The creator of the popular South Beach Diet advocates an aggressive four-step prevention plan to keep patients out of the hospital and off the operating table

Dr. Arthur Agatston: taking prevention to heart: the creator of the popular South Beach Diet advocates an aggressive four-step prevention plan to keep patients out of the hospital and off the operating table

Patrick Perry

Two decades ago, Miami-based cardiologist and researcher Arthur Agatston was puzzled. How could he better help high-risk heart patients under his care? What would improve cholesterol and insulin levels and make a more significant impact on his patients’ risk profiles? During the journey, he became what he terms an “accidental diet doctor,” creating what the world now knows as The South Beach Diet.

“It really started with my interest in cardiac prevention,” Dr. Agatston told the Post. “Statin drugs such as Lipitor, Crestor, and Zocor emerged about this time and allowed us to lower cholesterol a great deal and decrease heart attacks by about 30 percent. But still we were not addressing other causes of heart attacks. We were generally ignoring obesity because the then-nationally recommended low-fat, high-carb diet just didn’t work.”

In the 1980s and early 1990s, Dr. Agatston researched the latest studies on nutrition, including the vital role of dietary fiber, the concept of the glycemic index, and benefits of good fats. Armed with nutrition information, he developed a good-fats, good-carbohydrates eating plan and tried it with great success in his patients, then in scientific studies. Amazed by the positive results on both patient blood chemistries and their waistlines, he reported the results at national meetings.

News spread quickly. A local television station profiled the program, inviting the cardiologist to South Florida.

“That’s when the eating plan became known as the South Beach Diet and moved from the academic to the public realm,” explains Agatston. “I did not start out to write a diet book; it was just one piece of the prevention puzzle. The book happened after the television promotion. It became obvious that I should write the book, and I’m very happy I did. It’s given me a great opportunity to advance prevention. But the South Beach Diet really happened accidentally as part of the prevention package. Since we lived and worked close to South Beach in Miami, the name was a natural, popular, and sexy name that helped with marketing. We considered not giving it a chic name, but we felt that such an attractive name would encourage more people to become exposed to the solid science behind the diet.”

More than 20 million copies and countless pounds later, the South Beach Diet continues to change the way millions of people think about fats, carbohydrates and, most important, prevention.

“My primary mission is to prevent heart attacks and strokes,” stresses the busy cardiologist. “Preventing heart attack and stroke means also preventing the need for bypass and angioplasty, as well as saving people from procedures that have been recommended–either inappropriately or appropriately. People come to me because they don’t want to undergo a bypass or angioplasty; they want to be treated medically.”

In his latest book, The South Beach Heart Program: The 4-Step Plan That Can Save Your Life, Dr. Agatston outlines an aggressive prevention approach for treating heart disease that focuses on healthy eating, functional fitness, advanced testing, and medications, if necessary. The plan highlights the winning strategy that has kept his patients out of the hospital and off the operating table.

“Over the last 15 years, there has been a fantastic revolution in cardiac prevention,” stresses the cardiologist. “To some degree, it started with the Framingham Study–the first study that introduced the concept of cardiac factors back in 1967. But in recent years, knowledge about prevention has accelerated. It takes a while for the knowledge to filter down, and there’s inertia among doctors who continue to practice medicine the way they always did. The old way of treating coronary disease uses the plumbing approach, as compared with the newer healing approach. We know who’s going to win. The healing approach is not controversial in the medical literature, but the vast majority practice the plumbing approach. With the book, I hope to accelerate the time it takes to move most physicians to the healing approach. One of the best-kept secrets in medicine is that doctors who practice aggressive prevention have essentially stopped seeing heart attacks and strokes among their patients.”

The aggressive approach the doctor prescribes includes use of advanced diagnostic tests to detect cardiovascular disease in its earliest stages, before a heart attack or stroke occurs. These tests today are more widely available at major medical centers or in the offices of prevention-oriented cardiologists.

“We do several tests,” says Agatston. “One is the calcium score with a fast CT scan–Dr. [Warren] Janowitz and I developed the calcium score many years ago. The calcium score reflects the amount of plaque in coronary arteries. If you have plaque, lowering the cholesterol to prevent it from accumulating is very helpful. Another screening called the carotid intimal media thickness (CIMT) is used to measure the thickness of the carotid artery–the lining of the vessel wall. As we get older, the carotid artery thickens for a number of reasons: for example, blood pressure goes up with age and our cholesterol rises. A teenager has a much thinner carotid lining than 50- or 60-year-olds. How fast the process occurs is a reflection of the age of your arteries. A 50-year-old might have the carotid of a 30-year-old or a 70-year-old. The test helps predict both stroke and heart attack better than just total cholesterol level. The carotid test is done with ultrasound, because the carotid artery runs very close to the surface of your neck, so you can see it easily with ultrasound, whereas the coronary arteries are deep in the chest wall and you can’t see them with ultrasound; you need CT. We can see changes in the organs years before a heart attack or a stroke so that we have an opportunity to treat the risk factors that are causing the problem in plenty of time.

Other diagnostic measures include such blood tests as the high-sensitivity c-reactive protein (CRP), which measures underlying inflammation that is a risk factor for heart attack and stroke. The cardiologist also utilizes advanced blood screening to measure the type and size of cholesterol particles. According to Agatston, all plaque is not created equal. He focuses attention on the suspect soft, cholesterol-rich plaque lesions that result in the formation of blood clots that block the flow of blood to the heart.

“Size is important to know because we actually see heart attacks more commonly in people with total cholesterol of less than 200 than in people with cholesterol over 300,” notes Agatston. “Cholesterol greater than 300 is more dangerous, but few people have it. Most people who suffer heart attacks have relatively average cholesterol levels. One important reason is because total cholesterol doesn’t consider the size of the bad LDL cholesterol particles. LDL (or ‘lousy cholesterol particles’) get into the vessel and build up soft little plaques that are like little ticking time bombs. The smaller the LDL particle, the easier it can burrow into the vessel wall, creating plaques. We see elderly ladies with very high cholesterol levels–say 300–who have squeaky-clean vessels. They’ve never had a heart attack. They have very big LDL particles that do not fit through the tiny pores of the inner lining of the vessel wall. However, other people with much lower total cholesterol may have small LDL particles that easily get into the vessel wall and build up the soft plaques that can one day explode and cause a heart attack.”

The heart-healthy doctor highlights the positive role of good cholesterol.

“HDL, the healthy cholesterol, acts like a vacuum cleaner and sweeps up the bad cholesterol, delivering it to the liver where it is excreted,” explains the cardiologist. “Even though a low HDL with small particles leads to lower total cholesterol, it also leads to a higher risk of heart attack and stroke. In other words, when it comes to total cholesterol, lower is not always better. Now we understand why people have heart attacks with relatively low cholesterol levels. Size of the cholesterol particles is as important as the total number. I can show you two people with exactly the same total cholesterol–even LDL and HDL, but one has extensive plaque, because their particles are small while the other has squeaky clean vessels because the particles are big.”

To raise HDL levels, the cardiologist recommends exercise, statins, and niacin.

“Niacin is an excellent, often lifesaving medication,” observes Agatston. “What has held it back is the fact that it is generic, so it doesn’t have the marketing dollars behind it. Niacin works beautifully both alone in large studies and in combination of statins. We use it extensively in our practice.

Raising HDL appears more and more an important target in treating heart patients. Don’t think that statins are a magic bullet that you can take and forget about heart attacks; you can’t. Statins can decrease heart attacks by about 30 percent. People came to my practice who thought they were safe because they were taking a statin and then experienced a heart attack. In fact, many had low HDL and small particles that weren’t addressed by the statin. Those patients are now on combination therapy with a statin and niacin.”

Agatston’s focus on noninvasive medical treatment finds support from clinical studies. For example, the recent Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial that matched medicine against stenting in patients with chronic stable angina found aggressive medical therapy proved as effective as stenting in reducing the risk of heart attack or death.

“The report on the COURAGE trial was presented at the American College of Cardiology’s 2007 Scientific Sessions and reported in the New England Journal of Medicine,” Agatston notes. “The COURAGE trial was a very large trial that confirms what I already believed from many smaller trials and from what we know about how plaque progresses. It does confirm the approach we explain in the South Beach Heart Program. It is now clearer than ever that using a stent to open a blockage may relieve chest pain, but it’s not going to prevent a future heart attack. If someone with a blockage goes hiking and suddenly experiences chest pressure, you open, or stent, that blockage to relieve the pain. However, you will not prevent a future heart attack with the stent. You can also relieve the pain just as well with medicine, although it takes longer.

The cardiologist believes that we have focused on the wrong target.

“As a country, we have been spending billions of dollars going after the wrong plaques,” the cardiologist says. “We’re stenting and bypassing healed lesions, rather than curing with medication smaller lesions–the little soft-plaques growing in the vessel wall. These smaller lesions do not affect blood flow until they burst and cause an injury to the wall, resulting in a sudden blood clot. By literally drying up the soft plaques with good preventive methods, we can prevent heart attacks.”

The aggressive prevention regimen underscores the role of functional exercise to strengthen the body’s core muscle groups.

“When our ancestors dug a ditch or pitched hay, they bent over with a shovel and exercised their entire body; they didn’t just contract their biceps or pecs,” explains the cardiologist. “They had to squat and keep their back straight or it would break. They were exercising the core muscles of the entire body–legs, back, shoulders, pelvis–and doing both resistance and aerobic exercise at the same time. Core muscles help maintain posture and are very important. As a society, most of us have stopped doing functional exercise as part of our everyday activities. Now we go to gyms to make up for that lack of daily exercise. We began using machines to isolate and build muscles so they would look good in the mirror, but that really doesn’t improve our health or prevent injury. Functional exercise mimics everyday activity. If you’re working the biceps, use free weights, bend your knees, and keep your back straight during the exercise. In that way, you strengthen core muscles that help maintain posture, improve athletic performance and prevent injury.”

Swimming is an ideal exercise, as is Pilates, which Dr. Agatston performs.

“Swimming is a functional type of exercise, because you’re working your core muscles–arms and legs,” he explains. “It is also low impact–easy on the joints. It’s an ideal form of functional exercise. In Pilates, you’re mimicking functional exercise by working your muscle in many directions and concentrating on core muscles. Since I’ve begun Pilates, I don’t experience the aches and pains or minor injuries that I often got when playing tennis or lifting, because it improved my core strength.”

For most patients, weight loss is, of course, a major issue and a cornerstone of the South Beach program. The eating plan proves particularly beneficial for people who carry weight around the midsection–the proverbial apple- versus pear-shaped individual.

“For people who carry extra weight in their bellies (apples), it’s very predictable that if they follow the South Beach Diet, their bellies can literally melt away,” he has observed. “Overweight people without belly fat are often fit with healthy blood chemistries. The extra weight is often due more to slow metabolism than excess hunger, which is actually a fat-storing mechanism due to exaggerated swings in blood sugar that was an important survival mechanism when food was scarce. These pear-shaped people are often at low risk for heart disease, but it’s tougher for them to take off weight. Exercise becomes more important. They do not respond to the South Beach or any diet as well. But even if you have no weight to lose, you should follow the principles of South Beach, focusing on good carbohydrates and the good fats, because it’s a way to help maintain your general health as well as your heart health.”

The South Beach program is largely based on principles of the Mediterranean diet, highlighting the benefits of omega-3 fatty acids, fresh fruits and vegetables, and whole, unprocessed grains. During phase one, no starches–pasta, rice or bread of any type, sugar, or fruits–are consumed. Instead, lean protein, high-fiber vegetables, nuts, reduced-fat cheese, eggs, low-fat dairy and good fats such as olive oil take center stage. By the end of two weeks, not only do most people lose abdominal fat, but blood chemistries improve and the craving for refined starches and sugar diminishes.

Fiber is another important ingredient in the heart-healthy program.

“You get fiber in fruits, vegetables, whole grains, beans and other foods,” notes Agatston. “Soluble fiber from oats, for example, will lower cholesterol more. Insoluble fiber, such as Metamucil, is more important for bowel function. But both slow digestion of carbohydrates, which makes the greatest nutritional contribution to glycemic index. Both types of fiber fill you up and take away the swings in sugar and insulin that make you hungry all the time. We get only a fraction of the fiber that our ancestors did. Fiber is associated with nutrients, so when we take out the fiber, we’re taking out the nutrients and we’re left with sugar and starch–empty calories. That’s how we become malnourished

even while overfed. We used to think fiber was important primarily for bowel function. It was a British army physician, Dr. Denis Burkitt, who discovered the role of fiber while serving in Africa. He has a great quote: that for a given country, the smaller the stools, the bigger the hospitals–which I absolutely believe.”

As for the future, Agatston will continue his research into emerging risk factors and prevention strategies for heart disease. He will also explore the feasibility of a holistic nutrition, health, and lifestyle-management program in elementary schools–Healthier Options for Public Schoolchildren (HOPS)–through his research foundation.

The doctor’s passion for prevention remains clearly in focus.

“Preventing heart attacks is not something that we can hope for in the future,” he stresses. “We can prevent them today, right now. Unfortunately, we’re not applying what we know. And if we do not curb the present epidemic of obesity and diabetes, we’re not going to have the resources to treat all the resulting chronic, debilitating diseases. We’re literally not going to be able to afford it. So it’s very important to apply what we know now to practice prevention and for individuals to partner with their physician and be knowledgeable, because your physician has less time today than he had ten years ago to work with you. Individuals have to take responsibility and understand risk factors and go to their physicians with some knowledge and, frankly, a game plan.”

Three Principles of the South Beach Diet

1. Eat good fats. Choose good fats from olive oil, canola oil, peanut oil, flaxseed oil, walnut oil, avocados, nuts, and fish. Omega-3 (fish oil) supplements are also fine.

2. Eat good carbs. Good carbs include high-fiber, nutrient-dense fruits, vegetables, legumes, and whole grains.

3. Eat lean protein. Eat eggs, low-fat dairy, nuts, seeds, legumes, white-meat poultry, fish, shellfish, and lean cuts of meat.

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