Introduction - Are You 3D Healthy?
Updated on February 1, 2003

The 3D Health Concept

Discover. Design. Do. With these three simple steps anyone can achieve optimal cardiovascular health. These three steps define my 3D Health Program. Three dimensional health means discovering the health of your arteries with several critically important tests, designing a set of goals for keeping your arteries healthy, and then doing the program. Can the program be done on your own? Ideally, you will need a physician who can provide professional guidance. The ideal physician will help you interpret the results of your tests and will also guide you through the process of designing a program based on the test results. This book is designed to give you a thorough understanding of the 3D Health process. Once you have read it, you will be able to communicate effectively with the physician you choose to be your guide and mentor.

Who should read and use this book? Cardiovascular disease is the number one killer of Americans. We all have been directly or indirectly affected by its consequences. If you are in your forties or older, then you are my main audience. But if you are younger, you may want to familiarize yourself with 3D Health so you can understand your own future risks and how to best reduce them. You may also want to help your parents or other older friends and family members as they directly confront this alarming epidemic.

The Cardiovascular Disease Epidemic

How severe is this epidemic? I know I risk a few glazed eyes if I throw out too many numbers, but let’s throw out a few anyway. The following statistics are from the 2001 Heart and Stroke Statistical Update by the American Heart Association (AHA). Each year, the AHA releases a thorough update, which you can easily access through their website: www.americanheart.org. The main categories of cardiovascular disease (CVD) are coronary heart disease (heart damage from diseased arteries), cerebrovascular disease (stroke) and hypertensive disease (high blood pressure). Each year, about 1 million Americans die from CVD. But this number does not count the deaths where CVD was a contributing factor to the death (a statistic called “total mention mortality”). If we add these in, we find that CVD actually is involved in 1.4 million deaths a year, out of the total 2 million deaths in America!

One person dies of CVD every 33 seconds. How does this relate to other causes of death? If you add up the next six most important causes of death, you still need to add another 10,500 deaths to bring it up to CVD death numbers. Lung cancer, which is the number one cancer killer, kills 160,000 people a year, or less than 1/5 the number killed by CVD. Breast cancer kills 43,000 women each year, or less than 1/10 the number of women killed by CVD.

Let’s focus on coronary heart disease (CHD) for a minute. If you are a 40 year old male, your lifetime risk for developing CHD is 49%, or almost one in two men. For women, the lifetime risk at age 40 is 32%, or one in three women . CHD is caused by plaque build up in the arteries going to the heart (atherosclerosis of the coronary arteries). You will know a lot about CHD by the time you finish this book, but for now, just remember that plaque in the coronary arteries can lead to narrowing or blockage of the arteries, thereby injuring the muscles and conduction system of the heart. This is the single biggest killer of Americans, responsible for about half of the yearly deaths from CVD. Every 29 seconds someone has a “coronary event” somewhere in America. Every 60 seconds someone dies from such an event. There are a million heart attacks a year, 65% are first attacks, and 45% are recurrent attacks. How dangerous are heart attacks? Just consider that over 40% of heart attacks are fatal. What is the likelihood that you will have a warning symptom before your first heart attack? Half of men who died suddenly from CHD had no prior warning. In women, 63% who died suddenly had no previous symptoms.

Let’s turn our attention now to another manifestation of CVD- stroke. A stroke is a sudden event that interrupts blood flow to a part of the brain. Most strokes are caused by plaque build up in the carotid arteries. The carotid arteries can be found on either side of your neck, and you can feel them beating by placing your fingers just below your lower jaw on the right or left side. Your carotid arteries are quite a bit bigger than your coronary arteries, and don’t usually become completely blocked. Instead, a bit of plaque will break away and rush upstream with the flowing blood. Eventually, it will reach a blood vessel in the brain smaller than itself. It will plug the artery and prevent blood from going around it. Brain tissue cannot survive even short periods without oxygen and glucose (sugar). Quickly, very quickly, the starved brain cells die. Sometimes, the traveling bit of plaque will be very small and will be mostly composed of blood clot. This may dissolve so that the blood vessel opens again spontaneously. Instead of a full blown stroke, you get a mini-stroke, referred to as a TIA (transient ischemic attack). One American suffers a stroke every 53 seconds, and one death from stroke occurs every three minutes. Each year, this adds up to 600,000 strokes. Strokes may have serious long term consequences, and are a leading cause of long-term disability. About half of stroke survivors will recover completely, while up to a third will be permanently disabled. On fifth still require institutional care three months after the event.

If you find the above numbers somewhat frightening, then let me reassure you. Once you have learned and applied the steps of the 3D Health Program, you will be able to markedly reduce your risk for CVD. With the Discover step, I will help you precisely determine your level of risk. The Design step will outline what you need to do to lower risk. The Do step is up to you! Fortunately, CVD does not develop overnight, even if the symptoms can present in a sudden and frightening manner. The plaque which ultimately produces CVD begins to grow when we are quite young. It grows slowly and silently over many decades before symptoms occur. But most interesting of all, many people have arteries that are incredibly resistant to plaque. How do I know this? For the past three years I have been studying arteries using a revolutionary technique that can actually see plaque building up in the arteries. The technique, called arterial calcium scoring, is done with a very rapid CT scanner. First, let me describe the artery wall, and then I will introduce the calcium scoring concept.

Plaque and the Artery Wall

Blood vessels have several layers of cells. The inner layer closest to the blood is called the intima. This is where plaque grows. The intima is normally quite thin, consisting of a single layer of cells, a narrow space below that, and a flexible sheet-like structure called the basement membrane. When plaque develops, the intima thickens. The next layer is called the media. The media, or middle layer, controls the tone of the artery with smooth muscle cells that contract or relax, depending upon the situation. The outer layer is called the adventitia. It contains connective tissue to provide support for the artery wall.

Why is plaque something you should be concerned about measuring? The answer is simple. Your risk for CVD is directly proportional to the amount of plaque in your arteries. The medical term for plaque is atherosclerosis (Greek for fatty hardening). In the developed countries of the world, cultural, social and technological conditions have lead to a CVD epidemic. In other words, our environment is toxic to our arteries. Numerous factors we’ll soon look at can injure the artery walls. The injury process causes the formation of plaque. It happens gradually, over many decades, sometimes beginning as early as the second decade of life. Plaque can end up filling large segments of the intima. As the plaque accumulates, the arteries respond by expanding outwards. This compensatory response permits normal blood flow in the artery in the presence of even large amounts of plaque. But very often, in an unpredictable manner, plaque will rupture through the intima, and come into contact with blood. This provokes a sudden clot formation at the site of the rupture. Blood cells called platelets and molecules come together to seal off the rupture. Unfortunately, this can result in closure or narrowing of the artery. Bits of ruptured plaque and clot may also break away and cause damage downstream. At any given time, almost all the plaque in your arteries is in a stable state. The plaque is hidden from blood flow by the endothelial cells and scar tissue. Plaque rupture, when it does occur, only disrupts a small portion of the total plaque.

Plaque Volume and CVD Risk

We now know that risk for plaque rupture goes up as plaque volume goes up. This makes sense. Since any area of plaque can rupture, the more areas you have, the greater the likelihood for a rupture. If the chance for any single area to rupture is one in a hundred, or a 1% risk, and you have 10 areas, then risk goes up to one in ten, or a 10% risk. If you have a hundred areas, then you would have a 100% chance of having a rupture in at least one area. Of course, I’m oversimplifying, because we really don’t know what the actual risk is for a particular area of plaque. It probably changes over time. Some plaques are more dangerous than others. But overall, the more plaque you have, the greater your risk for a CVD event such as a heart attack or a stroke.

Calcium and Plaque

Arterial calcium scoring measures the calcium component of plaque. Most of plaque consists of inflammatory cells, cholesterol, broken up cells, and connective tissue. But as plaque grows, some cells from the media, or middle layer of the artery, move into the plaque and secrete calcium. Inflammation in other parts of the body also causes calcium deposits. We don’t really know why this happens. But whatever the reason, the calcium volume tracks very closely the plaque volume. With a special CT scanner, the calcium throughout the arterial system can be very accurately measured. My studies measured calcium in two areas: the coronary arteries of the heart, and the carotid arteries, which supply blood to the brain. I focused on these two areas because plaque volume in the coronary arteries predicts heart attack risk, while plaque volume in the carotids predicts stroke risk.

CT Scanners can Measure Plaque by Measuring Calcium

Cardiologists see patients who have symptoms of heart disease. Neurologists see patients who have symptoms of stroke. When symptoms occur, usually excessive amounts of plaque have already formed. Atherosclerosis creeps into our arteries very silently. Many twenty and thirty year olds already have significant amounts. In fact, we are seeing more and more people in their thirties with symptoms of heart disease. If you wait for symptoms to develop, you are losing an incredible opportunity to stop plaque before it becomes symptomatic. Unfortunately, very few doctors in America are treating silent atherosclerosis. In fact, even though the evidence supporting the use of arterial calcium as an accurate marker for plaque is overwhelming, few physicians have incorporated it into their practices. The CT scanners that do the best job of measuring plaque are called electron beam CT (EBCT) scanners. They are incredibly fast, and use very low doses of radiation. They are very expensive, and most radiology groups use cheaper and slower spiral CT scanners, which are adequate for most radiological studies but are too slow for high quality coronary calcium imaging. As a result, many cities may not have EBCT, although most large cities do. Even if a doctor has an EBCT he can send you to, he may not for several other reasons. First of all, he may not understand the relationship between calcium volume and plaque volume. He may not understand the relationship between plaque volume and risk. Finally, he may not know what to do with the results of the test.

Risk Factors like Cholesterol are Poor Predictors of CVD

Unfortunately, doctors in America are doing a terrible job of preventing cardiovascular disease. For that reason, you, the reader, must take control of your destiny. Do not expect your primary care physician to take charge and do all that’s possible to prevent CVD. Prevention of heart attacks and strokes is not a simple process. We don’t really know what causes plaque build up in some people and not in others. We all know about cholesterol and the other key risk factors, such as high blood pressure, smoking and diabetes. But what most people don’t know is that these are not causes of the disease, they are promoters of the disease. As cholesterol rises, risk rises, but cholesterol cannot be used to predict who has severe atherosclerosis. Most people who have heart attacks have cholesterol levels that are around the average levels for Americans. Many people with high cholesterol levels live into their nineties!

I have been a cardiologist for 16 years. I know from first hand experience that you cannot use standard risk factors to identify most high risk individuals. The reason is simple. The underlying cause of atherosclerosis is a non-specific injury to the artery wall that can be initiated by many substances or stresses. Our genes determine how well our arteries can resist chronic injury. Some people can go to McDonald’s every day, three times a day, and still have plaque-free arteries. Other people can eat sensibly and still succumb to a heart attack. Our genes did not evolve to promote survival in the twenty first century. Our genes are most adept at survival on the plains and in the forests of Paleolithic times. As
Society evolved from mostly active to mostly sedentary and from natural to processed foods, CVD incidence began to climb. When we get to the Discovery step of the 3D program, I’ll give you a method for determining your own unique CVD risk profile.

EBCT is Revolutionary

Since most risk factors don’t do a great job of predicting risk on the individual level (they work much better when measuring population risk), it makes sense to find something better. That’s where arterial calcium scoring enters the picture. If we measure the amount of calcium in the arteries, we are really measuring the amount of plaque or atherosclerosis. EBCT is the first method ever to come along that can precisely measure the plaque in our arteries. Even better, it does so noninvasively! It’s also quick, easy, painless and perfectly safe. EBCT represents a revolutionary advance in preventing the devastating effects of CVD. As you will see in the Discover chapter, the calcium score is the first thing you need to measure when you are at the appropriate age. If you don’t have significant amounts of atherosclerosis then your arteries are resistant to chronic oxidative stress. If you do have atherosclerosis, then you need to carefully look at your risk factors and follow the appropriate 3D F-Diagrams to design a program for prevention and restored artery health.

How does EBCT measure calcium? A CT scanner directs an x-ray beam through the body. On the other side of the body the beam meets what’s called a detector array. The detector measures the strength of the x-ray beam. The strength of the beam as it leaves the body depends on the kinds of tissue it went through. The denser the tissue, the weaker the x-ray beam. If the x-ray beams come from many angles through the body, the detectors record many different x-ray strengths. All this information is sent to a powerful computer. The computer builds up a picture of the inside of the body based on thousands of different detector readings. This picture represents a slice through the body. The machine takes many very thin slices. Each slice can be analyzed and read individually, or the slices can be blended into a three dimensional picture. The difference between EBCT and other scanners is two-fold. EBCT scanners have no mechanically moving parts to slow down data gathering. Each slice takes only 50 or 100 milliseconds (one thousandth of a second), while other types of scanners take 500 milliseconds or longer. EBCT also sends out a fairly weak x-ray beam. The speed and weakness of the beam mean much lower radiation doses are received by the person being scanned.

The speed of the EBCT scanner, when triggered to the heartbeat, can literally freeze the heart. Each heartbeat takes about 1000 milliseconds or one second at a heart rate of 60 beats per minute. A machine taking pictures at a 500 millisecond speed will see blurred arteries because it takes one half a heartbeat to take the picture. A machine taking pictures at 100 milliseconds, or one tenth of the heartbeat, will have much less blurring. When you measure the calcium in a blurred artery, the results are not nearly as accurate as a measurement done in a non-blurred artery. Non-EBCT scanners are getting faster all the time, so eventually they may catch up.

Once the pictures have been processed, they are sent to a special workstation. A modern workstation can be used to precisely measure the amount of calcium in each artery. A study of the coronary arteries on the heart usually involves forty slices, each one three millimeters thick. A study of the neck will have about thirty slices, each one five millimeter thick. On these slices, denser tissues are whiter, while less dense tissue is darker. Air looks black, while calcium looks white. When I score an area of calcium, I just take my mouse and circle it. I then tell the software program which artery I circled, and the program calculates the calcium score or volume. For you, the patient, it takes one thirty to forty second breathe hold to get the heart images, and one twenty to thirty second breathe hold to get the neck images. You remain fully clothed.

Now you can begin to see why EBCT is revolutionary. In a matter of less than two minutes I can get the information I need to tell you your risk for heart attack or stroke.

3D Health starts with your coronary and carotid calcium scores. First we discover your plaque, and then we decide what to do about it. If you don’t know your calcium scores, you don’t know whether your genes are protective or non-protective. Now that I have studied 10,000 people, I know what your score should be. I can rank you against thousands of others. If you have more plaque than the average for your age, then we need to try to determine how to stop it from progressing. Chapter 4 explains the different components of the Discover step. Once we know your unique risk profile, we can go on to the Design step in chapter 5 and put together a set of goals. The next set of chapters looks at all the programs for restoring 3D artery health. We look at nutrition, including appropriate supplements, exercise and emotional well being.

The greatest motivation of all is to know that what you are doing is working. After one or more years, your calcium scores should again be measured. If plaque is still building up too quickly, then the Design step needs to be reevaluated. Further changes may be necessary in medications, diet, supplements or exercise. If your plaque is not progressing, you can celebrate! The 3D Health program has accomplished its goal. The plaque in your arteries is no longer silently spreading. Less plaque means less plaque rupture. Older plaque is more stable plaque. You may even see your scores go down. 3D Health is designed to help you conquer the plaque in your arteries. When plaque is successfully treated, it can actually begin to regress, or shrink. You may have to live with some plaque for the rest of your life. But 3D Health will help you tame the plaque, converting it from an aggressive growth mode to a more benign stable mode. Stable plaque may go forever without rupturing. When you achieve stable plaque, you have greatly increased your chances for a longer life and a healthier, higher quality life. The health of your arteries impacts the whole of your body. Commit today to becoming 3D Healthy.