|
|
PREVENTION
In February 2007, the American Heart Association (AHA) released new guidelines that provide the most current clinical guidelines for preventing cardiovascular disease in women age 20 and older. While some of the guidelines deal with medication—when to prescribe, how much, the best choices—many deal with lifestyle changes that study after study have shown are effective at lowering blood pressure, reducing cholesterol levels, minimizing atherosclerosis and, overall, reducing a woman's risk of developing heart disease, based on her individual cardiovascular health. To view the guidelines, visit: http://www.americanheart.org.
In 2007, an update to these guidelines is expected to be released by the AHA. The update will provide the most current clinical recommendations for the prevention of CVD in women age 20 years.
Here's the run down on what you can do to reduce your risks for developing heart disease:
Quit smoking. Women who smoke are two to six times as likely to suffer a heart attack as nonsmoking women, and the risk increases with the number of cigarettes smoked per day. Smokers who have a heart attack are more likely to die and die suddenly (within an hour) than are nonsmokers. Cigarette smoking also acts with other risk factors to greatly increase the risk for coronary heart disease. Constant exposure to other people's smoke—called environmental tobacco smoke, secondhand smoke or passive smoking—increases the risk of heart disease even for nonsmokers. And, of course, smoking also increases your risk for developing lung and other cancers.
The good news is that quitting dramatically cuts the risk to your heart, even during the first year, no matter what your age. Even if you've had a heart attack, you'll benefit from quitting—some women's risk of having a second heart attack is cut by 50 percent or more after they stop smoking. The 2007 guidelines recommend that women use counseling, nicotine replacement, or other forms of therapy to help them quit.
Lower your blood pressure. Even slightly high blood pressure levels can double your risk for coronary heart disease. High blood pressure also increases your chance of stroke, congestive heart failure and kidney disease. The higher the pressure, the higher the risk. More than half of all women over 55 have high blood pressure. High blood pressure is more common and more severe in African-American women. Unfortunately, even in women who are aware of a diagnosis of hypertension, a large number do not have their blood pressure controlled to desirable levels.
Blood pressure is considered high when it stays at or above 140/90 mmHg over a period of time, but you are considered at risk for hypertension via a condition called prehypertension if your blood pressure is between 120/80 and 139/89 mm/Hg.
You should have your blood pressure checked whenever you visit a health care professional. At minimum, every two years for women over age 20; more frequently if borderline-high or high blood pressure is indicated, or if you have a family history of high blood pressure. Because blood pressure is so variable, it should be checked on several different days before a high blood pressure diagnosis is made.
The AHA prevention guidelines for women recommend drug therapy when blood pressure is 140/90 or above. Drug therapy is recommended at even lower blood pressure levels if you have blood-pressure related organ damage or diabetes.
If your blood pressure is only mildly elevated, you may be able to control it entirely through weight loss (if you are overweight), regular physical activity, eating a variety of fresh fruits and vegetables and low-fat dairy products, and cutting down on alcohol, fat and salt or sodium. Sodium is an ingredient that is found in many packaged foods, carbonated beverages, baking soda and some antacids. You can reduce the sodium in your diet by limiting the amount of table salt you add to your food; avoid canned vegetables and use fresh or frozen vegetables instead; and check food labels for sodium content.
Using birth control pills may increase blood pressure in some women.
Lower your blood cholesterol level. Today, more than half of the women over age 55 need to lower their blood cholesterol, and a quarter of all American women have blood cholesterol levels high enough to pose a serious risk for CHD. Cholesterol management guidelines issued by the National Cholesterol Education Program (NCEP), a division of the National Heart, Lung and Blood Institute (NHLBI), specifically zero in on reducing LDL cholesterol levels in adults. Elevated low-density lipoprotein (LDL) cholesterol is a major cause of coronary heart disease.
Starting at age 20, all women should have their blood cholesterol tested and repeated every five years, according to most recent NHLBI guidelines. If you have a health condition or are considered at risk for developing heart disease, your health care professional may recommend more cholesterol testing more frequently.
The American Heart Association recommends targeted cholesterol testing for children age two or older if their parents or grandparents had heart disease or vascular disease before age 55, or if their parents have cholesterol levels of 240 mg/dL or higher.
For most people, cutting back on foods high in saturated fat and cholesterol will lower both total and LDL cholesterol.
Both the AHA and the National Cholesterol Education Program offer specially designed cholesterol-lowering diets. Ask your health care professional for more information or visit their Web sites: www.americanheart.org and www.nhlbi.nih.gov.
Regular physical activity and weight loss for overweight persons also will lower blood cholesterol levels. Losing extra weight, quitting smoking and becoming more physically active also may help boost your HDL cholesterol levels.
Lose weight. Overweight women are much more likely to develop heart-related problems, even if they have no other risk factors. Excess body weight in women is linked with coronary heart disease, stroke, congestive heart failure and death from heart-related causes. The more overweight you are, the higher your risk for heart disease. Being overweight contributes not only to cardiovascular diseases, but also to other risk factors, including high blood pressure, high blood cholesterol and diabetes. Fortunately, these conditions often can be controlled with weight loss and regular physical activity.
Body shape as well as weight may affect heart health. "Apple-shaped" individuals with extra fat at the waistline may have a higher risk than "pear-shaped" people with heavy hips and thighs. If your waist is nearly as large as, or larger than, the size of your hips, you may have a higher risk for coronary heart disease.
Ideally, the AHA preventive guidelines for women recommend women maintain/achieve a body mass index (BMI) between 18.5 and 24.9 and a waist circumference of less than 35 inches. Your BMI, a measurement that considers height as well as weight, can be calculated online at www.nhlbisupport.com.
For lasting weight loss, engage in regular, brisk physical activity and eat foods that are low in calories and fat. For physical activity, the current recommendations for women who need to lose weight and maintain weight loss are for 60 to 90 minutes of moderate exercise (such as brisk walking) most, preferably all, days of the week. Do not try to lose more than one half to one pound a week.
Adjust your diet to include a wide variety of low-calorie, nutritious foods in moderate amounts from the basic food groups. Include pasta, rice, bread and other whole-grain foods, as well as fruits and vegetables, and keep other foods low in fat, since fat is the richest source of calories. But keep in mind that while many low-saturated fat food products are now available, many of them are still loaded with sugar and therefore high in calories.
Increase physical activity. Physical inactivity increases the risk of heart disease. It contributes directly to heart-related problems and increases the chances of developing other risk factors, such as high blood pressure and diabetes.
Fortunately, it doesn't take a lot of effort to become physically active. As little as 30 minutes of moderate activity on most, and preferably all, days of the week helps protect the heart and is recommended by the AHA. However, the recommendations rise to 60 to 90 minutes of moderate activity most, and preferably all, days of the week in women who need to lose or maintain weight. Examples of moderate activity are brisk walking or bicycling, raking leaves or gardening. Vigorous exercise includes running, jogging, swimming laps and cross country skiing.
If you prefer, you can divide the 30-90 minutes of moderate activity into shorter periods of at least 10 minutes each. If you already engage in this level of activity, you can get added benefits by doing even more.
If you have heart disease, regular, moderate physical activity lowers the risk of death from heart-related causes. However, if you have heart disease, check with your doctor first to find out what kinds of activities are best for you.
Once you get started, keep these guidelines in mind:
Go slow. Before each session, take five minutes for stretching and slow movement to warm up, and at the end of the session, take five minutes to cool down with a slower pace.
Listen to your body. Some stiffness is normal at first, but if you hurt a joint or pull a muscle or tendon, stop the activity for several days to avoid more serious injury.
Pay attention to warning signals. While physical activity can strengthen your heart, some types of activity may worsen existing heart problems. Warning signals include sudden dizziness, cold sweat, paleness, fainting or pain or pressure in your upper body during or after engaging in physical activity. If you notice any of these signs, call your health care professional or 911 immediately.
Keep at it. Unless you have to stop your exercise program for health reasons, stick with it. If you feel like giving up because you think you're not going as fast or as far as you should, set smaller, short-term goals. If you're getting bored, try engaging in an activity with a friend, or switch to another activity.
Be aware of diabetes. Diabetes, or high blood sugar, is a serious metabolic disorder that raises the risk of coronary heart disease. According to NHLBI, diabetes poses as great a risk for having a heart attack in 10 years as heart disease itself. Women with diabetes are also more apt to have high blood pressure and high blood cholesterol. About 75 percent of those with diabetes die of some type of cardiovascular disease. After age 45 about twice as many women as men develop diabetes. Deaths from heart disease in women with diabetes increased 23 percent over the past 30 years, compared to an increase of just 13 percent in men.
People with diabetes often have accelerated atherosclerosis, or a buildup of plaque in their arteries, meaning they develop the condition faster than those without diabetes who have other similar risk factors.
Women with diabetes often aren't aware of their significantly increased risk for heart disease. In fact, an American Diabetes Association survey found that 68 percent of those with diabetes were not aware of their increased risk for heart disease and stroke, and 60 percent didn't know they were at risk for high blood pressure and cholesterol, both of which increase their overall risk of heart disease and stroke.
While there is no cure for diabetes, it can be controlled. The most important first step is getting the right diagnosis. If you have diabetes, you should be treated as intensively as people with heart disease in terms of medication and lifestyle changes, according to NHLBI.
Today, the standard treatment to prevent heart disease in people with diabetes is a daily aspirin and a prescribed ACE inhibitor and statin. In fact, statin medications, best known for their cholesterol-lowering benefits, work so well at preventing heart disease in people with diabetes regardless of cholesterol level that in June 2003 experts began recommending that all people with diabetes, even those with normal cholesterol levels, take a statin. Not all statins have been shown to prevent a first heart attack, however.
The unprecedented recommendation came after the publication of the landmark Heart Protection Study that month in the journal Lancet. The study found that using 40 mg daily of simvastatin cut the risk of cardiovascular problems in diabetics by about a third, even in those whose cholesterol levels were normal. Overall, study researchers said, such an effect could prevent 70-100 out of every 1,000 people with diabetes from suffering at least one major cardiovascular problem, such as angina or a heart attack.
Additionally, tight control of your diabetes is important. The AHA preventive guidelines for women recommend that lifestyle and medication be used to achieve near normal HbA1C levels (less than seven percent). HbA1C is a blood test that provides a picture of blood sugar levels over time.
Additionally, tight control of your diabetes is important. The AHA preventive guidelines for women recommend that lifestyle and medication be used to achieve near normal HbA1C levels (less than seven percent). HbA1C is a blood test that provides a picture of blood sugar levels over time.
Finally, if you take birth control pills and have diabetes or insulin resistance, you should have regular blood sugar tests because contraceptive hormones can alter glucose levels.
Decrease stress. In recent years, we have heard a lot about the connection between stress and heart disease. Some common ways of coping with stress, such as overeating, heavy drinking and smoking, are clearly bad for your heart. Studies continue to investigate the direct effects of stress on your heart.
The good news is that sensible health habits can have a protective effect. Regular physical activity not only relieves stress, but also can directly lower your risk of heart disease. Also, participating in a stress management program following a heart attack lowers the chances of further heart-related problems.
Follow a heart healthy diet. Avoiding or limiting saturated fat and cholesterol from the foods you eat can help lower cholesterol and reduce the calories contributed to your diet by fat. The "Therapeutic Lifestyle Changes (TLC) Diet" plan, developed by the NHLBI, calls for less than seven percent of your calories to come from saturated fat and for less than 200 mg of dietary cholesterol.
Twenty-five to 35 percent or fewer of total daily calories can come from fat, provided most of these calories are from unsaturated fat, which doesn't raise cholesterol.
Also limit your sodium intake to no more than 2,400 mg per day.
The guidelines also encourage the use of certain foods rich in soluble fiber to boost the diet's LDL-lowering power. In addition, the AHA recommends women limit their intake of trans fatty acids overall.
Saturated fat is found mainly in food that comes from animals. Whole milk dairy products such as butter, cheese, milk, cream and ice cream all contain high amounts of saturated fat. The fat in meat and poultry skin is also loaded with saturated fat. A few vegetable fats—coconut oil, cocoa butter, palm kernel oil and palm oil—are also high in saturated fat. These fats are sometimes found in cookies, crackers, coffee creamers, whipped toppings and snack foods. Remember: Saturated fat boosts your blood cholesterol level more than anything else in your diet.
While unsaturated fat does not raise cholesterol levels, like all fats it has nine calories per gram. Polyunsaturated fat (found in many cooking and salad oils, such as safflower, corn, soybean, cottonseed, sesame and sunflower oils, and in some margarine) and monounsaturated fat (found in olive, canola and peanut oils) are examples of unsaturated fats.
Foods that contribute cholesterol to your diet come from animal sources. Egg yolks and organ meats (liver, for example) are very high in cholesterol. Meat and poultry have similar amounts of cholesterol. Eating less cholesterol will help lower blood cholesterol level.
In addition to the above recommendations, the 2007 AHA update recommends that women eat oily fish, such as salmon, mackerel or tuna, at least twice a week and consider taking a fish oil supplement containing 850-1000 mg eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) for women with heart disease and two to four grams of DHA and EPA in women with high triglycerides.
Below are some practical tips for managing your diet:
Eat a balanced diet with fish two to three times a week, if possible.
Choose lean cuts of meat, and remove fats from meats and skin from chicken before cooking. Eat up to six ounces per day.
Broil, bake, roast or poach foods rather than fry them.
Cut down on sausage, bacon and processed high-fat cold cuts.
Limit organ meats such as liver, kidney or brains.
Eat two servings of fatty fish, such as mackerel, tuna or salmon, per week.
Instead of whole milk or cream, drink skim or one percent milk. Try nonfat or low-fat yogurt in place of sour cream. Use nonfat or low-fat cheeses. Substitute sherbet and nonfat or low-fat frozen yogurt for ice cream.
Instead of butter, use olive oil or liquid vegetable oils high in poly- or monounsaturated fats. All fats and oils should be used sparingly.
Eat egg yolks only in moderation. Egg whites contain no fat or cholesterol and can be eaten often. In most recipes, substitute two egg whites for one whole egg.
Eat plenty of fruits and vegetables as well as cereals, breads, rice and pasta made from whole grains (for example, rye bread, whole wheat spaghetti and bran cereal). These foods are good sources of starch and fiber, and usually contain no cholesterol and little or no saturated fat.
Liquid vegetable oils are a good choice for sautéing vegetables, browning potatoes, popping corn and for making baked goods, pancakes and waffles. Use small amounts or try a vegetable oil cooking spray.
Plant stanol and sterol margarines. Plant sterols (also called stanol esters), work by blocking absorption of cholesterol in the digestive tract. Recent studies have shown that plant sterols effectively lower cholesterol even in people already on statin medications. Although name brands are not specifically mentioned, the American Association of Clinical Endocrinologists (AACE) lipid guidelines recognize plant stanol esters, like those found in Benecol and Take Control spreads, as effective dietary agents for lowering LDL or bad cholesterol by more than 10 percent. To get this effect, however, you have to "take" the full amount daily (2 grams a day), not just once in a while.
Heart Disease Prevention for Women with cardiovascular disease
The AHA preventive guidelines make several recommendations for women who have already been diagnosed with cardiovascular disease, including:
Cardiac rehabilitation. Women who have recently had a heart attack, or a coronary intervention, such as angioplasty or bypass surgery, should participate in some form of cardiac rehabilitation. Cardiac rehabilitation is a medically supervised program to help heart patients recover quickly and improve their overall physical and mental functioning. The goal is to reduce the risk of another cardiac event or to keep an already present heart condition from getting worse. Programs include counseling, exercise, help with identifying and modifying risk factors and returning to work, as well as lending emotional support.
However, several studies find that women are underrepresented in such programs, and do not get referred as often as men, even though the results are just as good for women as for men.
Evaluation for depression. Women with cardiovascular disease should be evaluated for depression and referred for therapy when necessary. Studies find that depression along with cardiovascular disease can increase the risk of complications and death.
Other Approaches to Heart Disease Prevention
Alcohol use. Several studies find that moderate drinkers—for women, this is one drink per day and for men, two drinks per day, according to the National Institute of Alcohol Abuse and Alcoholism—are less likely to develop heart disease than people who don't drink any alcohol. One drink equals 12 ounces of beer, five ounces of wine, or one and one-half ounces of 80-proof liquor.
If you are a nondrinker, this is not a recommendation to start using alcohol. And certainly, if you are pregnant or have another health condition that could make alcohol use harmful, you should not drink.
But remember, moderation is the key. More than two drinks per day can raise blood pressure, and binge drinking can lead to stroke. People who drink heavily on a regular basis have higher rates of heart disease than either moderate drinkers or nondrinkers.
Aspirin. The research on aspirin is promising. Aspirin may help to both prevent heart attacks in healthy or low risk women and treat heart attacks in women who have already had them. A study of more than 87,000 women found that those who took a low dose of aspirin regularly were less likely to suffer a first heart attack than women who took no aspirin. Women over age 50 appeared to benefit most.
Other recent research suggests that only a tiny daily dose of aspirin may be needed to protect against heart attacks. One study found that, for both women and men, taking only 30 mg of aspirin daily—one-tenth the strength of a regular aspirin—helped prevent heart attacks as effectively as the usual 300 mg dose. The smaller dose also caused less stomach irritation.
Aspirin also reduces the chances that women who have already had a heart attack or stroke will have, or die from, another one. If taken quickly, aspirin may also increase the chances of survival after a heart attack. The AHA guidelines for women recommend that women who are at high risk of coronary heart disease take a daily aspirin (or clopidogrel, brand name Plavix, if they can't take aspirin). Women at intermediate risk should consider aspirin therapy as long as their blood pressure is controlled and the benefit of the aspirin is likely to outweigh any stomach upset that may occur from daily aspirin. All women taking aspirin should discuss it with their health care professional first.
Keep in mind, however, that aspirin is a powerful drug with many side effects. It can increase your chances of getting ulcers, kidney disease, liver disease and a stroke from a hemorrhage. Because of these serious risks, you should not take aspirin to either prevent or treat a heart attack without first discussing it with your health care professional.
Folic acid. The AHA's new guidelines recommend that women at high risk for heart disease who have a higher-than-normal level of homocysteine should supplement with folic acid. Folic acid is one of three vitamins found to affect homocysteine levels, a risk factor for heart disease. This treatment has no side effects, but has not been proven to prevent heart attacks.
Omega-3 fatty acids. More and more research suggests that consuming fish and fish oil supplements (omega-3 fatty acids) can also lower the risk of CHD, and death from CHD. In fact, the heart disease prevention guidelines for women released in February 2007 by the AHA recommend that women at high risk of heart disease supplement their diet with omega-3 fatty acids. Women can get omega-3 fatty acids by eating two servings of fatty fish such as tuna, mackerel or salmon per week, as well as taking fish oil supplements. Women with heart disease should take a fish oil supplement containing 850-1000 mg eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), and women with high triglycerides should take for women with heart disease and two to four grams of DHA and EPA per day.
Despite past warnings about seafood and mercury content, a recent report released by the Institute of Medicine (IOM) showed that the heart benefits of seafood outweigh the risks in infants as well as in adults. As a result, they recommend that women eat at least two servings of fatty fish per week. This is true even for women who are pregnant, who might become pregnant, or who are nursing, as well as for young children—as long as they eat the recommended amounts of fatty fish—up to 12 ounces per week.
