Differences Between the Sexes on Cholesterol?

For a long time, medical studies didn’t include women because researchers were afraid that their menstrual cycle would skew results or that the subjects would become pregnant and have to stop taking a medication. Younger women were also less likely to have heart disease, which meant more participants would have to be included to be able to show a difference in outcomes if women were involved. More study subjects means more money to do the study, so leaving women out was a practical decision that wasn’t as sexist as it sometimes appears.
Fortunately, once the benefit of a particular therapy was shown in men, the economics made it favorable to study women as well, and later studies have shown that women benefit just as much as men do from cholesterol-lowering interventions, whenever the risk is equivalent. By the time women are in their midsixties, their risk of new coronary events is similar to that of similarly aged men, so there should be little difference in treatment at that point. In younger, premenopausal women, the risk for heart disease is less than that of men, so fewer women in this age group require treatment. However, when all risk factors are taken into account, men and women of equivalent risk for heart disease get treated to the same LDL target goals.

Why Won’t My Doctor Prescribe a Statin-Fibrate Combination?

Some primary care doctors are hesitant to prescribe this combination of drugs after the deaths and other problems caused when the no-longer-available statin Baycol was mixed with fibrates. There is also a warning in the labeling of all statin medications that generally advises that they not be used in combination with fibrate therapy. Lipid specialists know that despite the risks, a statin-fibrate combination is an extremely effective way to lower lipids when combined disorders are present. As long as a patient is fully educated to watch for serious muscle side effects, I believe this combination can be safely used. If a person were unable to recognize or communicate the presence of muscle pains for any reason, however, this combination treatment should probably not be used. If you have a combined lipid disorder but your doctor is shying away from statin-fibrate therapy, you might want to ask for a referral to someone in your community who specializes in the
treatment of lipid disorders.

How to Save Money on Drugs (2)

Shop Around for the Best Price
The same kind of comparison shopping you might do for a car or a coffeemaker can pay off for drugs.
• Buy by mail. If your prescription drugs are covered by insurance, see if the insurer has a mail-order pharmacy. Some offer lower co-payments.
• Call around. You’ll find that drug prices vary from store to store. Try independent pharmacies, national chains, and megastores such as Wal-Mart and Costco.
• Go online. You can find bargains or quickly compare drug prices on the Internet. (If you don’t have a computer, the ones at your public library are free to use, and many librarians will help you find information.) Many brick-andmortar pharmacies have websites that offer discounts on prescription drugs. So do “virtual” pharmacies, which do all their business online. For the most part, shopping for prescription drugs online is safe. One way to tell if the site is legitimate is the VIPPS (Verified Internet Pharmacy Practice Sites) seal of approval from the National Association of Boards of Pharmacy. You can also check with the board to see if an online pharmacy is licensed and in good standing.

Join a Group
Some organizations offer savings on prescription drugs as a perk. If you’re a member of AARP, for example, you can join its MembeRx Choice plan for $20 a year. It offers savings on topselling
drugs. If you served in the military, you may be eligible for the TRICARE Pharmacy or Senior Pharmacy programs. Buying groups such as the Peoples Prescription Plan and the United States
Pharmaceutical Group also offer savings and are open to everyone. (Find more information in the Resources.)

Look for Low-Income Options
Some money-saving options are aimed at low- to middle-income seniors without any drug insurance. The Together Rx Card, for example, provides savings on more than 150 widely prescribed medicines. Some states provide assistance with prescription drugs to low-income seniors or people with disabilities who do notqualify for Medicaid. To quickly find out if your state has such a benefit or if you qualify for other programs, try the National Council on the Aging’s BenefitsCheckUp Web site. (For more information, see the Resources.)

Reduce Your Need for Drugs
If you’re serious about cutting your drug bill, get serious about adopting a healthier lifestyle, which may cut the need for medication. Don’t stop taking your pills first and then try to make lifestyle changes. Make the changes first. When you start getting results, then talk with your doctor about medication changes.

How to Save Money on Drugs (1)

You don’t need the newscasters to tell you that prescription drug prices are on the rise or that insurers are covering less of the cost. For some people, the out-of-pocket outlay for prescription drugs extracts little more than a quiet moan at the cash register. For others, it means skipping medicine or meals in order to pay. Here are some tips for cutting costs.
Get Your Doctor’s Help
Unless a doctor knows you’re trying to cut corners, he or she won’t take price into consideration when filling out the prescription pad. But most doctors are willing and able to help once you mention your concern. Here are a few things to ask about:
• Generic drugs. Buying generic drugs instead of the more expensive brand-name versions is one of the most effective ways to cut your monthly drug bill. For example, a month’s supply of the 20 mg dose of the brand-name statin Mevacor costs about $70, while the same amount of generic lovastatin costs about $35. There’s no need to worry that a cheaper price means less quality. The Food and Drug Administration (FDA) regulates the production of generics just as carefully as brand-name drugs. The only difference may be in the inactive ingredients—things like fillers, coatings, and flavorings. Some doctors worry that the inactive ingredients change how much of the active ingredients the body absorbs. The FDA doesn’t share this concern, though. Some classes of drugs are so new that generic forms aren’t yet available. If your doctor prescribes one of these, ask if there’s a slightly older type of drug that does much the same thing.
• Cheaper brand-name drugs. Sometimes you can trade off convenience for savings. For instance, if your doctor suggests a brand-name combination drug, ask if you can save money by taking the component drugs one by one. In other cases, you can save by taking an older drug two or three times a day instead of using a newer (and more expensive) once-a-day formulation.
• Starting small. When you start a new drug, ask your doctor to give you a prescription for just a week or two. This way you can see if the dosage is right and if the drug agrees with you. If everything goes well, then you can fill a longer-term prescription. If it doesn’t, you aren’t stuck
with a stockpile of pills you paid for but can’t use.
• Starting low. Ask about starting a drug at the lowest possible dose, especially for a drug that’s relatively new.
• Splitting the difference. You expect to pay about twice as much for a two-pound box of pasta as you do for a onepound box. But the same pricing concept doesn’t always apply to drugs. Often, you can save money by asking your doctor to prescribe pills in twice the dosage you need.
Then you can cut them in half to double the number of doses. This approach is not for everyone, and it can’t be done for all drugs. Capsules and timed-release formulas, in particular, should never be split.

The Metabolic Syndrome

A person with metabolic syndrome has three or more of the following:
• A large waist (forty inches or more for men and thirty-four inches or more for women; to measure your waist size, don’t go by your belt measurement—instead, wrap a tape measure around the largest part of your midsection and make sure you keep the tape measure parallel to the floor)
• Borderline or high blood pressure (anything above 130/85 mm Hg)
• A high level of triglycerides (above 150 mg/dL)
• Low HDL (under 40 mg/dL for men or 50 mg/dL for women)
• High fasting blood sugar (above 100 mg/dL)
What does metabolic syndrome do to the body? Doctors and researchers think that metabolic syndrome’s impact on health is more than the sum of its parts. Basically, in people with this disorder, blood sugar levels stay high after a meal or snack instead of dropping to a base level as they do in most people. The pancreas, sensing still-elevated glucose levels, continues to pump out insulin. Constant high levels of insulin and blood sugar have been linked with many harmful changes, including damage to the lining of coronary and other arteries, increased triglyceride levels in the blood, changes in how the kidneys handle salt, and blood that clots more easily. Chronic overstimulation of the pancreas may exhaust it so that it stops supplying enough insulin.
This cascade of changes isn’t healthy. Damage to artery walls, high triglycerides, and increased chance of blood clots can lead to heart attacks and some strokes. Changes in the kidneys’ ability to remove salt contribute to high blood pressure, another path to heart disease and stroke. And dwindling insulin production by the pancreas signals the start of type 2 diabetes, which greatly increases the chances of having a heart attack or stroke, as well as nerve, eye, and kidney damage.
Even after heart disease appears, the metabolic syndrome continues to complicate things. Among almost sixty-five hundred men and women who had bypass surgery, for example, those with metabolic syndrome were four times more likely to have died within eight years of their surgery than those without it. This syndrome was especially hazardous for women, who were thirteen times more likely to have died.
Researchers from the Centers for Disease Control and Prevention applied the given definition of metabolic syndrome to almost nine thousand people who took part in the Third National Health and Nutrition Examination Survey. In this sample, about 23 percent had the metabolic syndrome. Applied to the entire United States, this would mean about forty-seven million Americans have this problem. The treatments outlined in the next chapters can decrease the chance that you’ll have the symptoms that characterize metabolic syndrom.

Things to Mention to Your Doctor if You Are About to Be Treated for an Abnormal Lipid Profile

Going to the doctor can be overwhelming or scary. And it’s easy to forget to ask questions or mention recent events that might have skewed a blood test result. I suggest that you bring a written list of questions or topics you want to cover. Here are some issues you might want to bring up with your doctor when discussing your recent lipid profile:

1. Tell the doctor if you had a flu or other major or minor illness shortly before the blood test was performed. These events can dramatically alter the lipid profile, either reducing or elevating several of the lipoprotein fractions.
2. If your diet was dramatically different from your typical diet in the weeks leading up to the lipid test, this is worth noting, because high alcohol or carbohydrate intake can cause a dramatic elevation in serum triglycerides.
3. If you were expected to fast and didn’t, don’t be embarrassed to say so. You could end up on the wrong drug treatment if this error is not identified.
4. If there is an abnormality (i.e., high cholesterol levels when there hadn’t been in the past), ask if your cholesterol will be measured again to make sure it wasn’t a fluke.
5. Ask how you and your doctor will use the results to decide on a treatment plan.
   

Alternative Remedies For Heart Desease

Several natural therapies are promoted as treatments for heart disease. Some have been put to the test in scientific studies and look promising, but others have not held up to scientific scrutiny. Many such herbal remedies and alternative treatments—available in drugstores and on the Internet—remain unproved and therefore should be taken with caution. And because herbs and other nutritional supplements are not reviewed for purity or effectiveness by the FDA, you can’t be sure that what you’re buying is effective or even that the bottle contains the substance on the label. If you take any herbal remedies, be sure to tell your doctor. These preparations may hinder or exaggerate the effects of prescription drugs used to manage cardiovascular disease. Indeed, heart patients are more vulnerable than most others to adverse drug interactions. Here is some information about two popular alternative remedies for heart disease. Of course, there are many others out there that I just don’t have the space to cover.
Coenzyme Q10
This vitamin-like substance is found in every cell in the body but is most prevalent in tissues with high energy demands, such as the muscles of the heart. Many advocates of alternative medicine believe that it can strengthen the heartbeat by increasing the cellular fuel available to the heart muscle. And some small studies have suggested that it might help patients with angina, heart failure, or other cardiovascular problems. But a few years ago, researchers in Australia conducted a rigorous trial that evaluated coenzyme Q10 in thirty patients with heart failure. All were taking conventional medicines, but for twelve weeks each subject also took either coenzyme Q10 or a placebo. At the end of the study, there was no change in the strength of the heartbeat as evaluated by echocardiography and cardiac catheterization. And the people who took coenzyme Q10 did not feel better or report improved ability to function.
Chelation Therapy
Chelation therapy uses infusions, or slow injections, of a chemical called ethylenediaminetetraacetic acid (EDTA). This process is sometimes used to remove toxic levels of lead, iron, or other metals from the body. (The metals exit the body via the urine.) Some experts think that the oxidation of LDL cholesterol requires interaction with such metals. The idea behind chelation for cardiovascular disease is that removing some of these metals from the bloodstream will also reduce oxidation—and this “antioxidant” effect might improve blood vessel function.

What a Heart Attack Feels Like

I hope you’ll get diagnosed and treated long before heart disease leads to a heart attack, but you should know the warning signs just in case. Unlike in the movies, where a person having a heart attack gropes his chest (and in the movies, unlike reality, it’s almost always a man) and falls to the floor, the symptoms of a reallife heart attack are often more subtle. They differ between men and women and from person to person. Generally, men will report the following:
• Pain or discomfort in the chest that radiates to the shoulder or arms, to the upper back near the shoulder blades, or to the neck or jaw
• Uncomfortable pressure, tightness, fullness, or ache at the center of the chest
• Shortness of breath, sweating, nausea, or dizziness

Women, on the other hand, usually report the following:
• Pain in both arms or shoulders
• Chest cramping or dull pain between the breasts
• Shortness of breath
• Feeling of indigestion
• Lower abdominal pain
• Severe fatigue (the least specific symptom, usually not caused by a heart attack.

Relaxation Techniques

Breath Focus
What Is It? Focusing on slow, deep breathing and gently disengaging the mind from distracting thoughts and sensations
Especially Beneficial: If you have an eating disorder or tend to hold in your stomach (may help you focus on your body in healthier ways)
May Not Be Suitable: If you have health problems that make breathing difficult, such as respiratory ailments or congestive heart failure

Progressive Muscle Relaxation
What Is It? Tensing and relaxing all the muscles of the body from head to toe in a progressive sequence
Especially Beneficial: At times when your mind is racing or if you have trouble sensing and releasing tension
May Not Be Suitable: If you have an eating disorder or have had recent surgery that affects body image or if you have a condition that makes tensing the body especially uncomfortable

Mindfulness Meditation
What Is It? Breathing deeply while staying in the moment by deliberately focusing on thoughts and sensations that arise during the meditation session
Especially Beneficial: If racing thoughts make other forms of meditation difficult
May Not Be Suitable: If you find it too hard to commit the thirty to forty-five minutes suggested

Are You Depressed?

Identifying the symptoms of depression can be a useful first step toward gaining a deeper understanding of how depression, bipolar disorder, or the long-lasting low-level depression called dysthymia (pronounced dis-THIGH-me-a) affects you. It may help you open a discussion with a doctor or therapist, too.
Be aware, however, that self-tests like this one cannot diagnose depression or any other mental illness. Even if they could, it’s easy to dismiss or overlook symptoms in yourself. It may help to have a friend or relative go over this checklist with you. Also, remember that your feelings count far more than the number of check marks you make. If you think you are depressed or if you have other concerns or questions after taking this test, talk with your doctor or therapist.
Depression Checklist
Start by checking off any symptoms of depression that you have had for two weeks or longer. Focus on symptoms that have been present almost every day for most of the day. (The exception is the item regarding thoughts of suicide or suicide attempts. A check mark there warrants an immediate call to the doctor.) Then look at the key that follows the list.

• I feel sad or irritable.
• I have lost interest in activities I used to enjoy.
• I’m eating much less than I usually do and have lost weight, or
• I’m eating much more than I usually do and have gained weight.
• I am sleeping much less or more than I usually do.
• I have no energy or feel tired much of the time.
• I feel anxious and can’t seem to sit still.
• I feel guilty or worthless.
• I have trouble concentrating or find it hard to make decisions.
• I have recurring thoughts about death or suicide, I have a suicide plan, or I have tried to commit suicide.

Now think about other symptoms you have noticed during this time:

• I feel hopeless.
• I have lost interest in sex, including fantasies.
• I have headaches, aches and pains, digestive troubles, or other physical symptoms.

Scoring the Test
If you checked a total of five or more statements on the depression checklist, including at least one of the first two statements, you may be suffering from an episode of major depression. If you checked fewer statements, including at least one of the first two statements, you may be suffering from a milder form of depression or dysthymia. Either way, your doctor may be able to recommend treatments to help.

Obesity in Pregnancy

The problem of mothers accumulating excess weight and developing obesity during pregnancy has been described for over 50 years and is a common reason given by obese women for their weight problem. Studies have shown that there is considerable variation in the amount of weight gained during gestation and that excess weight is often retained postpartum. Although the mean weight gain is quite small, some women experience extreme weight gains and others have cumulative increases in body weight after each pregnancy. Of equal concern is the potential impact upon the adiposity of a child born to an obese woman. Although only recently identified as of concern, the propensity of obese women to produce large babies, whether or not they display their increased susceptibility to gestational diabetes, is now linked to a much greater likelihood of these children becoming obese during childhood.

Family History of Obesity and/or Diabetes

It has long been known that obesity runs in families, although the determinants of that heritability are not likely to be all genetic, with parental influence on dietary and physical activity patterns also playing a role. Whitaker et al. examined the influence of parental obesity on the development of childhood obesity and its persistence into adulthood. They found that having at least one obese parent greatly increased one’s risk of becoming obese as an adult. However, the risks of adult obesity were magnified in subjects who had an obese parent and who were also obese as children. In younger children this effect was small or nonexistent (OR = 1.3 for children aged 1–2 years) but was very pronounced in older children (OR=17.5 in 15- to 17-year olds). Thus it would appear that identifying children with obese parents and intervening early to prevent unhealthy weight gain may allow the progression to adult obesity to be prevented.
It has also been well recognized for some time that the children of parents with type 2 diabetes are particularly susceptible themselves to type 2 diabetes should they gain weight. Recent studies have found that this susceptibility is much stronger in children whose mother, rather than father, had type 2 diabetes and have attributed this problem to the diabetic intrauterine environment. Therefore, preventive measures should properly be focused on the children of obese adults with or without a family history of diabetes and pregnant women with a history of type 2 diabetes.

Low HDL

Recommendations for people with low HDL levels are a little less cut-and-dried than those for the other lipid problems. That’s because we don’t have any studies showing specifically that if we raise HDL levels, heart disease risk goes down. We know HDL is good for the heart, so we believe that the higher the levels the better, but no studies have unequivocally proved that. Why? Because all the drugs we employ to raise HDL levels typically lower the LDL or triglyceride values at the same time. This makes it hard to tell which change caused the benefit of fewer heart problems. Recent animal studies have also shown that there may be good ways to raise an HDL cholesterol level and bad ways to do that, so without knowing how a drug has led to a change in HDL, one can’t readily predict if its effects would be beneficial or detrimental.
None of the statins alter HDL levels very dramatically (about 4 percent to 10 percent increase), whereas the fibrates and niacin do a better job of raising HDL levels (about 10 percent to 15 percent). Despite the unanswered questions about treating HDL, it is a very important blood value, with some studies indicating it predicts coronary disease risk better than any other single lipid value. The large observational study called the Framingham Heart Study suggests that every 1 mg/dL decrease in HDL increased the risk of having a heart attack by 2 percent to 3 percent. And the NCEP classifies an HDL level below 40 as a major risk factor for developing heart disease.
Most doctors don’t often prescribe medications to raise HDL levels, because the drug that works best—niacin—can be hard to take and may have side effects that are particularly undesirable in
the population most likely to have low HDL levels: diabetics. More options should become available in the near future, as the study of HDL metabolism is the most active area of cutting-edge research in the lipid field, and several new approaches are currently in early clinical trials. Luckily, though, there are a lot of lifestyle changes that raise HDL levels that are also beneficial to the rest of your cholesterol profile, your heart in general, and just about every other part of your body. The following can help you raise your HDL level:
• Exercising
• Not smoking
• Avoiding foods with trans fats (a lot of margarines, fried foods, some commercial baked goods)
• Losing weight if you’re overweight
• Drinking a small amount of alcohol every day (typically one drink for women, two for men)
Again, while we don’t know if raising HDL through these changes will help prevent heart disease, we do know that their other benefits will definitely decrease heart disease risk.

Stress Can Cause Brain Damage and Memory Loss

One of the body’s responses to stress is a heightened mental state and the ability to think on your feet. While this sounds wonderful, the downside is that the chemical that causes this mental alertness, cortisol, also kills brain cells. According to Dr. Robert Sapolsky, a Stanford University biologist who has extensively researched the physical effects of stress, the cells that are most vulnerable to destruction are the ones located in the hippocampus, the part of the brain responsible for memory. The hippocampus is also the area that deteriorates when patients contract Alzheimer’s disease and other memory disorders. This research seems to point to the idea that prolonged stress could be directly related to memory problems and other cognitive disorders.
Now that we’ve seen the toll that stress takes on the body and the emotions, let’s look at several strategies for managing stress.

Stress Contributes to Some Cancers

While the relationship between stress and cancer has not been definitely proven, enough information has been gathered to cause researchers to continue to explore the question. For example, the National Cancer Institute reports that some studies of women with breast cancer have shown significantly higher rates of occurrence of this disease among women who have experienced traumatic life events and stress within several years of their diagnosis. These factors include death of a spouse, social isolation, and other psychological factors.

Studies are also under way to explore the effects of stress on the immune response of women already diagnosed with cancer to see if stress reduction can slow the progression of the cancer. One major study conducted by Ohio State University and published in the Journal of the National Cancer Institute involved high-stress and low-stress women following surgery for stage II and stage III breast cancer. The researchers found that the women who reported high levels of personal stress had significantly lower blood levels of three important immune factors. The first two were the NK cells, which play a large role in the immune system’s search for tumors and virally infected cells, and T-lymphocytes, also known as white blood cells. When the researchers exposed the NK cells within the bloodstream of the high-stress women to extra amounts of gamma interferon, a compound that naturally enhances NK cell activity and the replication of viruses, they found a third significantly lowered immune response. The more stress a woman reported, the less effect the gamma interferon had on her NK cells.

Reductase Inhibitors (Statins)

Statins are the most widely used class of cholesterol-lowering drugs. Large, randomized clinical trials have shown—and continue to show—that people who use statins have a 20 percent to 40 percent reduction in death from incidents of major cardiac events in studies lasting two to six years.
The study that really brought statins into the limelight was called the Scandinavian Simvastatin Survival Study, or the 4S trial. It involved 4,444 men and women, ages thirty-five to seventy, who had preexisting heart disease and high total cholesterol levels. Half took the cholesterol-lowering drug simvastatin for five years, and half took placebo tablets containing no medication. By the end of the trial, LDL levels in the treatment group had fallen by 35 percent and total cholesterol dropped by 25 percent, while no change took place in the placebo group. The treatment group also had a 30 percent lower chance of dying during the trial and a 34 percent lower chance of having a major coronary event (a nonfatal heart attack or death from coronary heart disease).
Other studies that proved statins’ effectiveness in other populations followed in relatively short order. While the 4S participants all had preexisting heart disease, the 6,595 men who volunteered for the West of Scotland Coronary Prevention Study did not, though they did have high cholesterol. Those who took a statin (this time one called pravastatin) lowered their LDL and total cholesterol levels by 26 percent and 20 percent, respectively, and their risk of having a major coronary event by 31 percent, compared with those who took placebo tablets.
Then came the Cholesterol and Recurrent Events (CARE) trial. This study of pravastatin therapy involved 4,159 people who had recently had heart attacks but whose LDL cholesterol levels were only modestly elevated (the average was 140–150 mg/dL). Compared to subjects in the control group, those taking pravastatin for five years were less likely to have a stroke or a second heart attack or need a procedure to open a clogged artery In the space of just four years, these large studies marshaled powerful evidence of the value of statin drugs in lowering cholesterol.
And more studies continue to confirm this. The Heart Protection Study published in 2002, for example, studied the effect of simvastatin versus placebo in more than twenty thousand people in Great Britain with heart disease or diabetes, but with low enough LDL levels that statins would not necessarily be prescribed. Half were randomly chosen to receive simvastatin, the other half placebo. The ten thousand people receiving simvastatin had 18 percent fewer deaths from cardiovascular events and a 25 percent reduction in first heart attacks and stroke over the five years of the study. Even more recently, other studies have shown the benefit of lowering cholesterol levels lower than was previously recommended.
These and other studies demonstrated that statins reduce the risk of having a heart attack or other major coronary event for almost everyone—people with and without preexisting heart disease and those with high cholesterol, borderline-high cholesterol, and even normal cholesterol. This has prompted some to suggest that almost everyone should be taking a statin, and the United Kingdom has recently approved the sale of a statin as an over-the counter drug. Should everyone be on a statin? The answer is no. First, statins are not approved for use in women who are pregnant because they may cause fetal damage. Second, statins have side effects that, while rare, are serious. Third, statins are expensive, and many people can achieve acceptable levels of coronary disease risk without using medications at all. So, I think the message physicians should be bringing to their patients is not that everyone should be on a statin but rather that everyone should know their heart disease risks and be treated if those risks warrant it. A lot more people should probably be on statins than are currently taking them, but these drugs are definitely not for everyone.

Are You a Prospect or a Suspect?

In sports, a talented player who is just starting out in the game is known as a “prospect,” someone who is on the verge of accomplishing great things for his team. But if he doesn’t live up to his promise on the playing field, he soon becomes “suspect,” a person who is failing to live up to his potential. When this happens, his performance must improve or he is off the team.
I watched this happen with J.J. McCleskey when he was a sevenyear veteran with the Arizona Cardinals. When the tremendously talented J.J. was unable to complete the season four years in a row due to nagging injuries, he became suspect. His coach told him, “I don’t know what you’re doing in the off-season to get ready for the game, but whatever it is, you need to change it or you will have to start looking for another team.” I discovered that J.J.’s problem was repetitive hamstring pulls due to overstriding and improper training practices. After working with me during the off-season, J.J. was able to play the entire sixteen-game season. In fact, he was better in the last four games than most guys were in the first games of the season, and he ended up being a Pro Bowl alternate that year.
We all start out in life as a prospect, with a balanced physical, emotional, and mental system. As we age, however, our experiences tend to throw us off balance to varying degrees if we don’t learn to compensate. As the stresses of life and work add up, our health and stamina tend to decrease and we begin to lose the focus necessary for maximum performance levels. Even when we have tremendous experience and knowledge, we can still become suspect.
The following Performance Assessment Questionnaire serves as a tool to help you evaluate where you are now. Read each statement and check “never,” “sometimes,” or “always,” depending on how accurately the statement matches your current lifestyle performance levels. The eventual goal is to check off “always” for most questions. The areas where you check “never” or “sometimes” are the ones that need attention.

Telling Good Studies from Bad

An informed patient is in a much better position to partner with his or her physician to achieve optimal health. However, medical news can be misleading or hard to understand, and a little knowledge can indeed prove to be a dangerous thing. Even doctors can get caught up in promising preliminary studies and jump to false conclusions. So what can you do? What follows is a primer on interpreting medical news.

• Randomized controlled study. This is the gold standard of medical research. It means that researchers took a group of people and randomly gave some of them a therapy (a medication or prescription for a lifestyle change, for example) and gave the others (the control group) a placebo and compared the two results.
• Placebo. This is a fake treatment. If a controlled study is trying to determine whether a medication works, researchers will give the control group a fake pill so that subjects don’t know if they’re receiving the real thing. This is important because people’s minds can influence outcomes in important ways. Simply thinking that you are getting treated with something can often make you better.
• Observational study. This is the kind of study where researchers observe people as they live their lives and then draw conclusions. For example, researchers might ask people to write down everything they eat and their daily weight. From that data, researchers would draw conclusions about what kind of diets cause weight loss. In other cases, researchers work retrospectively—asking people to look back at their lives and note their lifestyles or drug treatments and their health problems.Though these kinds of studies can be helpful, they have their flaws. For example, unless researchers in the previous example also observed the patients’ exercise habits and measured their metabolisms, the results could be skewed. With retrospective studies, problems often occur because it’s extremely difficult for researchers to find a comparison group that is the same in every way as the group they’ve chosen to observe. A real-life example of the problems of observational studies is what happened with hormone replacement therapy (HRT). The data suggesting that HRT was good for the heart was based on observational studies. When HRT was put to a randomized controlled test, the old thinking was reversed. How could this be? We now assume that the women in the observational studies who took HRT also had healthier lifestyles that contributed to the fact that they suffered fewer heart problems.
• Preliminary data. Before a company or the government will fund a large, expensive trial (some of them run into the millions of dollars), they want to see preliminary data that support the researchers’ hypothesis. Retrospective studies are done first, because they are cheaper. However, their results may not hold up when the larger prospective study is finally done. This is exactly what happened with hormone replacement therapy. The retrospective studies made HRT look great, but the randomized, prospective study showed no benefit.

Unavoidable Risk Factors For Heart Desease : Age and Family History

Age

Heart disease becomes more prevalent with age. Simply put, older people have more heart attacks than younger people do. About 80 percent of people who die from heart attacks are over age sixty- five. In America, the risk for heart attack begins to accelerate in men after they reach the age of forty-five and in women after age fifty-five.

Family History

Coronary artery disease runs in families. While families share genes, they also share lifestyles such as smoking, diet, inactivity, or stress. Which is to blame, genetics or lifestyle? Both.

About a dozen genetic abnormalities have been identified that seem to increase the risk for different kinds of heart problems. For instance, defects in nine different genes can cause cardiomyopathy, a form of heart failure in which the heart is unable to pump blood efficiently. In 2002, researchers reported in the journal Circulation that a variant of a gene called the peroxisome proliferator alpha may predispose people to develop a dangerously enlarged heart after intensive exercise or as a side effect of high blood pressure. Genetic research is in its infancy, but the hope is that genetic testing will enable doctors to identify people at high risk for heart problems and perhaps help them avoid heart disease with preventive treatment.
But, in any case, genes are not the final word in determining who will develop heart disease. Researchers for the Framingham Heart Study, a long-term observational study that has tracked the health of more than five thousand people in a Massachusetts town since the late 1940s, estimate that having a family history of heart disease increases an individual’s risk by about 25 percent. To put this in perspective, smoking increases your risk ten times this rate. Moreover, not every family history is equally worrisome; it takes a strong history (for example, a father or brother afflicted before age fifty-five or a mother or sister stricken before age sixty-five) to increase your risk.
Many people with a family history of coronary artery disease have early signs of the disease. The American Heart Association now recommends that everyone undergo cholesterol profile screenings for heart disease at age twenty. If you have a family history, it’s vital for you to address risk factors like high blood pressure and elevated cholesterol, and to adopt a heart-healthy lifestyle in your youth.

Unavoidable Risk Factors For Heart Desease : Gender

In younger people, gender is a major predictor of risk. Before age sixty, one in five American men—but only one in seventeen women—will have had a coronary event. The naturally produced female hormone, estrogen, may be one of the reasons for this gender difference. But after a woman goes through menopause, this advantage is lost. Beyond age sixty, equality is the rule, and coronary artery disease kills 25 percent of women and men alike. In the United States, heart disease is the leading killer of both women and men.

However, there are a few concerns that pertain only to women. First, although the death rate from heart disease has declined for both genders, it is declining in women less rapidly than in men. Currently, 38 percent of women who’ve had heart attacks die within a year, compared with 25 percent of men.
Second, most women who die suddenly from coronary artery disease don’t have typical warning symptoms. Some may have had symptoms that they didn’t recognize as signs of heart attack because women’s symptoms often differ from men’s . Sometimes doctors pay less attention to women’s symptoms than they do to men’s because they know that younger women are less likely to develop heart disease. Academic medical centers like the one where I practice are spending more time educating young doctors to pay attention to women’s heart symptoms so that those symptoms are not dismissed as a less serious complaint, such as heartburn.

Given these issues, what should women do? Perhaps most important, they need to focus on prevention. For many years, doctors recommended hormone replacement therapy to women who were entering menopause because of evidence that it reduced the risk for heart disease as well as osteoporosis. But the heartprotective benefits of HRT have come under fire. Clinical trials have found that women with heart disease who take HRT do not actually slightly raises the risk of heart disease in both healthy women and women who have had previous episodes of atherosclerotic heart trouble.

It’s a different story for men and heart disease. While female hormones appear to provide some heart-protective benefits—at least for younger women—male hormones may contribute to heart disease in five ways:
• Boosting LDL and lowering HDL
• Promoting the accumulation of abdominal fat, which can lead to high triglyceride levels and diabetes
• Increasing the number of red blood cells and activating the clotting system
• Triggering spasms that narrow arteries
• Enlarging and possibly damaging heart muscle cells.

Scientists have discovered some of these effects after giving testosterone to laboratory animals. It will take time for researchers to determine whether a normal amount of testosterone increases a man’s risk for heart disease. Testosterone isn’t all bad for the heart—it appears to reduce the level of one newly identified cardiac risk factor, lipoprotein.

Anger: What’s Your Score?

Several studies have demonstrated that people with a low threshold for anger have a greater probability of high blood pressure and heart disease. When compared with calmer people, these individuals experience rage and fury more often, more intensely, and for longer periods of time.
Information from a long-term epidemiological study done at Duke University called Atherosclerosis Risk in Communities (ARIC) offers some perspective on the relative importance of this risk factor. As part of the investigation, subjects were asked to complete the Spielberger State-Trait Anger Expression Inventory, a questionnaire used by psychologists to assess how anger prone a person is. Subjects had to respond to these ten statements by answering:

Almost Never  1,
Sometimes  2,
Often  3,
and Almost Always  4.

The overall anger score is calculated by adding together the ratings for each statement.
• I am quick-tempered.
• I have a fiery temper.
• I am a hotheaded person.
• I get angry when I am slowed down by others’ mistakes.
• I feel annoyed when I am not given recognition for doing good work.
• I fly off the handle.
• When I get angry, I say nasty things.
• It makes me furious when I am criticized in front of others.
• When I get frustrated, I feel like hitting someone.
• I feel infuriated when I do a good job and get a poor evaluation.

Scoring: 22–40  high anger; 15–21  moderate anger; 10–14  low anger

In the Duke study, the higher a person’s anger score, the greater the risk of developing coronary artery disease during the seventy-two-month follow-up period. The findings don’t prove that anger causes heart problems or that measures to control anger will help anyone live longer. But they do suggest a close relationship between psychological and cardiovascular health.

Tobacco Exposure : The Risk Factors For Coronary Artery Disease

Everyone knows that smoking is a major health hazard: it’s the leading preventable cause of death in the United States. But some people may be surprised to learn that smoking is also the most potent cardiac risk factor, increasing risk by 250 percent. Another surprise: exposure to secondhand smoke is also a major cardiac risk factor, which is why passive smoking is the nation’s thirdleading preventable cause of death. (Alcohol is the second.)
In all, smoking accounts for 20 percent of all deaths from coronary artery disease. But within a year of quitting, smokers can cut this risk in half. Within two years, the cardiovascular risk for a former smoker is very close to that of a person who never smoked. Because smoking probably contributes to blood vessel inflammation, removing that irritant should slow the inflammatory process, resulting in a quick drop in heart disease risk.

I see a lot of patients who know they should quit smoking, but they’re not sure how. The best approach is two-pronged: use medicine, and get counseling and support.
Easing the craving for nicotine is a key part of stopping smoking. Nicotine patches, gum, lozenges, nasal spray, and cigarette-shaped inhalers deliver enough nicotine to satisfy the body without the tar, carbon monoxide, and other harmful chemicals found in cigarette smoke. An antidepressant known as bupropion (Zyban, Wellbutrin) also alleviates the symptoms of nicotine withdrawal, even in people who aren’t depressed. Combining bupropion and nicotine replacement may work the best of all.
Nicotine replacement is safe, even after a heart attack, and it’s much safer than continued smoking. These products don’t increase the clotting potential of blood or damage the fragile but important lining of blood vessels, as smoking does.
Nicotine replacement often isn’t enough on its own. Counseling and social support can help you break your “smoking cues,” the things you link to lighting up, like drinking coffee or finishing a big meal. You can get counseling one-on-one at a support group run by a hospital or local department of health, via the phone, or online. (Some options are listed in the Resources section.)
Remember that quitting smoking is a huge change, so it might take you a few tries to get off cigarettes for good. If you slip by having a cigarette or two after your quit date, try to figure out what went wrong and how to fix it the next time. Don’t convince yourself that as long as you had one, you may as well have another, and another. . . . The same holds true if you return to your old smoking habit. You may have to quit a few times. Not succeeding may just mean you need more help.

If Fish Is Good for Me, Should I Take a Fish Oil Supplement?

Interest in the heart-healthy benefits of fish oil dates back about two decades, beginning with a 1980 study showing that Eskimos in Greenland—who eat nearly a pound of fish a day—have low rates of mortality from heart disease. In subsequent years, there has been substantial research on the effects of fish oil on the heart and arteries. Laboratory studies have shown that fish oil, which contains what are known as n-3 or omega-3 fatty acids, makes blood platelets less sticky, helps protect the linings of arteries, and may also lower blood pressure.

Population studies from several countries have shown lower rates of heart disease in people who eat fish regularly. In 1998, data from the Physicians’ Health Study showed that eating fish once a week versus less than once monthly halved the likelihood of dying suddenly from a heart attack. Total heart attack rates (including heart attacks that led to nonsudden death) and total cardiovascular deaths were not affected by fish consumption or the amount of omega-3 fatty acids ingested. One year later, a report in the Lancet described a randomized trial in which men who’d had a heart attack received either a fish oil supplement, 300 mg of vitamin E, both, or neither. The group who received the fish oil supplement had significantly lower rates of heart attack, stroke, or death during the next three and a half years. Sudden-death rates dropped by 45 percent.
Additional support for fish oils comes from a report on nearly eighty thousand women in the Nurses’ Health Study. Published in 2001 in the Journal of the American Medical Association, this fourteen-year study found that eating fish at least twice a week versus less than once a month cut in half the risk of strokes caused by clots blocking an artery to the brain. The Nurses’ Health Study also found that eating one to three servings of fish per month cut the risk of heart disease by 20 percent, while eating at least five servings a week lowered risk by 40 percent.
Anyone hoping to benefit from fish oil would probably be better off sticking with dietary sources, primarily from cold-water fish such as salmon, trout, mackerel, sardines, and herring. Forgoing meat for cold-water fish—or any fish for that matter—may lower cholesterol and heart disease risk simply by reducing the amount of saturated fats in your diet.
Three groups of people may benefit from fish oil supplements. One group includes people with arrhythmias, or disordered heart rhythms. The omega-3 fatty acids in fish oil can stabilize wayward electrical activity in the heart and calm arrhythmias. The second group includes people with high levels of triglycerides, especially those who can’t control the problem through diet and exercise, because fish oil supplements have been shown to help lower triglycerides. The third group includes people with coronary heart disease. The American Heart Association recommends that these people eat one serving of fatty fish a day; recognizing that this may be more fish than most people will eat, the association notes that a supplement can be substituted.

Role of Low-Energy Expenditure in the Development of Obesity

Several studies support the idea that a low RMR is associated with weight gain. A low metabolic rate has been shown to precede body weight gain in infants, children, and in adult Pima Indians and Caucasians. Based on the assumption that formerly obese, weightreduced subjects exhibit the metabolic characteristics that predisposed them to obesity, several studies have compared metabolic rates in formerly obese subjects to those of weight-matched controls who have never been obese.
A meta-analysis of 12 such studies corroborates the prospective data by demonstrating a 3–5% lower mean RMR in the formerly obese subjects. Moreover, these data indicate that a low RMR is more frequent among formerly obese subjects than among never-obese control subjects. Studies of the contribution of the sympathoadrenal activity to this trait have yielded conflicting results, probably because comparisons of lean and obese subjects provide only very limited information about the role of the SNS in the aetiology of obesity. Furthermore, they do not discern between the causes and the consequences of weight gain.
How ever, longitudinal studies both in Pima Indians and in Caucasians have shown a relationship between low urinary norepinephrine excretion and weight gain, and a relationship between low urinary epinephrine excretion and the development of central obesity.
These results strongly suggest that a low SNS activity is also a risk factor for weight gain in humans. SNS activity increases in response to weight gain, thereby attenuating the original impairment.

An LDL Controversy

Although LDL is thought to be the major cholesterol-carrying culprit causing heart disease, there is still scientific controversy over the form LDL must take to cause atherosclerosis. For nearly twenty years, atherosclerosis researchers have hypothesized that LDL must change once it’s in the artery wall in order to cause artery blockages. The dominant view has been that LDL must first be oxidized to a more inflammatory form in order to cause serious artery wall damage. Oxidation is the chemical reaction that causes metals to rust by changing the structure of the metals’ molecules. Similarly, oxidation may change the chemical structure of LDL molecules by breaking down large fat-containing molecular chains.
Although there are literally thousands of studies that have suggested a role for oxidized LDL in causing heart disease, the use of antioxidants, such as vitamin E, has not resulted in any convincing decline in atherosclerosis in humans. This isn’t proof that oxidation is unimportant, it’s just that we don’t know yet. The precise form LDL must take to set off atherosclerotic plaque formation remains a bit of a mystery, but the link between high LDL levels and coronary disease is firmly established.

How Is Cardiac Arrest Different from a Heart Attack?

Most people think of a heart attack as something that happens quickly and causes someone to grab his or her chest and fall to the ground. That’s actually a picture of cardiac arrest. A heart attack, as
the term is commonly used today, generally means the blockage of an artery in the heart that kills some heart muscle. (Medically speaking, this is a myocardial infarction.) A heart attack usually gives some warning. Chest pain or other symptoms can prompt someone to get help before the blockage totally disrupts the heart’s rhythm.
Cardiac arrest, though, strikes suddenly and out of the blue. Most cardiac arrests occur when the heart’s powerful lower chambers, the ventricles, start beating very fast (ventricular tachycardia [ta-kih-CAR-dee-uh]) or fast and chaotically (ventricular fibrillation). Either one of these makes it impossible for the heart to pump blood to the body.
After just five seconds without blood circulation, a person passes out. In another few seconds, the lack of oxygen in the brain causes nerves to start firing, making the muscles twitch and the eyes roll back. Even that activity stops in less than a minute. The chances of surviving a cardiac arrest fall about 10 percent for each minute the heart stays in ventricular fibrillation. Shock the heart back into a normal rhythm within two minutes, and the victim has an 80 percent chance of surviving. Deliver that shock after seven minutes—the average time it takes an emergency medical team to arrive in many cities—and the odds are less than 30 percent.
If someone near you goes into cardiac arrest, calling 911 is a must. CPR is also important because it keeps blood flowing to the brain and other vital organs. If there’s an automated external defibrillator nearby, use it following the instructions on the device.