How to beat heart disease: 8 habits you must fix | Dr. Nour Makarem

0:00Welcome to ZOE Science & Nutrition, where world leading scientists explain how their research can improve your health.

0:14Heart disease is still the number one killer globally, responsible for around one in five deaths in the US. While these figures are deeply worrying, heart disease is not inevitable. Science has shown that there are simple, achievable lifestyle changes that you can make now that will significantly reduce your long-term risk.

0:38Today, I'm joined by Dr. Noor Makarum, a cardiovascular epidemiologist at Columbia University, whose research focuses on how lifestyle factors impact heart disease risk. Her work is helping reshape prevention science and shows that daily rhythms play a surprisingly important role in keeping your heart young. It's not just what you eat, it's when you eat it. She also explains how sleep can be your secret weapon against heart disease. By the end of this episode, you'll understand exactly what you need to do to protect your heart.

1:16Noor, thank you so much for joining me today. It's great to be here. Thank you so much for having me. So we always like to kick off the show at Zoe with listener questions. And we have a rapid fire Q &A and we have one strict rule. Okay. It's designed for scientists to be hard. you can say yes or no, or if you have to, a one sentence answer. Okay. Can poor sleep make you age faster? Yes. Do heart disease risk factors affect men and women in the same way? No. Does your ethnic background play a part in your risk of heart disease? Yes. Does when you eat impact heart health? Of course, yes. And finally, what's one thing that most people do wrong when trying to look after their heart?

2:06People sleep on sleep. People don't prioritize their sleep and don't realize that sleep is a really important way to prevent heart disease. My grandfather died of a heart attack. And it's also true, as my family tells me, I'm a bit of a hypochondriac, so I can worry about my health. And so I've definitely had chest pains in my life and wondered if this is the first sign of a heart attack. And I'm pleased to say, nor it never has been. It's been like indigestion or like some sort of minor muscle, you know, twinge after being at the gym. And despite all of that, I really want to keep my heart healthy.

2:43It's definitely something that I feel is really important. Now, I know you've got a lot of great advice and that the Heart Health Essential 8 that you were involved in creating is something that we will definitely get to. But before we go there, I'd like to sort of provide some context because every time someone talks about heart disease, like I find it quite complicated. So firstly, just that word heart disease, like I think everyone is like, oh, I'd like to avoid a heart attack. But what is heart disease? Basically, it's the narrowing of the arteries or the vessels in our body that supply blood to our heart, which of course is necessary for pumping blood to all of our organs so that we can function.

3:24And heart disease begins with the narrowing of those arteries, the decrease, or eventually even the abrupt stop to that supply of blood to our heart that can lead us to having a heart attack. And this is a process that happens for a lot of people over multiple decades of life before we get to that bad outcome of having a heart attack or a stroke in the case of the brain. I've also heard doctors often talk to me about high blood pressure. Has that got anything to do with this heart disease you're talking about? Yes. So high blood pressure or what we call hypertension is actually the number one cause of heart disease.

4:01It's the number one cause of dying from heart disease. Making sure that our blood pressure stays in the normal range is one of the best things that we can do to prevent developing cardiovascular disease or having a heart attack or a stroke. I'm actually really shocked to hear you say that high blood pressure is the number one cause of heart disease and heart attacks. Could you help me to understand what it is? Yes. Blood pressure refers to the pressure on the walls of those blood vessels when our heart pumps and also when our heart is not pumping. So that's what those measures correspond to. We have an upper reading when we measure our blood pressure, which is the systolic blood pressure.

4:36And then we have this lower reading, which is the diastolic blood pressure. Both of them have been linked to future risk of heart disease and to heart disease outcomes. But generally, the measure on the top, the upper reading, is the one that I would say is more strongly related to our future risk of heart disease. And is there a simple way that you can explain to me, I guess, how this high blood pressure and this narrowing of arteries links to the thing I guess we're all scared of, which is a heart attack, which I think of as like my heart stops? I don't study the physiology of high blood pressure.

5:09I study more about how lifestyle affects blood pressure and the preservation of heart health. But in general, you can think of it as a lot of pressure on the inner walls of the vessels. It creates damage. And then that kind of facilitates the development of dysfunction in that wall, the deposition of fat in that wall that eventually accumulates and leads to that blockage before we get to the adverse outcome, which is the heart attack or the stroke. Thank you. That's actually really clear. I've often heard heart disease called the silent killer. Yes. Why is that? Well, blood pressure actually is also what is called the silent killer because a lot of people go about their daily life and unless you measure your blood pressure, there's no way of knowing that you have high blood pressure unless you're regularly monitoring or seeing your physician every year.

5:58So in a way, blood pressure is the silent killer because if you're not checking, you might have high blood pressure and eventually develop the heart attack or the stroke. And so I won't just be aware that I have high blood pressure? There's no symptoms of high blood pressure. None at all? No. So that's kind of why, for the most part, it doesn't have any kind of overt symptoms, so people can really miss it. And like I said, essentially what you're missing is the number one risk factor of developing a heart attack or a stroke. Well, that's rather terrifying. Yeah. So I guess one of the messages here is that you should be monitoring your blood pressure.

6:30Yes, exactly. So that's something very positive that you can do for your heart is to monitor your blood pressure. Because if you do fall outside of that normal range or that healthy range, there are steps that you can take, of course, to lower it and to prevent progression into the bad outcome, which is the heart attack or a stroke. Now, when I was brought up, I was brought up on the one hand, definitely to think like something like heart disease is rather scary. But on the other hand, there wasn't really anything you could do. Like your genes pretty much determined what was going to happen. And if it wasn't that, it was sort of like how you're brought up as a child.

7:03So once that was done, it was all done. And I think my dad often was like, oh, you know, as he would eat whatever he chose to eat, which is not normally probably the healthiest thing. Like none of it matters anymore anyway, because at this point, I mean, it was many, many years. it probably would have been 40 when he said that. Is that true? Is this all locked down by the time we're 18? No, I think the interesting thing about heart disease is that so much of heart disease is actually preventable. It's interesting because it's the leading cause of death here in the United States, in the UK, and just generally globally.

7:36But it's the chronic disease, I would say, that is very much preventable. Actually, here in the United States, there's estimates that if all Americans had good heart health, we can prevent 2 million cardiovascular disease outcomes in the United States, which is huge if you think about it. So it's absolutely false that if you have a family history of heart disease or you have a genetic predisposition that there are no steps that you can take to prevent having a heart attack or a stroke. And if I follow all the lifestyle advice, I know you're going to take us through this podcast. Can I reduce my risk of heart disease a lot or are we just talking about like a few percentage points?

8:16No, you can reduce your risk of cardiovascular disease a lot. Studies generally show that people who take those steps that we're going to talk about and end up having high heart health can cut their risk of having a heart attack or a stroke by more than half. Having good heart health, A, it can lower your risk of developing a heart attack or a stroke. B, it can extend the years of your life you live healthy. So the years of your life you live without chronic disease, including cardiovascular disease, there are some studies that show estimates that you can essentially add 10 years to your life that you live healthy without chronic disease.

8:50So having high heart health and making those lifestyle changes can give you an extra decade of life. I like to do a little drum roll when announcing something exciting at Zoe. And that really exciting thing is that our plant-based gut supplement, Daily 30, is now available in the US. Daily 30 sold out in the UK when it launched, and now we're expecting it to sell out in the US too. And I think I know why, because I use it every day. I love it on my morning yogurt. Not only does it taste delicious, it actually gives me over 30 plants and plenty of fiber without my having to pop a tasteless probiotic or swirl some suspicious green powder into my water.

9:29You know what I'm talking about. Also, unlike so many other supplements, Daily 30 actually delivers. gut health, digestion, energy. Daily's 30s ingredients are designed to improve how you feel, and I feel it daily. Since I started taking it, I've noticed that I often don't need my mid-morning snack, and I feel like I have more energy to take on my busy schedule, and I thought I was doing a good job of eating well beforehand. Of course, I'm just one person, and I work at Zoe. However, because we're Zoe, we ran a randomized controlled trial as we developed Daily 30, And the results blew us away.

10:07And they helped us to create the gut supplement we sell today. One that's been constantly refined based on the latest research by the scientists that you often hear talk on this podcast. Oh, and if yogurt's not your thing, I know lots of people who tell me that Daily 30 tastes delicious on eggs, on salads, hummus. My wife likes it on pasta. Many Zoe members tell us it's great on avocado toast too. To get it, head to zoe.com, where right now listeners to the podcast can get 10 % off by applying the code FEEDYOURGUT at checkout. That's zoe.com with the code FEEDYOURGUT at checkout. You could be one of the first in the US to try the gut supplement that's changed my day, and I know it'll change yours too.

10:53One of the things that team was telling me about your research is that it's about biological aging and the link to heart health. And it sounds like there's some link between that maybe in what you were just describing to me. Can you tell us about that? This is actually a newer area of my research program that I am exploring, which is kind of the link between heart health, biological aging, mortality, or the risk of developing a heart attack or a stroke. What you're saying is correct. We find that in general, individuals who have a healthy lifestyle and therefore high heart health tend to age at a slower rate than individuals who have low heart health or who live an unhealthy lifestyle.

11:33And of course, biological aging is kind of a mechanism or a pathway that links our lifestyle to our risk of developing the bad outcome of a heart attack or a stroke. So when we slow down our body's aging process, we probably also are slowing down or lowering our risk of developing a heart attack or stroke. You know, there's been different studies by different teams that have really explored this question and showing, you know, obviously different estimates in terms of how much or by how many years you reduce your biological aging. But I've seen anywhere, you know, in the work that we've done, people who have high heart health tend to be six to eight years younger biologically than individuals who have low heart health.

12:13And Noor, when you say like their biological age or their five to six years younger, could you help me to understand what that means? It doesn't mean that literally their birth date has changed. No, it means that your body's age or your physiologic age is lower than your chronologic age. So let's say that you are 40 years old, you live a very healthy lifestyle, and you have high heart health. Biologically or physiologically, your body on the inside resembles more a 34-year-old, even though your chronologic age or the age based on the year that you were born is 40. You described it as on the inside.

12:45So this isn't like about sort of my appearance on the outside. It's about... So aging manifests in many ways. There's physical attributes to aging. So it could manifest on the outside in terms of how you look. you could look younger, but it also refers to the physiology inside your body that predisposes you to developing various diseases. So when you are physiologically younger, you're less likely to develop a chronic disease essentially. So it's sort of something all of us want. That's exactly it. Yes. Well, I feel like you've painted first this terrifying picture that we might all be walking around with the silent killer inside us, but then saying, actually, there's a lot that we can do to reduce that risk.

13:25Before we go into the advice, I'd like to discuss some more about areas of your research, because I know you've run some really interesting studies, particularly around sleep and circadian rhythms. I'd love for you to tell us about them and definitely to make sure you explain what circadian rhythms are as you do so. Sleep and circadian rhythms, those are two things that are very much intertwined and related, but they're also distinct. So let me start with sleep. So my work on sleep is focused more on what we call sleep health, which is kind of recognizing that sleep health is not just the absence of sleep disorders.

14:01A lot of people, when they think about sleep, they think about insomnia symptoms. So like symptoms of, which is difficulty falling asleep or staying asleep or having sleep apnea, which is, you know, related to breathing during sleep and snoring. But sleep health is a distinct concept from having those sleep disorders. It refers to more adopting positive, achievable sleep habits that can help us to optimize our health and that promote what we call healthy longevity. So having a long, healthy life. There's been many kind of ways to define this concept of sleep health. But right now, I would say one of the most widely accepted ways or definitions of sleep health is a construct that is based on six things.

14:42So the first thing is sleep duration or how much we sleep every night. and I would say that this is the most well-studied aspect of our sleep health. The second one I would say is sleep regularity and this is something that people don't think about very much but this refers to essentially how consistent are your sleep and wake time every day. Do you tend to go to bed at the same time each day and do you tend to wake up at the same time each day? And in general what studies show is that people who have regular sleep schedules So who tend to go to bed and wake up at a similar time each day, those individuals tend to be at a much lower risk of heart disease and a number of other chronic conditions.

15:23And studies are showing that people who have these irregular sleep patterns have double the risk of heart disease. It's very similar to what we see for things like established risk factors for heart disease like diabetes and smoking and obesity. So it's kind of this new risk factor that's emerged and we're seeing that, wow, it really can substantially increase someone's risk of developing heart disease. There's a lot of studies now that show that even individuals who get enough sleep every night, if their sleep is irregular, they're still at higher risk of developing hypertension and, you know, cardiometabolic diseases.

15:55So that's slightly terrifying. You're saying that's potentially as bad as smoking to have this really inconsistent sleep and wake time. Just one question before we move on. Like how perfectly do you need to go to bed at 10 p.m. every night in order for this to count as regularity versus what you're describing as irregular and this massive risk factor? People always ask that because no one can go to bed and wake up at exactly the same time every day, right? So I always say to people, as long as your sleep timing is not varying by more than 30 minutes to an hour each day, you should be okay. That's the practical advice that I would give.

16:33We start to see this substantial increase in risk for people whose sleep timing varies by an hour and a half, two hours, more than that each day. That's when you really start to see this kind of doubling in the risk of cardiovascular disease. So as long as you stick to this like 30 minute to an hour window, you can lower your risk. Point number three of sleep health. Point number three is the timing of sleep. When we sleep, we think that going to bed earlier is linked to lower risk of heart disease. Generally, if the midpoint of your sleep is earlier than 4 a.m., that's considered to be protective.

17:09But I would say that this aspect is a little bit less studied than the other aspects when it comes to sleep health. The fourth point is sleep satisfaction. So this is just like the subjective experience of feeling like your sleep is restorative and feeling rested when you wake up. I know it sounds like a very subjective thing, but it's actually been something that has been linked to heart disease, even over and beyond things that we can measure objectively, like how much someone sleeps. I'm not totally surprised to hear that because I think one of the things that's been really interesting that Zoe, working with scientists here, looking at impacts of nutrition, is that they all started very skeptical about self-reported impacts around energy and mood.

17:51And what's interesting is that as we scaled up the studies, they've started to say, oh, no, we're completely convinced because these correlations are incredibly strong. And these reports about mood, this is really real. But historically, they said they were sort of brought up that if you can't measure it with a blood test, preferably, it's sort of not real science. and like something self-reported about how you feel, that's sort of not the thing that's done as a scientist. I don't know if any of that is true also in heart health. Yeah, no, it's true. And I think, you know, it really underscores how much sleep is a sign of wellbeing, really.

18:30You're not always able to capture that from a biomarker or blood test. You know, that's something that extends beyond that. In a way, how well we sleep can be a marker of how stressed we are in our life. Two more, sleep efficiency, which is related to what we were just talking about. And this really refers to the amount of time in bed we are actually sleeping. And of course, having a higher sleep efficiency is a good thing. And the final one that is also related to all the metrics that I just discussed is daytime alertness. It doesn't seem like it's an aspect of sleep health because it's not referring to you when you're sleeping.

19:05But daytime alertness or daytime sleepiness is the opposite one, is also a marker of sleep health because obviously someone who is experiencing excessive daytime sleepiness, who is dozing off on the subway or at work, that's a marker of sleep that is not restorative and poor sleep health. And so when you look at all of these things together, you get like a sort of quantification of somebody's quality of their sleep? We look at them together because it's a way for us, first of all, to acknowledge that sleep is multidimensional. So it's not just one thing. It's not just how much we sleep, but also it allows us to measure kind of the gradient of healthy sleep.

19:43And when we look at them together, we find stronger associations with a number of chronic diseases. So in one study that we did, we looked at those individual metrics separately, and there were many of them, you know, were linked to chronic diseases like heart disease and diabetes and obesity and hypertension, et cetera. But when we look at them together, we find much more strong, consistent associations with all of those chronic disease outcomes. So what that tells us is basically that the whole is greater than the sum of its parts, that when you improve your sleep as a whole, the health benefits are just going to be much more pronounced.

20:19And Noah, you just mentioned as well as sleep, a whole bunch of other factors. And I think I heard you say is, you know, along with things like diabetes, did I hear you talk about obesity as well. So the quality of your sleep is actually related to putting on weight? Yes. All of the aspects of sleep that I just discussed actually have been linked to risk of obesity. There's very strong, robust associations between not getting enough sleep and weight gain. You know, there's many explanations for this. An obvious explanation is when you spend more time awake, you're more likely to eat and therefore you're more likely to have a higher caloric intake.

20:58there's been studies you know linking restricting your sleep to you know your energy expenditure even how much energy your body uses doesn't really compensate for the amount of time you're awake and the amount of calories that you're bringing in so you're more likely to end up in a net positive with your calories and that can promote weight gain over time and increase your obesity risk and what you're saying when i pull all this together is it's not as simple as just when you went to bed like gone on into the bed and when you left it's actually like these six things you put together give you this much more complete picture of the quality of your sleep.

21:30I think the best way to think about it is to compare it to diet, right? When we think about our diet, do we just think about one thing? Do we think about, oh, I'm just going to pay attention to how much sugar I put in my tea? No, you think about your diet as a whole, right? You think about, am I eating clean proteins? Am I avoiding processed foods? Am I paying attention to my salt intake? And similarly, when you think about your sleep, you can't just think about one aspect of your sleep. You also have to have this kind of holistic framing of how you think about your sleep health. And that's kind of how the field of sleep research has shifted.

22:04Very similarly to how the field of nutrition shifted. You know, if you look at the old studies on diet, it used to be like, you know, how do whole grains impact this or how does olive oil impact that? But now when we study diet, we look at dietary patterns as a whole. We look at a Mediterranean style diet. We look at other types of plant-based diets. So now our thinking on sleep has shifted as well. We think about it more kind of like as a sleep pattern as a whole, not just about one metric. Fascinating. I'm thinking for a second now about like the sort of devices that we get to measure sleep.

22:36And there's lots of them. Do they capture in general this overall sleep health that you're describing or are they really just in this old world of like sleep duration as the way that they're giving you feedback? So different devices measure different things, right? But I think that self-monitoring, so like those wristwatches, the different types of trackers that people use, this is a very good way actually to pay attention to your sleep or to keep track of how well you're sleeping. If you're, you know, looking at your sleepwatch and you're seeing that you're sleeping five to six hours every night, maybe it's time to pay attention and to find ways to get more sleep, to get to that optimal sleep duration that you need every night.

23:20Self-monitoring and keeping a sleep diary, for example, are really good ways to keep track of your sleep health, but you also have to pay attention to what your body is saying. It's funny, you get into the habit of checking in the morning whether or not you slept well, even though the truth is you already know. For example, I tend to do it particularly when I've slept badly and I want the justification of the The quantification of that I feel bad because I know I slept badly. I went to bed too late, which I now realize is very bad for my heart. Got up too early because I had too many things to do.

23:48That's really interesting. A lot of people say what you just said to me, which is essentially that I don't think I have good sleep health because I'm just thinking of this past week and I had to, you know, wake up super early and go to bed late and I'm not getting enough sleep. And so my sleep is bad. any improvement in your sleep during your life is going to have a benefit on your risk for developing heart disease. There was a large study that was done that was published in the past couple of years that I thought was fascinating. They measured people's sleep health over several years and they kind of looked at people who had consistently good sleep during their life, people who had consistently bad sleep in their life, people who had good sleep and then went to bad sleep and people who had the opposite, bad sleep, and then their sleep improved in their life.