Category: Guide to Preventing and Treating Heart Disease

If you need to lose weight, you and your doctor or registered nutrition- ist can design a healthy diet plan, which will involve determining a level of calorie intake that is appropriate for you—but one that contains at least 1,200 calories per day. Your exercise plan should ensure that you burn more calories than you consume. The healthiest and most effective way to lose weight is to limit the energy consumed in food, and then increase the amount of energy burned off by exercise, to achieve a slow but steady weight loss. Most experts recommend losing 1 to 2 pounds per week.
To lose 1 pound in 1 week, you need to burn about 3,500 excess calories; that is, you need to burn about 500 calories more per day than you consume. Dieters are plagued by the plateau phenomenon. When you achieve about a 10 percent weight loss, your body compensates by slowing your metabolism. It is important to keep exercising and not get discouraged during this time.

Exercise as a Part of Every Day

Your plans to exercise more are much more likely to succeed if you think of exercise as a pleasure rather than an obligation. It is important to choose activities that you enjoy and then ?nd ways to make them eas- ier to do often. Here are some tips to keep you going:
• Develop a variety of physical activities that you can choose from so that you don’t get bored. In addition to a walking routine, alter- nate sessions of some goal-oriented activity like gardening or a more intensive activity like bicycling to keep you interested.
• Find a friend or family member to exercise with you. You’ll both enjoy the sociability and both get the physical benefits. Wear comfortable, appropriate clothing when you work out, including shoes that ?t properly and suit your activity.
• Listen to music or watch television to keep yourself entertained.
• Avoid overdoing it. You don’t need to be an athlete, and you don’t need to exhaust yourself. Start with low-level or moderate exercise, then gradually increase the intensity and the time you spend, until you are up to a half hour or a full hour per day, most days.
• Look for ways to make your daily activities more physical. Do your own housework or yard work instead of hiring someone. Walk to the store instead of driving. Choose the long, hilly route instead of the shortcut.
You can also get more active in small ways that may not increase your heart rate but will burn up energy throughout the day. Instead of look- ing for ways to save effort, be imaginative about making yourself more active, whether you are at home, at the of?ce, or on vacation. Here are a few tips to get you started, but you can think of dozens more:
• Stop using the TV remote. And if you want a drink while you’re watching TV, don’t ask someone else to get it for you—get up and walk to the kitchen.
• Stand up and walk around while you talk on the phone. If you are waiting at a train station or airport, walk around instead of sitting.
• In a parking lot, choose a space farther away from the store instead of the one closest. Or park several blocks from your destination and make a round trip to and from your errand.
• Take every opportunity to climb stairs, at home or in public. Take the stairs instead of an elevator or an escalator.
• Participate in charity events that require you to walk or play a sport.
• When you’re traveling, take advantage of a hotel swimming pool or exercise room. Also, schedule a walking tour of a new city, rather than driving around.
• Consider buying exercise equipment like a stationary bicycle and use it while you listen to music or books on tape or watch TV.
• Make sure you are getting exercise during recreational time— walk instead of using a golf cart, rent a rowboat or a canoe instead of a motorboat, or play singles tennis instead of doubles.
• Purchase a pedometer, and walk with a goal of 10,000 steps a day.
Every 2,000 steps equal about a mile.

Exercising if You Are Older or Disabled

If vigorous activities are not an option for you because of advanced age or physical disabilities, some daily exercise will still bring health bene- ?ts. If you can walk, garden, or swim, gradually increase to longer ses- sions to get more bene?t without overdoing it. Some sports like table tennis, croquet, or shuf?eboard are excellent ways to get moving. If you are in a wheelchair, you can spend 30 to 40 minutes a day doing arm exercises or actively using the chair to get some good exercise. If possi- ble, join a class that offers a modi?ed exercise plan that suits your abil- ity. Such classes may be available through a senior citizen center, a retirement community, a hospital, or a YMCA.

Where Do I Start?

If you are inactive, any level of activity is a start in the right direction. A basic walking plan that increases your level of exercise gradually is an excellent beginning (see page 81). The key is to start slowly and build up; the goal is not to start a program quickly that you will need to stop; it is to develop a lifetime habit of regular exercise. The benefits of being more active far outweigh any risks for most people. Talk to your doctor before starting to exercise more if:
• You have ever had any kind of a heart problem, especially a heart attack.
• You have a family history of premature coronary artery disease.

• You have diabetes.
• You have problems with your bones or joints, such as osteoporosis or arthritis.
• You have high blood pressure and are not on medication.
• You are very overweight.
• You have high levels of cholesterol in your blood.
• You smoke.
• You are over 60 and you are not accus- tomed to any regular exercise.

To promote cardiovascular benefit for most people, about 30 minutes a day of moderate to vigorous aerobic activity most days of the week is a good start; the latest recommendations, however, suggest that you work your way up to 1 hour of exercise per day if you are overweight. You can accumulate the total in 10- or 15- minute sessions if you want to, but check with your doctor if you are under treat- ment for heart disease. The main point is to make exercise a regular part of your lifestyle. Try to burn about 1,000 to 2,000 calories per week (see page 81). To get a sense of an effective exercise pattern, you can think in terms of the so-called FIT formula: frequency (days per week); inten- sity (how hard—moderate or vigorous) or percentage of heart rate; and time (amount of time in each session or day). You can adjust these elements to suit your schedule, just as long as you expend enough energy to accomplish your ?tness goals. For instance, you can make a point of taking a longer walk three times a week and a shorter jog two times a week.
Frequency of exercise sessions and time spent in each session are easy to understand, even if it seems hard to ?nd the time to exercise.
If you cannot exercise every day, try to plan your sessions on noncon- secutive days of the week. If you are breaking up your time into shorter sessions, don’t forget to warm up and cool down brie?y for each session. If your activity is more vigorous, the cool-downs and warm-ups are especially important.
Intensity can be as simple as identifying moderate-level activities that ?t most naturally into your lifestyle, and then consciously sticking with them. A moderate activity raises your heart rate to at least 50 percent of its maximum (see box on page 78). A more practical de?nition of cardiovascular exercise might be any activity that raises your heartbeat to a level where you can still talk, but you start to sweat a little and breathe more heavily. If you have heart disease and your exercise is being planned with medical supervision, your peak heart rate achieved during exercise stress testing is a safe goal. But ask your doctor about this.
Examples of moderately active pastimes are:
• Brisk walking (3 to 4 mph)
• Gardening or yard work
• Active housework, such as vacuuming
• Swimming
• Tennis
• Golf, if you don’t use a cart
• Dancing
More physically demanding forms of exercise, done regularly, raise your heart rate to 50 to 85 percent of the maximum and are especially bene?cial:
• Aerobics classes
• Jogging or running
• Bicycling
• Games such as racquetball or basketball
• Cross-country skiing
• Handball

Americans know exercise is good for them. A proliferation of health clubs and ?tness centers, joggers in every park and walkers in every shopping mall, and constantly changing fashion trends in exercise gear are all evidence that we’ve gotten the message. Ironically, at the same time, advances in technology and labor-saving devices (along with other factors) have made us more sedentary and more overweight.
A sedentary lifestyle is hard on your entire body—muscles, bones, heart, lungs, arteries—because your body is a physical system that is built to move. In terms of cardiovascular bene?t, exercise ?rst strengthens your heart muscle and makes it pump blood more ef?ciently. In your bloodstream, it reduces harmful triglycerides, increases good HDL cho- lesterol, and improves the proportion of HDL to the bad LDL choles- terol. This effect is so important that being physically inactive is a major risk factor—just like smoking, high blood pressure, or high cholesterol levels—for developing coronary artery disease. It doubles your chances of having a heart attack.
At the same time, exercise tends to lower your blood pressure and reduce elevated blood sugar levels if you have diabetes, both of which in turn reduce your risk of heart disease. Of course, exercise also helps you control your weight and reduce obesity. So when you exercise, you are working on your high blood cholesterol, high blood pressure, or diabetes. You are less likely to develop these problems if you are active. Even a moderate increase in physical activity—30 minutes or more of brisk walking most days of the week—is enough to have a signi?cant positive effect on your heart and blood vessels. Exercise can bene?t you, no matter how old you are or what your current ?tness level is.
Exercise also helps you modify the effects of some other factors that are harmful to heart health. It reduces stress, anxiety, and depres- sion and their toll on your body. If you smoke, being active can make it easier to cut down or quit. Exercise never takes the place of other lifestyle changes you need to make to control as many of your risk fac- tors as you can (quitting smoking, eating more healthfully, and so on). However, a major research study in JAMA, the Journal of the American Medical Association, showed that overweight women who exercised had a longer life expectancy than overweight women who were not physically active.

Although high blood pressure is a common disease among all Americans, some groups are at higher risk, for reasons that are not fully understood. People in some racial or ethnic groups are more likely to develop high blood pressure. Some people are at higher risk because of other dis- eases, such as diabetes. Often these factors are interrelated; for instance, diabetes occurs frequently in people who are overweight, people with diabetes often have high blood pressure, and overweight is a contribut- ing factor in high blood pressure. Metabolic syndrome—also called insulin resistance syndrome—is a constellation of related factors such as obesity, high cholesterol levels, diabetes, and high blood pressure. The point is to know the factors that put you at risk for high blood pressure and then to take steps to bring your blood pressure under control.

Black Americans

No one knows why, but black men and women are more likely to develop high blood pressure than white Americans. It often develops at a younger

age, and it tends to be more severe. As a result, blacks are also more likely than whites to develop hypertension-related health problems such as an enlarged heart, retinopathy (damage to the blood vessels in the eye), heart disease, kidney disease, and stroke. The solution to these dispro- portionate common health problems is awareness and treatment:
• If you are black, it is especially important to have your blood pres- sure checked regularly. If it is elevated, you and your doctor can begin treatment immediately.
• A healthy lifestyle will go a long way to prevent and control your high blood pressure and reduce your risk of serious problems. Understanding that you are in a high-risk group is good motiva- tion to, for instance, start building eight or nine 1?2-cup servings of fruits or vegetables per day into your diet.

Women

Almost half the 65 million Americans with high blood pressure are women. The disease is more common among black and Hispanic women than in any other group. As a woman grows older, her chance of having high blood pressure becomes greater than a man’s. A woman may have had normal blood pressure throughout her life, but after menopause, she is considerably more likely to develop hypertension.
A woman’s reproductive life may also affect her blood pressure. In some women, using birth control pills or becoming pregnant can raise blood pressure. Here are some considerations to keep in mind:
• If you have high blood pressure and you are pregnant or consid- ering pregnancy, work with your doctor to control your blood pressure before and during the pregnancy. Many women with high blood pressure have healthy babies, but prenatal health care is especially important. If you are on medications for high blood pressure, talk to your doctor about whether you should be taking them while you are pregnant. Some blood pressure medications such as ACE inhibitors should not be used during pregnancy. However, do not stop taking the medications without consulting your doctor ?rst.
• High blood pressure during pregnancy (called gestational hyper- tension) occurs in about 6 to 8 percent of pregnancies. It is more common among women with chronic hypertension or diabetes. Gestational hypertension can lead to a condition called preeclamp- sia, which can be life-threatening to both the mother and the fetus.
• If you have had gestational hypertension or preeclampsia during a pregnancy at some time in your life, you may be at higher risk for developing high blood pressure or other cardiovascular problems later in life. Your doctor should know about this part of your med- ical history.
• Blood pressure usually does not increase signi?cantly as a result of hormone therapy for menopause in most women, with or without high blood pressure. However, hormone therapy can increase blood pressure in some women, so if you need to take hormone therapy for menopausal symptoms, your doctor will want to check your blood pressure initially and then monitor your blood pres- sure regularly. Also, using oral contraceptives may cause blood pressure to rise.
• Even if high blood pressure has never been a problem for you, take extra care to monitor yourself after menopause. Get your blood pressure checked regularly.
• Every woman can reduce her risk of developing high blood pressure, or help control high blood pressure, by eating more healthfully, being physically active, and drinking in moderation. High blood pressure is a highly preventable condition.

People with Diabetes

Diabetes, a condition in which your body cannot make or respond properly to the hormone insulin, is occurring at an ever-increasing rate among Americans. Research suggests that, for reasons that are not completely understood, as many as 60 million Americans may have a condition called insulin resistance—an inadequate response to their own insulin—that greatly increases their chances of developing diabetes and heart disease at some time in their lives. Many authorities attribute the increase in the number of individuals with insulin resistance to lifestyle changes in the population, particularly weight gain and lack of exercise. The most common cause of diabetes-related death is cardiovascular disease, but many people are unaware of this link.

Diabetes has a hereditary component, and people who have family members with diabetes are at greater risk for developing the disease. More women are affected than men, and black, Hispanic, and Native American people are especially susceptible. People with diabetes often have high blood pressure, high cholesterol, or both, which increases their likelihood of developing heart disease still further.
People with diabetes are classi?ed by whether they produce suf?cient amounts of insulin. A person with type 1 diabetes does not produce any and must take insulin as a medication. Most people with diabetes (more than 90 percent) have type 2, meaning that they produce insulin (a hormone that changes glucose, or “blood sugar,” into energy), but their bodies are resist- ant to insulin’s action, and they do not utilize it prop- erly. As a result the body cannot transfer sufficient amounts of energy from food to body cells. Because the cells are not taking in glucose, it builds up in the blood, leading to “high blood sugar” (hyperglycemia), or diabetes.
If you have type 2 diabetes, the changes in your body’s chemistry brought on by high glucose levels can increase the buildup of fatty deposits inside the arter- ies (atherosclerosis; see page 152), which can impede blood ?ow. These changes can also make the blood clot more easily, which can lead to a heart attack or a stroke. High blood pressure and high blood choles-

terol combined with diabetes make the risk for heart attack or stroke greater than the risk from either one. The bottom line is that if you have diabetes you can greatly reduce your chances of cardiovascu- lar disease by bringing down your blood pressure or cholesterol as needed.
Awareness of these links is the place to start to improve your health. By working with your doctor to control your high blood pressure, you can help reduce the risk of complications from diabetes. Controlling your blood pressure and cholesterol levels is likely to prolong your life and greatly improve its quality.

Secondary High Blood
Pressure

About 5 to 10 percent of people diagnosed with high blood pressure have secondary hypertension, meaning that their condition is a secondary result of another prob- lem. These underlying problems may include a kidney abnormality, a structural abnormality of the aorta, a narrowing of certain arteries, or certain types of hor- mone abnormalities. These sec- ondary causes of high blood pressure are more common in children and young adults.
These problems can usually be corrected, causing blood pressure levels to drop to healthy levels. For example, a surgeon can repair a narrowed or defective artery.
When your doctor examines you, he or she can usually rule out these problems as causes of high blood pressure by taking a careful medical history, giving a thorough physical examination, taking blood tests, performing urinalysis, and taking some fur- ther tests. These tests generally do not require a hospital stay.

Children

Even babies and children can have high blood pressure. Doctors used to think that high blood pressure in children was secondary (caused by some other condition). But now they know that children can have primary hypertension—that is, high blood pressure—for unknown reasons. The condition may be hereditary. It is more frequent and severe in black families, although scientists do not know why.
The average blood pressure level for children and teenagers has risen considerably over the past 25 years, mainly because of the increase in overweight and obesity. Today, guidelines for blood pressure in chil- dren include a prehypertension category, just as adult guidelines do. Like adults, children can have a syndrome of risk factors—including overweight, high blood pressure, and insulin resistance—that increases their risk of diabetes and heart disease.
Treatment for children with high blood pressure usually involves the same types of lifestyle changes that bene?t adults: weight control, a healthful diet, and regular exercise. Doctors will prescribe medications if necessary. Ensuring that a child has a healthy weight and blood pres- sure early in life gives him or her a head start on preventing serious dis- ease later on.

Living with High Blood Pressure

If you are being treated for prehypertension or hypertension, you can monitor your own health in several important ways:
• Be your own best advocate. Stay with your treatment plan—healthy lifestyle habits and medication—to get the best results.
• Know your blood pressure and have it checked regularly. Those already being treated for high blood pressure should have theirs checked more frequently; ask your doctor how often. Make sure that your family mem- bers (parents, brothers and sisters, children) have theirs checked regularly, too.
• Keep appointments with your doctor so that he or she can monitor your treatment and make adjustments if necessary. Ask your doc- tor or other health-care provider any ques- tions that interest or concern you about your treatment.
• Follow a healthful diet, cutting down on fatty foods such as red meat and increasing your intake of fruits and vegetables and whole grains; also, exercise 5 times a week (or, more ideally, every day).
• Keep track of your blood pressure. Remember, you cannot tell from the way you feel how high your blood pressure might be.
• Keep a diary of your blood pressure reading every time you measure it at home, or have it checked by a health-care professional. Record the date and the reading. Find a handy placeto keep the diary. Bring your diary to your doctor’s appointment.
• Talk to your doctor about the names and dosages of your blood pressure medications and how to take them. Don’t hesitate to ask questions. Again, keep a written record that you can refer to and show to family members. Keep a written list of your medications, including dosages, in your purse or wallet.
• If you notice any problems (side effects) that you think could be related to your medica- tions, talk to your doctor about them. The problems may not be related to your medi- cine. Or you may need a change in dose, or perhaps another medicine might work for you without side effects.
• Refill your blood pressure medications before they run out, even though you feel fine.
• Tell your family members that you have high blood pressure and get their support for your treatment plan. If possible, have your partner or a family member go with you to your doc- tor’s office to hear firsthand about your medications and how to make lifestyle changes.
• If you have a severe headache, changes in your vision, numbness on one side, or dizzi- ness, seek emergency medical treatment immediately. You could be having a stroke.
• Have your eyes checked periodically by a qual- ified physician such as an ophthalmologist.