Cardiovascular diseases (including stroke) account for over 39 percent of deaths in the United States, according to American Heart Association (AHA) statistics. In other words, about one in four Americans who die each year does so from CVD. How do the death rates from cancer and other causes compare to that from CVD? Cardiovascular disease (from cardio meaning "heart" and vascular meaning "blood vessels") is not a single disease. It's a collection of many diseases that affect the heart and the blood vessels. Common forms of CVD include coronary heart disease (i.e., heart attack, angina pectoris, atherosclerosis in the heart's blood vessels), congestive heart failure, rheumatic heart disease, congenital heart disease, stroke, high blood pressure, pulmonary (lung) disease, diseases of the arteries and veins, and renal disease. As you read this chapter, note how these relate to each other. Which type of CVD claims the most American lives? Did you know that studies show that lower educational levels are directly associated with increased incidence of death from CVD?
Coronary heart disease, the most prevalent form of CVD, is still the single largest killer of American men and women (about one of every six deaths). While costs for treatment of CVD are spiraling upward, the death rate for these diseases appears to be declining. Advances in medical treatment and education and healthy lifestyle changes can be credited for the declining death rate. However, don't become complacent about these facts. We still have a long way to go. Cardiovascular disease is the number-one health concern in the United States. It is a killer.
Is coronary artery disease (CAD) the same as CHD? Basically yes. Health professionals use the terms interchangeably. The heart is a muscle (a little larger than a fist) that works all the time. It never stops beating. Each day, the average heart beats 100,000 times and pumps about 2,000 gallons of blood. The heart pumps blood continuously through the circulatory system, which includes the lungs and blood vessels (i.e., arteries and veins). The arteries, arterioles (small arteries), and capillaries (very tiny blood vessels) carry oxygen- and nutrient-rich blood to all parts of the body. Veins and venules (small veins) carry oxygen- and nutrient-depleted blood back to the heart and lungs. If all the vessels were laid end-to-end, they would extend for about 60,000 miles. That's enough to encircle the earth more than twice.
Besides providing oxygen and other nutrients to all tissues of the body, the heart must supply itself with oxygen. This is accomplished by a separate circulatory system, which nourishes only the heart muscle. The two coronary arteries (the right coronary artery and the left coronary artery) branch off the aorta and then divide into many smaller arteries that lie in the heart muscle and feed the heart. The most important factor in your heart's health is the efficiency of your coronary arteries to transport blood to your heart. The heart requires a steady supply of oxygen-rich blood to function properly. The most common barrier to that supply is CHD/CAD, in which the arteries become blocked or narrowed. CHD/CAD is most commonly the result of atherosclerosis.
Blood is supplied to the heart from the right and left coronary arteries, which branch off the aorta. If a coronary artery is blocked by a blood clot caused by a ruptured fatty patch, a heart attack occurs; part of the heart muscle may die due to lack of oxygen.
You supply the ingredients for what damages or protects the blood vessels of the heart through what you eat, how you exercise, and how you react to stress. You have the power to make your heart stronger.
What causes the injury? Unhealthy lifestyle factors create the injury, or "nicks" (microscopic tears) in this delicate tissue.
When these delicate endothelial cells are injured, microscopic tears or nicks result. The tears pull away from each other and form a gap. This "nick" (or injury) has to be closed quickly to protect and keep the blood vessel lining smooth. The body tries to repair the "nicks" by covering them with cholesterol (especially the "bad" type) and other substances causing fatty patches of plaque to build up. To counter, the body's immune system is alerted and sends in white cell protectors to attack the plaque buildup. In trying to heal the damaged area, inflammation develops at the site. The inflamed plaque, which is actually like a "blister," soft on the inside, with a thin skin covering, gets irritated. After time, it becomes unstable, then cracks, and a clot is released into the bloodstream. A heart attack or stroke may result if the clot flows to the heart or brain. We now know this is what generally happens in a heart attack or stroke rather than plaque growing so large that it alone blocks an artery.
What are the unhealthy lifestyle factors that injure the endothelium lining of the arteries, especially the coronary arteries, and leads to atherosclerosis (and increases inflammation)? Although there is a strong genetic component to atherosclerosis, you can largely control many contributing factors: diet, inactivity, unhealthy weight, smoking, high blood pressure, high blood cholesterol (the "bad" type and triglycerides ... sugars and alcohol), diabetes, and chronic inflammation. Chronic inflammation can also develop from things as diverse as sexually transmitted diseases, your reaction to perceived emotional stress, anger, and gum (periodontal) disease. To reduce the risk of atherosclerosis and inflammation, become physically fit, consume a diet high in omega-3 fats (fish), don't smoke (and avoid secondhand smoke), control blood pressure, and reduce weight (if overweight). Gum disease can increase inflammation and can be prevented by practicing good oral health (i.e., flossing every day and brushing your teeth for two minutes twice a day).
Atherosclerosis causes three-fourths of all deaths from CVD, coronary heart disease and stroke, but does not suddenly develop at age 65. It is a long, progressive process beginning when you are a toddler. Keep in mind that you are as old as your arteries. The good news: YOU can slow down how fast your arteries age.
Atherosclerosis may lead to angina pectoris, or chest pain/discomfort due to CHD/CAD. It is the most common symptom of CAD. In women shortness of breath is often the first signal of angina. This pain/discomfort occurs when a coronary artery becomes partially blocked, causing an oxygen debt in the heart muscle. Often, angina pectoris is brought on by sudden exertion or vigorous exercise, emotional stress, or even extreme temperatures when the blood flow to the heart is insufficient to meet its oxygen demands. Typical angina is uncomfortable pressure, fullness, and squeezing or pain in the center of the chest. The discomfort may also be felt in the neck, jaw, shoulder, back, or arm. Many types of chest discomfort are not related to angina, such as that caused by acid reflux (heartburn) and lung infection. Angina is a sign that someone is at higher risk of heart attack. Myocardial infarction (MI), or heart attack, results when one or more of the coronary arteries is partially blocked by atherosclerotic deposits called plaque. Plaque blisters can rupture, causing a blood clot (thrombus) to form, which chokes off the supply of blood to the heart muscle.
The portion of heart muscle beyond the blockage is deprived of oxygen, resulting in injury or death of that portion. If a damaged area is large enough or in a vital area of the heart, the individual will die. However, many people do survive a heart attack and are capable of living productive lives.
A number of studies have shown that in some damaged hearts, new blood vessels develop to nourish the area that is being starved of oxygen and other nutrients. This is called collateral circulation. Everyone has collateral blood vessels, which are microscopic and are closed under normal conditions. However, in some people with coronary heart disease, these vessels seem to enlarge and form a detour around the blockage to provide alternative routes for the blood. Exercise appears to be one practical way to increase myocardial oxygen demand, which in turn may stimulate the development of collateral vessels.
"Classic" or more common signs
Uncomfortable pressure, fullness, squeezing, or pain in the center of the chest that lasts more than a few minutes or that goes away and comes back.
Pain or discomfort in other areas of the body: shoulder, neck, jaw, back, or stomach, one or both arms.
Less common signs
Atypical chest pain, stomach or abdominal pain.
Nausea or dizziness.
Shortness of breath and difficulty breathing.
Unexplained anxiety, weakness, or fatigue.
Palpitations, cold sweat, or paleness.
Not all of these signs occur in every heart attack. If some of these symptoms do occur, don't wait. Get help immediately! Call 911.
Note: Women are much less likely to have the crushing chest pain type of heart attack seen on TV. They may experience less dramatic, lighter symptoms such as fatigue, shortness of breath, indigestion, or a burning feeling in the back. This makes their condition harder to recognize, leading to a higher risk of death.
A stroke occurs when blood flow to the brain is interrupted either by a blockage (ischemic stroke) or by a burst blood vessel (cerebral hemorrhage). More than 87 percent of strokes are ischemic. The brain needs a continuous supply of oxygen-rich blood to function. When a blood clot interrupts the flow of oxygen, the brain does not receive the nourishment it needs, and brain cells die. When considered separately from other CVDs, stroke, primarily caused by atherosclerosis, is the fifth leading killer of Americans. About 800,000 Americans will have a stroke this year—that's someone every 40 seconds.
Many Americans, however, cannot name a single warning sign or do not know that a stroke is treatable if caught early. So, a group of researchers developed a quick way to identify the signs of a stroke by determining the top three symptoms; then combined them with the most important action step in the acronym F.A.S.T. It a first step in the assessment process or sign of a stroke. If the person has trouble with any of these simple commands, emergency services (911) should be called immediately. The first 60 minutes after symptoms appear is referred to as the Golden Hour. If a person gets advanced medical care in the Golden Hour, the chances of surviving with less permanent damage is greater.
Hypertension: It is the most important risk factor for stroke.
High LDL cholesterol: This increases plaque in the arteries, which can increase blood clots.
Gender: Stroke is more common in men than in women, but because women live longer than men, more women die of stroke each year. Use of birth control pills, pregnancy, and childbirth pose special risks for women.
Diabetes: Those with diabetes have almost double the risk of stroke.
Age: The incidence more than doubles in each decade after age 55 (for women) and 45 (for men).
Smoking: Smoking or secondhand smoke doubles the risk of stroke by making blood vessels stiff.
Race: African Americans have nearly twice as many fatal strokes as whites and more than twice as many as other minorities.
Lifestyle: These risk factors can be controlled: high-fat, high-cholesterol diet; smoking; sedentary lifestyle; and alcohol or drug abuse.
More than two drinks a day for men and more than one for women can lead to multiple medical problems. Illegal drug use has been linked to stroke.
Family history: Risk increases if your mother, father, sister, brother, or a grandparent has had a stroke.
Primary Risk Factors (Controllable)
Inactivity is a real killer. It affects just about everything: brain, heart, blood vessels, bones, liver, gut, sleep, anxiety, mood, self-esteem, weight, and your body's ability to process sugar. The American Heart Association states that "becoming more active keeps the number-one killer at bay."
The American lifestyle is sedentary. We no longer have to hunt and grow our food, build our homes, or walk to school and work. Our ancestors did not have to build physical activity into their daily lives; it was a part of their lifestyle. Modern conveniences and technology have eliminated physical activity from our lives. Sedentary jobs have increased 83 percent since 1950! People sit at work all day; many have a long commute home and sit in front of the TV at night.
Countless studies link inactivity to CVD. The U.S. Surgeon General's report warns couch potatoes: "Beware, sitting around is hazardous to your health." Additionally, the Centers for Disease Control and Prevention (CDC) has named physical inactivity as our nation's most common cardiac threat. Why? Because 80 percent of adults don't get the recommended amount of exercise (aerobic and muscle strengthening). Remember, the heart is a muscle, and muscles have to be used or they will atrophy. Many experts believe that today's best buy in the prevention of CVD is exercise.
"Effect of Prolonged Sitting and Taking Breaks in Sitting Time on Endothelial Function" in Medicine & Science in Sport & Exercise concluded that three hours of sitting time results in significant CVD risk, whereas breaking up sitting time is beneficial for reducing cardiovascular risk. Easy five-minute walks can reverse harm done to leg arteries during three hours of prolonged sitting. This research provides more evidence about the dangers of sitting too much and not moving enough.
Even if you exercise, too much sitting is bad for your heart. Getting vigorous exercise each day is a great way to enhance your health. But, according to a recent study, it's not enough to offset the negative health impact caused by sitting several hours the rest of the day. In a recent study in the Annals of Internal Medicine Journal, researchers found that despite the health benefits of exercise, people who sit for long periods are at increased risk of death. Many people spend more than half their day sitting, as much as 8 hours per day. Researchers reported that longtime sitting increases the risk of dying from all causes by 24 percent. However, people who sit for long periods but also exercised were one-third less likely to die. Have you seen the Sit/Stand and Treadmill Desk?
The most convincing support for exercise and improved health and increased longevity was recently published in the British Journal of Sports Medicine. "The Stand Up for Longer Life Study" supports earlier research that the chromosome level is involved, specifically on the telomeres. Telomeres are the protective caps on the ends of each chromosome that help cut DNA decay and shrinkage. They have been compared with the protective caps on the ends of shoelaces. Longer telomeres have been linked to lower risk of CVD, type 2 diabetes, aging and some cancers. This study found that people who sat less while also following an exercise program had lengthened telomeres. The telomeres lengthened only in exercisers who reduced their sitting time. Otherwise, telomeres shortened, increasing the aging process of chromosomes as well as increasing chronic health issues. Each time a cell divides, its telomeres shrink or deteriorate. Do you want to stave off CHD, cancer, and other age-related health problems? The Rx ... stop excessive sitting and get moving!
The Old Order Amish who still live like most Americans did 300 years ago (i.e., no modern conveniences like electricity, telephone, automobile, etc.) have low levels of obesity and type 2 diabetes. Why? Because only 4 percent of Amish are obese. The men accumulate approximately 18,000 steps per day, and the women about 14,000 steps per day. By most standards, 10,000 steps per day is considered to be reflective of a very active lifestyle. The lesson the Amish have for us is that our bodies didn't change, we did. Refer to Chapter 4 for more information on the 10,000-step lifestyle goal. Do you know how many steps you take in a day?
Okay, so lots of exercise, at a moderate to vigorous intensity level, is great for a long and healthy life. However, if you feel overwhelmed by this recommendation, we have good news. Even 15 minutes helps! A recent study found that those who exercise just 15 minutes a day (or 90 minutes a week) cut their risk of death by 14 percent and extended life expectancy by 3 years compared with those who did no exercise. Each additional 15 minutes reduced the risk of death by another 4 percent, compared to the inactive group. For the sedentary, the key is this: Some exercise is better that none. Even simple body movements such as taking activity breaks while studying, working on the computer, or watching TV, called nonexercise activity thermogenesis (NEAT), are beneficial. Get off the couch and start moving!
The old saying "Use it or lose it!" is true. You don't have to run marathons to be physically active. Small increases in daily activity can significantly burn up excess calories, and make the heart muscle a stronger and more efficient pump. Exercise does more than build strong muscles and help prevent heart disease. It also boosts brain power and may offer hope in the battle against Alzheimer's.
Ride your bike, walk to school, and play tennis instead of watching others doing these activities. Park at the back of the parking lot instead of right next to the building. Get a pedometer and try to accumulate 10,000 steps in a day. There are many ways to add activity to your daily life. Remember, it doesn't have to be exhausting! Stand up right now and walk around!
Blood pressure is the term used to define the pressure exerted by blood on the inner walls of the arteries. It is also the force exerted by the heart while pumping blood through the body.
What was once considered normal blood pressure (120/80) is now labeled prehypertension, and treatment is recommended. Hypertension nearly triples CVD risk for men and doubles it for women.
There are two blood pressure levels, recorded as two separate numbers in fraction form (for example, 120/80). When the heart contracts and pumps blood into the arteries, the pressure increases. This is the systolic, or pumping, pressure, recorded as the upper number. The diastolic, or resting, pressure is the force of the blood against the arteries when the heart relaxes and fills with blood between beats. It is recorded as the lower number. Both the systolic and diastolic numbers are important. High levels of either or both mean greater risk for heart attack and stroke.
Normal blood pressure is 119/79 or below. However, many experts contend that the new gold standard or "optimal" blood pressure should be 115/76 because damage to the arteries from the pressure of blood pounding through them begins to increase at this point. This means your risk of CVD increases! Prehypertension is acknowledged as blood pressure between 120/80 and 139/89, which until 2003 was considered normal but now is considered to be in the "danger zone" before full-blown hypertension develops. This unsafe condition calls for lifestyle changes and monitoring. Hypertension, or high blood pressure, measures 140/90 or more and requires medical treatment.
One in three American adults has high blood pressure, and about 30 percent more have prehypertension. In 90 percent of the cases there is no known cause. However, factors that can increase your chances of developing high blood pressure are heredity, cigarette smoking, male gender, age, being an African American, obesity, sensitivity to sodium, heavy alcohol consumption, use of oral contraceptives, stress, and a sedentary lifestyle. In a small number of cases, hypertension is caused by a specific condition, such as kidney disease, a tumor of the adrenal gland, or a defect in the aorta. This is called secondary hypertension. The cause of secondary hypertension can be identified and treated successfully. How do you know if your blood pressure is too high? The only way to know is to have it checked.
You cannot feel high blood pressure—and usually there are no symptoms until complications develop. That is why hypertension is called the "silent killer." You can be hypertensive for years and be unaware of the damage occurring. Even warning signs associated with advanced hypertension may go unnoticed but may include headaches, sweating, rapid pulse, shortness of breath, dizziness, nosebleeds, and visual disturbances.
Cholesterol is not a true fat but a waxy substance found in the bloodstream. Because it is soluble in fats rather than in water, it is classified as a lipid, as fats are. About 75 percent of total body cholesterol is manufactured in the liver, while 25 percent comes from dietary sources—mainly from foods of animal origin.
From all the bad press cholesterol gets, you would think cholesterol is our body's enemy. Not true. It is vital for our existence. Cholesterol is necessary for healthy cell membranes, brain cells, digestion, and adrenal glands. The problem with cholesterol is that your body makes most of what it needs, and the normal American diet adds much more. Health experts recommend that we keep dietary cholesterol consumption to less than 300 milligrams per day (less than 200 if you have high blood cholesterol). Hypercholesterolemia is the term for high cholesterol levels in the blood.
When evaluating your blood lipid profile for risk of CVD, consider two factors: (1) the total amount of cholesterol/triglycerides found in the blood and (2) the way cholesterol/triglycerides are transported in the bloodstream.
Total Amount of Lipids Knowing your total cholesterol level provides you with a rough estimate of your heart disease risk. Blood cholesterol is measured by analyzing a small blood sample in a laboratory. Total cholesterol level includes the amount of cholesterol carried by high-density lipoprotein, low-density lipoprotein, and very low-density lipoprotein. The National Heart, Lung, and Blood Institute relates blood cholesterol level to CVD risk.
Transportation of Lipids Like oil and water, cholesterol and blood (because it is mainly water) do not mix. Cholesterol must attach to a protein molecule to be carried through the bloodstream. This combination is called a lipoprotein. This amazing system is also in place to assure that cholesterol is circulated wherever it is needed. However, some cholesterol-carrying lipoproteins play central roles in the development of atherosclerotic plaque and CVD.
The action begins in the liver where cholesterol is packaged for delivery. The two main types of lipoproteins basically work in opposite directions. The first is low-density lipoprotein (LDL) cholesterol, and the second is high-density lipoprotein (HDL) cholesterol. Which of the two types is harmful and which is helpful?
Average HDL levels in adult Americans are about 45 to 65 mg/dl, with women averaging higher values than men. The female sex hormone estrogen tends to raise HDL levels, which may explain why premenopausal women are usually protected from heart disease. Studies suggest that HDL levels above 70 may protect against heart disease, while those below 35 signal coronary risk.
Triglycerides Triglycerides are manufactured in the body to store excess fats. They are also known as free fatty acids, and in combination with cholesterol, they accelerate the formation of plaque. Triglycerides are carried in the bloodstream by very low-density lipoprotein (VLDL). They are mainly manufactured in the liver from alcohol, starches, and refined sugars (honey included). Alcohol, starches, and sugars are not fats, but the body can convert them into fats and then dump those fats into the bloodstream. To lower triglycerides, it is important to decrease consumption of alcohol, sugar, refined carbohydrates and to reduce consumption of animal fats (poultry skin and lunch meats), saturated fats, trans fats.
As a general rule, you should keep your triglyceride level below 150 mg/dl of blood. However, some reports indicate that triglyceride levels over 100 should be cause for concern, especially if you have other CVD risk factors.
You should know your cholesterol level and have it checked annually, especially if you have a positive family history of CVD. The best way to do this is to have a 12-hour fasting blood test that is analyzed by a reputable laboratory. Over-the-counter tests that don't require fasting are not as reliable. Remember, cholesterol levels are controllable.
Primary Risk Factors (Controllable)
4. Cigarette Smoking
Cigarette smoking is a primary risk factor. Currently, 20 percent of men and 15 percent of women in this country smoke cigarettes. About a quarter to a third of college students smoke. Nicotine increases heart rate and blood pressure and constricts blood vessels. Carbon monoxide also creates cardiovascular stress by impairing the transport of oxygen in the blood. Smoking kills more than 480,000 a year—that's one in five Americans. Some health professionals are calling tobacco use a "weapon of mass destruction." Every cigarette package is required by law to carry a strong consumer warning. And, tough new FDA regulations now include e-cigarettes, hand-rolled cigars, hookah, and pipe tobacco to be regulated exactly like tobacco.
Do e-cigarettes help you quit smoking? A recent analysis of twenty e-cigarette studies by the University of California, San Francisco found that they may actually keep you hooked on tobacco products. Researchers found that the odds of quitting were twenty-eight percent lower for e-cigarette users than for those who only smoked traditional cigarettes.
Numerous studies have proved that cigarette smoking causes oral cancer, lung cancer, and emphysema, and in women it is linked to cervical cancer, early menopause, and damage to the fetus during pregnancy. The number of Americans killed each year from smoking is greater than the number killed during World War II and the Vietnam War combined. No level of smoking is safe!
The AHA reports that smokers have more than twice the risk of heart attack of nonsmokers. Even limited smoking (four to five cigarettes per day) increases CVD risk. Also, smoking increases the risk of developing peripheral vascular disease (narrowing blood vessels in the arms and legs), which may lead to developing gangrene and, eventually, to amputation.
Passive smoke, synonymous with secondhand smoke, is the cigarette smoke inhaled by nonsmokers from environmental air. The American Heart Association provides conclusive evidence that secondhand smoke is not a mere annoyance—it's lethal. About 41,000 people die each year from diseases caused by secondhand smoke (CVD 34,000 and lung cancer 7,300). Smoking bans are the only way to protect nonsmokers. The research reveals that secondhand smoke is remarkably effective in damaging the cardiovascular system:
1. Nonsmokers may be more susceptible to heart and vascular damage from secondhand smoke than smokers are, even though they absorb much smaller doses of the smoke's toxins. That is because smokers develop compensatory responses to some of the adverse cardiovascular effects of cigarette smoke—but nonsmokers do not get the "benefit" of these adaptive responses.
2. Carbon monoxide, a substance in secondhand smoke (and in inhaled cigarette smoke), injures the endothelial cells. Carbon monoxide decreases the amount of oxygen carried in the blood. It also reduces the heart's ability to use the oxygen it does receive.
3. Exposure to secondhand smoke can cause blood platelets to become stickier in nonsmokers, increasing formation of clots, which can lead to a heart attack or stroke.
4. Secondhand smoke increases atherosclerosis by lowering HDL cholesterol.
5. It increases chronic inflammation.
6. Nonsmokers exposed to secondhand smoke at home or work will die from CVD.
7. It increases insulin resistance.
8. Secondhand smoke is a human carcinogen, killing about 7,300 nonsmokers a year through lung cancer.
Although studies show that smoking has declined by more than 49 percent since 1965, this downward trend appears to be leveling off. There are still more than 3,800 new smokers every day. The Surgeon General states that about 90 percent of people who use tobacco started as teens and three out of four teens continue into adulthood. Nicotine exposure at a young age may cause lasting harm to brain development. A nonsmoker should not begin to smoke. Smokers should stop now. Don't hesitate, do it! Ninety percent of smokers who quit do so on their own!
Primary Risk Factors (Controllable)
Obesity has escalated to epidemic proportions in the United States and is continuing to increase at an alarming rate. See "The Numbers" earlier in the chapter. Weight wise, Americans are evenly divided. More than one-third are obese, one-third are overweight, and one-third are normal or underweight. In fact, more than 68 percent of the U.S. population is now obese or overweight. Ninety percent of people with type 2 diabetes are overweight. In addition to increased risk of CVD, obesity is a strong predictor of sleep-disordered breathing, as well as development of numerous cancers, nonalcoholic fatty liver, gallbladder disease, and reproductive abnormalities. Obesity, considered a chronic disease, causes more than 300,000 premature, preventable deaths per year. See the Diversity Issues box. Obesity is uncomfortable; increases the burden on the vital organs, especially the heart; and is directly linked to CVD. Obesity is expensive, too. Annual medical costs for an obese person are 37.7 percent more than those for someone of normal weight.
It is especially risky to have excess body fat in the belly. The belly area carries two kinds of fat—subcutaneous fat, the kind you can see and pinch, and visceral, or belly fat, which surrounds the abdominal organs deep inside the body. Subcutaneous fat may be unsightly, but it is not particularly dangerous. Visceral fat, on the other hand, is hazardous to your health, even if you are not overweight! It appears to be metabolically more active than fat elsewhere and it
1. more than doubles the risk of dying from a heart attack.
2. interferes with liver function and impairs the body's ability to use insulin, increasing the risk of type 2 diabetes.
3. secretes lipids (such as triglycerides; appetite-stimulating hormones, and inflammation-fueling chemicals) into the bloodstream.
4. is linked to women's increased CVD risk after menopause.
5. may cause colon cancer and increases risk of rectal, pancreatic, endometrial, and postmenopausal breast cancers.
So, how do you lose belly fat? The first step in the medical treatment of this condition is the classic combination of diet and exercise. Note: Visceral fat is often the first to go.
Waist measurement and the ratio of your waist to hip measurement is the way to estimate one's body fat and to assess your health risk. A high-risk waistline is 35 inches or more for women, 40 inches or more for men—even if you are at normal weight. What is your ratio? What is optimal for men and women?
Obesity is controllable and can be reversed. Even modest weight reduction (5 to 10 percent of body weight) can help reduce your risk of obesity, heart attack, stroke, and cancer.
Physical inactivity is a major factor in the development of obesity in men, women, and children. Spending too much time in front of screens (i.e., TVs, computers, ipads, smart phones) is one of the main culprits. The number of hours per day that Americans spend in front of screens is approximately eight. Some call this "death by SCREENS." The Journal of the American Medical Association reported that for every 2 hours of TV watched, death rates increased by 13 percent. Americans should limit TV viewing to about 1 hour or less a day to prevent physical and mental inactivity. The hours sitting in front of a computer screen or video game screen add to this dire situation. Of course, consuming more calories than are used in daily activity also contributes to obesity. Note: Accumulating 10,000 steps expends approximately 500 calories!
Diabetes mellitus, or DM—which includes both type 1 and type 2—is a disease that affects how the body uses glucose, a sugar that is the body's main source of fuel. This chronic disease is characterized by the body's inability to produce enough of the hormone insulin or use it properly. In the normal digestive process, the food you eat is changed to glucose. Insulin (which is produced in the pancreas) carries the glucose in the blood to the body's cells so that the body the gets the energy it needs. In diabetes, this normal process is interrupted. When glucose doesn't reach the cells, it accumulates in the blood and the underfueled cells are starved for energy. This surplus glucose is eliminated by the kidneys, which pass it off in the urine. Too much sugar in the urine and in the blood is a classic sign of diabetes.
Diabetes is found in two forms, type 1 and type 2. Genes have a hand in both types, but more so in type 1. Yet, research on identical twins reveals that when one twin develops type 1 diabetes, the other twin has only a 30 to 50 percent chance of developing it. If genes were the only factor involved as a type 1 diabetes cause, both identical twins should get it. Something else, in addition to genes, has to be at work. Individuals with a genetic tendency to develop type 1 diabetes appear to be fine until something "triggers" the onset of the disease. It may be a virus that attacks the pancreas that triggers the onset, or it may be something in the environment. Type 2 diabetes results from a combination of environmental and genetic factors and is heavily influenced by obesity. Scientists believe that a genetic predisposition for type 2 can be warded off, even prevented, by lifestyle interventions of weight management and exercise.
Insulin-dependent diabetes, also known as type 1 or juvenile onset, occurs when the immune system attacks and permanently disables the insulin-making cells in the pancreas. In this form, the pancreas makes little or no insulin. Page 269The diabetic must receive insulin injections every day to stay alive and must carefully watch his or her diet and exercise regularly. Type 1 diabetes occurs most often in children or young adults. Symptoms develop rapidly, usually within a period of months or even weeks. Approximately 1 million Americans have type 1 diabetes. Medically supervised medication and lifestyle strategies are key to controlling (or managing) type 1.
More common (90 to 95 percent of diabetics) is non-insulin-dependent diabetes, once known as adult-onset or type 2, in which the pancreas makes insulin, but either the amount is insufficiently released or the body cannot properly use what is available. This type of diabetes can often be controlled without insulin injections through other medications, diet, and weight management. This form of the disease usually occurs in people over 40 years old and is associated with aging and obesity. New data, however, show a dramatic rise of type 2 in children and young adults, making the term "adult-onset diabetes" obsolete. Because the onset of type 2 is gradual, the disease may go undetected for years. Diabetes seriously increases the risk of developing cardiovascular disease. About 65 percent of people with diabetes die of some form of CVD. Part of the reason for this is that diabetes affects cholesterol and triglyceride levels by producing a different kind of LDL that is even worse for the arteries than is ordinary LDL. This accelerates atherosclerosis. Even so, type 2 diabetes can be delayed or averted by weight management and physical activity. One condition shared almost universally by type 2 diabetics is obesity. Not all obese people become diabetic, but 90 percent of people with type 2 diabetes are overweight or obese.
The surge in youth obesity in this country has paralleled a rise in childhood type 2 diabetes. At one time, type 2 diabetes was almost unheard of in children. They almost always had type 1. A advisory from the American Academy of Pediatrics and the American Diabetes Association (ADA) calls for diabetes testing of overweight children with any two other risk factors starting at age 10 or at puberty, if it comes earlier.
Many people know their blood pressure and cholesterol levels, but few know their glucose level. A substantially elevated glucose level is the chief diagnostic sign of diabetes. Unfortunately, far too few people are properly tested. As a result, researchers say that millions of people who have type 2 diabetes don't know it.
One in three Americans have a condition called prediabetes (or insulin resistance), which is a precursor to diabetes. It means your blood glucose level is higher than normal, but not high enough to be diagnosed as diabetes. About 90 percent of people with prediabetes don't know they have it. Prediabetes should not be taken lightly. It means you are on course to develop type 2 diabetes, heart disease, and stroke, and even if you don't, you face a higher risk of cognitive decline and certain cancers. The millions of people with prediabetes can be protected from developing full-blown diabetes—and its life-threatening complications—by losing weight, increasing physical activity, and eating a heart-healthy diet.
The main reason public health experts are urging wider glucose testing is that it is the only way to catch diabetes early. The disease usually causes no symptoms for a decade or more, even though it is silently festering the entire time. That's 10 to 12 years during which diabetes quietly eats away at your vision, injures your kidneys and nerves, and sets the stage for CVD. This is damage that would be preventable if only people learned sooner that they have type 2 diabetes.
According to the American Diabetes Association's new guidelines, all people age 45 and older should have their fasting blood-glucose level tested at least every 3 years. Several groups of people are at greater risk and should be checked for diabetes at least once a year. Get tested, starting at age 35, if you
1. Are overweight, especially with extra belly fat.
2. Have a brother, sister, or parent with diabetes.
3. Are a member of high-risk population: African American, Hispanic, Native American, Alaska Native, Asian American, Pacific Islander.
4. Had a baby weighing more than 9 pounds or had gestational diabetes (diabetes during pregnancy).
5. Have an HDL cholesterol of 35 or less or a triglyceride level of 250 or more.
6. Have hypertension or take antihypertension drugs.
7. Had a minimally elevated glucose level on a previous test.
8. Have obstructive sleep apnea and chronic sleep deprivation (less than 6 hours per day). These are emerging risk factors.
Two readings of 126 mg/dl or more on a fasting blood glucose test taken on different days means you have diabetes. A less elevated reading, from 100 to 125, indicates impaired fasting glucose, which means you have prediabetes or are insulin resistant and face a sharply increased risk of diabetes. An A1C is another DM test that can be used. It provides an estimate of your average blood glucose levels over the previous 2 to 3 months. The more excess glucose in the blood, the higher the percentage of A1C. No fasting is required for this test. Regardless of your glucose level, you are probably prediabetic if you have low HDL, high triglycerides, high blood pressure, or excessive abdominal fat (i.e., a waist measurement of more than 35 inches for a woman and 40 inches for a man). Numerous studies have concluded that a large waist is a better predictor of CVD and type 2 diabetes risk than body weight, body mass index, or other measures.
Certain lifestyle changes can improve insulin resistance, such as:
1.aerobic exercise, at least 30 minutes every day; and two or three strength-training workouts per week.
2. losing weight (5 to 7 percent of body weight).
3. stopping smoking.
4. eating more fiber and whole grains and less simple carbohydrates (sugar and other sweets) or following the DASH diet.
5. reducing alcohol intake.
They may also help improve the associated HDL, triglyceride, and blood pressure problems. Those steps can also help people who have type 2 diabetes (and sometimes even those with type 1) control their glucose level.
Two symptoms that occur in many people with diabetes are increased thirst and frequent urination. That's because excess glucose circulating in your body draws water from your tissues, making you feel dehydrated. To quench your thirst, you drink a lot of water and other beverages, and that leads to more frequent urination. These are other signs and symptoms of type 2 diabetes:
1. Flulike symptoms. Because glucose is not reaching your cells, you may feel very tired and weak.
2. Weight loss or weight gain
3. Blurred vision
4. Frequent hunger
5. Dry skin
6. Slowly healing wounds
7. Itching, tingling, or numbness in the extremities
8. Frequent vaginal or skin infections
Combinations of these symptoms
Unless detected and controlled, diabetes can ultimately lead to stroke, heart disease, kidney failure, blindness, amputation of limbs from gangrene, and death. The good news: Type 2 diabetes is almost entirely preventable. People who have a healthy weight and lifestyle have a 90 percent lower risk.
1. Low-density lipoprotein (LDL). LDLs are considered "bad" because they carry a large amount of cholesterol. They carry cholesterol from the liver out to the rest of the body. The lower density of the lipoprotein allows it to attach easily to the inner wall of the blood vessel, thus accelerating the atherosclerotic process. A high LDL cholesterol level increases your risk for atherosclerosis, CVD, and stroke. It is recommended that LDL levels be kept below 100 mg/dl, especially if you have CVD or diabetes. How can you lower LDLs? Reduce consumption of saturated and trans fats. They are two of the worst culprits.
Very low-density lipoproteins (VLDL) are even more dangerous because they contain the largest amount of triglycerides and an increased risk of CAD. VLDL is usually estimated as a percentage of your triglyceride level.
2. High-density lipoprotein (HDL). HDL carries cholesterol from the blood back to the liver where it is broken down for elimination from the body or sent out again as needed. It is considered the "good" cholesterol because the dense structure of the lipoprotein allows it to act as a garbage collector in clearing away plaque and other debris as it flows through the bloodstream to the liver to be excreted from the body. The higher your HDL cholesterol level, the better and the more protection from CVD it provides. Plus, it helps to ward off Alzheimer's. HDL also acts as an anti-inflammatory agent. HDL levels above 40 mg/dl are recommended. How can you boost your level of HDL?
Lose excess weight.
Increase omega-3s (fish oil) and fiber, (in supplements, tuna, salmon)
Use monounsaturated fats (e.g., olive oil, canola oil, sunflower oil) as primary fat, while keeping total fat intake low.
A lipoprotein analysis gives a more accurate picture of your CVD risk than does total cholesterol alone. This analysis breaks down the total cholesterol into its components, or lipoproteins. Problems occur when there is too much LDL cholesterol for the HDLs to pick up promptly, or if there are not enough HDLs to do the job.
What causes LDL and HDL to get out of balance in some people? There is genetic variability in how efficiently (or inefficiently) a person metabolizes dietary saturated fat and cholesterol. Some people can eat almost anything and their blood cholesterol levels remain stable. Others find that even a small amount of dietary fat makes their blood cholesterol levels increase. Most of us are somewhere in between on this spectrum. An unhealthy combination of "good" and "bad" cholesterol quadruples the risk of heart attack.
Total Cholesterol/HDL Ratio Scientists believe that the ratio of total cholesterol to HDL cholesterol is a better indicator of risk for cardiovascular disease than is the total value alone. To determine your ratio, take a laboratory blood test that will reveal your total cholesterol and HDL cholesterol levels. Next, divide the total cholesterol level by the HDL cholesterol level to find the ratio. For example, if the total cholesterol measures 160 and the HDL cholesterol 40, your ratio would be four to one (4:1) (160 ÷ 40 = 4). This would place you in the near optimal category. Everyone should strive for a ratio that is 4:1 or lower. The lower this ratio, the lower the risk for CVD. A ratio above 4:1 increases your CVD risk.
A family history of heart disease in brothers, sisters, parents, or grandparents increases the risk of developing CVD. Tendencies toward high blood pressure, stroke, peripheral blood vessel disease, rheumatic fever, high blood lipid levels, obesity, and early heart attack appear to be somewhat hereditary. This is why your physician is so interested in your family history. A family's lifestyle also may contribute to heart disease and stroke. For example, family members may be overweight, smoke, eat large amounts of cholesterol and saturated fat, or be physically inactive. You should find out as much as possible about your family's medical history. You can be alerted early to a possible risk and take preventive measures. Although CVD is the leading cause of death for both men and women, males have a higher risk of heart attack, especially earlier in life. The gender factor exists because men have heart attacks 10 years earlier than women. Until age 55, men also have greater risk for hypertension than women do. The incidence of stroke is higher for males than females under age 65. The increased male risk is not clearly understood. Some credit the increased risk to the male sex hormone testosterone, which triggers the production of low-density lipoproteins, thereby clogging blood vessels. Others say a male's lifestyle may be the culprit.
We do know that a female's hormonal makeup is protective until menopause. Female hormones signal the liver to produce more "good" cholesterol (HDL) and make blood vessels more elastic than a male's blood vessels, especially during childbearing years. After women reach menopause (usually in their early to middle fifties), their rate of heart-related problems equals or surpasses that of men. Part of the explanation for this is that women tend to go up in waist size (even if weight does not) after menopause due to increased visceral fat (the kind that promotes inflammation). This is due to a hormonal shift: decreased levels of estrogen that are no longer needed to sustain pregnancy, and increases in testosterone and the male tendency to bulk up around the middle in contrast to the pre-menopausal tendency for females to store excess fat in the buttocks and thighs. Lower estrogen may increase appetite and trigger cravings for sweets and fatty foods. Other factors that come into play for postmenomausal women at this time include a sharp rise in LDL cholesterol, which remains higher during this transition, a more sedentary lifestyle, and weight gain. It is crucial that women in their early to mid-forties begin to gradually increase physical activity. How much? At least an hour of moderate-intensity exercise a day is needed, according to the most recent studies. Second, they must become more aware of dietary habits to help offset metabolic changes that can lead to weight gain with menopause.
It is imperative that males and postmenopausal women modify other risk factors to protect their cardiovascular systems.
We all feel stress, but we each feel it in different amounts and react in different ways. Too much stress over a long time and unhealthy responses to it can damage our health. Stress is unavoidable. It includes happy, wonderful, and positive events as well as sad, destructive, and negative ones. For example, the death of a family member and the birth of a child, while perceived differently, are stressors that produce the same physiological response in the body. Stress has been found to cause a rise in heart rate, blood pressure, depression, and blood cholesterol, and it can lead to excessive smoking or eating—all linked to CVD.
Stress causes chemical wear and tear on the body by releasing stress hormones into the bloodstream. Large amounts of stress hormones are found in the bloodstreams of people who react to stressful situations with hostile and angry behavior. How you respond to stress seems to be the critical factor. You should recognize stress in your life (the positive and the negative) and learn to handle the stressful situations in a healthful manner. Coping with stress successfully is vital in today's hectic, in-the-fast-lane lifestyle. Exercise, relaxation techniques, and behavioral modification are excellent methods for reducing stress.
Several studies have linked emotional behavior to increased risk of heart disease. Until recently there were just three emotional behavior patterns or personality types—Types A, B, and C. Now a newly coined personality type, Type D (which stands for "distressed"), has been identified and may be the type with the most dangerous risk for CVD.
Early studies identified Type A people as the ones at greater risk of having heart attacks. However, more recent research indicates that it is only when a Type A person exhibits the behaviors of hostility and anger that a serious risk is apparent. These behaviors arouse the fight-or-flight response, significantly elevate blood pressure, overstimulate the production of stress hormones, and have been documented to increase coronary artery atherosclerosis. Some studies found that hostility levels are a more accurate predictor of heart disease than high cholesterol, hypertension, smoking, or obesity. The other Type A behaviors do not seem to be as significant but may eventually lead to hostile, angry reactions to stress. That's why Type A behavior should be recognized. Types B, C, and D will also suffer adverse health consequences when angry, hostile behaviors are exhibited.
Type D people possess negative emotions and tend to be depressed, anxious, irritable, insecure, and distant. Some scientists believe that the social and emotional problems associated with Type D personality can increase the chances of developing cardiovascular disease.
We are not born with hot reacting, angry, and hostile behaviors. These behaviors are learned, and for the sake of our health, we can unlearn them.
Drinking too much alcohol raises blood pressure and triglyceride levels, damages the heart muscle, and increases risk of stroke and heart failure. The American Heart Association reports that binge drinking in college raises C-reactive protein levels and may lead to heart disease later in life.
Alcohol consumption, especially of red wine, has received attention as a protective factor against CVD because it is thought to raise HDL cholesterol in the blood and might help prevent clotting that leads to plaque buildup inside arteries. "Moderate" consumption of alcohol (one drink for women per day and two drinks for men per day) is the amount associated with a reduction in the rate of CVD. The following amounts are examples of one drink:
1. 1½ oz. of bourbon, scotch, vodka, gin
2. 5 oz. wine
3. 12 oz. beer
If you don't drink, don't start. A protective effect of alcohol consumption is still being debated, but many adverse effects are well documented. Besides causing automobile accidents and social disruption, excess intake of alcohol can cause diseases of the liver, pancreas, and nervous system, and increase breast and colon cancer risk. To put the benefit of moderate drinking in perspective, the reduction in heart disease risk is comparable to what you might achieve by exercising regularly or by cutting blood cholesterol levels through a low-fat diet.
Stimulant illegal drugs such as heroin, cocaine, methamphetamine ("meth"), and MDMA ("Ecstasy") can also cause serious CVD problems, including heart attack, stroke, and sudden cardiac death. Fatalities have been recorded even in first-time users of illegal drugs. Intravenous drug use carries a high risk of infections of the heart.
Also known as syndrome X, insulin-resistance syndrome, and prediabetes syndrome, metabolic syndrome is a dangerous cluster of symptoms that raise the risk of heart disease, stroke, diabetes, and some cancers. Also, it is linked to cognitive decline. It is defined as having three or more of the following five risk factors:
1. Elevated blood pressure: blood pressure higher than 130/85
2. Elevated glucose: fasting blood sugar of 100 mg/dl or higher
3. High triglycerides: triglycerides of 150 or higher
4. Low HDL ("good") cholesterol: HDL cholesterol less than 40 for men and 50 for women
5. Obesity: a waist measurement of more than 35 inches for women and 40 inches for men
Do you have metabolic syndrome? It is a silent disease that affects millions of Americans. Scientists know a lot about the components that make up metabolic syndrome, but they know less about the overall syndrome. The key element seems to be insulin resistance, but that is largely a result of obesity (especially abdominal or visceral fat) and lack of exercise. Thus, the root cause is hard to determine.
The best treatment for metabolic syndrome is a healthy diet, regular exercise, and weight loss, even if you don't lose much.
THE FUTURE ... FOCUS ON LIFESTYLE
The cost of treating cardiovascular diseases in this country is staggering. Many scientists believe we will be more successful if we focus on prevention rather than rely on expensive, high-tech treatments. "An ounce of prevention is worth a pound of cure" will in all likelihood be the slogan of the twenty-first century. Heart disease prevention in our future will focus primarily on lifestyle changes and approaches that involve "mind and body" concepts. Many scientists are already substantiating these trends in their research and medical practices.
One example is Dr. Dean Ornish, cardiologist, clinical professor of medicine at the University of California, San Francisco, and pioneer in the treatment of CVD. He found that after treating his patients with the current, recommended medical procedures—medication, angioplasty (balloon technique), and coronary bypass surgery, all expensive and dangerous—most did not stay well. Despite the procedures, some died and many returned for further treatment. He began to question the wisdom of such dramatic medical care for heart disease. He found it interesting that lifestyle factors could trigger all mechanisms known to cause CVD. The lifestyle choices we make each day, such as what we eat, how we respond to stress, how much we exercise, and whether we use tobacco, have a profound impact on the heart's health. With this concept in mind, he developed a plan that focuses on lifestyle. His program, "Reversing Heart Disease," is having significant success in reducing atherosclerosis without medication or surgical procedures. The program involves the following lifestyle changes:
1. A special diet is recommended. The Reversal Diet is 10 percent fat, 70 to 75 percent carbohydrate, 15 to 20 percent protein, and 5 milligrams of cholesterol per day. In comparison, the typical American diet is 40 to 45 percent fat, 25 to 35 percent carbohydrate, 25 percent protein, and 400 to 500 milligrams of cholesterol per day. The Reversal Diet allows, but does not encourage, moderate alcohol consumption (less than 2 oz. per day). It excludes caffeine, allows moderate use of salt and sugar, and is not restricted in calories.
2. Smoking is prohibited.
3. Thirty minutes a day or 1 hour every other day of moderate exercise is prescribed.
4. Stress management methods are prescribed every day. These include yoga stretches, progressive relaxation, abdominal breathing, meditation, and imagery.
5. Psychological support should be enhanced. This involves increased time spent talking about feelings with friends and family and participating in spiritual and religious activities.
Heart disease is the number-one killer in the United States. Extensive studies have identified 16 factors that increase the risk of developing CVD. These factors definitely lead to the development of atherosclerosis. The most significant factors are inactivity, high blood pressure, a high blood lipid profile, cigarette smoking, obesity, and diabetes (plus prediabetes). These 6 are labeled primary and all can be controlled. Four additional primary risk factors for CVD are positive family history, male gender (+ postmenopausal women), race, and age. These primary risk factors are all uncontrollable. There are 6 more CVD factors labeled secondary. These are all controllable. They are stress, emotional behavior (especially negative emotional behaviors such as hostility and anger), excessive alcohol consumption (+ some illegal drugs), metabolic syndrome, C-reactive protein, and homocysteine. Of the total 16 risk Page 277factors, how many are under your control? (Answer: 12). The more risk factors you have and the longer they are present, the greater the chance you have of developing heart disease. By age 20, you already have fatty deposits in your coronary arteries. If your risk of CVD is low, keep up the good work by maintaining a healthy lifestyle. However, if your coronary risk is high, now is the time to act. You can't do anything about your race, heredity, sex (gender), or age. However, you can choose to act on the 12 risk factors under your control.
Several treatments are available for coronary arteries that become blocked due to advanced atherosclerosis. These include exercise and diet modification, drug therapy, angioplasty, and coronary bypass surgery. The cost of treating CVD continues to spiral upward every year. To counter this trend, many scientists are convinced that preventing CVD through lifestyle change is the key to maximizing heart health.
Adopting a healthy lifestyle early in life can add years to your life and life to your years. In addition, great discoveries await us as the field of mind and body research gains wider acceptance in the quest for increased well-being.