IN the history of mankind, wars have been waged throughout the centuries.
Behind every conflict, there is always an initiator that provokes revolt or annihilation, and sets the stage for battle.
There will also be the collaborators who fan the fires of discord, and the rebels who fight for the cause.
Certainly, there has never been a battle without collateral damage.
In the chronicles of war within the body, cholesterol is the unwitting rebel.
In its attempt to patch up the wounds of arterial damage, it itself is drawn into a web of deceit, which - with the help of other collaborators - sets ablaze the fires of inflammation within artery walls.
As this waxy agent becomes involved in the complex formation of atherosclerosis (the forerunner of heart disease), the good work cholesterol does in maintaining cell membrane integrity, keeping hormones in balance, and sustaining cellular functions goes unnoticed.
Instead of being the good guy, cholesterol has gained notoriety as the bad guy of heart disease.
In order to keep our body functioning, the network of waterways known as the arteries need to be kept open and clear to deliver nutrients, oxygen, hormones and other essential substances to the organs.
If blood supply is cut off, organs will perish - and so will the body's owner.
One such organ is the heart, but what happens here can occur elsewhere as well.
In my previous article (Cholesterol: Friend or Foe?), I discussed the role of cholesterol in the development of heart disease.
I noted that it is not just the overall cholesterol levels that are important, but more crucially, the levels of LDL-cholesterol.
We now know that as LDL-cholesterol becomes oxidised, it literally "sticks" under the inner lining of arterial walls, forming a fatty sludge that sets off inflammation.
Specialised white blood cells, like an efficient army, try to clean up the mess.
But in the process, they cause much collateral damage, with the scars of battle showing up as fibrosis and hardening of the artery walls, thus, paving the way for high blood pressure, heart disease and stroke.
The real cuprit
The real culprit
To reduce the casualties of war, the real instigators of unrest should be unmasked and neutralised. In this case, it is the troublemaker called homocysteine.
This amino acid has been identified as a key initiator of atherosclerosis, and has been proposed as the mastermind behind heart disease and stroke.
Eggs, meat and dairy products are rich sources of homocysteine, which is an intermediate product of protein metabolism.
The body further breaks it down to a form (cysteine) that can be utilised, through certain enzymes with the help of vitamins B6, B12 and folic acid.
Excessive levels of homocysteine (as a result of a high protein diet, deficient vitamins or a genetic enzyme defect) can irritate the inner lining of artery walls, thereby preparing these sites for plaque formation.
It appears that homocysteine is not the direct cause of heart disease, but it orchestrates the chain of events behind the scene, like a puppet master.
And the fall guy is, undoubtedly, our misunderstood friend (or foe) cholesterol.
In his book The Homocysteine Revolution, Harvard University pathologist Dr Kilmer S. McCully reveals his research on children with genetically high homocysteine levels in the late 1960s.
Upon performing autopsies on these children after their deaths, he found that they had advanced atherosclerosis.
After much intensive study and research of past cases, he made the provocative suggestion that homocysteine may have been the cause of damage to arteries and triggered the atherosclerosis.
This did not go down well in the medical community as much research was focused on anti-cholesterol treatment.
Going against the grain cost him his job and research grant, and his research was largely forgotten.
However, over the last 20 years, there has been a resurgence of interest in his work as other scientists looked at the link between homocysteine and cardiovascular diseases.
Harvard professor Dr Meir Stamfer studied data collected on 15,000 participants in the Physician's Health Study (reported in the Journal Of The American Medical Association, 1992), which supported the association of mildly elevated homocysteine levels and heart disease.
Subsequently, many studies have confirmed homocysteine as a predictive marker of heart disease, stroke and peripheral artery disease.
At present, there are a few ongoing large, randomised trials in the United States and Canada, studying the impact of lowering homocysteine levels on the incidences of heart attack and stroke.
However, despite having such a prime suspect for the role of instigator, the verdict is not certain. Some say it is guilty; others think it deserves a "fair" trial.
In the meantime, its clandestine operation of provoking heart disease goes on.
As the development of atherosclerosis involves homocysteine, the oxidation of "bad" (LDL-cholesterol) and subsequent arterial inflammation, there is much research that can be done from a nutritional point of view.
How else can one interrupt the cycle of oxidation and inflammation?
Antioxidants are known to quench the ravages of free radicals.
Vitamin E, in particular, has been likened to a bodyguard travelling in the same vehicle carrying cholesterol from the liver to the tissues; thus, offering protection to the LDL-cholesterol from being oxidised.
Much has been written about the protective benefits of red wine as it contains certain antioxidants.
OPC (oligomeric proanthocyanidins) belongs to a class of nutrients called flavanoids, which is extracted from the seeds of red grapes.
This grape seed extract is said to benefit the heart by preventing the oxidation of LDL-cholesterol.
A word of caution though; swallowing a bowl of seeds is not in the best interest of the bowels, as seeds cannot be digested.
The role of omega-3 fish oil in preventing heart disease is well documented. Taking high-quality fish oil can reduce the chances of a heart attack by at least 20%.
Omega-3 is an essential fatty acid that has anti-clotting and anti-inflammatory effects - working like a fireman dousing the flames of inflammation.
Niacin (vitamin B3) has been shown to increase HDL-cholesterol. High doses can, however, cause troublesome flushing symptoms.
Recent research has suggested that low levels of sunshine (vitamin D) has been linked to a higher risk of heart disease, and most people are deficient in this area.
Oats contain many nutritious and healthy ingredients. Among the various types of oats, a logical choice is rolled oats, which does not need prolonged cooking. In fact, soaking it for 10 minutes offers a slightly chewy meal, but if left overnight in the refrigerator, it turns into tasty porridge.
A wave of interest swept across the world when the United States Food and Drug Administration (FDA) approved food claims that oats reduce heart risks.
This grain can reduce LDL-cholesterol through beta-glucan (soluble fibre found in oat bran) and avenenthramide, which has antioxidant and anti-inflammatory functions.
If, despite sound nutritional and healthy lifestyle measures, your cholesterol - in particular, the LDL-cholesterol - remains elevated, then lowering it by pharmaceutical means to a target level is a therapeutic goal.
The main message here is not to abandon anti-cholesterol treatment if prescribed by your doctor, but to adopt preventive actions at the same time.
A group of drugs that effectively lower cholesterol is popularly called the statins. In high doses, apart from potentially raising liver enzymes, side effects like muscle weakness can occur. The statin blocks the enzyme that produces cholesterol, but also blocks the synthesis of coenzyme Q10.
Understanding the cause of heart disease carries the hope that we can avoid or postpone that massive bang in the chest!
The big question is: When do we start to take action? Before or after we get the disease?
Even the less informed would agree that practising a healthy lifestyle should start early.
Sadly, many are oblivious to the "war within our bodies" and need a wake-up call to take heed. Indeed, some unfortunate people will never get a second chance!
Dr C.S. Foo is a medical practitioner.