Articles on Medical Diseases and Conditions

Tag: High Blood Pressure

  • Other Imaging Techniques

    Still more advanced technologies can be used to study your heart’s structure and function. These procedures include computed tomogra- phy (CT), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and positron emission tomography (PET). Such techniques are used to get more detailed information or to avoid more invasive procedures. These scanners are not available at all hospitals or diagnostic centers and are used only when needed to answer speci?c questions your physician may have.

    Computed Tomography

    CT scanning is an advanced X-ray technique that can take cross-sectional images of your heart. To have a CT scan done, you lie on a movable table that slides into the tubular CT scanner. Many images are taken from all sides of your body. A computer combines these images to construct a detailed cross section of a structure. Your doctor can assess images of your heart, lungs, or major blood vessels. CT scans are often used to see if calci?cation, a natural reaction to injury, has occurred in your blood vessels as a result of atherosclerosis (see page 152), or in your heart muscle as a result of a heart attack. As with other X-ray techniques, CT scanning passes some radiation through your body, but it is a minimal, safe amount that does not remain in your body after the test.

    In some cases, a contrast agent (iodine-based dye) is injected into your bloodstream to get a clearer image. If you are not being injected with the dye, you will be told not to eat for about 2 hours before the test. If you are being injected with the dye, you should not eat for about 4 hours beforehand. In some people, this contrast agent causes hot ?ushing and other allergic symptoms, but this reaction is rare .
    You will be asked to put on a hospital gown and lie down on the table. If a contrast medium is being used, an intravenous line will be placed into your arm. The table will be moved slowly into the scanner. The technician will start taking pictures, and you will be asked to lie still and hold your breath brie?y as each image is taken. After the test, you may resume your usual activities.

    Electron Beam Computed Tomography

    Electron beam computed tomography (EBCT or fast CT) is a faster form of CT scanning that takes images in about one-tenth of a second (compared to 1 to 10 seconds for a conventional
    CT scan). Because the heart is always in motion, a conventional CT sometimes creates a blurred image. EBCT is fast enough to avoid this prob- lem. EBCT enables your doctor to detect calci- ?cation in your arteries. EBCT is sometimes used for “whole body screening” for healthy people, but there is no evidence it is effective for that purpose.

    Spiral Computed Tomography

    Spiral computed tomography (or spiral or hel- ical CT) is another form of fast CT scanning. For a conventional CT, you rest on a table while the scanner is moved slightly for each picture; with spiral CT, you lie on a table that moves slowly through the scanner while it takes images nonstop. These scanners are particu- larly helpful in ?nding aneurysms (ballooning in the wall of a weakened artery) and blood clots in the lungs (pulmonary emboli).

    Magnetic Resonance Imaging

    MRI is another technology that uses magnetic ?elds and radio signals to form an image. Brie?y, the MRI scanner surrounds your body with a magnetic ?eld that reacts with magnetic elements in your body (such as hydrogen). The reaction causes radio signals from which a computer can construct an image. MRI scans produce images that are similar to those from a CT scan, but no radiation is used, and the MRI shows slightly different tissues. The test is painless, does not involve any injections, and does not pose any known risks. People who have pacemakers or other internal metallic devices cannot have an MRI, but people with arti?cial heart valves that are not magnetically active can have one safely. This test can be performed safely in the second half of pregnancy.
    You do not need to prepare in any way for an MRI. You will change into a hospital gown and lie on a table that will be placed in the scan- ner, which is a long, narrow tube. Some people with claustrophobia may find the scanner uncomfortable. However, many scanners are now made with open ends that eliminate this problem. If you are con- cerned about being inside the scanner, talk to your doctor before the test is done; a sedative may be administered to help you relax through the test.
    When you are inside the scanner, you may be asked to hold your breath brie?y while images are taken. You may hear loud noises inside the scanner. Sometimes you can listen to music through headphones while you are inside the scanner, but the technician’s instructions will also be transmitted via the headset. After the test, you can go about your usual activities.

    Magnetic Resonance Angiography

    MRA uses an MRI scanner to analyze the blood vessels leading to the brain, kidneys, and legs. This type of scan is done using different set- tings on the scanner, so the procedure is the same as for an MRI from your point of view. Usually, an MRA is done using gadolinium, a mag- netic contrast agent to which virtually no one is allergic. This contrast agent is given as an injection, usually in your arm, before the scanning is done.

    Positron Emission Tomography

    PET scanning uses information about the energy released by subatomic particles in your body to form an image. A radioactive substance is injected into your body that will travel to damaged or malfunctioning tissues. These tissues have increased or decreased metabolic activity. The PET scanner detects and measures the radioactive substance in these areas of your body, and a computer constructs images. A PET scan is highly accurate because it shows your heart tissue at work. The uses for this technology are still developing, but it has the poten- tial to show how your heart uses energy at a cellular level. Currently, PET scans are used mainly in research rather than in patient care or diagnosis of heart disease.
    You do not need to prepare for a PET scan in any way. You will be asked to remove your clothes from the waist up, and a technician will place a ring of detectors around your chest. You will lie down on a table that will be moved into the PET scanner. The scanner is shaped like a large funnel, and your body will be in the tube. The technician or doctor will take a picture of your heart before the radioactive sub- stance is injected. You need to keep your arms above your head during this part of the test, which takes about 15 to 30 minutes. Then the radioactive material will be injected, usually in your arm. You will have to wait about 45 minutes for the substance to move into your heart. Again, you will be asked to keep your arms over your head while the images are being taken. After the test, you may resume your usual activities.

    Multidetector CT Scans

    A type of CT scanner with more detectors than a conventional CT machine can be used to provide the same kind of infor- mation about the coronary arteries as an angiogram reveals (see page 146). Because having a CT scan is easier and less expensive than an angiogram, the multidetector CT scan might be used more frequently in the future. A recent application is CT angiography, in which dye is injected and images are made of the coronary arteries that may detect both calcified and noncalcified deposits. CT angiography is being used as a screen- ing tool in high-risk people and as a diag- nostic tool in some hospital emergency departments with specialized chest pain centers. Medical experts are working on standards to guide the use of the new multidetector scanners.

  • Multiunit Gated Blood Pool Scan (MUGA)

    A multiunit gated blood pool scan (MUGA) is an assessment of how your blood pools in your heart during rest or exercise, or both. The test shows how well the heart pumps blood and whether it has to compen- sate for blocked arteries. It also reliably measures your ejection fraction, which is the percentage of your blood pumped out of your ventricles with each heartbeat. The ejection fraction normally increases during exercise.

    What to Expect

    If you are having only a resting scan MUGA, no special preparation is necessary. You should check with your doctor whether you need to stop taking any heart medications for a day or two beforehand. If you are having an exercise MUGA, you should not eat or drink anything other than water the night before the test. Depending on the extent of the testing, you should allow 2 to 4 hours for its completion. For the test, you will usually be asked to change into a hospital gown, and a techni- cian will attach electrodes to your chest. The electrodes will be wired to a nuclear imaging computer. Then the technician will draw a small amount of your blood and mix it with the radioactive tracing material. About 10 minutes later, he or she will inject the prepared blood back into your arm. Then you will lie down on a table while the technician takes a number of images of your heart with the gamma camera. If you are having only a resting MUGA, the test is complete and you can go home.
    If you are having an exercise MUGA, you will move to a different table with pedals at the foot. While you lie on the table, you will pedal as if you were on a bicycle, and the technician will take images. You will pedal through a warm-up stage, and then the exercise will be gradually increased until you are tired. You will be carefully monitored through- out the test.
    After your MUGA, you may feel tired, but you can return to your usual activities. The harmless radioactive substance will leave your body in 2 or 3 days. This test should not be performed during pregnancy.

    What the Results Mean

    The full results of your test will be ready in a few days. In addition to the images produced, the computer also calculates the size and shape of your ventricles and measures the amount of blood in them. A low ejec- tion fraction may be due to blockages in your coronary arteries or a problem with a heart muscle.

  • Evaluating a Heart Problem

    If you experience any symptoms that might be indicators of a heart problem—such as chest pain, shortness of breath, or a pounding heart—see your doctor immediately. He or she will interview you thoroughly about your medical history and symptoms and then do a physical examination to try to detect what might be causing the symptoms. Depending on what the examination reveals, he or she may order further testing to diagnose the problem. If you know what to expect, you will probably feel more relaxed about the exam, and you can be better prepared to answer questions. It will be very helpful if you can bring in notes with speci?c details about when you experienced a symptom, how often it recurred, and how long it lasted.

    Medical History

    If you are seeing a doctor for the ?rst time, he or she will ask some gen- eral questions about your medical history. If you are reporting a speci?c event, the questions will focus on that event. Here is a general outline of what to expect:
    • Questions about your chief complaint. Your doctor will want to know what brought you into the of?ce. He or she will ask speci?c questions such as how it felt, when it occurred, what you were doing when it occurred, or what seemed to relieve it. Be as thor- ough and speci?c as you can be. Do not hesitate to volunteer information beyond the questions.
    • Questions about your medical history. Information about other medical conditions you have or have had can help indicate possi- ble causes for your symptoms and rule out unnecessary tests or inappropriate treatments. Again, written notes may help you remember illnesses, tests, or surgery that you have had. If you are seeing a specialist, your other doctor or doctors may be able to send medical records and test results in advance of your appoint- ment. If you are referred to a spe- cialist, ask the referring doctor for pertinent test results to take with you to the appointment.
    • Medications. Your doctor will want to review all the medications you are taking; bring a list that includes dosages to the appointment. It is important to include herbal prepa- rations and nonprescription med- ications, because they may interact with other drugs. Also, know and remember your drug allergies.
    • Family history. Be prepared to answer questions about the medical history of your parents, siblings, and children. This information gives the doctor clues about hereditary aspects of some conditions and your overall risk.
    • Lifestyle. Information about habits such as smoking or drinking, diet, and exercise are important. Some of these factors may help explain a symptom; for instance, caffeine can cause an irregular heartbeat in some people. Do not worry about looking bad or being embarrassed by your habits. This information can help a great deal with diagnosis and treatment. You may also be asked questions about your workplace and about stress.
    • Other organ systems. Your doctor may systematically review other body systems to make sure nothing is overlooked.

    A Physical Examination in Detail

    A cardiovascular physical examination will include taking your blood pressure (see page 43), measuring your heart rate and rhythm by check- ing your pulses, inspecting the veins in your neck, checking your body for swellings, and listening to the sounds of your breath, heart, and

    blood vessels. You will probably be asked to change out of your clothes into a hospital gown and sit or lie on an examining table.
    • Measuring your heart rate and rhythm. Your doctor will check the pulse at your wrist, in the carotid arteries in your neck, or in the femoral arteries in your groin. The pulses enable him or her to measure your heart rate and to determine if your heart- beat is regular, skips beats, or has extra beats. An absent or reduced pulse at one of the sites may indicate a blockage in a blood vessel.
    • Veins in your neck. The doctor will look at (not feel) the jugular vein in your neck to observe the pulse. The location and size of the pulse indicates the pressure on the right side of the heart and the possible presence of excess ?uid in your system.
    • Swelling. Swellings in parts of your body such as your legs and ankles can indicate excess ?uid or a blockage in a vein.
    • Listening to your breath. Listening to your breath sounds by placing a stethoscope on your chest can reveal ?uid building up in your lungs (which makes a crackling sound) or scarred tissue in your lungs. Thumping on your chest can help locate where the ?uid is; a ?uid-?lled area sounds dull instead of hollow.
    • Listening to your heart. Putting the stethoscope on four distinct sites over your heart, your doctor can listen to blood ?owing through your heart and heart valves. A heart murmur is the sound of turbulence caused by a problem with a valve or another heart structure. You may be asked to stand up, squat, or lie back, because murmurs change when you are in different positions. Extra sounds, called gallops, or other types of sounds may indicate vari- ous types of heart problems. Some unusual sounds are completely harmless.
    • Listening to blood vessels. Your doctor can evaluate blood ?ow in large blood vessels by listening at different points in your neck, abdomen, and groin. Turbulence in these vessels makes a sound called a bruit, which may indicate blockage.
    Depending on what the doctor learns from this basic examination, or “cardiac workup,” he or she may order blood tests, imaging procedures, or other tests of cardiac function in order to diagnose more speci?cally and plan treatment.

    After a physical examination including listening to your heart and lungs with a stethoscope—your doctor will need more detailed infor- mation about your heart. The doctor will ask questions about diseases you have been diagnosed with, any persistent symptoms you have noticed, and your family medical history. A variety of tests are available to examine the structure of your heart, how well it functions, whether it is damaged or diseased, and the nature or extent of the disease.
    Which tests you take depend on your symptoms, your medical history, your general cardiac condition, and your doctor’s assessment. Usually you will have some simple tests ?rst, such as an ECG (an electrocardiogram, which records your heart’s electrical activity), and then additional tests as needed to assess your particular problem. In addition to electrocardiography, other means of testing include blood tests; echocardiography (which uses sound waves to examine the heart valves and chambers); different types of stress tests (to study the heart while it is working harder); nuclear imaging (using safe amounts of radioactive materials to study heart function); other imaging tech- niques; and in some cases, more invasive tests that are done in a hospi- tal setting.
    The tests can reveal useful information speci?c to your heart symp- tom or problem that will help guide your treatment. Many of the tests are noninvasive, meaning that they do not involve a needle stick or the introduction of any catheters (tubes) into your body. Knowing how and why a test is performed will help you feel more comfortable, and under- standing something about the possible results will help you learn about your heart along with your doctor. Don’t hesitate to ask questions before or after any test. Many tests require your permission or informed consent, and your doctor should fully explain beforehand any risks from the tests.

  • Physical Examinations and Diagnostic Tests

    The best way to monitor your health is to see your doctor and work together as a team for your health. Many of the major risk factors (such as blood pressure and cholesterol) are apparent only with a med- ical examination. The earlier you can identify a problem area and start to work on it, the more likely you will be able to prevent the develop- ment of more serious disease. For instance, an evaluation of prehyper- tension (see page 43) or prediabetes (see page 106) gives you a head start on these risk factors. As you work on one risk factor (for instance, exer- cising more to lower cholesterol) you will very likely be improving oth- ers as well. Know all your risk factors from your medical history—not only high blood pressure, diabetes, and smoking, but also risks from
    menopause, aging, and lifestyle choices regarding food and exercise.

  • Stress

    In addition to the major risk factors for heart disease (high cholesterol, high blood pressure, physical inactivity, smoking, and diabetes), stress can be a contributing factor. The effects of stress on your heart health are dif?cult to study and quantify in part because people not only expe- rience different levels of stress, but they also respond differently. Researchers have identi?ed several ways that stress may adversely affect some people’s hearts:
    • Under stress, your body releases extra hormones (epinephrine and norepinephrine) that raise your blood pressure, which may over time injure the lining of your arteries. As the arteries repair them- selves, they may thicken, which promotes the buildup of plaque.
    • A stressful situation tends to raise your heart rate and blood pres- sure, so your heart requires more oxygen. In someone who already has heart disease, this oxygen shortage can bring on chest pain (angina).
    • Stress increases the clotting factors in your blood, which increases the chances that a blood clot will form and block an artery, espe- cially one already partially closed by plaque.
    Then, of course, there are the ways that many people may choose to deal with stress—overeating, smoking, drinking excessively—that are damaging to the cardiovascular system.

    The fact is that everyone is under stress of some kind at least intermittently and perhaps much of the time. You can usually recognize symptoms of your own stress in the form of aches and pains, dif?culty ?ghting off mild infections like colds, sleeplessness, or feelings of anxiety or irritability. You also probably know when some of your less healthy coping mecha- nisms are escalating—as, for example, when you put on weight during a tough time, or start smoking more.
    Learning to manage stress makes good sense for your overall health. But more research is needed before experts can reliably recommend specific methods of stress reduction as treatments for cardio- vascular diseases. Generally, if you or your doctor believes that stress is having a harmful effect on your health, you can work on several strategies to manage its impact:

    • Communicate with family and friends about the things that trou- ble you. Their support and love will help reduce your response to stressful situations.
    • If you feel a sense of urgency because of competing demands on your time, consider time management techniques that will help you prioritize and set realistic expectations. Your workplace, library, or the Internet may offer speci?c methods. Also, be cau- tious about agreeing to take on new projects.
    • Choose a relaxation technique, such as yoga, meditation, or biofeedback, and make time to master it and practice it regularly. Although there is no conclusive medical proof these techniques can lower blood pressure, there are some promising studies point- ing in that direction.
    • When you know that a speci?c problem is causing you anxiety, talk to your doctor or other health-care provider about a support group that focuses on that problem. These resources may be avail- able through a community center, hospital, religious organization, or YMCA.
    • Professional counseling or psychotherapy may help you through certain dif?cult periods. Your doctor can help refer you to an     appropriate professional. If medications such as antidepressants are appropriate, your doctor or a psychiatrist can prescribe them and help you get essential counseling as well.
    • Use commonsense therapy: eat a healthy diet, exercise regularly (see the box on page 80), limit alcohol and caffeine, and do not smoke.
    Managing stress, or preventing stress in the ?rst place, is especially important to people who have already had a heart attack or a stroke. Preventing another heart attack or stroke called secondary prevention by doctors is a key goal for the doctor-patient team. As noted repeat- edly in this book, lifestyle changes are crucial to prevention or second- ary prevention, and stress management should be a key focus of lifestyle changes that also include controlling your cholesterol level, controlling your blood pressure, losing weight if needed, exercising regularly, and stopping smoking.
    Depression may be related to stress but is a disorder that needs treat- ment. It is natural to a certain degree to feel “blue” or be upset after a heart attack or a stroke. However, if you have persistent depression, it is important to note that it is treatable—that is, not just “something to live with” (see also “Depression after a Stroke,” page 232). Depression symptoms include prolonged periods of feeling sad or unable to cope, strong feelings of guilt, strong feelings of pessimism or loss of hope, a loss of interest in normal pleasures (including sex), unusual weight changes (unintentional losses or gains), and dif?culty relating to loved ones or coworkers. If you or a loved one has depression, seek treatment from your primary care doctor; he or she will make treatment sugges- tions, possibly including medications or talking therapy, or refer you to a psychiatrist or other mental health professional.

  • Peripheral Artery Disease

    Peripheral artery disease (PAD) occurs when the blood vessels in the leg are narrowed or plugged by the buildup of plaque. Atherosclerosis, the process that causes PAD, tends to start earlier in life and progress more rapidly in people with diabetes. In most people, PAD is symptomless in its early stages. If the disease progresses to a severe stage, however, the most common symptom is pain in the leg muscles—not the joints— when you exert yourself. This symptom, called intermittent claudica- tion, means that the muscles in your legs and feet are not getting enough blood and oxygen when they are working. The pain of intermit- tent claudication comes on with activities such as walking and is relieved by rest or stopping the activity. Without treatment, PAD can progress to the point where the blood supply is so poor that it can lead to dam- age of skin and muscle tissue deprived of blood in your lower legs and feet. Surgery on the blood vessels or even amputation may be necessary in severe cases. A large number of amputations of toes, feet, or legs occurs in people with diabetes and PAD.
    As many as one in three people with diabetes has peripheral artery disease, but they may not realize it if they have not experienced any signs. Your risk of having PAD is higher if you smoke, have high blood pressure, have high cholesterol, are overweight, are physically inactive, are over 50 years old, have a family history of cardiovascular disease, or have already had a heart attack or a stroke.
    If you notice that your calves hurt when you exercise but stop hurting when you rest; if you often sense numbness, tingling, or cold- ness in your legs or feet; or if you have sores or infections on your feet or legs that don’t heal, see your doctor right away to be tested for PAD.
    If you have experienced neuropathy, a common diabetic symptom that is a burning sensation in the feet or thighs, you might easily con- fuse the two types of pain. Describe the pain as speci?cally as possible to your doctor. He or she may want to test for the condition even if you are not experiencing symptoms, especially if you have some of the risk factors in addition to your diabetes.
    The most common test for PAD is checking the pulses in your ankles and feet. If you have PAD, your treatment will begin with lifestyle changes, including quitting smoking, controlling your diabetes, control- ling your blood pressure, being more physically active, beginning an exercise program to improve blood ?ow, and eating a low-fat diet to control your cholesterol. Your doctor may also prescribe medications, such as drugs that treat your leg pain so that you can walk farther; antiplatelet agents, which help prevent blood clots; or statins, which help lower your blood cholesterol.

  • 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.