The tragedy of much of the heroic effort which goes into surgical intervention for cardiovascular disease is that it touches on just a part of a severely compromised system. What is the long­term point or value of bypassing a blocked region with an unclogged vein or artery if the rest of the channels are already somewhat damaged and if little is done to alter those habits and patterns which led to the clogging in the first place? What value a new heart if the system it is pumping blood through is silted up?

When chelation unclogs circulatory obstructions this affects almost the entire system, and a host of factors which could rapidly set the degenerative ball rolling again if they remained behind, such as heavy metals and low density lipoproteins, are removed from the body along with the metastatic calcium. Even then it would be but a short­term improvement if the underlying habits which led to the degenerative changes were not addressed, whether these involve lack of exercise, poor stress coping abilities, smoking and alcohol abuse, dietary imbalances, toxic encumbrances or any combination of these and other causes.

The changes needed to keep the new­found circulatory improvement (after EDTA or surgery) are the very ones which would have prevented the circulatory decline in the first place and can be broadly divided into the eating pattern followed and the many factors in the person's life which lead so inevitably to arterial damage and all that follows.

Those elements which need to be seriously considered include:

• Changing dietary habits.
• Providing specific nutrient aids.
• Increasing aerobic activity.
• Decreasing exposure to smoke, alcohol and toxins.
• Learning stress­proofing techniques.

A prescription for a healthy heart is a prescription for good health generally. All the same features are present and these are now so well established that it almost seems not worth repeating the same 'rules', However, cardiovascular health is in such an appalling state that those who know, and hopefully follow, most of the healthy­heart guidelines will hopefully forgive a brief repetition of the most important points.

Fats
A great deal of agreement exists (a rare thing in science and even rarer in medicine) as to what needs to be done in dietary terms to meet the needs of the cardiovascular system in a modern world. Expert committees have deliberated and come to clear decisions on matters such as the need for a reduction overall in the amount of fat that is eaten.

The average West European and American eats anything up to (and sometimes beyond) 40 per cent of their total energy intake from fats, much of which is of the undesirable saturated type. Various health authorities such as the Senate Committee and NACNE in the UK advise reducing this to between 30 and 35 per cent.

Nathan Pritikin, the revolutionary health expert who developed a diet and exercise programme for cardiovascular dysfunction (Pritikin, 1980), advised reducing this to a miniscule 10 per cent.

Elmer Cranton suggests that a more easily attainable (although still difficult) target is 20 per cent, virtually cutting fat and oil intake in half with the majority of this in the form of polyunsaturated and mono­unsaturated (olive oil) forms.

In practical terms this means avoiding fat on meat and avoiding most meat derived from pigs, cows or sheep as well as skin of poultry. This leaves game, poultry apart from skin, and fish as sources of animal protein for those who do not wish to adopt a vegetarian mode of eating. Game has a fat level of less than 4 per cent as a rule (some beef contains up to 30 per cent fat) and this is usually high in polyunsaturated or monounsaturated fats compared with the less desirable saturated form found in dairy produce and domesticated animal meat.

This highlights an important message: not all oils and fats are bad for cardiovascular health, indeed some are vital. We need essential fatty acids in our diet (hence the word essential in their title) and we can learn a good deal by looking at the dietary habits of people who live in regions (such as the Mediterranean basin) where heart disease is a rarity. Among the important differences in their diet is a very high intake of monounsaturated oil (olive), which has been shown to have a cholesterol lowering effect. They also eat abundant fish, a major source of eicosapentenoic acid, a protective factor for the cardiovascular system (and of course garlic which reduces the adhesiveness ­ stickiness ­ of blood platelets). Another Mediterranean bonus is the eating of the herb purslane, a rich source of gamma linoleic acid (also found abundantly in linseed) and an important source of essential fatty acids. Inclusion of these factors ­ garlic, fish (especially cold water varieties), linseed and olive oil instead of other salad oils ­ all act to protect the heart and its functions.

No frying or roasting of food should be done and dairy produce ­ apart from skimmed milk and very low­fat yogurt or cottage cheese ­ should be avoided.

Eggs
Approximately one person in five is affected by a rise in blood levels of cholesterol after eating eggs. The other four show little or no change in their cholesterol levels after eating normal quantities of egg. It should be realized that most cholesterol (which is an essential part of every cell of the body) is made in the body, unrelated to dietary intake of the substance but influenced by such factors as overall fat intake, sugar intake, smoking and, in some instances, coffee intake. The moderate eating of eggs (three or four per week) seems therefore to be without danger for most people.

Carbohydrates and sugars
Cardiovascular health is improved when refined carbohydrates play only a very limited part in the diet. This means substituting wholegrain for white flour products and white rice. Wholegrain products, brown pasta, bread and rice are readily available and contain high levels of fibre which helps clear excess cholesterol from the intestines (especially oats), as well as providing essential vitamins, minerals and trace elements, which are largely or entirely removed in any refining process.

At present we in the West eat around 45 per cent of our food as carbohydrate, with an average of half of this as refined sugars and flour products. The expert guidelines suggest that we should increase carbohydrates to around 58 per cent of our diet but with the simple sugars, etc., declining to no more than 15 per cent of our dietary intake.

'Complex carbohydrates' are the major nutrients contained in vegetables and fruits, nuts, seeds and beans, and of course whole grains (milled but not refined). So a diet which emphasizes vegetables at both main meals with brown rice, pasta and/or bread, as well as abundant use of fresh nuts and seeds (sunflower, sesame, pumpkin, linseed, etc.) and the members of the bean family (lentils, chickpeas, etc.), as well as fresh fruit to the extent that these foods account for just under two thirds of the total food eaten ­ is the target we are set.

No wonder vegetarians have such fine cardiovascular health.

Protein
As described under the heading Fats, the types of animal protein most likely to assist in achieving the aims being set are game, poultry (minus its skin) and fish. In the USA and UK an average intake of around 12 per cent of total energy consists of protein, and this is thought to be a reasonable level.

A useful strategy to enhance heart health would be if this 12 per cent were made up of more vegetable sources of protein (pulses, for example) and less from animal sources. Again, the example can be given of the vegetarian who combines nuts and grains, or pulses (bean family) and grains, for their protein content, and who have an infinitely better degree of cardiovascular function than do meat eaters.

Fibre
Eating a diet rich in complex carbohydrates ensures adequate fibre, which is necessary for cholesterol clearance from the digestive tract. Not all fibres are the same, however: oat bran acts quite differently (in cholesterol mopping terms, that is) from wheat bran (see Chapter 12). Authorities in the West urge that we eat up to 30 grams of fibre daily, with half of this from cereals and the rest from fruits and vegetables. In rural Africa (where cardiovascular disease is rare) the intake of fibre is anything up to 150 grams daily. Interestingly, when people from the African countryside migrate to cities and adopt a diet low in fibre their cardiovascular health declines rapidly.

The best cholesterol­lowering fibres are found in oats, fruits and vegetables and the leading providers are: blackberries, bananas, apricots, apples, raspberries, prunes, passion fruit, damsons, haricot beans, bean sprouts, broccoli, cabbage, carrots, celery, lentils, mushrooms, peas and potatoes.

Alcohol
This is an area of some debate, with a very small amount of alcohol (1 1/2 glasses of wine or 1 pint of beer daily) being shown to enhance cardiovascular function (but with some negative effect on liver function) and anything more than that amount having negative effects. Overall health experts agree that alcohol is undesirable but that these limits are fairly safe.

Coffee
The drinking of boiled coffee in any quantity has been shown to increase levels of cholesterol in the blood.

Salt
Because of its known association with increased blood pressure (a major factor in cardiovascular degeneration), salt intake should be reduced dramatically from its current level of around 12 grams daily to no more than 3 grams per day per person, none of which should be added at table. It is now known that damage from salt starts when we are very young and if children can be taught to enjoy unsalted food they could be saved a good deal of distress later in life.