Articles on Medical Diseases and Conditions

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  • Controlling High Cholesterol

    Many people with diabetes have trouble keeping their levels of blood lipids (fats in the blood) at healthy levels. If you have diabetes, have a blood lipid pro?le (cholesterol check; see page 25) done at least once a year, more often if your doctor recommends it. People with diabetes are more likely than the average person to have low levels of HDL cholesterol and high triglycerides.

    They are more likely to have high levels of very high low-density lipoprotein (VLDL), a type of cholesterol particle that is particularly prone to forming plaque buildup.
    It is extremely important for people with dia- betes to keep their cholesterol and triglyceride levels low. Most people with diabetes need med- ications in addition to lifestyle changes to keep their blood lipid pro?le at target levels. Your doc- tor may prescribe one or more of several types of cholesterol-lowering drugs.

  • Controlling High Blood Pressure

    As many as two out of three people with diabetes have high blood pres- sure. The only way to know you have high blood pressure is to be tested. If you have diabetes, you should have your blood pressure checked every time you go to a doctor, or at least two to four times a year. Because both diabetes and high blood pressure are major contributors to cardiovascu- lar disease, it is even more important that a person with diabetes keep blood pressure at a lower level (less than 130/80 mm Hg) than it is for others. In addition to diet, exercise, smoking cessation, and moderate alcohol consumption, your doctor may recommend one or more med- ications: diuretics, ACE inhibitors, beta blockers, angiotensin-2 receptor blockers, or calcium channel blockers .

  • Preventing a Heart Attack

    A major concern is to prevent coronary artery disease (the most com- mon form of cardiovascular disease), which can lead to a heart attack.

    Your doctor will work with you to make the lifestyle changes that will help you minimize your risk of heart attack. Your goal is to keep your blood glucose, blood pressure, and cholesterol levels appropriately controlled.
    • Controlling your blood glucose level requires careful monitoring. Your doctor may show you how to check your blood glucose levels at home every day. Your doctor will also probably do a test called an HbA1C: a blood glucose test that measures the amount of sugar attached to the hemoglobin mole- cule. This estimates the average blood sugar level for the last 2 to
    3 months and shows how well the blood sugar is controlled over time. Your target will be an HbA1C of less than 7, which means that throughout the day for the period being measured, your blood sugar levels averaged less than 150.

    • Controlling your blood pressure to a level below 130/80 mm Hg will ease the load on your heart and help preserve kidney function.
    • Controlling your cholesterol involves target rates for each of three different types of blood lipids (fats): LDL, HDL, and triglycerides (see pages 26–29). For those with type 2 diabetes, the the goal is to achieve an LDL level of 100 mg/dL, or even better, less than 70 mg/dL.

    Taking Aspirin to Prevent Heart Attacks

    Your doctor may recommend that you take a low-dose aspirin every day, in addition to any other medications you may take. A person with diabetes tends to form blood clots more easily than most people, and aspirin appears to keep red blood cells from forming clots.
    Your doctor can recommend the lowest pos- sible effective dosage for you, usually between
    81 and 162 milligrams. Because some people experience irritation of the stomach lining from taking aspirin, you may prefer to take enteric- coated aspirin tablets. The coating enables the aspirin to pass through your stomach without dissolving. It dissolves in your intestine instead, reducing the risk of unpleasant side effects such as stomach pain or nausea.
    Some people cannot safely take aspirin every day. You should not take it if you know you are allergic to it, you have a tendency to bleed easily, you have had bleeding from your diges- tive tract recently, you have liver disease, or you are under 21 years old (the effects of aspirin on younger people have not been fully studied). For those who cannot take aspirin, your doctor may prescribe an alternative such as clopidogrel.

    Warning Signs of a Heart Attack
    Call 911 or the emergency number for your area right away if you experience any of these symp- toms of a heart attack:
    • Chest pain or discomfort
    • Pain or discomfort in your arms, back, face, neck, or stomach
    • Shortness of breath
    • Sweating or light-headedness
    • Indigestion or nausea
    It is vital to get help immediately because treat- ment within the first hour of symptoms of a heart attack can be lifesaving. Diabetes can affect your nervous system, so that you may not experience any symptoms, or the symptoms may be milder than in most people. It is especially important that you and your family know the signs so that you can respond to them quickly and seek treatment if they occur.

  • Controlling Diabetes

    For a variety of reasons, diabetes is increasing in the American pop- ulation at an alarming rate, even among younger people. Most authorities place most of the blame on the increase in overweight and obesity, along with a sedentary lifestyle. Diabetes is a serious disease in which the body does not produce or properly use a hormone called insulin. Produced in the pancreas, insulin is necessary to turn the sug- ars in the blood and in food into energy. In a person with diabetes, because insulin is de?cient or not working well, sugars (glucose) build
    up to dangerously high levels in the blood.
    There are two types of diabetes: type 1, also known as juvenile diabetes, and type 2, the most common form, usually diagnosed in adults. In a person with type 2 diabetes, the body does not use its sup- ply of insulin ef?ciently—a condition called insulin resistance. At ?rst the body can compensate by making more insulin. With time, however, the pancreas begins to fail and loses its ability to make enough insulin to overcome the body’s resistance to insulin. Once this occurs, blood sugar levels rise to unhealthy levels. In this section, the focus is on type 2 diabetes and its role as a major risk factor in the development of car- diovascular disease.

    The Link between Diabetes and Heart Disease

    Diabetes can lead to many serious medical problems, but the most life-threatening of these is cardiovascular disease. Most people with diabetes—about two out of three—die of heart disease, stroke, or peripheral vascular disease. Treatment, through lifestyle changes and one particular medication (metformin), can help control diabetes and also reduce the risk of heart disease. With more people developing dia- betes or its precursor, prediabetes (see below), it is important to get the message across that diabetes and heart disease are very strongly linked. The sooner you begin to control prediabetes or diabetes and reduce your risk of heart disease, the healthier and longer your life will be.
    Diabetes appears to lead to heart disease through the process of ath- erosclerosis, which is a narrowing of the arteries caused by the buildup of plaque deposits, beginning with damage to the inner layer of the artery walls (the endothelium). The damaged walls promote the accu- mulation of lipids that develop into plaque, and the plaque buildup increases the likelihood of blood clots. Atherosclerosis can lead to a heart attack (when the blood supply to your heart muscle is cut off), coronary artery disease (when the blood supply to your heart is reduced), peripheral artery disease (when blood vessels in your legs are blocked), or a stroke (when a blood clot cuts off the blood supply to your brain). Although the entire disease process is not fully understood, diabetes may contribute to the initial damage to the endothelium, impair the ability of the artery walls to expand to accommodate blood ?ow, and render the body prone to make clots.
    Some groups, including people of African American, Hispanic, or Native American descent, are at greater risk of developing diabetes because of their genetic makeup. Those with a parent or sibling with diabetes are at the highest risk. For reasons that are unclear, diabetes is more common and more severe in women than in men. But there is also a group of factors often typical of people with diabetes: obesity, physi- cal inactivity, high blood pressure, and high cholesterol. All of these factors also contribute to the development of heart disease.

    Prediabetes

    As more of the U.S. population develops diabetes or the insulin resist- ance syndrome associated with it , doctors have become more aggressive about diagnosing and treating it, or preferably preventing it in the ?rst place. A new term, prediabetes, has sprung up to identify people whose blood glucose levels are higher than normal but not high enough to be diagnosed as diabetes. Both the oral glucose tolerance test and the fasting plasma glucose test measure your blood glucose level (in milligrams per deciliter, or mg/dL) after you have fasted overnight. Either test can be used, but they result in differ- ent readings (see box on page 108).
    If you are overweight and age 45 or older, ask your doctor to arrange a test for prediabetes at your next routine physical examination. If you are at a healthy weight and are 45 or older, you can ask your doctor if a test is appropriate. If you are younger than 45 and overweight, your doctor may recommend a test, depending on the presence of other risk factors such as a family history of diabetes, high blood pressure, or high cholesterol readings.
    If you are in the prediabetes range, you can and should do something about it right away to prevent or delay the development of diabetes. Many people can return their blood glucose levels to normal with relatively small changes in lifestyle alone. You can bene?t from even a modest weight loss of 5 to 10 percent of your body weight. If you can’t get down to your ideal weight, even a loss of 10 or 15 pounds can make a signi?cant difference. Similarly, increasing your level of activity to just moderate exercise (like walking) for 30 minutes a day is enough to make a difference. It’s worth it to change your lifestyle at this early stage. Your doctor will also talk to you about other risk factors such as high blood pressure, high cholesterol, and smoking.

    If You Have Diabetes

    Having diabetes means that you are at much higher risk for developing heart and peripheral vascular disease (in your legs). You and your doc- tor will closely monitor your diabetes (by regularly measuring your blood glucose levels) and your blood pressure and cholesterol levels. Taking care of your heart will involve lifestyle changes including a healthful diet (see pages 83–98); losing weight or making sure you don’t gain too much ; quitting smoking if you smoke now; keeping your alcohol consumption moderate, if you drink at all; and perhaps taking medication, also.

    What Is Insulin Resistance Syndrome?

    Insulin resistance syndrome, also called metabolic syndrome, is a combination of harmful health characteristics that dramatically increases the likelihood that a person will develop either type 2 diabetes, cardiovascular disease, or both. The syndrome is on the rise in the United States; more than one in four Amer- icans has it. The underlying causes of insulin resistance syndrome and its increase in the U.S. population are overweight or obesity, a sedentary lifestyle, and some genetic factors. You are considered to have the syndrome if you have three or more of the following characteristics:
    • An accumulation of fat around the waist (an apple shape, see page
    102): a waist measurement of more than 40 inches for a man or 35 inches for a woman
    • A high triglyceride level (see page 29): more than 150 mg/dL
    • A low “good” HDL cholesterol level: less than 40 mg/dL for a man or less than 50 mg/dL for a woman
    • A blood pressure level of 130/85 mm Hg or more
    • A high fasting glucose level (see page 108), an indicator of insulin resistance: 110 mg/dL or more

  • Strategies for Losing Weight

    If you are overweight or obese, you and your doctor can start immedi- ately to bring your weight down. It’s not easy to con- template making major changes in your eating and exercise habits, but it is possible—and a positive attitude is a big help. Try to drink at least eight glasses of ?uid a day; avoid calorie-laden soda, fruit juices, and alcoholic drinks. Also, eliminating extra calories by not putting sugar and cream into your coffee can help you lose weight.
    Many dietary and exercise programs are available commercially. Some dieters have reported short-term success with a high-protein diet or a modi?ed high-protein diet with additional vegetables, fruits, and whole grains. In general, though, be cautious about programs that eliminate entire groups of foods other than sweets or foods high in sat- urated fat or programs that require a very abnormal diet regimen that will be hard to stick to if you travel or are sick. Some diets may alter your body chemistry and change your cholesterol levels in unwelcome ways.
    If you have been diagnosed with high blood pressure, diabetes, or heart disease, a long-term program of balanced eating is by far the best for your health.
    You will be most successful at shedding excess weight and keeping it off if you think in terms of making permanent changes to become a healthier, more active person. Here are a few strategies:
    1. Talk to your doctor or dietitian in detail about your eating habits—how you eat during a typical day and over the course of a week. Talk about the results of your previous efforts to lose weight. Think about what triggers that urge to overeat. Try to identify the problem areas, like that sweet roll in the morning, or crackers and cheese before dinner. Once you know your own patterns, you can start substituting healthier choices.
    2. Develop an eating plan that reduces calories overall. A goal of about 1,200 to 1,600 calories per day is a good general target for weight loss. Think about how to cut down on energy-dense foods (like butter, sugar, meat, potato chips) that have lots of calories even in small amounts. Replace them with less energy-dense foods (like fruits and vegetables) that you can ?ll up on.
    3. Set a realistic, measurable goal to get started. One or two pounds a week is a healthy rate at which to shed overweight. At ?rst you may lose more weight, but then a plateau period will follow in which you are still being careful and yet not losing. Continue your program of eating less and exercising more. Remember that even a relatively modest weight loss (for example, 10 pounds if

    you are overweight, or 10 percent of your body weight if you are obese) can have real health bene?ts.
    4. Exercise, exercise, exercise! Burning off calories is the other half of the weight-loss equation. It is very dif?cult to lose weight by diet alone; as you reduce calories, your body slows its metabolism to compensate for that. Exercise prevents that from happening and helps your body burn more calories, even at rest. Develop an enjoyable exercise plan that fits into your life. Get a friend involved to make it more fun and to bene?t both of you.
    5. Become more active all day long—walk around while you talk on the telephone, take the stairs instead of an elevator, park your car in the space farthest from the supermarket, and start mowing your own lawn. Spend more time outside.
    6. Set speci?c goals not just for the amount you want to lose, but for how you are going to lose weight. Make a point of eating one more serving of vegetables each day. Or, if you have not been exercising, start with one 15-minute walk each day. Using a pedometer to measure your steps will help you reach a target number every day; a minimum of 10,000 steps is recommended to keep you healthy.
    7. Keep track of your progress with a food diary and a record of time spent exercising. You will be encouraged as you see your habits improve, and you can spot trouble areas or backsliding more easily.
    8. About backsliding: we all do it. You can get back on track. When you feel the urge to overindulge, do something else for just 15 minutes to distract yourself. Better yet, take a brisk walk.
    9. Allow occasional splurges into your life for special occasions as appropriate. The key is to consider your eating at birthday parties or weddings as an exception, not an everyday habit. The long-term key to healthy eating is moderation.

  • High Blood Pressure:Overweight and Obesity

    n the last 25 years or so, people in the United States have become pro- gressively more overweight and obese. Today, about 65 percent of Americans are considered overweight and about one-third are obese, and the numbers of obese and overweight people keep rising. To check if you
    are overweight or obese, see the body mass index table on page 101.
    Also important is how one’s body fat is distributed. A disproportion- ate amount of body fat, especially if it is distributed around your waist area, creates an even greater risk of developing a range of health prob- lems, including high blood pressure, high blood cholesterol, diabetes, heart disease, and stroke. Research shows that an overweight or obese person’s heart muscle changes and pumps less effectively, even without evidence of heart disease.
    Independent of any other factors, obesity seriously increases your risk of developing cardiovascular disease. Obesity is associated with high levels of “bad” LDL cholesterol and triglyceride levels, lower levels of “good” HDL cholesterol, higher blood pressure, and diabetes. It also harms your muscles and joints and increases your risk of certain kinds of cancers, including cancers of the breast, prostate, and colon.
    Most people who are obese simply consume more calories than they burn off. It is most probably that combination of rich diet and lack of physical activity that has led to our epidemic of obesity in the United States. But other causes also contribute to the problem:

    • Obesity tends to run in families. This is largely a result of shared lifestyle behaviors.
    • Aging slows your metabolism, making it more dif?cult for your body to burn calories quickly, so you don’t need as many calories to maintain your weight. As we get older, we need to be concerned about calorie intake.
    • Men burn more energy when they are at rest than women do, so they need more calories to maintain their weight. After meno- pause, a woman’s ability to burn calories decreases still more.
    • Foods that are high in calories and fat but relatively low in nutri- tional value, served or purchased in excessively large portions, are a habit for many people.
    • Lack of exercise is strongly related to obesity. More than two- thirds of Americans report no habitual physical activity.
    • Childhood obesity tends to lead to adult obesity. Researchers think that the fat cells a person forms as a child remain into adult- hood. Dieting in adulthood decreases the fat-cell size rather than the number.
    • Some illnesses such as an underactive thyroid or depression can cause obesity, but this occurs only rarely.

    Body Mass Index

    A useful way to estimate your body fat is a formula called the body mass index (BMI). The BMI is an assessment of your weight relative to your height and is a good indicator of the proportion of fat in most people’s bodies. You can calculate your BMI by multiplying your weight in pounds by 703, dividing by your height in inches, then dividing again by your height in inches. (For example, let’s say your weight in pounds is
    140, and you are 67 inches tall. Multiply 140 by 703 to get 98,420. Divide that by 67 to get 1,468.95. Divide again by 67 to get 21.92. This is your BMI value.) Since these calculations are fairly complicated, see the convenient chart of body mass index by height and weight . According to the National Institutes of Health:
    8

    • A BMI less than 18.5 is considered underweight.
    • A BMI from 18.5 to 24.9 is considered normal. In this range you are at minimal risk of heart disease, provided you have no other risk factors.

    • Some individuals are inappropriately classi?ed as overweight or obese due to large muscle mass or frame size.
    • A BMI from 25.0 to 30.0 is of?cially classi?ed as overweight. In this range, your risk of cardiovascular disease increases slightly.
    • A BMI of 30.0 or more is considered obese. Your risk level is high.

    • A BMI of 40.0 is extreme obesity or morbid obesity. Your risk level is extremely high.

    Waist CircumferenceAnother way to estimate body fat is by measuring your waistline. Your waist circumference is the measurement of your natural waist, just above your navel. A high-risk waistline is more than 35 inches for women and more than 40 inches for men, and indicates central obesity. Waist cir- cumference is a means of determining whether you tend to store fat around your waist (for an apple shape) or around your hips and thighs (for a pear shape). Apple-shaped people tend to have higher levels of “bad” cholesterol and triglycerides that clog arteries and raise the risk of heart disease.

  • Moderating Your Alcohol Consumption

    Drinking too much alcohol can be harmful to your cardiovascular sys- tem in numerous ways: it can contribute to high blood pressure, raise your level of harmful triglycerides, and add empty calories that contribute to overweight or obesity. Excessive drinking or binge drinking can lead to stroke, diseases of the heart muscle (cardiomyopathy), and disturbances of the rate or rhythm of the heartbeat (arrhythmias).
    Some recent research suggests that a person who has a pattern of frequent, heavy drinking, especially over a lifetime, is much more likely to develop insulin resistance syndrome, a dangerous cluster of risk factors for heart disease. Also, heavy episodic drinking is a harmful pattern. Studies support the guidelines recommending moderate alcohol consumption: if you do drink, it’s much healthier to have one drink a day than to have seven drinks on the weekend.
    If you enjoy drinking alcohol occasionally, the heart-healthy recom- mendation is straightforward: drink in moderation, which means no more than one drink a day if you are a woman, or two drinks a day if you are a man. One drink is de?ned as one 12-ounce can of beer;
    11?2 ounces of 80-proof liquor such as vodka, gin, Scotch, whiskey, and  others; 1 ounce of 100-proof liquor; or a 4-ounce glass of wine. Drink- ing with food may be better, because food slows down the absorption of alcohol. A person who drinks alcohol with a meal usually drinks more moderately.
    You may have read about ?ndings that moderate consumption of alcohol, especially red wine, has health bene?ts. It now appears that all forms of alcohol are associated with these bene?ts. Studies have suggested that moderate drinking raises HDL cholesterol, helps prevent blood clots, reduces the risk of heart attack and the most common type of stroke (ischemic), and reduces blockages in the arteries in the legs, among other ?ndings. Men over 50 years of age appear to derive the greatest cardiovascular bene?t. Study is focused on certain components in red wine or dark beer called ?avonoids and other antioxidant compounds, which may contribute to the effect on HDL cholesterol. A sub- stance called resveratrol, found in red wine, may be the agent that reduces blood clot formation.
    Alcohol is certainly not the only way to derive these bene?ts, how- ever. Some of these substances can also be found in grapes or red grape juice, and antioxidants are found in many fruits and vegetables Exercise increases HDL. Aspirin can reduce blood-clotting. Researchers are still not sure whether wine, beer, or liquor is more bene?cial, and the interaction of other lifestyle factors is still in question. Even drinking in small amounts can dim your alertness and affect your coordination and reaction time, increasing the chances of accidents and falls. When you weigh the possible bene?ts of drinking alcohol against the many serious risks, there is no reason to start drinking every day if you do not already.

  • Reading Nutrition Labels

    Food labels tell you a great deal about the contents of foods, and they are a big help in making reasonable choices to limit the fat, sodium, and cholesterol in the foods you eat. Both the ingredients list and the nutri- tion facts panel are useful. By law, the ingredients list is in descending order of weight to give you an idea of the proportions of the ingredients in the package. The nutrition facts label tells you the number of serv- ings in the package, as well as the amount and percentage of recom- mended daily values, such as total fat, saturated fat, cholesterol, sodium, ?ber, and carbohydrates (including sugar). As the label tells you, these percentages are based on a diet of 2,000 calories a day. The label also tells you the ?ber and sugar content of the food. At the bottom of the panel, the percentages for vitamins A and C, calcium, and iron are listed (see the following section, “Nutrients”).
    If you are concerned about heart disease, you will probably be pay- ing closest attention to the percentages of fat, saturated fat, and sodium. As a general rule, choose foods that are low in saturated fat; avoid foods containing trans fats and sodium. A daily value of 5 percent or less sat- urated fat is low; 20 percent or more is high. If you consume a food high in fat at one meal, it is wise to try to balance that with low-fat items at the next meal.
    Another item to look for is trans fat, which is formed when vegetable oil is hardened (hydrogenated) in the manufacturing process (see page 30). Like saturated fat and cholesterol, trans fat raises harmful LDL cholesterol levels in the blood. Check the ingredients list for trans fat, shortening, or hydrogenated or partially hydrogenated veg- etable oil and limit your use of products containing them. Recently, the FDA began requiring that the amount of trans fat be listed on the nutrition panel under total fat and saturated fat. However, the labeling regulations allow as much as 0.5 g of trans fat per serving to be listed as “0 g,” so make sure the label does not mention hydrogenated oil or par- tially hydrogenated oil, both trans fats.

    Nutrients

    Whether you are at risk of cardiovascular disease or not, a healthy, bal- anced diet is one of the best ways to take care of your body. Eating a variety of fresh foods is bene?cial in part because these are the best sources of nutrients that your body needs. A great deal of research has focused on speci?c vitamins and minerals in an effort to isolate those that are of particular bene?t to your heart and blood vessels. At this time, many of these ?ndings are inconclusive. Some physicians recom- mend taking a multivitamin and mineral supplements each day, but there is no evidence this is bene?cial. (See page 89 for recommenda- tions about omega-3 oil supplements.)

    Antioxidants

    Antioxidants are believed to slow oxidation of harmful LDL choles- terol, a process that may cause the development of fatty buildups in the arteries (see page 152). Antioxidant vitamins (E, C, and beta carotene, a form of vitamin A) are found in fruits, vegetables, whole grains, and nuts. These foods are all part of a heart-protecting diet. Experts recom- mend a diet rich in the food sources of antioxidants, but studies show no bene?t to taking antioxidant supplements to prevent atherosclerosis or any other cardiovascular disease. In fact, one study showed negative effects from taking large doses of supplement vitamin E. This is prob- ably because supplement forms of vitamin E are processed substances that differ from the natural vitamin E that occurs in the foods men- tioned above.

    Calcium

    Doctors recommend getting plenty of calcium in your diet by eating low-fat dairy products and vegetable greens such as kale, broccoli, and soybean products. Daily calcium requirements vary by age and gender. The DASH diet, which is rich in calcium because it recommends eight servings or more a day of fruits and vegetables, as well as low-fat dairy, is proven to lower blood pressure (page 47). Use of calcium supple- ments to prevent high blood pressure has not been proven.

    Iron

    Some research has indicated that a high level of iron stored in the body may be linked to a greater incidence of heart attacks. But many other studies have failed to demonstrate this effect, and research continues. There is no evidence today to support reducing your iron intake or to justify screening of patients with cardiovascular disease to check their iron levels.

    Minerals

    Magnesium, a mineral found in leafy vegetables, dried peas and beans, nuts, and seeds, may have a positive effect on blood pressure. But the link is not clear enough to recommend the use of magnesium supple- ments. Magnesium-rich foods are good for you in any case.
    The effects of other minerals on heart health are the subject of research, but there are no clear-cut conclusions. Fluoridation of public water supplies is not harmful to your cardiovascular system. A relation- ship between water hardness and heart health has not been demon- strated. Some sources of water are high in sodium, and a person with a tendency toward high blood pressure should avoid such drinking water. A number of trace elements including zinc, copper, cadmium, and lead have been studied without any demonstrable impact on cardiovascular disease.

    Potassium

    Potassium is an essential element that plays a role in balancing the ?uid content between body cells and body ?uids. Eating foods rich in potas- sium may protect some people from developing high blood pressure. Some people who take diuretics to control high blood pressure may be potassium-de?cient because potassium is lost in increased urination. Doctors may recommend that these people take potassium supplements or eat foods rich in potassium. Bananas, cantaloupe and honeydew mel- ons, oranges and grapefruit, prunes, raisins, tomatoes, and low-fat dairy products are all rich in potassium and are part of a healthy diet. On the other hand, some blood pressure medications such as ACE inhibitors cause the body to retain potassium, so your doctor may advise you to limit intake of potassium-rich foods (including salt substitutes contain- ing potassium).

  • Other Protein Sources: Dried Beans and Eggs

    Plant sources of protein and other nutrients, such as dried beans, peas, lentils, or soybean curd (tofu), can supplement your
    diet and substitute for meat, poultry, and ?sh. These

    foods are high in complex carbohydrates and are lower in saturated fats and calories than animal products such as meat.
    Eggs are a good source of protein, B vitamins, and iron, and they are low in saturated fat and total fat. But they are also a source of confusion for many people because they are high in cholesterol. One whole egg contains almost three quarters of the daily limit for cholesterol, so if you eat a whole egg, try to avoid or limit other sources of cholesterol (meat, poultry, and whole-milk dairy products) that day. Limit your intake of egg yolks when possible because that is where the cholesterol is. If you have heart disease or are at high risk, limit yourself to no more than three egg yolks per week; use egg-substitute products or egg whites instead. Baked goods such as doughnuts and coffee cake contain eggs, so be sure to include any eggs eaten this way in your total of three eggs per week.

    Fats and Oils

    Apart from the saturated fat and total fat you may consume in meat or dairy products, fats and oils from other sources increase your total fat intake per day. Nutrition labels measure fats in grams. How much total fat and saturated fat (in grams) you can consume depends on the num- ber of calories you burn off each day. To arrive at that number, see the table on page 91.
    Use fats and oils sparingly and shop for foods lowest in saturated fat and cholesterol. Use more poly- or monounsaturated oils (see pages
    30–32). Check the labels on vegetable oils and margarines and choose products with liquid vegetable oil as the ?rst listed ingredient and no more than 2 grams of saturated fat per tablespoon (canola, olive, corn, saf?ower, sesame, soybean, and sun?ower oils). Use margarine as a substitute for butter and choose tub or liquid
    forms that are low in saturated fat and trans fat.

    When possible, use soft margarines that contain plant stanols and sterols. Switch to low-calorie salad dressings and mayonnaise.
    Adjust your cooking style to use more low-fat cooking methods such as baking or roasting, grilling, poaching, and braising. Also, use a nonstick cooking spray instead of butter or oil for cooking or baking.
    Several types of fat substitutes in foods have been developed to help people lower their fat intake. Any fat-modi?ed product on the market has been approved by the U.S. Food and Drug Administration and is considered safe. But they have not been avail- able long enough to fully assess the long-term bene- ?ts or risks. In the context of an overall healthful diet, you may ?nd that using some fat substitutes gives you some extra options.

    Desserts, Snacks, and Beverages

    Traditional desserts are generally high in calories, saturated fat, choles- terol, and perhaps trans fat. You can save these treats for special occa- sions only and cut down your portion size. Your best choices for every day are fruits, fat-free yogurt with fruit, frozen no-fat yogurt or low-fat yogurt, low-fat ice cream (3 grams of fat per 1?2 cup or less), or ?avored gelatin, ices, sherbets, or sorbets. Angel food cake is a healthier choice than denser cakes, and you can choose cookies in small quantities.
    Choose snacks from healthful food groups: fruits; raw vegetables with or without low-fat dip; low-fat crackers; plain, unsalted, unbut- tered popcorn; and unsalted pretzels are good choices. In the store, read labels carefully and avoid high sodium and trans fats.
    Choose beverages such as water, vegetable juice, low-calorie soft drinks, coffee, or tea. All three of these areas—desserts, snacks, and beverages—offer an opportunity to get extra servings of fruits or veg- etables as substitutes for junk food or sugary treats.

    Sodium

    The typical American diet is salty: most Americans consume about 4,000 to 5,000 milligrams (almost two teaspoons of salt) per day. That may not sound like much, but the recommended level of salt consumption is no more than 2,400 milligrams per day. And for those who have high blood pressure, are over age 50, or are black, less than 1,500 milligrams per day is recommended. Although the body’s response to salt varies widely from person to person, people who reduce their sodium (salt) intake to the recommended level or below have lower blood pressure and are less likely to die from heart attack or stroke than those who don’t. A lower salt intake is especially helpful as you grow older, when high blood pressure is more common and sensitivity to salt (see page 51) often increases.
    If you already have high blood pressure and you are sensitive to salt, reducing sodium intake can lower your blood pressure. If you are on blood pressure medication, less sodium in your diet can improve the effectiveness of the drugs. If you are at risk for developing high blood pressure, you may be able to avoid it by eating less salt and changing your diet in other ways (see pages 83–91).
    The salt that you shake onto your meal at the table is only a small part of the sodium you consume. Processed foods and restaurant foods are by far the biggest culprits in adding excessive salt to your diet. But even natural foods such as dairy products, meat, and vegetables have some sodium. To cut back on salt, try these tips:

    • Read labels on packaged foods carefully. Look for the words sodium, soda (which is baking soda, a sodium compound), or the chemical symbol Na. All of these indicate sodium content.
    • Choose fresh or frozen vegetables instead of canned as often as possible. If you do use canned products, drain and rinse them before adding them to other dishes.
    • Select salt-free or low-sodium versions of products such as broths, nuts, crackers, and soups.
    • If you buy frozen meals, purchase those with the lowest sodium levels.
    • Limit your intake of salty snacks like potato chips. Avoid highly processed and high-salt products like most canned soups, frozen entr?es, and sandwich meats.
    • Use low-fat dairy products, which are also lower in salt content.
    • Season your foods with herbs and natural ?avorings like lemon or lime juice instead of salt. Try salt-free lemon pepper or other sea- soning blends to boost ?avor.

    • At restaurants, ask to have your meal prepared without salt.
    • Check the labels (ingredients list and warnings) on over-the- counter medicines such as antacids; many of these products con- tain signi?cant amounts of sodium.
    • Ask your doctor about the use of “lite” salt. Some people use so much of these products to get the ?avor they want that they end up getting more sodium than they would from regular table salt.

  • Eating Healthfully for a Lifetime

    Of all the advancements made in our understanding of heart disease and how to prevent it, perhaps the greatest is the clear, consistent
    link between healthful eating habits, coupled with regular exercise, and the prevention of heart problems. By following some fairly simple guidelines about how to eat healthfully, you can substantially improve your overall heart health and reduce your risk of developing high blood pressure, high blood cholesterol, and overweight or obesity, three of the major contributors to cardiovascular disease. The bene?ts don’t stop there; very similar dietary habits also help you prevent breast, prostate, and other cancers; control type 2 diabetes; avoid osteoporosis (bone loss); and perhaps lengthen your life. For an excellent diet plan to improve your health, see the information on the DASH diet. As you start eating more healthfully, you will probably get the most satisfaction from the immediate benefits: you’ll have more energy and you’ll shed excess pounds. Today, eating better is also easier and more enjoyable because a delicious variety of fresh, good-for-you foods are more widely available for more seasons of the year than ever before.
    Of course, there is also no shortage of diet advice, nutritional claims for speci?c food products, and con?icting headlines about the value—or the hazards—of certain foods. Don’t let fads or eye-catching news stories distract you from a commonsense approach to your diet.

    You’ll do better if you don’t think about dieting, but about developing new ways of eating for the long term.
    If you are trying to accomplish a speci?c goal, like lowering your blood pressure or your cholesterol levels, your doctor may work with you to develop an eating plan designed to help you achieve your target. But for those of you working on an overall heart-healthy eating pattern, the American Heart Association has developed a set of general guide- lines to help you change your current habits for the better and maintain a healthy pattern throughout your life; see the box above.

    Fruits and Vegetables

    The good news just keeps pouring in about the healthy bene?ts of fruits and vegetables in your diet, especially for your heart. Fruits and

    vegetables are the best source of vitamins, minerals, and ?ber. They have few calories and no cholesterol, and are low in fat and sodium. You can ?ll up on them at meals and snack on them in between. Generally, the most colorful fruits and vegetables are the most loaded with vitamins, including antioxidant vitamins.
    Antioxidant vitamins are so called because they may slow down the process of oxidation in your arteries—a chemical process that enables cells in your artery walls to more easily absorb fatty acids and LDL cholesterol. As a result, antioxidant vitamins may reduce the accumulation of plaque in the arteries that can lead to atherosclerosis and stroke. The major antioxidant vitamins are vitamin E (found in vegetable oils, wheat germ, and nuts), vitamin C (found in green and red peppers, broccoli, spinach, tomatoes, pota- toes, and citrus fruits), and carotenoids (found in yel- low, dark green, and red vegetables and fruits). It is important to know that taking vitamin supplements does not have the bene?cial effects of a balanced diet.
    Any fruits and vegetables you choose are a healthy addition to your diet. Some major research shows that fruits and green, leafy vegetables (spinach, kale, collards) are especially associated with a reduced risk of developing heart disease.

    Eating Plan for Healthy Americans

    The American Heart Association has designed these guidelines to help you reduce your risk of cardiovascular disease. Following this plan will improve your overall condition if you already show signs of heart and blood vessel problems, or even if you are currently enjoying good health. These are general guidelines; see also the DASH diet, pages 47–50.
    • Eat a variety of fruits and vegetables (nine or more servings per day).
    • Eat a variety of grain products, including whole grains (six or more servings per day).
    • Include fat-free and low-fat milk products, fish, legumes (dried peas or beans), skinless poultry, and lean meats.
    • Choose fats and oils with 2 grams or less of saturated fat per tablespoon and no trans fats, such as liquid and tub margarines, olive oil, and canola oil.
    • Balance the number of calories you eat with the number you use each day. To arrive at that number, multiply the number of pounds you weigh now by 15 calories. This represents the number of calories you burn in one day if you are moderately active. If you exercise very little, multiply your weight by 13 instead of 15.
    • Exercise to stay fit and to burn the number of calories you eat. Walk or exercise actively in some other way at least 30 minutes on most days of the week; one hour a day or more is considered optimal.
    • Limit your intake of snacks, soft drinks, or candy that are high in calories.
    • Eliminate foods high in saturated fat or trans fat, such as full-fat milk products, fatty meats, tropical oils, and partially hydrogenated vegetable oils. Instead, sub- stitute more foods from the first four categories listed in the first column of this box.
    • Trim your salt consumption.
    • Drink alcohol in moderation, if at all. That’s one drink a day if you are a woman or two drinks a day if you are a man. One drink is
    12 ounces of beer, 4 ounces of wine, 11?2
    ounces of 80-proof spirits, or 1 ounce of
    100-proof spirits.

    Daily Servings of Fruits and Vegetables

    Eat at least eight servings a day of fruits and vegetables—more is even better. Choose from all fruits and vegetables except coconut, which contains harm- ful tropical oils. Consider olives and avocados as fats (see page 90). Starchy vegetables such as potatoes are included in the category of grains and grain products (see page 86).
    Examples of serving sizes:
    • One medium piece of fruit
    • 1?2 cup chopped, cooked, or canned fruit
    • 3?4 cup (6 ounces) fruit juice
    • 1?4 cup dried fruit
    • 1?2 cup cooked or raw vegetables
    • 1 cup raw leafy greens
    • 3?4 cup (6 ounces) vegetable juice

    Grains and Grain Products

    Grains, grain products such as breads, and starchy vegetables are rich in complex carbohydrates, which provide you with energy. They also con- tain vitamins, minerals, and fiber. Contrary to what many people believe, they are also usually relatively low in fat and calories. If you are eating less fat and sugars (also a type of carbohydrate), you can health- fully ?ll up on grains. There are two important points to remember: choose whole grain products, and watch out for added fat, calories, and sodium in the preparation or processing of these foods.
    Whole grains are healthier than re?ned grains because they retain the germ (the nutrient-rich core of the grain) and the bran (the outer layer of the grain, containing nutrients and most of the ?ber). If you are unsure about whether a product is whole grain, check the label for the term “whole wheat” or “whole grain” as the ?rst item in the ingredients list. Choose whole grain breads, English muf?ns, bagels, and bread- sticks; whole grain pastas; and brown rice. Limit white rice, white bread, and egg noodles.
    It’s easy to consume hidden or not-so-hidden calories in the way you prepare foods or the way they are processed. Of course, limit high-fat and sweetened products such as croissants, sweetened cereal, crackers, and potato chips. (Unsalted pretzels and plain popcorn are better snack substitutes.) When you are cooking at home, cut back on butter and cheese and use seasonings liberally to boost flavor. Check sodium levels carefully if you use boxed grain mixes.
    The ?ber in foods comes in two forms: soluble (meaning that the ?ber is partially broken down in your intestine) or insoluble (the ?ber passes through your system without being broken down). Both types of ?ber are part of a healthy diet. Soluble ?ber is found in oat bran, oatmeal, beans, peas, citrus fruits, and apple pulp; it helps lower cholesterol. Insoluble ?ber, found in whole wheat breads and cereals, cabbage, beets, carrots, cauli?ower, and apple skin, encourages good bowel function but does not lower cholesterol.
    Fat-free and Low-fat Milk Products

    Dairy products provide you with protein, cal- cium, and nutrients including phosphorus, niacin, ribo?avin, and vitamins A and D. Right now, the impact of calcium on the risk of heart disease is not entirely clear, but people who do not consume much calcium tend to have higher blood pressure, so dietitians recom- mend getting plenty of calcium from foods (1,000 milligrams per day for adults below the age of 50; 1,200 milligrams per day over 50). Fat-free or low-fat (1?2 percent or 1 percent) dairy products contain slightly more nutrients than whole or 2 percent milk but are much lower in fat, saturated fat, cholesterol, sodium, and calories. If you have dif?culty giving up whole milk (31?2 or 4 percent fat), try decreasing gradually to get accus-
    tomed to the difference.
    For those who eat cheese, choose natural or processed cheeses with no more than 3 grams of fat per ounce and no more than 2 grams of sat- urated fats per ounce. Part-skim cheeses such as mozzarella are popular with those watching calories and fat content. If you like ice cream as a dessert, choose instead sherbet or sorbet, low-fat yogurt, low-fat ice cream, or low-fat pudding.

    Meat, Poultry, and Fish

    Eating relatively small portions of meat, poultry, or ?sh will still provide you with adequate amounts of protein, B vitamins, and iron. The trick is to limit your portion sizes and think of meats as a side dish or garnish rather than as the centerpiece of your meal. Try mixing small amounts of meats with pasta, rice, or vegetables for a ?lling entr?e.
    When you shop for meats, look for cuts with little or no visible fat. Choose “choice” or “select” rather than “prime” cuts of beef. Lean veal, lamb (leg or loin), and pork (tenderloin or loin chop) are good choices. Lean ham is a good choice, although cured ham and Canadian bacon are higher in sodium than other meats. Most ground meats today are clearly labeled with the percentage of fat; look for lean or extra lean, with no more than 15 percent fat. Organ meats such as liver are high in cholesterol but are iron- rich. You can enjoy small portions of these meats once or twice a month. When you prepare meat, make sure that you trim off visible fat before cooking, and cook without adding fat: broil, roast, grill, or stir-fry with a little olive oil.
    Poultry meats (chicken, turkey, Cornish hens) are low in fat if you take off the skin before you cook them. Ground turkey is low in fat; check the label for the per- centage of fat in ground chicken. Low-fat processed sandwich meats (low-fat chicken or turkey, turkey ham, lean boiled ham) are available now, but check sodium levels on the label.
    Fish, particularly oily ?sh, is an excellent source of protein but does not contain the saturated fats found in other meats. The recommended two servings a week are a minimum—eating ?sh and shell?sh more frequently helps you lower your dietary fat and cholesterol. Choosing ?sh and seafood may be confusing at ?rst because of some precautions about the health bene?ts of certain types. Here are a few key points:
    • Oily or fatty ?sh are particularly good for you because they have high levels of omega-3 fatty acids (see box on page 89). Oily ?sh include mackerel, lake trout, herring, sardines, albacore tuna, and salmon.

    • Sword?sh, king mackerel, shark, and tile?sh may contain undesir- able levels of mercury, while farm-raised ?sh contain environ- mental contaminants. Exposure to mercury is a concern especially for children and for pregnant and nursing women. For the general population, however, the bene?ts of eating ?sh far outweigh the hazards. Eating a variety of ?sh reduces your risk of adverse effects caused by levels of mercury or other contaminants.

    • Although some shell?sh (such as shrimp and cray?sh) are higher in cholesterol than most ?sh, they are lower in saturated fat and total fat than meats and poultry, so they are still a heart-healthy choice.

    Daily Servings of Meat, Poultry, and Fish

    Eat no more than two servings (6 ounces total) of cooked lean meat, poultry, or fish per day. Choose fish two or more times a week.
    Examples of serving sizes (3 ounces):
    • A piece of beef the size of a deck of cards
    • A hamburger 3 inches across and 1?2 inch thick
    • Half a chicken breast
    • A chicken leg and thigh without skin
    • 3?4 cup flaked fish