The report of a seminar on cardiovascular disease organised by the Malta Association of Public Health Medicine (MAPHM), highlights the somewhat higher incidence of Maltese deaths due to cardiovascular disease compared to the EU average and also the need for preventive strategies.
That we have higher rates of cardiovascular disease than our Mediterranean neighbours is to be expected, given our higher rates of type 2 diabetes (partly due to small population inbreeding), high levels of obesity and smoking, relative lack of exercise and also because the diet of an increasing proportion of our people now consists mainly of fast foods rather than the healthy elements of a Mediterranean diet.
Our national health service tried to deal with the problem by setting up coronary bypass surgery and angioplasty services. In recent years we also had official statistics indicating improved longevity.
This newspaper, however, if my memory serves me right, also reported (sometime in these last few years), inferior post-heart attack survival in Malta compared to the EU average which, if true, would suggest that we might indeed need to improve preventive measures rather than rely almost entirely on cardiac procedures.
In this respect, a recent publication of the American College of Physicians is timely. In a leading article of What's New In ACP Medicine, doctors Raymond Gibbons, of Mayo Medical School, and Stephan Fihn, of Washington University Medical School, suggest a recent rethink has been occurring in the indications for coronary angioplasty. Deaths from cardiovascular disease and stroke have dropped dramatically in the US in the last 30 years, being responsible for a four-year increased life expectancy between 1970 and 2000. About seven per cent of this improvement is attributable to bypass surgery and angioplasty, while the rest has been attributed to lifestyle changes and medical therapy that reduce cardiovascular risk factors. The authors also claim that two important recent studies have challenged the assumption that angioplasty improves outcome in patients with multi-vessel disease.
One of these trials on multi-vessel disease patients followed up for four years showed no significant difference between those treated with angioplasty and those with medical treatment. In the other trial, unlike previous ones, medical therapy consisted of risk factor reduction, resulting in very high rates of adherence to national guidelines for blood pressure, lipid levels, exercise, diet and smoking cessation. When added to such medical therapy, angioplasty did not provide any advantage with regard to endpoint of death or heart attack. The authors claim that these two trials have resulted in a paradigm shift in clinical practice, with patients and doctors more likely to opt for a trial of medical therapy before attempting angioplasty.
The MAPHM is therefore quite right in calling for better education of the risk factors for cardiovascular disease, namely, smoking, high blood pressure, disordered blood fats, diabetes, abdominal obesity, diet and lack of exercise.
The healthiest diets are those based mainly on vegetables and fruits, which combine a high nutritive content and fibre with low calories. The legume family of vegetables (beans, peas and lentils) are very rich in protein and soluble fibre. Plant and fish protein are healthier than meat protein. The healthiest fat is olive oil, not meat or milk/butter/cream/cheese fat, nor margarine containing trans-fatty acids (partially hydrogenated oils).
Nuts contain healthy oils and soluble fibre.
Foods made from refined flour, refined rice, potato and refined sugar (high glycaemic carbohydrates) should be avoided or severely restricted - too much of them results in high blood sugar and increased risk of abdominal obesity, high blood pressure, disordered blood fats and diabetes (metabolic syndrome).
Observing the local scene, where white bread, white pasta, potato, pizza and pastries seem to be the staple diet of an increasing proportion of the population (the steadily increasing numbers of pastizzi outlets also confirms it), the MAPHM would appear to have quite a task ahead.
Their diet awareness educational work has not been made any easier by a much publicised recent Maltese food book which recommends eating lots of eggs, meat, cream and cheese. This book is obviously based on the controversial Atkins diet. Although reducing foods made from white floor, potato, white rice and sugar will reduce weight, too many eggs, meat, cream, butter and cheese will increase the risks of cardiovascular disease in the long run.
Populations who are predominantly vegetarian and eat fish instead of meat suffer less cardiovascular disease and cancer than populations who eat a lot of dairy produce and meat. Recently published American research claims processed meats, such as salami, are also closely linked to bowel cancer, one of the biggest killers in western countries. A very recently published Cambridge study claims eating plenty of vegetables and fruits, no smoking, avoiding obesity and exercise may add up to 14 extra years to your life span.
The protective effect of fish oils (omega-3) on the cardiovascular system, initially studied in Eskimos in the 1950s, is now well established. The National Institute for Health and Clinical Excellence (Nice) in the UK has issued guidelines advising doctors to prescribe omega-3 fish oils for heart attack sufferers, aiming to reduce cardiac deaths. Higher consumption of fish oil omega-3 fatty acids increases survival rates after heart attack by up to 43 per cent.
Fish oil guards against stroke, makes the blood less likely to clot (as with warfarin and aspirin), improves the blood fats picture and reduces risk of cardiac atrial fibrillation.
Fish oil is probably the number one health food supplement you should consider. The more expensive fish oils have been purified and any traces of heavy metal contamination removed.
Prof. Cilia-Vincenti is a former human disease mechanisms teacher at London and Malta universities.