Lifestyle and Cardiovascular Disease

Lifestyle is decisive for cardiovascular disease risk

What science tells us and what you can do about it

Reading time 21 minutes

Author Jaap Versfelt; medical reviewer drs Jeroen Lammers, cardiologist

Key points from this article:

• Lifestyle determines the risk Up to 90 percent of the chance of cardiovascular disease is influenced by lifestyle, such as smoking, nutrition, and exercise.
• Metabolic dysfunction Disruption in metabolism increases the risk of heart disease and is caused by insulin resistance and chronic low-grade inflammation.
• LDL cholesterol Besides the level of LDL cholesterol, the size of LDL particles also appears important for cardiovascular disease risk.
• Effect of lifestyle adjustments If someone is able to eat healthier, exercise more, drink less alcohol, or quit smoking, this reduces mortality risk more than statins alone.
• Ultra-processed food It is advisable to reduce the intake of refined carbohydrates and choose foods with a low sugar spike.
• Low-carbohydrate diet Research shows that a low-carbohydrate diet is most effective for reducing cardiovascular disease risk factors.
• Fat in food New studies show that fat in the diet does not necessarily increase cardiovascular disease risk. With fat from olive oil, avocados, and fatty fish, the risk actually decreases.
• Individual advice Lifestyle adjustments should be made under the guidance of a medical professional.

1. Introduction

Lifestyle determines 90 percent of the risk of a heart attack and 90 percent of the chance of a stroke. In short, what you do daily makes an enormous difference. Everyone knows that smoking is an important risk factor, but what can you do besides quitting smoking (if you smoke at all) to reduce the risk of cardiovascular disease?

In this article, we bring in the science. We show evidence that lifestyle determines cardiovascular disease risk. We nuance the prevailing ‘eat less fat’ advice with new research. We compare the effect of lowering LDL cholesterol with medication to the effect of lifestyle change on mortality risk, with a striking outcome. And then we discuss one of the most important causes of cardiovascular disease: metabolic dysfunction, manifesting as insulin resistance, obesity, type 2 diabetes, and abnormal blood lipid values. We explain what metabolic dysfunction is, how to identify it, and what you can do about it with your diet and other lifestyle adjustments. And we show that there is one diet that reduces cardiovascular disease risk the most.

With the insights from this article, you can determine whether you have an increased risk of cardiovascular disease (spoiler alert: with the ‘normal’ Western diet of mainly ultra-processed and carbohydrate-rich food, you run more risk). Additionally, you’ll get tools to reduce the risk of these diseases. Or, if you’re already a patient, to reduce the chance of recurrence.

2. Lifestyle: decisive for cardiovascular disease risk

In this chapter, we show that cardiovascular diseases are mainly caused by lifestyle choices, and that metabolic dysfunction is one of the most determining factors.

2.1 Lifestyle is the most determining factor for cardiovascular disease risk

Cardiovascular diseases are largely not genetic diseases:

• Heart attack The Interheart study from 2004 showed that lifestyle determines more than 90 percent of heart attack risk. This cohort study (where data from people is collected over a long period, see 2.2) followed groups of a total of 29,972 men and women for years. The researchers concluded that several factors strongly increase heart attack risk. Almost all these factors are related to lifestyle. Think of factors such as smoking, diabetes, high blood pressure, large waist circumference, alcohol consumption, and lack of exercise. Together, lifestyle factors determined 90 percent of heart attack risk in men and even 94 percent in women (Yusuf, 2004).
• Stroke Similar conclusions also come from a review study (summary research) on risk factors for stroke. The researchers conclude “Through lifestyle modifications, approximately 80 percent of strokes could be reduced” (Allan, 2008). Another study, the Interstroke study published in The Lancet, reports approximately the same: “Ten modifiable risk factors such as diet, alcohol use, and exercise are together associated with approximately 90 percent of stroke risk” (O’Donnell, 2016).

2.2 The biggest risk factors for cardiovascular disease

To establish what the most important risk factors are, researchers use large-scale observational research. In this type of research, a large group of people is followed for a long time, looking at connections between their lifestyle and cardiovascular diseases.

Examples of such studies are:

• The (above-mentioned) Interheart study, in which 29,972 men and women participated.
• The Women’s Health Study, with 28,024 women, who were followed for 21 years (Dugani, 2021).
• The Framingham Heart Study, with 14,428 men and women, started in 1948 and still ongoing (O’Donnell, 2008).
• The PURE study, with 155,722 men and women across 21 countries (Yusuf, 2020).
• The (above-mentioned) Interstroke study, in which 26,919 people participated (O’Donnell, 2016).

What do these five studies have in common regarding risk factors for a heart attack or stroke? We show this in the table below, arranged by what people do, what they have, and what can be measured.

Several things stand out in this analysis. Not every study reports exactly the same, but there are many similarities:

• What you do As expected, smoking is a major risk factor, followed by an unhealthy diet and lack of exercise.
• What you have Three conditions that are often closely related, obesity, high blood pressure, and type 2 diabetes, each increase heart attack risk. It is striking how dangerous having diabetes is, with the risk factor comparable to smoking.
• What you can measure A number of blood values can map the risk. Favorable are low triglycerides and high HDL cholesterol. Additionally, high LDL cholesterol is a risk factor.

2.3 Metabolic dysfunction as a central theme

What do many of these risk factors have in common? Except for smoking, they have much to do with what we call metabolic dysfunction.

In metabolic dysfunction, normal metabolism is disrupted, so the body cannot efficiently produce, store, or use energy. This can manifest through an increase in weight, rise in blood pressure and blood sugar levels, and changes in triglyceride and HDL cholesterol values, as well as a shift in LDL particle size (more on that later).

Metabolic dysfunction is, among other things, a consequence of insulin resistance and low-grade inflammation.

• Insulin resistance is a reduced sensitivity of body cells to the hormone insulin. This means more and more insulin is needed to keep blood sugar levels stable. This elevated insulin concentration has negative effects, such as sodium retention.
• In chronic low-grade inflammation, the immune system is continuously slightly activated, without you noticing it directly.

Low-grade inflammation and insulin resistance also reinforce each other.

Deep dive: Metabolic dysfunction

Metabolic dysfunction is the cause of the most common chronic diseases. In this extensive article, we explain what it is, how to recognize it, and what you can do about it with lifestyle changes.

Read more about metabolic dysfunction

3. What about LDL cholesterol?

We have seen that metabolic dysfunction, alongside smoking, is a very large risk factor for cardiovascular disease. What happens when there is a suspicion of cardiovascular disease? Many patients are prescribed LDL cholesterol-lowering medication (for example, statins) by their doctor. And patients with high blood pressure get a blood pressure lowerer. Additionally, doctors often give stop-smoking advice, exercise advice, and dietary advice. However, what is often missing is a conversation about metabolic dysfunction. While the above studies clearly show that metabolic dysfunction may be the most important risk factor for cardiovascular disease. In the follow-up conversation with the doctor, often only LDL is discussed.

Why has LDL cholesterol taken such a central role when it comes to cardiovascular disease? How well do LDL cholesterol-lowering statins work compared to lifestyle interventions?

3.1 Why is LDL cholesterol known as the bad cholesterol?

While HDL cholesterol is known as the ‘good’ cholesterol, LDL cholesterol is called the ‘bad’ cholesterol. There are various reasons for this. First, because LDL is found in the plaques (deposits) in the arteries involved in such an infarction after a heart attack.

Additionally, a clear relationship has been found between the concentration of LDL cholesterol in the body and the chance of cardiovascular disease. The higher the LDL cholesterol (for example, due to a genetic mutation), the greater the chance of an infarction. And vice versa, the lower the LDL cholesterol (for example, through use of cholesterol-lowering medication) the smaller the chance of a heart attack.

3.2 Besides LDL cholesterol level, the size of LDL particles is relevant

LDL cholesterol is cholesterol that is transported in small packages called LDL particles (Low-Density Lipoprotein). Two things can be measured from the LDL cholesterol in the blood:

• The mass of cholesterol in the LDL particles (this is the normal measurement and is called the level of LDL cholesterol or simply ‘LDL cholesterol’).
• The size of the LDL particles with which the cholesterol is transported in the blood.

What research shows is that not only the cholesterol mass matters, but also the size of the LDL particles. Smaller LDL particles represent an increased risk. Some studies:

• Cardiovascular disease Research shows that people with small LDL particles have more risk of cardiovascular disease than people with larger particles (Liou, 2020, Pichler, 2018). People with the smallest LDL particles in their blood have even three to four times more chance of coronary heart disease than people with the largest LDL particles (Lamarche, 1997).
• Longevity A Dutch study, the Leiden Longevity Study, among children of centenarians, shows that people with large LDL particles live longer. The researchers found no connection between the level of LDL cholesterol in the blood and longevity (Vaarhorst, 2010).

Where do smaller LDL particles come from? Research shows that smaller LDL particles are associated with metabolic dysfunction. Some studies:

• Metabolic dysfunction has, among others, these four characteristics: high fasting insulin, low HDL cholesterol, excess abdominal fat, and high blood pressure. Research shows that 100 percent of women with these four characteristics have many small LDL particles, while only 6 percent of women without these characteristics have many small LDL particles (Selby, 1993).
• Research shows that carbohydrates in the diet, especially refined carbohydrates like white bread, cookies, and soft drinks, contribute to forming more of these small LDL particles (Siri, 2005).

Does only the size of LDL particles matter then and not the level of LDL cholesterol? It’s not that simple. Someone with a higher LDL cholesterol level in the blood still runs more risk than people with lower levels (Otvos, 2011).

Therefore, both addressing the size of LDL particles (by improving metabolic health) and lowering LDL cholesterol levels can be relevant. LDL cholesterol level is often addressed with statins.

3.3 How effective are statins compared to lifestyle interventions?

We are not going to give medical advice in this article. This article is about lifestyle and cardiovascular disease. Yet we want to give a consideration: what benefits you most as a patient?

Research on lifestyle adjustments among patients with coronary heart disease published in Journal of the American College of Cardiology (Maron, 2017) shows the following effects on mortality risk (the figures are based on ranges from the studies Iestra, 2005 and Khera, 2016).

• Quitting smoking: 36-44% reduction in mortality risk.
• Reduction of overweight: 34% reduction in mortality risk.
• Dietary adjustment: 9-44% reduction in mortality risk.
• Reduction in alcohol consumption: 20% reduction in mortality risk.
• More physical exercise: 12-24% reduction in mortality risk.

Let’s compare these results with the effect of using statins in people with coronary heart disease. A meta-analysis with the results of 21 studies shows that using statins reduces mortality chance by an average of 14 percent (with a range of 8% to 33%) (Byrne, 2022).

With lifestyle, a greater reduction in mortality risk appears to be achievable than with statins. As the researchers write, “These findings emphasize the importance of discussing risk reductions when making well-informed clinical decisions with individual patients.”

In other words, if patients are open to lifestyle adjustments (and can maintain the changes), they can significantly further reduce their mortality risk with lifestyle. To be clear, we are not saying you should only choose lifestyle. Prevention of cardiovascular disease is a sum of the effects of lifestyle change and medication.

Those lifestyle adjustments (besides quitting smoking) are mainly about addressing metabolic dysfunction. But how do you determine if you are metabolically healthy or not?

4. Establishing metabolic dysfunction

We know that metabolic dysfunction is closely related to (among other things) insulin resistance and low-grade inflammation. Of these two conditions, insulin resistance is the easiest to establish.

With insulin resistance, the body has difficulty efficiently processing the ingested energy. This affects not only blood sugar levels but also other processes that together regulate the body’s energy balance, such as fat and protein metabolism. Due to reduced insulin sensitivity, the pancreas produces more and more insulin to transport glucose to the cells. The elevated insulin level that results can lead to disruptions of other metabolic processes such as fat storage in the liver and muscles and the regulation of inflammatory processes.

Insulin resistance can be fairly reliably established with the following questions:

• Is there more fat around the belly (waist circumference > 102 cm men and > 88 cm women)?
• Is BMI higher than 25?
• Is blood pressure elevated (systolic > 135 mm Hg, diastolic > 85 mm Hg)?
• Are there patches of darker colored skin (acanthosis nigricans) or skin tags on the skin in the neck, armpits, or other areas? (Tremel Barbato, 2012)
• Is there polycystic ovary syndrome (PCOS) or erectile dysfunction?
• Is there a family history of heart disease, high blood pressure, or type 2 diabetes?
• Is there fluid retention in the form of thick ankles?

Additionally, there are a number of blood values that a doctor can test that indicate insulin resistance:

• High fasting glucose value (> 5.5 mmol/L)
• High fasting triglycerides (> 1.7 mmol/L)
• Low HDL cholesterol (men: < 1.03 mmol/L, women: < 1.29 mmol/L).

With a ‘yes’ to one of the questions or one of the mentioned blood values, there is probably insulin resistance. With two ‘yeses’ or blood values, the patient is almost certainly insulin resistant (Bikman, Why we get sick, 2020, p. xviii).

To establish insulin resistance with full certainty, more blood values are needed. Below are some of the most common methods to directly test insulin resistance with the corresponding healthy values:

• Rising HbA1c value: > 40 mmol/mol.
• Fasting insulin measurement: > 6 uU/ml.
• HOMA-IR index: the index is calculated from measurements of fasting glucose and fasting insulin. A value above 1.5 fits with insulin resistance.
• The oral glucose tolerance test: insulin > 30 uU/ml, 1 to 2 hours after ingestion of a glucose solution (75 grams).
• Elevated ALAT and GGT values: >40 U/l. This indicates fatty liver.

A repeatedly elevated white blood cell count (leukocytes > 7) and a slightly elevated CRP (> 1) is a signal for chronic inflammation, which often accompanies insulin resistance.

If you establish insulin resistance, what is known about an effective approach to get rid of it? To answer that question, we first need to know how lifestyle causes low-grade inflammation, insulin resistance, and thus metabolic dysfunction.

5. How lifestyle contributes to metabolic dysfunction

In how lifestyle contributes to metabolic dysfunction, a large number of factors play a role. Two important ones are nutrition and exercise. Additionally, there are other factors.

Nutrition

In the past 50 years, the consumption of ultra-processed food rich in refined fats, sugars, and white flour has increased strongly. 61 percent of the energy intake of the average Dutch person now consists of this industrially produced food (Vellinga, 2022). Examples of ultra-processed food are fast food like pizza, hamburgers, and kebab, but also ‘regular’ supermarket bread, sunflower and rapeseed oil, milk replacers, breakfast cereals, many types of bread spreads, meat substitutes, soft drinks, and diet drinks.

Eating ultra-processed food has many negative effects on our health. A French study (Rico-Campa, A., 2019) in which 20,000 people were followed for 15 years showed strong connections between the consumption of ultra-processed food and increased risks of type 2 diabetes, cardiovascular disease, cancer, depression, and stomach and intestinal disorders. The participants in the study who ate the most ultra-processed foods had a 62 percent higher mortality risk compared to those who consumed the least.

Ultra-processed food stimulates chronic inflammation in the body. Refined fats and carbohydrates can cause oxidative stress, which activates inflammatory processes (Dickinson, 2008). Another example of how ultra-processed food causes inflammation is through higher levels of harmful advanced glycation end products (AGEs) that form when proteins and fats are exposed to sugars in the production process (Geng, 2023).

The inflammation contributes to insulin resistance. Additionally, eating a lot of ultra-processed food with many added sugars causes insulin spikes in the blood. Long-term exposure to such spikes eventually leads to body cells becoming insulin resistant.

The ultimate study that demonstrated the harmful effect of ultra-processed food (Hall, 2019) showed that people who eat ultra-processed food ate about 500 kcal more per day (in the form of more sugar and fat) than people who ate the same ratio of carbohydrates, proteins, fats, sugar, salt, and fiber. The study demonstrated very well scientifically that it is not so much the ratio of macronutrients that is important for energy intake, but that the degree to which food is processed makes people eat (unnecessarily) a lot of it.

Deep dive: Ultra-processed food

Ultra-processed food makes up more than half of our diet and is linked to serious health risks. Discover what ultra-processing means, which products are included, and how you can make healthier choices.

Read more about ultra-processed food

Exercise

The lack of physical activity is associated with higher levels of inflammatory markers, such as CRP (C-reactive protein) (Furman, 2019). Muscles that are loaded by walking, running, or strength training release substances (such as myokines) that reduce chronic inflammation. The reduction of inflammation helps improve insulin function, thereby improving insulin sensitivity.

Additionally, regular physical activity can cause muscles to take up glucose independently of insulin, which helps keep blood sugar levels stable and reduces the risk of insulin resistance (Kumar, 2019).

Other factors

There are a large number of other factors that contribute to low-grade inflammation and insulin resistance and thus to metabolic dysfunction:

• Smoking Smokers have a significantly higher insulin spike in their blood when they eat carbohydrates than non-smokers.
• Alcohol Excessive alcohol use increases the risk of insulin resistance through fatty liver, inflammatory reactions in the body, and a disrupted hormone balance.
• Lack of sleep One week of too little sleep already makes our body 30 percent more insulin resistant. Sleeping half as long as normal for two days can make even healthy people insulin resistant.
• Chronic stress Stress leads to elevated cortisol, which contributes to appetite, blood sugar elevation, inflammation, and thus to insulin resistance and metabolic dysfunction.
• Environmental pollution The past 200 years have been characterized by an enormous increase in exposure to various harmful substances, such as through air pollution, hazardous waste, and industrial chemicals (like PFAS). Each year, an estimated 2,000 new chemicals are introduced into daily products such as food, personal care products, medicines, household cleaners, and agricultural pesticides. These chemicals can also promote inflammatory processes.

We now know that our Western lifestyle causes metabolic dysfunction. What can you do about it?

6. Effective interventions to address metabolic dysfunction and cardiovascular disease

With lifestyle adjustments, you can address metabolic dysfunction and reduce the risk of cardiovascular disease. Think of eating healthier, getting enough sleep, relaxing more, and exercising more (including less sitting). All these adjustments promote insulin sensitivity and reduce chronic inflammation.

Of these adjustments, nutrition and exercise are the most directly influenceable. In this article, we focus on the topic of nutrition.

Deep dive: The 6 lifestyle pillars

Besides nutrition, there are five other lifestyle pillars that together influence your physical and mental health: exercise, sleep, stress, social connection, and environment. Discover how you can strengthen all these pillars.

Read more about the 6 lifestyle pillars

6.1 What is good nutrition?

There are a number of things you can do to address metabolic dysfunction with nutrition:

• Reduce intake of ultra-processed food. A first step is to stop drinking sugary drinks (like soft drinks), reduce consumption of products with added sugars and refined starch (like breakfast cereals, cookies, candy, and sauces), and reduce inflammation-promoting seed oils (sunflower oil, rapeseed oil, soybean oil, etc.).
• Choose foods that cause fewer sugar spikes. A number of foods cause high sugar spikes and thus increase insulin resistance. These are called foods with a high glycemic load. The food contains many carbohydrates that are also quickly released. Think of white bread, cookies, and fruit juices.
  Whole, natural food gives fewer insulin spikes. Think of animal products like meat, fish, milk, and eggs, certain fruits like apples, blueberries, olives, and avocados, certain vegetables including broccoli, lettuce, and carrots, and nuts like walnuts and cashews. In this table you’ll find the glycemic load of more than a hundred foods.
• Limit the number of eating moments. Avoiding snacks becomes easier if someone eats fewer carbohydrates. After eating or drinking many (refined) carbohydrates, there is first a rapid glucose and insulin spike and then a drop in blood glucose. This glucose dip can be accompanied by cravings for quickly digestible carbohydrates. By avoiding refined carbohydrates and industrial oils (like sunflower oil), hunger decreases. Once the cravings disappear, two to three wholesome meals per day suffice.
• Limit food intake to a time period of six to eight hours per day. By building in a longer fasting period, your body gets to burn fat better. You can do this by, for example, skipping breakfast, eating from 12:00 to 18:00, so that on such a day you only eat for 6 hours and fast for 18 hours. In this limited eating window, make sure you get all essential nutrients.
• Limit the amount of carbohydrates. Depending on how insulin resistant someone is, there is more or less room for whole grain products, starchy vegetables, fruit, and honey. To determine how many (or few) carbohydrates someone can handle, a continuous glucose meter is useful. If after a meal the glucose rise is greater than 1.6 mmol/l, it is advisable to further limit carbohydrates. For many (pre)diabetes patients, this means limiting carbohydrates to less than 50 grams per day.

Recipes: Low-carb cooking

Looking for tasty recipes that fit a low-carbohydrate lifestyle? From breakfast to dinner: discover our collection of delicious and healthy dishes compiled by chef Gauko Kuiken.

View the low-carb recipes

Few people will disagree from a health perspective with the advice to limit ultra-processed food and choose unprocessed, fresh products. But what about our recommendation to limit carbohydrates? Is there evidence for that?

Deep dive: Data Driven Fasting

Learn how to achieve better results with data-driven fasting. Discover the principles of intermittent fasting based on your own blood sugar measurements.

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6.2 Evidence for the importance of limiting carbohydrate consumption

Recently, an umbrella review (Chatzi, 2024) was published that summarizes all research on diets and their effect on cardiovascular disease risk. It concerns research in people who have an increased risk of a heart attack or stroke. The study combined 25 meta-analyses, each with multiple randomized controlled trials (RCTs), into one overview.

The effect was analyzed of 26 risk factors including triglycerides, HDL and LDL cholesterol, BMI, blood pressure, HbA1C, fasting glucose, and fasting insulin. The researchers conclude that of all diets studied, the ‘low carbohydrate diet’ had the greatest effect on risk factors. In this diet, total carbohydrates are limited, with a focus on reducing refined carbohydrates (think white bread, white rice, pasta, cookies, pastries, candy, and soft drinks). See the overview in the table below.

We have seen in this chapter that limiting ultra-processed food and reducing (refined) carbohydrates can help improve metabolic health and reduce the chance of cardiovascular disease.

But what happens when you limit carbohydrate intake? As humans, we get our energy from three types of nutrients: carbohydrates, proteins, and fat. When we reduce carbohydrates, we almost automatically eat more fat. Because there is a natural maximum to protein intake. Isn’t more fat dangerous? Haven’t we been warned for years about eating too much fat?

7. What about fat, isn’t that dangerous?

Traditionally, it is thought that a diet high in fat leads to elevated LDL cholesterol, which in turn leads to fat accumulation in blood vessels, increasing cardiovascular disease risk. This has led to the advice to eat less fat.

7.1 The origin of the low-fat diet advice: epidemiological research

The ‘less fat’ recommendation is based on the diet-heart hypothesis of researcher Ancel Keys from the 1950s. Keys developed the hypothesis in his Five Countries Study and evaluated the hypothesis in his much more famous Seven Countries Study. In the latter of these two epidemiological studies, started in 1958, he examined the eating habits, lifestyle, and health of people in seven different countries (including the Netherlands).

Keys concluded that there is a connection between the consumption of saturated fat and the presence of coronary heart disease. His work formed the basis for the advice to reduce saturated fat intake to prevent heart disease. Incorrectly, it is sometimes said that Keys’ research also showed a relationship between the intake of cholesterol and/or fat and the chance of cardiovascular disease. The Seven Countries Study did not show that.

7.2 What kinds of fats are there and do they pose a risk for cardiovascular disease?

There are different fats, each with their own effect on cardiovascular disease. We discuss them below:

Monounsaturated fat

Monounsaturated fat is found in olive oil and avocados. This type of fat has been shown in a number of studies (for example Guasch-Ferré, 2017) to reduce cardiovascular disease risk.

Polyunsaturated fat

Polyunsaturated fat is found in fatty fish, nuts and seeds, and in industrially produced oils like sunflower oil. This fat contains the essential fatty acids omega 3 and omega 6. Omega 3 is mainly found in fatty fish, flaxseed, and walnuts. Omega 6 is found in sunflower oil, soybean oil, and nuts.

Both omega 6 and omega 3 fatty acids lower cardiovascular disease risk. Omega 6 fatty acids work mainly by lowering LDL cholesterol, while omega 3 fatty acids lower triglycerides, promote blood flow and heart and blood vessel function, and regulate thrombosis and inflammation (Djuricic, 2021).

Our Western diet is rich in industrially produced oils with lots of omega 6 (like sunflower oil). As a result, there is often an imbalance between omega 6 and 3. An excess of omega 6 increases cardiovascular disease risk (Zhang, 2024). This argues for limiting the consumption of such seed oils.

Saturated fat

Saturated fat is mainly found in animal products like butter, cheese, and meat, and in some plant sources like coconut oil. These fats are often solid at room temperature.

The most controversy exists around saturated fat. The WHO recommends limiting saturated fat consumption to 10 percent of total calorie intake. The advice is based on a number of systematic reviews of multiple randomized studies (RCTs) and has ‘moderate’ evidence strength according to the WHO (WHO).

There has been much criticism of the WHO report. An example is the following response from a group of scientists (Astrup, 2019).

• Not all saturated fatty acids are equal Different saturated fatty acids have varying effects on health. Grass-fed meat, for example, contains more fatty acids like omega-3 and heptadecanoic acid than grain-fed meat. These fatty acids are associated with a lower risk of heart disease.
• Food source and context are important The effect of saturated fats depends on the food source. Much of the research used looks at isolated fats, but the overall dietary pattern and the food matrix (such as dairy, meat, or chocolate) play a larger role in cardiovascular disease risk than just the fat content.
• LDL cholesterol as a risk factor is not completely reliable LDL cholesterol is used by WHO as a measure of heart disease risk, but not all LDL particles are equally harmful. Especially small LDL particles increase risk. Saturated fats often increase LDL particle size, which does not necessarily indicate an increased risk of heart disease.

In short, scientists have not yet reached consensus. What should you do as a citizen or doctor?

Experience in practice shows that saturated fat intake has no effect on LDL cholesterol in some people, while doctors see an increase in LDL from 3.0 to 7.0 in others.

Summarizing everything, it is therefore not automatically wise to replace every form of carbohydrate with any fat. The most favorable effect can be expected from replacing refined carbohydrates with a combination of proteins, monounsaturated fat, and omega 3 fats. In short, replace fast food with fish prepared in olive oil and eat grass-fed meat.

8. Conclusion

Science shows that cardiovascular disease risk is largely (up to 90 percent) determined by lifestyle choices. Besides smoking, sleeping, and relaxation, what you eat and how much you exercise are also important risk factors.

In the Netherlands, the average person eats too much (ultra)processed food, too few vegetables (and fruits) and fish. We exercise too little and sit too much. As a result, anyone who thinks they eat ‘healthy’ by their own standards already runs an increased risk of cardiovascular disease.
The average Dutch diet consists of 61 percent of our calories from ultra-processed food, and we eat many refined carbohydrates with a high glycemic load. That dietary pattern contributes to metabolic dysfunction and an increased chance of cardiovascular disease. The first effects of the diet are noticeable in the form of excess belly fat, fatigue after meals, cravings for sugary food, and difficulty losing weight.

If you recognize this in yourself, you have an increased chance of a heart attack or stroke. Therefore, have your blood values measured and consider avoiding ultra-processed food (no candy, ready-made meals, jarred sauces, soft drinks, etc.), choose foods with a low glycemic load (avoid white bread, white rice, and fruit juices), try to skip snacks, and reduce the amount of starchy carbohydrates (like potatoes, rice, wheat, etc.) and replace them with healthy carbohydrates from vegetables (for example kale, endive, and broccoli) and to a lesser extent fruit.

Less ultra-processed and fewer carbohydrates. This almost automatically means eating more fat. That doesn’t have to be a problem if you choose monounsaturated fat (olive oil, avocado) and omega 3 fats (fatty fish, walnuts, and grass-fed meat).

Research shows that LDL cholesterol is a risk factor for dying from cardiovascular disease and that statins can somewhat reduce the chance of death. However, there are other measures that can reduce the chance of death much more, namely lifestyle change. If you as a healthcare provider or patient settle for only using statins, you are missing a big opportunity. Much more can be achieved with lifestyle change than with medication alone.

Finally, no person is the same. What we describe in this article is what works for large groups of people according to research. The information is not medical advice for individual people. We do not advise changing an existing treatment. We recommend everyone with chronic conditions to seek proper advice on their treatment and lifestyle from qualified medical professionals.

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Veelgestelde vragen

What are the main risk factors for a heart attack?

Research shows that 90% of heart attack risk is determined by lifestyle factors. The most important are: smoking (increases risk 2-3x), an unhealthy diet, lack of exercise, high blood pressure, type 2 diabetes (increases risk comparable to smoking), and obesity. Metabolic dysfunction also plays a central role, characterized by insulin resistance and chronic low-grade inflammation.

What is the effect of a low-carbohydrate diet on cardiovascular disease?

A recent umbrella review showed that a low-carbohydrate diet is the most effective diet for reducing cardiovascular disease risk factors. This diet has a strong positive effect on triglycerides, HDL cholesterol, weight, blood pressure, HbA1C, and fasting glucose/insulin.

What is metabolic dysfunction and how does it affect heart health?

Metabolic dysfunction is a disturbance of normal metabolism where the body cannot efficiently produce, store, or use energy. This manifests as weight gain (especially abdominal fat), elevated blood pressure, increased blood sugar levels, and disrupted lipid values. It is caused by insulin resistance and chronic low-grade inflammation.

Which lifestyle changes reduce cardiovascular disease risk the most?

The effectiveness on mortality risk in patients with coronary heart disease is: quitting smoking (36-44% reduction), losing weight when overweight (34% reduction), dietary adjustments (9-44% reduction), less alcohol (20% reduction), and more exercise (12-24% reduction). For comparison: statins reduce mortality risk by an average of 14%.

How can you recognize metabolic dysfunction?

Metabolic dysfunction can be recognized by: waist circumference >102 cm (men) or >88 cm (women), BMI >25, blood pressure >135/85 mmHg, dark skin patches or skin tags, PCOS or erectile dysfunction, family history of heart disease/diabetes, and thick ankles. With two or more characteristics, someone is almost certainly insulin resistant.

Why is the size of LDL cholesterol particles important?

Small LDL particles are more harmful than large particles; people with the smallest LDL particles have 3-4x higher risk of coronary heart disease. Small LDL particles are associated with metabolic dysfunction. Refined carbohydrates like white bread and soft drinks contribute to more small LDL particles.

How does ultra-processed food contribute to cardiovascular disease?

Ultra-processed food (61% of Dutch energy intake) increases risk by: stimulating chronic inflammation, high levels of harmful AGEs, causing insulin spikes leading to insulin resistance, omega-6 imbalance, and promoting excessive calorie intake (on average 500 kcal/day more).