and other alcohols protective against heart disease and what constitutes "moderate" intake?

When you are talking about wine, the recommendation is one glass for women and two glasses for men per day.  One benefit of red wine includes resveratrol, which has been identified as an antioxidant. As far as red wine and wine in general, we know there are a lot of antioxidants, those chemicals in there with a lot of positive effects on health.

Isn't the amount of resveratrol from wine needed to be efficacious so much higher than one person could ever consume in their diet alone?

Yes, in a number of studies the dose has been shown to be higher than normal consumption could provide. We don't recommend people start on wine for that reason alone if they didn't drink it previously. It's important to be aware of the sources of micronutrients, and I think red wine in particular is one source of certain antioxidants. 

I enjoyed the numerous references in the book to large scale studies that have demonstrated the cardio-protective benefits of certain diet and drug therapies.  Have you published any articles linking long-term adherence to the South Beach Diet with actual reduced mortality from cardiac events?

No. We do have longer-term diet studies underway at the Mayo Clinic, and they are looking good.  The evidence for this way of eating is based on many observational studies that are smaller, short-term studies.  In observational studies, the preponderance of evidence is certainly in favor of the good fat and the good carbohydrate focus of such a diet.

What do you say to critics who contend that the first phase of the South Beach Diet is too restrictive with regards to carbohydrates?

Well, we have studied that and to clarify, we emphasize getting enough carbohydrates, a minimum of carbohydrates from vegetables and other healthy sources.  As far as the first phase, people really do have to cut back on carbohydrates to lose real belly fat and fight cravings. The low-carbohydrate focus works incredibly well at stopping cravings, and then people can add more nutrients back with good carbohydrate foods. There is some really positive feedback from some people who are doing well and want to stay on the carbohydrate-restrictive phase for longer. We do not advocate it as a way for everyone to promote rapid weight loss, but it's a great jumpstart. We see improvement in the lipid results over the first few months.

The chapter entitled "Principles of the South Beach Diet" includes lists of foods to enjoy in Phases 1 & 2. I noticed that Phase 2 includes specific portion recommendations whereas Phase 1 does not. Any particular reason for this?

Well, when you are restricting all the starches and sugars, in general the portion takes care of itself.  And, it is true, this book is a guide; we don't really want people measuring or counting anything.  We think it's a lifestyle - when you make your choices in traditional societies, nobody is measuring food, or counting carbohydrates, or calories. When you make the right choices in general, the portions take care of themselves. Throughout the book, we wanted general awareness about proper foods and realistic portion sizes.

There is a part in the book that chides some cardiologists' propensity for prescribing statins, saying, "...that some not so jokingly say that they should be put in the water supply!" Your endorsement is not as strong, and you mention that low-risk people should not take statins because they would be exposed to the unnecessary possibility of side-effects. But elsewhere in the book you say that you have only encountered one case of a serious statin-related side-effect. What, then, are the less-serious side-effects that may afflict someone on a statin drug?

There are some nonspecific side-effects, including pain, muscle aches, some memory loss...and most of these are all reversible. We haven't seen any life-threatening side-effects from statins, and they really are a cost-effective approach to managing heart disease in some cases. But to say they should go in the water supply....

...you would all be out of jobs.

Oh, yeah. It's much more cost-effective to eat more healthfully because statins alone only prevent about 30% of heart attacks.  And, we think that therapy in general should be tailored, and there are maybe other unknown side-effects of the drugs.  If you don't need the drug, we don't think you should take it.

You mentioned muscle pain as a possible drug-related side-effect. What are your thoughts on CoQ10 for treatment of muscle pains associated with statin use?

It is one small study that was presented, and I think it was at the Heart Association meeting a few years ago. There was a manuscript about the positive effects of CoQ10. Theoretically, as a supplement it should help. We do recommend it because it does seem to reduce muscle pain.  It is not a cure-all and there may be more side-effects we don't know about; we don't know for sure.

I am interested to know your thoughts on the dairy and weight-loss link. Do you think milk drinkers are generally healthier than the average population and just consume fewer calories or each day, or do you think there is a deeper nutrient-based relationship between dairy and weight?

Oh, I honestly don't know whether it's the calcium or what it is about milk that is linked to weight loss. On that topic, I don't have a strong opinion.  I don't think anybody knows at this point.

With the recent findings that the diabetes drug Avandia may increase risk for heart attack, some physicians are calling for a discussion surrounding national recommendations that encourage doctors to prescribe medications for people with multiple diseases to drive certain lab values down to questionably low levels. Besides achieving target lab values, what do you think are other important milestones or goals for people looking to prevent heart attacks and stroke?

Well, the debate about Avandia and Actos is far from over. People are very skeptical about that last study because it comes at the risk of overlooking the many other positive studies. But, as far as for people who have metabolic syndrome, pre-diabetes, or early Type II diabetes, they can't reverse it without medication alongside diet and exercise. And, we see success when they are using medication and lifestyle changes. We deal with patients as they are--and optimally, lifestyle changes are the first recommendation, but sometimes, especially if the people are older, more middle-aged and older people, their LDL do not respond as readily to diet and lifestyle changes, and medication is helpful in that situation.

I was surprised to see that The South Beach Heart Program book spends much less time outlining dietary recommendations than it does explaining the pathophysiology of heart disease, diagnostic tests, and medication therapy. How does the food component of The South Beach Heart Program differ from the original South Beach Diet? Why would someone want to go out and buy this book if they already know the South Beach Diet?

As far as the diet goes, there is a lot of information about certain foods, including antioxidants in The South Beach Heart Program. But, the book is revolutionary in that it calls for intervention in the prevention of heart disease; not looking at the situation ten or twenty years down the road when diet and lifestyle changes are so much harder to enact and the disease has progressed. Doctors are preventing disease right now, and it's too bad that certain patients are not getting the benefit of what we already know about heart disease and stroke prevention.

I know that you are a preventive cardiologist, and you know a lot about nutrition; but I would say that a lot of other patients do not have that luxury, and their physicians are not very well versed in nutrition or in recommending lifestyle changes.  What do you recommend to someone who is not your own patient and whose cardiologist does not have an extensive nutrition background? Do you advocate for referrals to a registered dietitian as a part of a comprehensive approach to preventing heart disease and stroke?

Absolutely. We recommend that in our book. We have a good relationship with the American Dietetic Association Foundation and we believe in working very closely with registered dietitians to help make nutrition recommendations that are effective in preventing and reducing the incidence of heart disease and stroke.