Nourishing Rakta Part One: Lipids, Heart Disease and Alzheimer's risk

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In this article, we will look at how to lower heart disease risk and Alzheimer's risk using diet. Here, the teachings of Ayurveda intersect with cutting edge biomedicine in fascinating ways.

From the Ayurvedic standpoint, we are all quite familiar with risk factors and dietary guidance for heart disease. We know that kapha individuals will have a greater risk of atheroma leading to coronary heart disease, while vata individuals are stress-prone and so can develop vata hridrog (heart disease). Now, the latest discoveries in biomedical science and genetics have led researchers to an interesting conclusion: there are three types of people with different lipid profiles and disease risks.  To understand this we will have to take a brief look at plasma lipids.

When a patient brings their blood test results, they will often be concerned about their total cholesterol. However, a typical blood test will also show the break-out of HDL 'good' to LDL 'bad' cholesterol. HDL or high-density lipoproteins are the smallest lipoprotein molecules in the blood and also the most dense because of their higher ratio of protein to cholesterol. They act as physiological vacuum cleaners, picking up cholesterol from blood vessel walls and transporting it to the liver, adrenals and gonads. Higher proportions of HDL protect against heart disease (1, 2). LDL or low-density lipoprotein, is implicated in the creation of plaque in the arteries and hence is thought to play an important role in heart disease (3).

 If your patient has had a more sophisticated test, their specific apolipoprotein levels will have been determined. Apolipoproteins A, C, E, J, L and M are contained in HDL, while apolipoproteins B and E are components of LDL (4 ,5, 6, 7).   Apolipoprotein E (ApoE) is of particular interest to us as Ayurvedic practitioners. ApoE is involved with triglyceride, phospholipid, cholesteryl ester and cholesterol transport in and out of cells and is a ligand for LDL receptors. ApoE has been implicated in autoimmune conditions such as multiple sclerosis (8) and in neurodegenerative diseases such as Alzheimer's (9) as well as in coronary heart disease (10). It has been found to suppress lymphocyte proliferation (11).

 So now we get to the really interesting part: genetic polymorphism of apoE. In humans, there are three main types of apoE, epsilon 2, 3 and 4, giving different disease susceptibilities. And since one gene is inherited from each parent, there are six apoE types in all: 2/2, 2/3, 3/3, 2/4, 3 /4. This of course cannot help but remind us of the various prakruti types in Ayurveda. ApoE types epsilon4, including 4/4 and 3/4, have been found to have a higher risk of heart attacks, coronary heart disease and Alzheimers (12,13) They also tend to have higher fasting blood sugar and hence propensity to diabetes (14). ApoE epsilon3 types have a neutral risk of heart disease and apoE epsilon 2 types have a lowered risk of strokes (15) but, according to some studies, do have a higher risk of heart disease as compared to the 3/3 type (10).

So far, few of my thousands of patients have had their ApoE genotype determined. Speculatively though, we can see apoE epsilon4 types as having many characteristics of kapha syndrome, with an increased tendency to diabetes, atherosclerosis, and heart disease. We could perhaps imagine that the 'neutral' 3/3 type, who will get heart disease in response to dietary and lifestyle risk factors, as similar in some respects to pitta types and the 2/2 types as vata types, who do have an increased risk of heart disease, as Madhava Nidhanam states, because they are susceptible to stress and worry (16). This topic needs and merits further research.

In the meantime, many patients do come to see us because they are worried about their cholesterol and yet reluctant to take statin drugs. For the kapha type, suspecting that they may well be apoE epsilon 4, we need to take steps lower their array of risks. Smoking is a typical kapha addiction that is extremely dangerous for cardiac health. Sedentary lifestyle is of course another risk factor lethal to kapha. Fried foods, refined sugars and refined starches are similarly important to address. Inflammation plays a key role in atherosclerosis and heart disease (3) and is related to a Standard American Diet (SAD) high in meats and low in vegetables. The kapha/suspected apoE 4 type must be guided towards a diet high in omega 3 fatty acids. As one of my patients characterized her Ayurvedic diet: "I'm following an Indo-Mediterranean diet."  Emphasizing plant-based food rather than meats, both the Ayurvedic and the Mediterranean diets lower cardiovascular risk and increase the anti-inflammatory omega three fatty acids in the diet. Although fatty fish such as salmon has been emphasized as a key to heart health, fruits and vegetables are alternative sources of omega threes. Indeed, the mass consumption of fish oil is likely to have a devastating effect on fish species. Instead, emphasize flax oil, olive oil (here's where the Mediterranean gets into the picture), legumes--an Ayurvedic mainstay--along with nuts, berries, cruciferous vegetables, basil, garlic and leafy greens.

Turmeric is a super-food that distinguishes the Indian diet. Not only will turmeric help reduce inflammation (17) and have blood-thinning effects (18), it will also help prevent the other great risk apoE epsilon4 presents--Alzheimer's (19).

For the pitta type, supposed apoE epsilon 3, susceptibility to heart disease is a result of inflammation. As well as stressing an anti-inflammatory diet rich in omega three fatty acids, consider all the other ways to reduce pitta's tendency to inflammation. Health begins in the mouth, an important site of inflammation that can lead to heart disease (20). Use of herbs such as neem and triphala in dental care, using a tongue scraper and regular 'oil pulling', rinsing the mouth with sesame, sunflower or coconut oil can help reduce pitta's susceptibility to heart disease. Again, use turmeric as a spice and herbal supplement to reduce inflammation and give anti-inflammatory teas such as tulsi tea (21).

And for the vata suspected apoE epsilon2, stress management is key, along with a basic vata-soothing Ayurvedic diet. Vata's tendency to worry predisposes to heart disease, since anxiety generates pro-inflammatory cytokines, which lead to arterial plaque formation. A good yoga routine emphasizing shivasana and pranayama, a daily meditation practice and soothing teas such as a mix of brahami and tulsi will help shift vata out of the high-risk group without use of medications.

Hopefully further research will illumine the relationship between prakruti and apolipoproteinE genotypes. iN the meantime, as we have shown, it is interesting to note modern biomedicine pointing to three main types in terms of cardiac risks. As Ayurvedic practitioners, we can tailor primary prevention to the individual constitution.

1. Castelli, W. P. (1998). Cholesterol and lipids in the risk of coronary artery disease. The Framingham Heart Study. Can. J. Cardiol., 4 (Suppl A), 5A-10A.

2. Assmann, G. and Schulte, H. (1992). Relation of high density lipoprotein cholesterol and triglycerides to incidence of atherosclerotic coronary artery disease (The PROCAM experience). Am. J. Cardiol., 70 , 733-737.

3 Göran K. Hansson, M.D., Ph.D.Inflammation, Atherosclerosis,and Coronary Artery Disease N Engl J Med 2005;352:1685-95. (Interesting article worth reading)

4.  Gaubatz JW, Heideman C, Gotto AM Jr, Morrisett JD, Dahlen GH. Human plasma lipoprotein [a]. Structural properties. J Biol Chem. 1983 Apr 10;258(7):4582-9.  

5.  Yang, C.Y.; Gu, Z.W.; Weng, S.A.; Kim, T.W.; Chen, S.H.; Pownall, H.J.; Sharp, P.M.; Liu, S.W.; Li, W.H.; Gotto, A.M., Jr.; and Chan, L. Structure of apolipoprotein B-100 of Human Low Density Lipoproteins. Arterio¬sclerosis 9, 96-108 (1989).

6. Jackson RL, Baker HN, Gilliam EB, Gotto AM Jr. Primary structure of very low density apolipoprotein C-II of human plasma. Proc Natl Acad Sci U S A. 1977 May;74(5):1942-5.

7.  Rall SC Jr, Weisgraber KH, Innerarity TL, Bersot TP, Mahley RW, Blum CB. Identification of a new structural variant of human apolipoprotein E, E2(Lys146 leads to Gln), in a type III hyperlipoproteinemic subject with the E3/2 phenotype. J Clin Invest. 1983 Oct;72(4):1288-97.

8. Fazekas F, Strasser-Fuchs S, et al Apolipoprotein E ε4 is associated with rapid progression of multiple sclerosis Neurology September 11, 2001 vol. 57 no. 5 853-857

9.   D. E. Kang, T. Saitoh, et al, Genetic association of the low-density lipoprotein receptor-related protein gene (LRP), and apolipoprotein E receptor, with late-onset Alzheimer's disease Neurology July 1, 1997 vol. 49 no. 1 56-6110.  Carlos Lahoz,  Ernst J. Schaefer, et al, Apolipoprotein E genotype and cardiovascular disease in the Framingham Heart Study Atherosclerosis Volume 154, Issue 3 , Pages 529-537, 15 February 2001

11. Alan D. Cardin, Terry L. Bowlin and John L. Krstenansky Inhibition of lymphocyte proliferation by synthetic peptides homologous to human plasma apolipoproteins B and E Biochemical and Biophysical Research Communications Volume 154, Issue 2, 29 July 1988, Pages 741-745

12. Eichner JE, Kuller LH, Orchard TJ, Grandits GA, McCallum LM, Ferrell RE, and Neaton JD. Relation of apolipoprotein E phenotype to myocardial infarction and mortality from coronary artery disease. Am J Cardiol 7: 160-165, 1993

13. Albert Hofman  Alewijn Ott et alAtherosclerosis, apolipoprotein E, and prevalence of dementia and Alzheimer's disease in the Rotterdam Study The Lancet, Volume 349, Issue 9046, Pages 151 - 154, 18 January 1997

14. Angelo Scuteri,1,2 Samer S. Najjar et al apoE4 allele and the natural history of cardiovascular risk factors Am J Physiol Endocrinol Metab 289:E322-E327, 2005. First published 15 March 2005;

15. Mark O. McCarron, MA, MRCP, David Delong, PhD and Mark J. Alberts, MD APOE genotype as a risk factor for ischemic cerebrovascular disease A meta-analysis Neurology October 1, 1999 vol. 53 no. 6 1308

16. Madhava Nidhanam Ch 29 v 1.

17. Young-Joon Surh,  Kyung-Soo Chun et al, Molecular mechanisms underlying chemopreventive activities of anti-inflammatory phytochemicals: down-regulation of COX-2 and iNOS through suppression of NF-κB activation Mutation Research/Fundamental and Molecular Mechanisms of Mutagenesis
Volumes 480-481, 1 September 2001, Pages 243-26

18. Chattopadhyay, Ishita, Kaushik Biswas, Uday Bandyopadhyay and Ranajit K. Banerjee Turmeric and curcumin: biological actions and medical applications Pub 2004Current Science 87, 1, 44--53

19. Balasubramanian, K. Molecular orbital basis for yellow curry spice curcumin's prevention of Alzheimer's disease. Journal of Agricultural and Food Chemistry 54 (10) 3512-3520 2006

20. Sok-Ja Janket,   Alison E. Baird et al Meta-analysis of periodontal disease and risk of coronary heart disease and stroke Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology
Volume 95, Issue 5 , Pages 559-569, May 2003

21. Surender Singh, K. Majumdar and H. M. S. Rehan Evaluation of anti-inflammatory potential of fixed oil of Ocimum sanctum (Holybasil) and its possible mechanism of action Journal of Ethnopharmacology
Volume 54, Issue 1, October 1996, Pages 19-26

22.  Michael Maes, Cai Song, Aihua Lin, et al. The Effects Of Psychological Stress On Humans: Increased Production Of Pro-Inflammatory Cytokines And Th1-Like Response In Stress-Induced Anxiety Cytokine, Vol. 10, No. 4. (April 1998), pp. 313-318.

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Alakananda Ma M.B., B.S. (Lond.) is a Certified Ayurvedic Doctor (NAMA) and graduate of a top London medical school. She is co-founder of Alandi Ayurveda Clinic and Alandi Ayurveda Gurukula in Boulder Colorado, as well as a spiritual mother, teacher, flower essence maker and storyteller. Alakananda is a well known and highly respected practitioner in the Ayurveda community both nationally and internationally.

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