Yes NoWhen I was in grade school, a friend’s father died suddenly of a heart attack. I will never forget how shocked I was that someone who appeared to be so vigorous and healthy one day could be dead the next day. I began to worry about my own father’s health. Whenever he was late coming home from work, I was afraid that he, too, had suffered a heart attack. This experience had a profound effect on me and played a role in kindling my interest in heart disease.
Later, as a medical student, I learned that medical science offered little information about heart disease prevention. During my training, I asked a close family friend who was an experienced cardiologist how heart attacks could be prevented. His answer: “Pick the right parents.”
I was frustrated by his response, but at that time the fact that early heart attacks tended to run in families was pretty much the extent of our knowledge in cardiac prevention. We also knew that men over the age of 50 were more vulnerable than younger men to heart attack and stroke. And we really didn’t think much about women in connection with heart disease, because we mistakenly believed that women were somehow at much less risk for heart attacks! As for prevention, we had virtually no proven strategy for people who had a history of premature heart disease in their families. It was during my training that the results of the earliest studies on risk factors for heart disease began to come to light.
Whenever I tell my patients to stop smoking or to get more exercise or to lower their LDL (“bad”) cholesterol, I owe a debt of gratitude to the Framingham Heart Study. Without it, preventive cardiologists like me would have little advice to give. Before the Framingham study, we knew very little about risk factors for heart disease, and much of what we thought we knew was wrong. For example, we didn’t know that high blood pressure put someone at risk of having a heart attack or stroke. Nor did we recognize the role of cholesterol and other blood fats such as triglycerides in promoting heart disease. And until 1960, smoking was not proven to be dangerous.
Launched in 1948, the Framingham Heart Study was the first long-term study of cardiovascular health. It followed approximately 5,000 people living in the small town of Framingham, Massachusetts. The first order of business was to conduct a thorough medical examination on all of the participants and interview them about their health habits and family medical history. Did they smoke? What did they eat? How often did they exercise? Did they drink alcohol? Did they have close family members with hearse?
Following the initial interview, the researchers monitored the health of the volunteer subjects over a period of several decades. This gave the researchers the opportunity to correlate the health of the volunteers with the data they had gathered at the beginning of the study. For example, they would be able to see if smokers had a higher incidence of heart attacks than nonsmokers. They could determine if high blood pressure was more common in people who were overweight. This was plodding, tedious work, but it ultimately produced a great deal of lifesaving information.
The Framingham study made quite an impression on me as a young doctor. I particularly admired William Castelli, MD, who took the reins as director of Framingham in 1979 and held that position until 1995. He deserves tremendous credit not just for his research but also for traveling around the country spreading the prevention message in an especially entertaining way. I attended as many of his lectures as I could in the 1980s, and they bolstered my interest in cardiac prevention. His positive message was that it was possible to prevent heart attacks and strokes by improving bad cholesterol numbers through lifestyle changes and medications. We didn’t have all the tools back then that we have now, but it was an excellent jump start in the right direction.
The important work of Framingham continues. In 1971, the investigators recruited 5,124 children of the original volunteers and their spouses for a second influential study—the Framingham Offspring Study—which is shedding new light on genetic risk factors. Another group of researchers is studying the various subcategories of LDL and HDL cholesterol, deepening our understanding of the genesis of atherosclerosis.
Unfortunately, much of this information has yet to filter down to the public. For example, in a 1997 survey of heart attack victims who had high blood pressure, 85 percent did not know that hypertension increased the risk of a heart attack. An alarming 26 percent of the victims who smoked cigarettes did not know that smoking is a major risk factor for heart attack and stroke. This tells us that tens of millions of people are in the dark about what puts them at risk for cardiovascular disease. They don’t know what lifestyle changes they can make to lower their risk, and they may not understand their risk factors well enough to comply with their doctors’ recommendations. To obtain more information on the Framingham Heart Study, see Helpful Resources, page 263.
The first evidence that diet and lifestyle could be risk factors for heart disease came from the famous Framingham Heart Study, a longterm look at the lives and health of some 5,000 men and women who resided in the small town of Framingham, Massachusetts Commissioned by the Public Health Service in 1948, this study has produced a wealth of information on risk factors for heart attack and stroke. Framingham data taught us about the important connection between heart disease and cholesterol as well as between heart disease and smoking. The Framingham study was also one of the first trials to include women, and it provided some early insight into the differences in the way men and women experience heart disease. It was, in fact, the Framingham study that coined the term risk factors.
Today, thanks to information gleaned from the Framingham study and subsequent investigations, we have a better understanding of the factors that cause heart attack and stroke. I designed the questionnaire in this chapter to help you understand where you stand in terms of your own risk factors. If you are at risk, my prevention approach will enable you to minimize that risk. But there’s an important point that I can’t stress enough. Obvious risk factors tell only half the story. Many heart attacks occur in people with few or no conventional risk factors. This is why I urge even those of you who think that you are not at risk to take advantage of the new, noninvasive medical tests that I describe in Step 3 of the program. By having these advanced tests, you will have a far more complete picture of your cardiovascular health.
SO WHERE DO YOU STAND?
How many known risk factors for heart disease do you have? Answering this question is an essential first step in implementing your own aggressive heart disease prevention program. The questions on pages 36–39 will give you a general idea of your risk level, based on information you are likely to have from your last medical examination and facts you already know about your family history and lifestyle. A copy of your most recent lab test results will help you answer questions about your blood fats (lipids), such as cholesterol and triglycerides. If you don’t know the answers to some of the questions—for example, your blood pressure or cholesterol levels—you should check with your doctor. If you haven’t had a physical examination within the past 2 years, make an appointment to have one, and be sure to discuss the advanced screening tests that I recommend.
You will notice that there are two questionnaires, one for men and one for women. We now know that the risk factors for men and women are somewhat different, and the questionnaires reflect this. After you complete the questionnaire, turn to pages 40–59 for a discussion of what your answers mean.
“I looked at my test numbers and had no idea
what they meant.”
I didn’t know much about my risk for heart disease. I guess I depended on my doctor to keep me informed, and he didn’t tell me enough. And I never knew enough to ask the right questions. The last time I saw him for a checkup, he ordered blood tests. I got a letter in the mail with the results. My cholesterol was 245, and there was an arrow pointing up. I guessed that the arrow meant it was too high. My triglycerides (I didn’t know what those were) were 152. Another upward arrow. My HDL was 43. No arrow. Must have been okay. Then there was “LDL/HDL” and “Cholesterol/HDL,” followed by some more numbers. That letter was not helpful at all. I looked at my test numbers and had no idea what they meant. All I knew was that something must have been wrong, because he wrote on the sheet: “Elevated lipids. Strict diet. Recheck 3 months.” Seven words. He also included a sheet about starting the strict diet. I didn’t go on the diet. I just handed the information to my wife, and she filed it away. The next time I saw my doctor, he didn’t mention anything about the letter, the tests, or the diet. It was like the exam never happened. I changed doctors. At least I was smart enough to do that.
Not long after I started seeing my new doctor, I started having mild chest pains. The new doctor gave me a comprehensive battery of tests including a stress test, a heart scan, and advanced blood testing for CRP and homocysteine. The difference was that she explained what all the tests were and what the results meant. I’m lucky. Not only did I find a doctor who explained things, but my chest pains turned out to be acid reflux. What I learned is that tests are important and so is having a doctor who communicates effectively. ■
Are You at Risk for Heart Disease?
1. Have you ever been diagnosed with cardiovascular disease, including a heart attack, angina, or stroke, or have you undergone angioplasty or bypass surgery?
Yes No
2. Are you 40 years of age or older?
Yes No
3. Do you smoke or do you have extensive exposure to secondhand smoke?
Yes No
4. Have you been diagnosed with diabetes, prediabetes, or metabolic syndrome?
Yes No
5. Are you taking medication to treat high blood pressure or is your blood pressure greater than 140/90?
Yes No Don’t Know
6. Do you have a waist circumference of more than 40 inches?(If you don’t know, use a tape measure to find out.)
Yes No
7. Do you have a high Calcium Score?
Yes No Don’t Know
8. Do you have an HDL, or “good,” cholesterol level of less than 40 mg/dL?
Yes No Don’t Know
9. Do you have an LDL, or “bad,” cholesterol level of more than 130 mg/dL?
Yes No Don’t Know
10. Do you have a family history of early heart disease? (Do you have a brother or father who was diagnosed with heart disease before the age of 55 or a sister or mother who was diagnosed with heart disease before the age of 65?)
Yes No Don’t Know
11. Are your triglycerides greater than 150 mg/dL?
Yes No Don’t Know
12. Is your fasting blood glucose greater than 100 mg/dL?
Yes No Don’t Know
13. Do you have a homocysteine level of more than 12 μmol/L?
Yes No Don’t Know
14. Do you have a C-reactive protein (CRP) level of more than 3 mg/ L?
Yes No Don’t Know
15. On average, do you spend less than 2 hours a week exercising at least moderately (for example, brisk walking, golf, active gardening)?
Yes No
16. Do you eat fish at least twice a week?
Yes No
17. Do you eat fresh fruits and vegetables and whole grains on a daily basis?
Yes No
18. Do you make a conscious effort to avoid trans fatty acids in your diet?
Yes No
Are You at Risk for Heart Disease?
1. Have you ever been diagnosed with cardiovascular disease, including a heart attack, angina, or stroke, or have you undergone angioplasty or bypass surgery?
Yes No
2. Are you 55 years of age or older or are you postmenopausal?
Yes No
3. Do you smoke or do you have extensive exposure to secondhand smoke?
Yes No
4. Have you been diagnosed with diabetes, prediabetes, or metabolic syndrome?
Yes No
5. Are you taking medication to treat high blood pressure or is your blood pressure greater than 140/90?
Yes No Don’t Know
6. Do you have a waist circumference of more than 35 inches? (If you don’t know, use a tape measure to find out.)
Yes No
7. Do you have a high Calcium Score?
Yes No Don’t Know
8. Do you have an HDL, or “good,” cholesterol level of less than 50 mg/dL?
Yes No Don’t Know
9. Do you have an LDL, or “bad,” cholesterol level of more than 130 mg/dL?
Yes No Don’t Know
10. Do you have a family history of early heart disease? (Do you have a brother or father who was diagnosed with heart disease before the age of 55 or a sister or mother who was diagnosed with heart disease before the age of 65?)
Yes No Don’t Know
11. Are your triglycerides greater than 150 mg/dL?
Yes No Don’t Know
12. Is your fasting blood glucose greater than 100 mg/dL?
Yes No Don’t Know
13. Do you have a homocysteine level of more than 12 μmol/L?
Yes No Don’t Know
14. Do you have a C-reactive protein (CRP) level of more than 3 mg/ L?
Yes No Don’t Know
15. On average, do you spend less than 2 hours a week exercising at least moderately (for example, brisk walking, golfing, active gardening)?
Yes No
16. Do you eat fish at least twice a week?
Yes No
17. Do you eat fresh fruits and vegetables and whole grains on a daily basis?
Yes No
18. Do you make a conscious effort to avoid trans fatty acids in your diet?
Yes No
UNDERSTANDING YOUR RISK FACTORS
How many times did you check the “Yes” box? The more times you answered “Yes” to questions 1 through 15, the greater your risk of having a heart attack or stroke. If you answered “Yes” to questions 16 through 18, you have reduced your risk of heart attack or stroke. But not all of the questions are equal. The first seven questions relate to particularly strong risk factors, and if you answered “Yes” to any of those, you need to be especially vigilant about maintaining your heart health. And while you can’t change your age, alter your family medical history, or undo your own medical history, there are steps you can take to prevent your risk factors from destroying your future.
You may be surprised by what you have learned about yourself and your risk for heart disease. The important point that I want to make is that whatever your degree of risk, if you follow the South Beach Heart Program and work with your doctor, you will significantly reduce it. You do not have to experience a heart attack or stroke! They are preventable!
Question 1
Past History of Heart Disease
Here’s the bad news: If you have had a heart attack, you have a one in five chance of dying within the next 10 years. Now for the good news: You can improve the odds by taking positive steps to protect your heart. My practice is filled with people who came to me after suffering a heart attack and have not gone on to have another. In fact, by following my preventive approach, they improve their heart health over time.
If you have a history of heart disease, getting advanced diagnostic blood testing (see Step 3) is not optional, it’s a necessity. It’s the only way you will be able to find out whether you have the kind of cholesterol-carrying particles in your blood that are good, bad, or really terrible. (The really terrible kind accelerates the accumulation of cholesterol under the protective lining of your artery walls, leading to the buildup of the soft plaque that I described in the last chapter.) Advanced blood testing is also the only way that you will be able to find out whether you have dangerous amounts of other substances in your blood, such as C-reactive protein, a marker for inflammation that can damage the lining of your arteries. I discuss this substance in the explanation of Question 14.
Depending on what type of offending substances advanced testing detects in your blood, your doctor will determine the type of treatment that will be most effective for healing your artery walls and preventing plaque buildup, plaque rupture, and blood clotting—in other words, for preventing future heart attacks. Typically, treatment includes the lifestyle changes and medications that I describe in Part 2 of this book. If you have a history of heart disease, you must be especially conscientious about making these changes if you want to save your heart and your life. Unfortunately, cardiac care units are filled with people who did not follow a prevention strategy.
Question 2
Age and Your Heart
For both men and women, age is a major risk factor for heart disease. The older you are, the more wear and tear there has been on your artery walls, the longer and harder your heart has had to work, and the more time you’ve had to accumulate arterial plaque. It’s not surprising, then, that four out of every five deaths due to heart disease occur in people over age 65.
Men, on average, show signs of cardiovascular disease about 10 years earlier than women do, and on average, men are 5 years younger when they have their first heart attack. Because men tend to get heart disease earlier than women, many women believe that they are at low risk for heart disease. They are mistaken.
Women do get heart disease, but usually later than men because their female hormones generally offer special protection for the heart while they are premenopausal. However, once a woman reaches menopause, usually in her late forties or early fifties, her estrogen levels sharply decline and her risk of having a heart attack dramatically increases. And by age 65, women are even more likely than men to develop high blood pressure. Notably, a woman who undergoes early menopause is at greater risk for heart disease than her peers who are still menstruating and still cycling estrogen.
Chronological age alone does not tell the whole story. I want to stress that just because you are in your sixties or seventies doesn’t mean that your heart health is deteriorating. Recently, I reviewed the heart scan of a 74-year-old male patient who exercised daily and followed a healthy diet. There was absolutely no calcified plaque in his coronary arteries, which meant that his risk of having a heart attack was extremely low. He may have indeed chosen the right parents, but that still doesn’t completely account for his good health. Some credit must go to his heart-healthy lifestyle.
That same day, I reviewed the scan of a 58-year-old woman who was overweight and sedentary. Her arteries were loaded with plaque, which put her at much greater risk of having a heart attack than my older male patient. My point is that you can have healthy arteries well into old age if you make the right lifestyle and therapeutic choices and take steps to reduce those risk factors that are within your control.
What is really important is the “physiologic” age of your arteries. Just as we are impressed by the sharp minds of many elderly people, we have also seen that they can have young arteries despite their advanced years. In many non-Western societies, where food is not overprocessed and exercise is part of everyday life, the arteries of the elderly are clean and heart attacks and strokes are rarities.
WOMEN, HORMONES, AND HEART DISEASE
It may appear as though women don’t get heart disease because they tend to develop it later in life than men, largely due to the protective effects of natural estrogen. As long as women are having regular menstrual cycles, they enjoy a significant, although not absolute, level of protection. Naturally produced estrogen is linked with lower levels of LDL (“bad”) cholesterol and triglycerides and higher HDL (“good”) cholesterol. When a woman’s estrogen production plummets in her late forties to early fifties, she begins to lose her hormonal advantage.
For decades, experts advised women to take hormone replacement therapy (HRT) to protect their hearts as well as to relieve menopausal symptoms and strengthen their bones. Estrogen’s heart-protective properties looked so promising that nearly half of all postmenopausal female physicians took HRT, a rate higher than that of the general public, according to a 1997 study.
That all changed in 2002, when preliminary results from the Women’s Health Initiative, a 15-year research program, caused a dramatic turnaround in the thinking about HRT. Compared with women who did not take HRT, women who took Prempro, a combination of estrogen and progestin, had a startling 29 percent increase in deaths from heart disease, along with a 22 percent increase in total cardiovascular disease. These results stunned the health community and caused a great deal of confusion in the general public.
But as it turns out, the HRT story is probably far from over. A review and analysis of many of the published HRT studies recently appeared in the Journal of General Internal Medicine. The authors pointed out possible explanations for the disparities between the earlier observational HRT studies of women who had chosen, in consultation with their physicians, to be on HRT and the more recent controlled trials. One factor that appears to be important is the timing of when HRT is started. Those women who begin it later appear to be more likely to experience heart attacks than those who begin HRT soon after menopause. In addition, much of the increased risk seems to occur in the first year HRT is started and may be due to an increased tendency to develop blood clots in the first year of HRT use.
I wish I could give women more definitive advice on this subject, but at this time the research is just too inconsistent. Whether beginning HRT earlier after menopause and perhaps at lower dosages is safer is frankly unknown at this time. Therefore, any decision on whether to begin HRT should be made with your physician after careful review of the potential risks and benefits for your particular situation.
“I feel younger now than I did 2 years ago.”
I’m 85 years old, and I have pulmonary hypertension (high blood pressure in the arteries that supply the lungs). It can be very serious. When I went to see Dr. Agatston 2 years ago, I wasn’t doing well. I couldn’t walk across the room without getting out of breath. I was overweight and I felt terrible. He put me on a healthy diet and told me to get some exercise. Thanks to that, I’ve lost 40 pounds. I breathe a lot better now and I can do a lot more things. I like to walk, but I’m not a youngster. I go to the gym three times a week to walk on the treadmill and do the bike. I do as much as I can. When I get tired, I stop, but I feel much happier and I look much better. I feel younger now than I did 2 years ago. I used to eat a lot of sugar and a lot of junk. Now I don’t eat fried foods, and I don’t eat sugar. I don’t keep it in my house. If you visit me and you want sugar, you have to bring your own! Now I eat a lot of chicken soup with fresh vegetables. I take care of myself. I do my own shopping and my own cooking. I’m still driving. I never expected to make it to this age. But here I am, thanks to a great lifestyle. ■
Question 3
Smoking
Whenever I hear about a young person falling victim to a heart attack, the first question I ask is “Did the person smoke?” The answer is very often “Yes.”
At any age, smoking at least doubles your risk of heart disease. In fact, smoking can trigger a heart attack even if your arteries are nearly perfect. Once you light up, smoking narrows your arteries, raises your blood pressure, increases your risk of irregular heartbeat, and makes your blood sticky and more likely to clot. Smoking also lowers your HDL (“good”) cholesterol and increases arterial inflammation. This is a recipe for a heart attack. There is a good reason that cigarettes are called “coffin nails.”
I am blunt with my patients who smoke. I tell them that as long as they keep lighting up, all prevention bets are off. I warn them that they’ll age faster and have the telltale wrinkled skin and dry, lifeless hair that go along with smoking. And I shock them by telling them that I think they’ll be lucky if they actually do die quickly from a heart attack, because a long and lingering death from emphysema or lung cancer from smoking is far worse.
If you smoke, and particularly if you have other risk factors for heart disease, each time you light a cigarette, you’re playing Russian roulette with your heart. For example, a smoker who has high blood pressure and high LDL (“bad”) cholesterol has 14 times the normal risk of having cardiovascular disease. A woman who takes birth control pills (which increase the risk of blood clots) and who also smokes has a much greater risk of heart disease than does a woman who takes birth control pills but does not smoke.
By the way, you don’t need to smoke cigarettes yourself to experience their negative effects. According to a sobering study published in 2005, simply spending time every day in a smoke-filled environment makes you one-third more susceptible to heart disease than a person who smokes a pack a day. Laws that prohibit smoking in public places may be lifesaving.
The good news is that as soon as you stop smoking, your risk of heart disease begins to decline. According to the US Surgeon General, 20 minutes after you quit smoking, your blood pressure returns to the level it was at before you smoked that last cigarette. Within 2 weeks, your risk of suffering a heart attack begins to decrease. Within 1 to 2 years after you quit smoking, your risk of heart disease nearly returns to normal.
If you want help in your effort to stop smoking, talk with your doctor. Medications, including Zyban (bupropion) and the recently released Chantix (varenicline), have helped several of my patients stop smoking. You can also take advantage of the advice and support offered by the Office of the Surgeon General and organizations such as the American Heart Association, the American Lung Association, and the American Cancer Society (see Helpful Resources, page 263).
Diabetes, Prediabetes, and Metabolic Syndrome
If you are an American age 40 to 70, the odds are about 40 percent that you answered “Yes” to the question about whether you’ve ever been diagnosed with prediabetes, diabetes, or metabolic syndrome. Shocked by this statistic? You should be! Not long ago, diabetes and prediabetes were rare. Now they are virtual epidemics in the United States, putting tens of millions of Americans at high risk for heart disease. In fact, diabetes is such a strong risk factor for heart disease that medical professionals define it as a “coronary heart disease risk equivalent.” This means that a person with diabetes has the same high risk of a heart attack as someone who has already had one. Up to 70 percent of people in coronary care units have prediabetes or diabetes. Women, take note: If you have diabetes and have suffered a heart attack, you have an even greater risk of having another heart attack or heart failure than a man who has diabetes and has suffered a heart attack.
Diabetes is well known as a disease characterized by the body’s inability to process sugars and starches. Less well known are the problems that people with diabetes have processing fats in their diet.
There are two common types of diabetes: juvenile-onset, or what’s now known as type 1 diabetes (which usually appears abruptly before age 30), and adult-onset, or type 2, diabetes. About 90 percent of all those with diabetes in the United States have type 2. Prediabetes, sometimes called metabolic syndrome, insulin resistance, or Syndrome X, will lead to full-blown type 2 diabetes if it goes unchecked. The difficulty with processing fats and the risk of heart attack and stroke begin in the prediabetes phase, which is defined as a blood sugar level of 100 to 125 mg/dL.
The problem with type 2 diabetes and prediabetes is that people who have these conditions process fats abnormally, leading to low levels of good HDL and elevated levels of triglycerides. They also have more small HDL and more small, dense LDL (see the explanation of Question 9, page 51). In addition, they often have high blood pressure and more inflammation in their arteries, strong risk factors that I’ll talk more about in the next chapter.
To help reduce these risks, national guidelines recommend that people with diabetes keep their blood pressure below 130/80. Giving up cigarettes is even more important for people with diabetes than it is for others, because smoking and diabetes are a deadly combination.
Type 2 diabetes is also closely linked with obesity (see Chapter 5), which explains why, as the American population gets fatter, the rate of type 2 diabetes is soaring. What is even more alarming is that there are millions more “diabetics in training” in our country today. I am speaking of our children, who, as they grow fatter and less fit, are rapidly becoming prediabetic or even diabetic. Type 2 diabetes can no longer be called an “adult-onset” disease.
Luckily, type 2 diabetes is largely a “man-made” disease that we can unmake if we set our minds to it. Exercise, weight loss, and strategic dietary changes—particularly eliminating the highly processed “bad carbs” found in baked goods, breads, snack foods, and other starchy and sugary favorites—are all very effective in reversing insulin resistance. I discuss the connection between heart disease and diabetes in more detail in Chapter 5.
Question 5
High Blood Pressure (Hypertension)
High blood pressure, or hypertension, is defined as blood pressure of 140/90 or higher, but it isn’t as simple as that, as I explain below. The top number measures systolic pressure, which is the level of pressure in your blood vessels when the heart beats, pushing blood out into your arteries. The bottom number measures diastolic pressure, the pressure in your blood vessels when the heart rests between beats. Roughly 65 million Americans are hypertensive. That represents one out of three adults, and the number keeps creeping upward. Up to the age of 45, hypertension is more common among men than women. From ages 45 to 54, the percentage of women is slightly higher, and after that, it is much more common in women than in men. African Americans are at particularly high risk. According to the American Heart Association, the incidence of hypertension in the African American population is higher than for any other population in the world.
Carrying extra pounds, getting too little exercise, and just growing older increase your chance of becoming hypertensive. At least two of these risk factors—weight and exercise—are within your control. But the more risk factors you have, the greater your risk for heart attack.
High blood pressure is dangerous because it stiffens and narrows blood vessels, forcing the heart to work harder. Overworking the heart causes the heart muscle to thicken, like any muscle being worked strenuously. Over time, this can lead to heart failure. Moreover, high blood pressure promotes atherosclerosis by weakening the protective lining of the artery walls and allowing bad cholesterol to burrow in.
As with cholesterol and blood sugar numbers, expert guidelines defining what actually constitutes “high” versus “normal” for blood pressure keep changing. The reason for this is that these numbers were originally determined by what the average blood pressure was in the population rather than by what is optimal. The latest numbers are now based on what is considered hypertensive or prehypertensive, but even these new guidelines may continue to change as more information becomes available. As of this writing, blood pressures of anywhere between 120/80 (normal) and 139/89 are labeled prehypertension. The American Heart Association estimates that 59 million Americans are in this category. It also estimates that people with prehypertension may be three times as likely to have a heart attack as those with normal blood pressure.
Because blood pressure guidelines do keep changing, I prefer to simplify the matter for my patients this way: The higher your blood pressure, the greater the stress on your heart and vessels and the greater your chance of having a heart attack or stroke. The lower your blood pressure, the less the stress on your vessels and the longer you will live.
Rarely are there symptoms of high blood pressure, which is why it is called the “silent killer.” It is not uncommon for patients to call me in a panic because they took their blood pressure when they had a headache or were not feeling well and found it to be elevated. The real question is “Which came first, the high blood pressure reading or the headache?” This chicken or egg question is easy to answer. It is the headache or other lousy feeling that came first. In fact, any pain or stressful situation will cause the release of adrenaline and raise your blood pressure. While regular exercise lowers blood pressure, it is normal for your blood pressure to be elevated during and soon after a workout.
Unfortunately, the association of headache and hypertension remains in the popular culture because of a condition called malignant hypertension, which today is very rare and seen almost only in those who have had severe high blood pressure that has gone untreated for many years. I did see a rare case of malignant hypertension in an emergency room setting during my training in the 1970s. But this was in an emergency room that served an economically disadvantaged community that received very little routine medical care. In my practice since then, I do not recall ever seeing a case of malignant hypertension. So remember, blood pressure is an important issue that must be treated over months and years. It need not be micromanaged.
You can lower your blood pressure by attaining and maintaining a healthy weight, exercising regularly, cutting back on excess salt, and eating a diet that focuses on fiber-rich fruits, vegetables, and whole grains. I discuss these lifestyle measures in detail in Step 1 and Step 2 of my prevention program. In addition, your doctor will tell you whether you also need to take a hypertension medication. There are now very effective high blood pressure medications available that have few, if any, side effects. If your doctor recommends that you take one to lower your blood pressure, it would be foolish not to. I explain more about these medications in Step 4.
Question 6
Waist Circumference
Have you found it necessary to loosen your belt a notch or two from time to time? Are you having trouble zipping up your favorite pair of jeans? An expanding waistline is not just a problem for your tailor. The circumference of your waist is an indicator of your odds of having a heart attack or stroke.
If you have an apple-shaped body and carry much of your weight around your middle, you are at greater risk for cardiovascular disease than if you have a pear-shaped body and store fat mainly in your buttocks and thighs or evenly over your entire body. Studies have found that waist circumference is an excellent predictor of who will develop diabetes and heart disease. Belly fat can also make you more vulnerable to a stroke. In a 2005 Israeli study of more than 1,000 men, those with large bellies were 11⁄2 times more likely to die from a stroke than men with a more even distribution of fat.
The bottom line is, if you have belly fat, it’s very important to get rid of it through diet and exercise. Read more about What Your Waistline Says about Your Heart in Chapter 5.
Question 7
Calcium Score
A Calcium Score is the measurement of the amount of calcium in your coronary arteries, which reflects the total amount of atherosclerotic plaque present. It is an indication of how all your risk factors interact with each other to cause heart disease. The higher your Calcium Score for your age, the greater your risk of a heart attack or stroke. I believe that most men over the age of 40 and most postmenopausal women over the age of 50 should have a heart scan to determine their Calcium Score. (See Chapter 6 and Step 3 for further discussion of heart scans and Calcium Scores.) Of all the risk factors discussed here, the Calcium Score is the single strongest indicator of risk for heart disease.
Question 8
HDL (High-Density Lipoprotein) Cholesterol
HDL is the so-called “good” type of cholesterol that protects against atherosclerosis by removing cholesterol from the plaque in your arterial walls and transporting it back to the liver, where it is excreted. This is called reverse cholesterol transport. If you have an HDL level of less than 40 mg/dL for men and 50 mg/dL for women, you are at greater risk of having plaque build up in your arteries. Said another way, the lower your HDL, the greater your risk for heart disease; the higher your HDL, the lower your cardiac risk. We often call HDL levels over 90 the longevity syndrome because this amount usually means very low cardiac risk. I instruct such patients to just make sure they drive safely so they will realize their longevity.
I consider your HDL a “lifestyle factor” because it is influenced a great deal by diet and exercise, as well as by your genetics. One way you can boost your HDL is through good nutrition. Ironically, the low-fat, high-carbohydrate diet that was adopted during the low-fat craze of the early 1980s could actually lower your good cholesterol and increase your risk of having a heart attack. That’s because it focused on eating the wrong carbohydrates and eliminating all fats—even the healthy ones. We now know that following the principles of the South Beach Diet, which means eating moderate amounts of good fats and lean protein, as well as plenty of high-fiber, nutrient-dense carbohydrates (like those found in fresh fruits and vegetables and whole grains), can help to raise HDL levels. Even a glass of wine with your dinner may help. I discuss this on page 149.
Another way you can raise your HDL is to stop smoking. A review of 24 studies published in 2003 found an average increase of 3.9 mg/dL for HDL after smoking cessation. This is appreciable.
Moreover, if you are overweight, and especially if you have a predominance of belly fat, you can raise your HDL by shedding some pounds. One good way to do this is to exercise more. Not only does exercising help you lose weight on its own, it will increase your good HDL. The more you exercise, the greater the rise. Marathoners typically have very high HDL levels.
Finally, a number of medications, including niacin, fibrates, and to a much lesser degree statins, can also increase your HDL. In fact, niacin is the one drug that can raise your HDL substantially. This action alone is one of the reasons medications can dramatically lower the risk of heart attack. (I’ll talk more about niacin and other beneficial medications and supplements in Step 4.)
LDL (Low-Density Lipoprotein) Cholesterol
LDL is referred to as “bad” cholesterol because its particles burrow through the endothelial barrier (the inner artery lining) and deposit cholesterol in the plaques that form underneath the endothelium, in the artery walls. Rupture of these plaques leads to blood clots (and arterial spasm), which can block the arteries leading to your heart or brain and result in a heart attack or stroke. Even though 130 mg/dL or higher is a risk factor, ideally, your LDL level should be less than 100 mg/dL, especially if you have other risk factors. For patients who have already had heart attacks and for those at high risk, my goal for LDL cholesterol is less than 70 mg/dL.
It’s not just your overall LDL number that you need to be concerned about, however. Just as important is the size of your LDL particles. The smaller and denser your LDL, the greater your chance for heart attack. As you will learn in Chapter 4, advanced blood tests can tell you how many of these harmful particles you have. If your diet is poor—that is, if you are eating high amounts of bad carbs and bad fats—simply switching to the South Beach Diet can help reduce your LDL cholesterol and raise your good HDL cholesterol over time. But in some cases, diet alone may not be sufficient and medication may be required. As I explain in Chapter 7, statin drugs can be very effective in reducing LDL.
Question 10
Family History
Often, my patients who’ve had one or both parents die of a heart attack at a young age ask me whether the same thing will happen to them. My answer is “It doesn’t have to.”
The fact that one or both of your parents died prematurely of heart disease does put you at greater risk, but it doesn’t make it a fait accompli. There are other factors that will affect your own heart health, including lifestyle. For example, if your father smoked, rarely exercised, and ate a diet high in bad carbs and bad fats, his death could have been hastened by any or all of these factors. You may have been dealt a bad set of genes, but there’s a great deal you can do to reduce and even eliminate their negative impact. I have numerous patients with bad family histories who still have good hearts, and I have patients with good family histories who come to me with badly diseased hearts.
You may have inherited a specific gene or cluster of genes that makes you more likely to have bad cholesterol and/ or other bad blood lipids, which lead to heart problems. In fact, there is a fairly common genetic disorder that results in unusually high levels of the kind of small, dense LDL particles that I mentioned in the explanation of Question 9. There is also a rare genetic abnormality called familial hypercholesterolemia, which affects 1 in 500 people in North America. If you have inherited this mutant bad gene, your total cholesterol may be 350 or higher, even if you exercise and eat a heart-healthy diet. Lipoprotein (a) or Lp(a), which I discuss in Chapter 4, also runs in families but is not affected by diet or exercise.
For the treatment of small, dense LDL, getting plenty of exercise and eating a healthy diet is the primary approach. Patients with familial hypercholesterolemia always require statins along with leading an optimal lifestyle.
Many people know that the cardiovascular health of their parents influences their level of risk, but they are unaware that the health of their siblings matters as well. According to a recent article in the Journal of the American Medical Association (JAMA), if you have a brother or sister with cardiovascular disease, your own risk is increased by as much as 100 percent. In fact, if you grew up in the same household as your sibling, your sibling’s medical history is likely to be even more informative than your parents’. You and your brothers and sisters not only have similar genes, but you also ate similar food and grew up in the same environment.
Question 11
Triglycerides
Triglycerides are the form in which fat is stored in your body’s fat cells. Your triglyceride level is almost always strongly influenced by lifestyle. Remember the low-fat, high-refined–carbohydrate diet that I referred to earlier? The one that we used to think was heart protective? It actually elevates your triglycerides. Two decades ago, when I first began putting my patients on this type of diet, which was recommended back then, I was often dismayed to see their triglycerides go up. This, of course, was the opposite of what I was hoping to achieve. We now know that it was not the carbohydrates per se that raised the triglycerides, but the bad carbohydrates—sugars and starches devoid of fiber and other nutrients—that did it.
The same thing happened when I experimented with an extremely low fat diet that was also popular at the time. When I put one patient with a moderately high triglyceride level of 220 mg/dL on it to lose weight, he did not lose weight, and his triglycerides soared to over 500. His was just one of many cases like this that made me begin to question the conventional dietary wisdom of the time. Today, I recommend a diet that contains lean protein and moderate amounts of good fats (those found in oily fish, olive oil, and nuts) and good carbs (those found in vegetables, fruits, and whole grains). If patients follow this plan, reductions in triglycerides can be dramatic.
If you have high triglycerides (over 150 mg/dL is borderline high) and low HDL (less than 40 mg/dL if you’re a man and less than 50 mg/dL if you’re a woman), your risk of heart disease is compounded. To find out if you have this added risk, divide your triglyceride count by your HDL count. Ideally, the resulting number will be 2 or lower. For example, if your triglyceride level is 200 and your HDL is 40, divide 200 by 40 and you get 5. This is much higher than the desirable ratio, and it tells you that you have a heightened risk of a heart attack that will need to be addressed.
Your triglyceride level can also give you insight into your LDL particle size. In general, the higher your triglycerides and the lower your HDL, the smaller and denser your LDL and the greater your risk of heart disease. If your triglycerides are higher than 200 and your HDL is lower than 45, it is very likely that you have too much small, dense LDL.
There are a number of ways to lower your triglycerides. In addition to eating the healthy diet that I describe in Step 1, losing weight and getting more exercise can help. Medications such as niacin and fibrates are also effective at lowering triglycerides, increasing HDL, and enlarging LDL particle size. You’ll learn more about these medications in Step 4.
Blood Glucose
For many years, we have known that high blood glucose (sugar) is an indicator of diabetes. Now that we know that people with type 1 or type 2 diabetes and even prediabetes are at increased risk of heart disease, we view high blood sugar as a warning for these conditions.
National guidelines recommend that you keep your fasting glucose level below 100. If your glucose level is measured when you have not been fasting, then 139 is the upper limit. If your level is between 100 and 125 in the fasting state, or between 140 and 199 when you’ve recently eaten, you meet the criteria for a diagnosis of prediabetes, or insulin resistance. Above these levels, you have actual diabetes and your risk of heart disease goes up even more.
Blood glucose responds to lifestyle changes, including weight loss, exercise, and improvements in diet. (For more on diabetes, see Chapter 5.)
Question 13
Elevated Homocysteine
Homocysteine is an amino acid, a building block of protein that if allowed to rise to unhealthy levels in the blood can promote blockage of blood vessels. High levels of homocysteine have been associated with heart attack and stroke, which is why I recommend that people get their homocysteine checked each year. See page 214 for more on this test.
Elevated levels of homocysteine are also associated with depression and Alzheimer’s disease. A recent study conducted at Tufts University showed a direct link between high homocysteine levels and the degree of blockage of the carotid arteries, which deliver blood to the brain. And according to numerous studies, mental stress can cause a temporary bump in homocysteine.
For years, we’ve known that a combination of B vitamins (folic acid, B6, and B12) can lower homocysteine levels. Therefore, it seemed reasonable and desirable to prescribe this B-vitamin cocktail for people with high homocysteine. In one study, stroke patients were given a vitamin supplement containing these three B vitamins to see if it would lower their homocysteine and help prevent another stroke. The vitamins did lower homocysteine, but they did not reduce the occurrence of another stroke, heart attack, or death. In a separate Scandinavian study, researchers concluded that taking high doses of vitamin B6 and folic acid in combination may actually increase the risk of heart attacks and strokes. This doesn’t mean that you shouldn’t get your homocysteine levels down, but I recommend that you do it by consuming foods that are rich in vitamin B, and not by taking supplement pills.
In fact, it’s possible to get a significant reduction in homocysteine through dietary changes. An article in the American Journal of Clinical Nutrition found that those who included specific types of foods in their diets had the lowest levels of homocysteine. These foods included milk, yogurt, bell peppers, and cruciferous vegetables such as broccoli and cauliflower. All of these foods are mainstays of the South Beach Diet (see Step 1), and I urge you to eat more of them whether your homocysteine is high or not.
Elevated CRP
C-reactive protein (CRP) is a marker for inflammation. A higher than normal level of this protein circulating in your blood not only increases your risk of having a heart attack, but also puts you at risk for numerous other diseases, from arthritis to cancer. I recommend that everyone have a high-sensitivity CRP (hs-CRP) test (see page 213) as part of the South Beach Heart Program.
Inflammation in the arteries, represented by the level of hs-CRP, is thought to help precipitate plaque rupture. This is followed by blood clotting and vessel spasm, which can lead to a larger clot and possibly a heart attack.
Getting your CRP level as low as possible may reduce your risk of heart attack, stroke, and cardiac death. Why is this? New research shows that CRP is associated with reduced nitric oxide levels in the body. Nitric oxide promotes the health of your arteries. A deficiency in nitric oxide can also slow the formation of new blood vessels, which could make your body less efficient at creating a network of vessels to bypass blocked or narrowed arteries (see page 28).
A diet rich in saturated fat and trans fats as well as processed foods can promote inflammation in the body (see “Inflammation: The Bane of Civilization,” page 79). A recent study comparing the health of people 55 to 64 years old in the United States to those in Great Britain found that the American subjects had CRP levels that were 20 percent higher than those of the British. I believe that this difference in CRP is due to the pro-inflammatory fast-food American diet. Adopting the healthy eating principles of the South Beach Diet, which recommends anti-inflammatory good fats as well as other heart-healthy foods, is one way to bring down your CRP.
If you are overweight, losing belly fat can have a dramatic effect on CRP. Fat cells are not passive storage depots; they are 24-hour factories that churn out a host of substances, including chemicals called cytokines, which promote inflammation. In one study, a group of obese women who lost weight reduced their CRP by an average of 26 percent. People who are very obese and opt for gastric bypass surgery, or stomach banding, can cut their CRP level in half. If you are a smoker, giving up the habit will eliminate a major source of inflammation. Exercise is also anti-inflammatory.
Statin drugs and other medications can also help to reduce your CRP level.
Question 15
Sedentary Lifestyle
Our bodies work best when we are physically active, and they break down when we are not. As we age, our sex hormones decrease (even before menopause in women), and we have a tendency to lose muscle and bone. Since muscle and bone require more calories for maintenance than fat does, even at rest, when this deterioration happens, our metabolism slows down, and muscle does, in a sense, turn into fat. To prevent bone and muscle loss and to maintain your metabolism, exercise becomes even more important as you get older.
When you have a sedentary lifestyle, a number of undesirable changes can follow. Your blood pressure goes up, your triglycerides increase, your level of good HDL falls, and you are more likely to gain weight, especially around your middle. This is a picture of a heart attack in the making. Currently, only 25 percent of Americans get enough exercise. The solution, of course, is to get up and move. You’ll be reading a lot more about how exercise can help your heart in the South Beach Heart Workout, Step 2 of the program, beginning on page 173.
Question 16
Two Fish Meals a Week
If you’re not eating at least two fish meals a week, you are missing out on the heart-healthy “good fats” that are plentiful in certain types of seafood, especially in oily, deepwater fish such as tuna, rainbow and lake trout, salmon, herring, sardines, and Spanish mackerel. The medical literature continues to feature excellent studies on the many health benefits of adding good fats to our diet. According to the American Heart Association, consumption of omega-3 fatty acids (found in the fish mentioned above) can decrease the risk of abnormal heart rhythms (arrhythmias) and even slightly lower blood pressure. As I explain on pages 242–43, omega-3 fish oil supplements are a good substitute for fish. Certain fish are high in mercury and other contaminants and should be avoided.
Question 17
Fresh Fruits, Vegetables, and
Whole Grains Every Day
What’s on your plate at a typical meal? It should be filled with lots of “good carbs”—fresh fruits and vegetables and whole, unprocessed grains. Unlike highly processed refined carbs, good carbs contain fiber that slows down their digestion, preventing sudden swings in blood sugar that can lead to cravings.
Another benefit of “good carbs” is that they are sources of thousands of phytochemicals, compounds such as flavonoids and isoflavones that are believed to help protect us from many diseases of civilization, including heart disease. In fact, a recent study linked eating whole-grain foods (such as steel-cut oatmeal, bran flakes, and whole-wheat bread and pasta) with a 36 percent lower risk of coronary heart disease.
To date, there is no pill or capsule that has been shown to duplicate the benefits of whole foods. If you want to take advantage of nature’s full bounty, you have to eat the real thing. In Step 1 of my program, you’ll get a lot more information on how adopting good nutritional principles can improve the health of your heart.
Question 18
Avoid Trans Fats
If you aren’t already making a conscious effort to avoid eating foods that contain trans fats (aka trans fatty acids), you should be. Trans fats are man-made fats found in stick margarines, shortening, deep-fried foods (including french fries), and any products that contain partially hydrogenated or hydrogenated oil. Refined, processed carbohydrates, including many commercially baked breads, cookies, chips, crackers, and other snack foods, may contain trans fats. There is no healthy level of trans fats. The more you eat, the worse they are for you. My best advice is, try to avoid foods containing trans fats altogether.