Be Healthy Spring 2016 - High cholesterol

STRESS AND

HEART DISEASEPREVENTION

METHODS

FITNESS TIPS AND HEALTHY RECIPES

A POSSIBLE LINK TO HIGH

CHOLESTEROL

Be knowledgeable. Be well. Be healthy.

Spring 2016

High cholesterol

PLANT-BASED FOODS — GOOD MEDICINE

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The issueHigh cholesterol

By the numbers

FocusHeart attack and strokeStress and heart disease

Peripheral arterial diseasePrevention

Metabolic syndrome

Healthy stepsNutrition

RecipesFitness

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Peripheral arterial disease:Common, but often undetected

Recipe:Buttons and bows pasta

HighcholesterolSpring 2016

Editor’s note: The information presented in Be Healthy is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recom-mend that you take advantage of screenings appropriate for your age, sex, race and risk factors and make timely visits to your primary care physician.

PublisherMelvin Miller

Health EditorKaren Miller

Senior EditorYawu Miller

Art DirectorDaniel Goodwin

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Please contact Karen Miller at

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The liver makes most of the body’s cholesterol. In truth it makes enough for all the jobs it has to accomplish. Contrary to a commonly-used term, cholesterol is not “bad.” Nor is it “good.” There’s only one cholesterol. It’s actually a victim of circumstance. Because it is a waxy, non-soluble substance, it has to travel in the bloodstream on protein carriers called lipoproteins, which are named according to their density. LDL, or low density lipoproteins, escort cholesterol to the cells, while HDL or high density lipoproteins, clean up the excess leftovers and return them to the liver for disposal.

LDL’s biggest cargo is cholesterol, but it transports triglycerides and other lipids as well.

Here’s how cholesterol gets its bad rap. The LDL particles, especially when

dense and small in size, can cling to the walls of arteries causing a blockade that can eventually prevent the passage of blood and nutrients. Because cholesterol is a part of this transit system, it gets most of the blame for forming a plaque called atherosclerosis.

It is this plaque that is associated with heart attacks, strokes and periph-eral arterial disease.

The LDL does not have affinity for a particular artery. All arteries — regard-less of their location — are fair game. The reason it is so strongly linked to heart attacks is because of the devastating out-come. Heart disease is the number one killer in this country.

StatsHigh cholesterol is common. “No race is spared,” said Dr. Pradeep Natarajan, who specializes in preventive cardiology at Massachusetts General Hospital. “But risk factors may vary among groups.” According to the Centers for Disease Control and Prevention, one out of every three adults has high cholesterol. Half do not get treated and two-thirds do not have it under control.

People tend to ignore conditions that do not directly affect their daily activ-ities. However, cholesterol is not to be ignored. It is linked to two leading causes of death. It can precipitate kidney failure if arteries leading to the kidney are at-tacked and it can result in amputation if the legs are afflicted.

TestingHigh cholesterol is silent. Similar to high blood pressure, you don’t know you have it unless you are tested. The recommended test is called a lipid panel, which measures total cholesterol, HDL, LDL and tri-glycerides. Generally, desired readings are

The issue: High cholesterol

Cholesterol not really a villain

High cholesterol: Common and silentCHOLESTEROL GETS A BAD RAP. BUT ACTUALLY IT’S ONE OF THE GOOD GUYS. YOUR BODY COULD NOT SURVIVE WITHOUT IT. Cholesterol is a major component of the walls of cells, offering support as well as protection from unwanted invaders. It is a key component in several hormones, including estrogen, progesterone and testosterone. There’d be no vitamin D without cholesterol.



PHOTO: ERNESTO ARROYO

Pradeep Natarajan, M.D., M.MSc specializes in preventive cardiology at the Massachusetts General Hospital Corrigan Minehan Heart Center.


less than 200 for total cholesterol; more than 40 for HDL; less than 100 for LDL and less than 150 for triglycerides.

The results are not always that clear-cut. Total cholesterol could test as normal, but include higher than desired LDL. To get a better look, some health providers perform additional calculations to de-termine one’s risk of heart disease more accurately. For instance, the cholesterol to HDL ratio (chol/HDL) is considered a better risk predictor of heart disease. A number below five is acceptable, accord-ing to the American Heart Association.

Screening should begin at 20, accord-ing to Natarajan, with subsequent testing every four to five years for those of low risk and those who test normal. People of high risk, such as those with a genetic disorder (hypercholesterolemia), or those with diabetes or heart disease should be tested more frequently. The exact screening schedule is based on individual circumstances.

At one time a 12-hour fast (no food or liquid, just water) was required before screening. That rule has been somewhat relaxed recently. However, a meal high in fats just before the test can artificially raise the triglyceride levels.

Prevention and treatmentWith the exception of a genetic predis-position to the disorder, high cholesterol is largely preventable. The oft repeated foursome applies here: exercise; a healthy eating plan of fruits, vegetables, whole grains and healthy fats; weight control and abstinence from smoking. When first diagnosed with high cholesterol, change in lifestyles is first in order with one excep-tion. “An LDL greater than 190 requires medication,” said Natarajan. “That’s the top 95th percentile.” That means that the LDL is on the high end and poses a risk for cardiovascular disease.

If lifestyle cannot control cholesterol levels, medication, such as statins, niacin and fibrates, is prescribed. Healthy lifestyles, however, remain integral to treatment.

New guidelinesThe medical profession has made a recent major shift regarding the effect of diet on


SCREENING RESULTSIt is recommended that screening for cholesterol begin at age 20 and be repeated every three to five years. Those of higher risk, such as those with diabetes, heart disease, stroke or a family history of high cholesterol, may get screened more frequently. However, sched-ules are tailored to a person’s particular circumstance.

The interpretation below may be different for those with heart disease or diabetes. Tests are measured in mg/dL.

Reading Interpretation

Total Cholesterol Below 200 Desirable 200-239 Borderline high 240 and above High

LDL Cholesterol Below 100 Optimal 100-129 Near optimal 130-159 Borderline high 160-189 High 190 and above Very high

HDL Cholesterol Below 40 Poor – a major risk for heart disease 40-59 Better 60 and above Best – considered protective

against heart disease

Triglycerides Below 150 Desirable 150-199 Borderline high 200-499 High 500 and above Very high

Source: National Heart, Lung, and Blood Institute

The lipid panel tests for total cholesterol, LDL cholesterol, HDL

cholesterol and triglycerides.

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high cholesterol. After years of warning consumers about eating foods high in cholesterol, such as red meat or eggs, it’s been found that food actually contributes little to the body’s cholesterol. This warn-ing might have backfired. “We told people not to eat any fat,” said Natarajan, “but they continued to eat refined carbohy-drates.” Unfortunately, one bad habit re-placed another. Sugar-sweetened bever-ages and foods like white rice can produce cholesterol and triglycerides.

The modified warning does not apply to all fats. Trans fats are still taboo. Un-saturated fats, such as those in tree nuts and salmon, however, are recommended.

Another shift centers on the risk of a cardiovascular event, such as a heart attack or stroke, and the use of statins. For years


A CLOSER LOOKTotal cholesterol does not always give an accurate picture of the extent of cholesterol in the body. It is more of a glimpse. For instance, it can include a higher LDL than desired. Some providers go a step further to determine one’s risk for cardiovascular disease.

Test Acceptable results

Total cholesterol/HDL ratio Below 5

Triglyceride/HDL ratio Below 4

Non-HDL (Total cholesterol minus HDL) 130-159

HDL/LDL ratio Over 0.3

No race is spared. But risk factors may vary among groups.”— Dr. Pradeep Natarajan Massachusetts General Hospital

“

Journal of Medicine, this change would increase the number of people eligible for statins by roughly 13 million people.

Regardless, Natarajan sees some advantages to the revised tool. It now includes race as a factor. The previous assessment tool stemmed from find-ings from the Framingham Heart Study, which included no people of color. “It opens up an avenue of discussion,” he ex-plained. “Does this model fit my patient in front of me? At what point should we consider statins?”

There is still much to learn about cholesterol. It is indeed a complex com-pound. What we do know is that it tends to travel in bad company — high blood pressure, smoking, obesity, diabetes and unhealthy diet. The good news though is that when you take measures to tackle cholesterol through healthy living, you take on the others at the same time.

the National Heart, Lung, and Blood Insti-tute presented a self-assessment tool that, depending on answers regarding blood pressure, cholesterol, smoking, age and gender, estimated a respondent’s risk for a heart attack within 10 years. A risk exceed-ing 10 percent raised a red flag.

In 2013 the AHA and the American College of Cardiology revised the test by adding the risk factors diabetes, di-astolic blood pressure and race. They changed the 10-year risk estimation to a composite of both heart disease and stroke with a cutoff of 7.5 percent.

The change has not resonated favor-ably among all cardiologists. While the test still applies to people with known risk factors for heart disease, it now ad-vises a group of seemingly healthy people to consider statins based only on age and race. For instance, the ACC/AHA guidelines suggest that African American females aged 70 and older with no listed risk factors “should be on a moderate to high intensity statin.” According to a study published in the New England

COMPLICATIONSThe buildup of plaque called athero-sclerosis, which is attributed to choles-terol, is linked to several life-threaten-ing conditions.

n Angina (chest pain)n Heart attackn Stroken Peripheral arterial disease

(buildup of plaque in the legs)

RISK FACTORSA risk factor is a characteristic that increases the likelihood of develop-ing a particular condition. It is not a guarantee, however, that it will develop. Some risk factors related to high cholesterol can be controlled or monitored.

RISK FACTORS THAT CANNOT BE CONTROLLEDn Family history: It can run in families,

particularly if geneticn Age: The risk increases with age n Sex: Occurs in both genders, but men

typically have lower HDL levels than women

n Race: Occurs in all races, but is more frequent in Mexican American males and African American females

RISK FACTORS THAT CAN BE MODIFIEDn Unhealthy diet: Diets high in trans fats

and added sugars have been linked to high cholesterol

n Physical inactivityn Obesity n Large waist circumferencen Smoking


By the numbers: Cholesterol

People with high total cholesterol have twice the

risk of heart disease.

2XThe percent of U.S. adults that have

total cholesterol of 240 or higher

13%

Less than one-half of adults with high LDL get treatment

½Less than one-third of adults with high LDL have it under control

½3The percent of U.S. adults that have high triglycerides

25%The number of U.S. adults that

have high LDL (“bad”) cholesterol

74MILLION


Focus:High cholesterolCommon, but often preventable

11

I want to talk to more women and change the picture of a cardiac patient.”— Melissa Blount

“PHOTO: STEVEN ADAM

S PHOTOGRAPHS

Stress may have aggravated Melissa

Blount’s high choles-terol, which result-ed in a 95 percent

blockage in one of the arteries in her heart.

» Heart attack and stroke 10

» Stress and heart disease 11

» Peripheral arterial disease 12

»Prevention 14» Metabolic syndrome 16


FOCUS: High cholesterol

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BY FAR THE MOST FEARED OUTCOME OF HIGH CHO-

LESTEROL IS A HEART ATTACK. That fear is realized every 43 seconds in the U.S., according to the Centers for Dis-ease Control and Prevention. Each year roughly 700,000 people suffer a heart attack and almost 120,000 people do not survive. A common cause of a heart attack is plaque buildup, or cholester-ol, in the arteries feeding the heart muscle, but cholesterol does not act alone. Other risk factors are age, tobacco use, high blood pressure, diabetes and even stress.

Heart disease spares no one. It is the leading cause of death for people of most ethnicities in this country, including African Americans, Hispanics and whites. It is second only to cancer in Native Americans and Asians.

It is possible to prevent heart attacks. Change in lifestyle is key, but control of blood pressure, diabetes and cholesterol is pivotal. Every 1 percent reduction in cholesterol level results in a 2 percent reduction in heart disease, according to the American Heart Association.

UNCONTROLLED BLOOD PRESSURE IS MORE FRE-

QUENTLY CORRELATED TO STROKE, BUT HIGH CHOLES-TEROL DOES ITS FAIR SHARE OF DAMAGE. The same mechanism that leads to a heart attack can cause a stroke. Arteries supplying blood to the brain become jammed with plaque. When the brain is robbed of its nu-trients and energy a stroke ensues. Although only three pounds in weight, the brain hogs 20 percent of the body’s blood. That’s because it requires huge amounts of energy to get its work done. It controls movement, thinking and even emotions.

Each year almost 800,000 people in the U.S. have a stroke, and 130,000 die

from the condition. Although stroke is the fifth leading cause of death in this country, it is the third among African Americans. The risk of having a first stroke is twice as high in blacks than in whites, and blacks are more likely than whites to succumb to the dis-ease. Stroke shares the same risk factors as heart disease — age, smoking, high blood pressure and diabetes. Scientists at the

National Institute of Neurological Disorders and Stroke predict that, with reduction of these risk factors, Americans should be able to pre-

vent 80 percent of all strokes.

Heart attack and strokeMajor complications from cholesterolHEART ATTACK

STROKE

SYMPTOMSn Pain or discomfort in the jaw,

neck or backn Feeling weak, light-headed or faintn Chest pain or discomfortn Pain or discomfort in arms or shouldern Shortness of breathn Extreme fatigue (common in women)

SYMPTOMSn Sudden numbness or weakness of

face, arm or leg, especially on one side of the body

n Sudden confusion, trouble talking or understanding speech

n Sudden trouble seeing in one or both eyes

n Sudden trouble walking, dizziness or loss of balance or coordination

n Sudden severe headache with no known cause

Blood flow through a clear artery.

Obstructed blood flow

through a partial-ly clogged artery.


MELISSA BLOUNT, 46, HAD IT ALL. A LOVING HUSBAND,

A BEAUTIFUL DAUGHTER AND A PROMISING CAREER IN CLINICAL PSYCHOLOGY. There was one thing missing, though — a baby sister or broth-er for Safiya, her only child.

Her efforts to have another child sev-eral years ago almost cost her her life.

According to Blount, she was in pretty good health — except for one “minor” detail. Blount had high cholesterol. “I’ve had that since my 20s,” she explained. It’s possible it runs in her family since her mother is afflicted as well.

Other than that, Blount seemed rel-atively healthy. She did not have high blood pressure or diabetes; she was active; and her weight — although a little higher than she preferred — was within acceptable limits.

Blount made the decision to avoid statins for her cholesterol. “It’s bad for the fetus,” she explained. Her decision is understandable. The U.S. Food and Drug Administration has established a very clear warning about statins: “Do not use these medicines if you are preg-nant or nursing.” The drugs may cause birth defects, and the risks outweigh the benefits.

Blount preferred natural alterna-tives to control her cholesterol. She followed a healthy eating pattern and exercised regularly, both of which are recommended to keep cholesterol in check. But things went awry. In one year she suffered several losses. Her grand-mother died; her father-in-law died; her husband was laid off; the couple was forced to short-sell their home; and there were no savings to speak of. On top of all that, while Blount was trying to develop a practice in Chicago, the family of three was living with a friend in a two-bedroom apartment.

“My stress level was incredibly high,”

she explained. She gained weight but continued to ex-ercise. Even that wasn’t going well. “I became very short of breath,” she said, “even when walking short distances.” To compound matters, treatment by a fertility specialist was not providing results.

Unknowingly, Blount’s stress could have exacerbated her condition. Adrenaline and cortisol — two stress hormones — trigger the production of cholesterol. There is increasing research to indicate that stress — and how a person deals with it — can increase LDL, or “bad” cholesterol levels.

Things came to a head after visiting relatives in Detroit for Thanksgiving. Pains that felt like indigestion, tingling in the arm and shortness of breath es-calated during the visit. Instead of calling 911 or visiting the emergency department, Blount chose to return to Chicago.

“I was in so much pain,” she said, but it still did not register that she was suffering a cardiac event. Her stress test two days later, however, confirmed it. She didn’t last 20 seconds on the treadmill. A sub-sequent catheterization (test to diagnose heart disease) found a 95 percent block-age in the “widow maker,” a heart artery so called because of the low survival rate when it’s obstructed.

This finding was a surprise to her as well as the medical staff. She did not fit the classic profile of a person suffering from so critical a cardiac condition. Still Blount did not grasp the seriousness of the situation and was more concerned about its impact on her efforts to have a child. She got it, though, when the

cardiologist explained, “I am trying to save your life so you can be here with your daughter.” She had a stent inserted to open the artery.

Blount’s story has both a sad and happy ending. She did not have another child, but she did sidestep a serious heart attack. Her private practice is thriving. Her cholesterol is under control with drugs, including statins.

She speaks out for other women. “I want to talk to more women and change the picture of a cardiac patient,” she said.


Stress and heart diseaseA possible link to high cholesterol

PHOTO: STEVEN ADAMS PHOTOGRAPHS

Melissa Blount and her daughter Safiya.


It is well known that atherosclerosis, or plaque, can block arteries in the heart and brain, resulting in a heart attack or a stroke. However, cholesterol, the chief component of plaque, shows no favorit-ism. It exists in other arteries, including those of the arms and legs.

Most often PAD refers to cholesterol buildup in the arteries supplying the legs.

Many people have not heard of the condition. They attribute its symptoms to old age, arthritis or being out of shape. That’s understandable. The symptoms are tricky. Further confusing the situ-ation is that the symptoms come and go. Most often people experience clau-dication, or pain in the calves or thighs during an activity, such as walking. After a short rest, however, the pain subsides only to return when the walk continues.

That’s because walking requires a greater flow of oxygen-bearing blood to the extremities. Oxygen provides energy, the fuel for all physical activity. Pain ensues if a blockage prevents an ade-quate supply of blood to the muscles. The demand for oxygen — and the pain — de-crease with rest.

Claudication is characterized by its con-sistency. If you can make it only two blocks without pain on Monday, chances are you can make it only two blocks without pain on Tuesday. In some situations, the pain can become so incapacitating that it

severely impacts one’s functional activities.As the disease progresses, symptoms

can include leg numbness or weakness, sores on the foot or leg that fail to heal and change in skin color or temperature of the leg. Men may experience erectile dysfunction.

High cholesterol is the leading cause of PAD, but diabetes, high blood pres-sure, obesity and smoking all add to the problem.

PAD is common. The American Heart Association estimates that 13 million people in this country are afflicted. It is more common in blacks and people over the age of 70. Yet, it often goes undiag-nosed. Initially, it is painless. The first sign that the problem even exists is often the lack of pulses in the leg, but an exam-ination of these pulses is not a common part of a physical examination.

In addition, some elderly people or those with chronic illnesses tend to be more sedentary. They don’t engage in a physical activity that elicits claudication.

Fortunately, there is reliable testing for the disorder. A physical exam will detect the lack of pulses in the foot. Ultrasounds will check for blood flow, and an angio-gram — injection of dye into the artery — will find the blockage. A common but simple test is the ankle-brachial index in which the blood pressure of the artery in the ankle is compared to that in the arm.


NOWADAYS THE WORD “PAD” BRINGS TO MIND A TABLET OR NOTE-BOOK OR SOME OTHER ELECTRONIC DEVICE. But to the medical commu-

nity, it means peripheral arterial disease, a blockage of arteries in the limbs and organs.

Peripheral arterial diseaseCommon, but often undetected

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Readings of less than 1.0 indicate narrow-ing of the arteries in the leg.

It is sometimes possible to manage the symptoms and stop the progression of the disease by following a healthy life-style and taking medications to control cholesterol, blood pressure and glucose. A daily aspirin is often recommended to prevent clots.

Other situations require a more ag-gressive approach, which mirrors that of treatment of heart disease. Angioplasties to open the arteries, or bypass surgery to build a blood supply around the blockage are common procedures.

PAD cannot be ignored. It is a sign that cholesterol is also building up elsewhere, which increases the risk of a heart attack or stroke, concluded the National Heart, Lung, and Blood Institute. Blockages in the artery feeding the kidney can cause kidney failure. In severe cases, when med-icine and surgical interventions are insuf-ficient, amputation is required.

But there is good news. Researchers from the Harvard T.H. Chan School of Public Health studied the impact of cer-tain risk factors on the incidence of PAD. They followed 45,000 male health pro-fessionals for 25 years and found that four risk factors — high cholesterol, smoking, diabetes and high blood pressure — were

the major culprits behind PAD.Having just one of these factors dou-

bled the risk, and men with all four were 16 times more likely to be afflicted. Of the men ultimately diagnosed with PAD, 96 percent had one or more of the condi-tions. Time was also a factor. The longer the man smoked or had diabetes or high cholesterol, the higher the risking of de-veloping PAD.

These results suggest that PAD can be prevented. Lifestyle changes to prevent the four risk factors or adherence to a medica-tion regime can reduce the risk of not only PAD, but also stroke and heart disease.

SYMPTOMS OF PADn Painful cramping in hip, thigh or calf

muscles after physical activitiesn Leg numbness or weaknessn Sores or wounds on the toes, feet,

or legs that won’t heal n Shiny skin on the legsn Change in color of the skin of legsn A lower temperature of one leg

compared to the other legn Slower growth of toenails and slower

hair growth on feet and legs n Erectile dysfunction, especially among

men who have diabetes



PHOTO: USED WITH PERM

ISSION OF MAYO FOUNDATION FOR M

EDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED.

A common symptom of PAD is claudication,

or pain in the leg, usually

during exercise.

ANKLE-BRACHIAL INDEXThe ankle-brachial index is a common test used to diagnose PAD. The blood pressure is taken in the arm and the leg. The index is determined by dividing the systolic blood pres-sure (top number) of the arteries near the ankle by the systolic blood pressure in the arms.

Blood pressure ankle

Blood pressure arm

Interpretation of results can vary slightly, but an ABI of less than 0.50 is a sign of serious arterial disease that requires prompt treatment.

ABI Score Interpretation Recommendation1.0-1.4 Normal None

0.9-1.0 Acceptable None

0.8-0.9 Some arterial disease Treat risk factors

0.5-0.8 Moderate arterial disease Requires referral to vascular specialist

Less than .5 Severe arterial disease Requires referral to vascular specialist

Source: Stanford Medicine 25

IN MANY CASES HIGH CHOLESTEROL CAN BE

PREVENTED BY FOLLOWING A HEALTHY LIFESTYLE. So powerful is healthy living that when first diagnosed with high cholesterol the first choice of treatment is often lifestyle change. When this recommendation is not as effec-tive as desired in reducing cholesterol levels, medication — in conjunction with healthy lifestyles — is prescribed.

SmokingCigarette smoking might provide a “buzz” from that quick jolt of nicotine, but it wreaks havoc on your health. Cig-arette smoking is the most preventable cause of death and illness in this country. Most people associate it with cancer, and rightfully so. Lung cancer is the most common cancer death in this country and cigarette smoking is linked to 80 percent of those deaths. But smoking does its fair share of damage to the car-diovascular system. More than 480,000 deaths a year are attributed to smoking, according to the Centers for Disease Control and Prevention.

The chemicals in tobacco smoke harm your blood cells and damage the struc-ture and function of blood vessels making them fertile ground for atherosclerosis, the buildup of plaque attributed largely to cho-lesterol. The American Heart Association has found that smoking lowers the level of the so-called good cholesterol in the blood and raises triglycerides, another type of lipid in the blood associated with heart disease.

Switching to smokeless tobacco doesn’t avert the problem. Smokeless tobacco ac-tually puts more nicotine into the blood-stream than do cigarettes. Although it is

chewed rather than inhaled studies sug-gests that it still raises blood pressure and cholesterol levels, and can increase your risk of having a heart attack.

It might be difficult to quit smoking, but the advantages are huge. The Mayo Clinic reports that quitting smoking can increase HDL by up to 10 percent.

Call 800-QUIT-NOW (1-800-784-8669) for information and help quitting.

ObesityCorrelating a few extra pounds to cho-lesterol seems a bit of a stretch. If that is true, that explains why high cholesterol is so common. According to the CDC, more than one-third of U.S. adults are obese as well as 17 percent of children age 2 to 19.

In fact, body weight has a direct asso-ciation with cardiovascular risk factors, including high cholesterol. This means that as weight increases, so does LDL cholesterol and triglycerides. Yet, it does not take an excessive weight loss to re-verse the direction of these numbers. In an article published by the Obesity Action Coalition the researcher found that losing just 5 to 10 percent of body

weight can result in a five-point in-crease in HDL cholesterol and an aver-age 40-point decrease in triglycerides. That means a 200-pound person can realize improved health by losing just 10 pounds.

Obesity is measured by the Body Mass Index, or BMI, a correlation of height and weight. The BMI is not perfect. It cannot distinguish between muscle and fat and can push a muscular person into the “overweight” category.

It also cannot take into consideration the location of the fat. Abdominal, or visceral, fat is centered at and above the waist giving a person an apple shape. Unlike the external fat that can be grasped, visceral fat is internal and lies between the organs in the abdomen. As opposed to fat found in the thighs, for instance, visceral fat is biologically active and can increase the risk of cardiovas-cular disease and type 2 diabetes, and is linked to high cholesterol levels.

Healthy eatingIt is hard for many people to eat healthy foods for many reasons. Time and money

Prevention of high cholesterolIt’s possible to eat your way to good health



BMI: BODY MASS INDEXObesity is measured by the Body Mass Index, or BMI, a correlation of height and weight.

BMI = Weight in pounds

(Height in inches x Height in inches) x 703

BMI Definition Waist Size Desired Measurement18.5-24.9 Healthy Men Less than 40 inches

25-29.9 Overweight Women Less than 35 inches

30 or more Obese



PHOTO: THINKSTOCK.COM/ISTOCK/W

EERAPATKIATDUMRONG

are high on the list. Demanding work schedules and inadequate salaries make it easier to grab a quick bite at a local fast-food restaurant. The food may be fast and not make a huge dent in one’s wallet, but it comes with a heftier price.

Fast food is often higher in added sugar, trans fat, sodium and artificial chemicals. In addition, it typically comes in larger portions, thereby providing unnecessary calories. These calories accumulate in the body as fat deposits, which increase the risk of cardiovascular diseases.

The Mediterranean Diet and the DASH Eating Plan developed by the Na-tional Heart, Lung, and Blood Institute are recommended choices. Both em-phasize plant-based foods like fruits and vegetables, whole grains, such as whole wheat bread, and healthy fats, like those

found in fatty fish and nuts. It does not mean that meat lovers have

to go cold turkey. It is suggested to limit red meat to a few times a month.

The good news is that neither plan controls exactly what a person should eat. Individual preference and taste dictate choices. The key is to choose a variety from all food groups and minimize foods high in sodium, trans fats and saturated fats.

A dietitian can help design an individ-ual healthy eating plan.

ExerciseNext to healthy eating, exercise is the most difficult lifestyle change to adopt. People prefer to watch television. In the 2014 survey on American use of time, the Bureau of Labor Statistics found that persons age 15 and older spent 2 hours

and 49 minutes a day watching TV and 17 minutes in sports and exercise. This lack of activity, when combined with an unhealthy diet, provides fodder for high cholesterol and other cardiovascular risks, such as high blood pressure and diabetes.

Yet, studies have shown that mod-erate-activity aerobic exercise can raise HDL cholesterol levels and lower tri-glycerides. More intense and longer bouts of exercise have an impact on LDL levels.

The Department of Health and Human Services recommends that adults engage in 150 minutes a week of moderate-intensity exercise, like walking or biking, and two days a week of mus-cle-strengthening exercises.

It’s hard to get going, and 150 minutes a week sounds insurmountable. Ten minutes a day is a good start.

« The chemicals in cigarette smoke damage the linings of arteries, which can promote the buildup of plaque.

AT A GLANCEHealthy lifestyles can help improve the levels of choles-terol in the blood. You want to increase your HDL and lower your LDL and triglycerides.

HDL

LDL

levels should be

higher

and triglyceride levels should

be lower



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The name is uncommon but the syn-drome is not. According to a recent study published in the Journal of the American Medical Association, nearly 35 percent of all U.S. adults and 50 percent of those 60 years of age or older were estimated to have the condition in 2011-2012.

Metabolic syndrome, also referred to as Syndrome X, is a cluster of five con-ditions that occur together, thereby in-creasing the risk of heart disease, stroke and diabetes. Abnormal levels of choles-terol and triglycerides are smack in the middle of it.

The five conditions are low HDL cho-lesterol, high triglycerides, increased blood pressure, high blood glucose levels and excess body fat around the waist. Each condition by itself can be damaging enough to health, but when additional conditions are thrown into the mix, the risk of the complications increases. The National Heart, Lung, and Blood In-stitute defines the syndrome as the simultaneous existence of three or more of the conditions.

Most threatening is that, al-though a person can have three or more of these disorders lurking, there’s a high probability that he or

she will be unaware of it. For the most part they have no symptoms. Those with high glucose levels may experience increased thirst or problems with vision, but often, even advanced cases of diabetes are silent. A large waist is a tell-tale sign, but the av-erage person would not associate a larger than average waist with heart disease.

Several factors increase the risk of metabolic syndrome. It occurs more frequently in people over the age of 60. Although it is common in people of all races, Hispanics and Asians are more frequently targeted. Women who had gestational diabetes, or diabetes during pregnancy, or those with a family history of type 2 diabetes are of greater risk than the general public.

CHANCES ARE YOUR DOCTOR WILL NOT SIT YOU DOWN AND TELL YOU THAT YOU HAVE METABOLIC SYNDROME. The name itself

can send shockwaves of panic and fear. Such a strange diagnosis would undoubtedly cause unnecessary angst.

Metabolic syndromeA combination of disorders

TRAITS OF METABOLIC SYNDROMEn Large waist circumference

» 35 inches or higher for women » 40 inches or higher for men

n High triglyceride level — at least 150 mg/dL, or if on treatment for high triglycerides

n Reduced HDL cholesterol in mg/dL » Less than 40 for men » Less than 50 for women

n Increased blood pressure — at least 130/85 or if taking blood pressure medications

n Elevated fasting blood sugar — at least 100 mg/dL or on medications to control high glucose

The good news is that aggressive life-style changes can often prevent the inci-dence of metabolic syndrome, or control it if diagnosed. It’s a common foursome that’s often repeated because it applies to almost every health condition — exercise, weight loss, healthy eating and smoking cessation. General recommendations are 30 minutes a day of moderate-intensity exercise; a healthy eating plan that in-cludes fruits, vegetables, whole grains and healthy fats; a 5 to 10 percent weight loss if overweight; and complete abstinence from all tobacco products. Even one cigarette a day is too much, according to

several studies.If these changes do not do

the trick, medications are available to help control blood pressure, cholesterol and glu-

cose levels. Medications are even available to quash the

desire to smoke.The most severe

threat of metabolic syndrome is that it’s a harbinger of a slew of life-threatening ill-nesses. It’s a wake-up

call that if changes to lifestyle and adherence to medication are ignored, more devastating illnesses are waiting down the line.

Apple-shaped people, or those who carry more weight around the waist, are thought to have a higher risk of heart disease and diabetes than pear-shaped people who carry more weight around the hips. »


Healthy Steps

High cholesterol is one of the leading risk factors for heart disease. When not controlled, it can cause several life-threatening complications, such as heart attack and stroke. With exercise and healthy eating, high cholesterol can often be prevented or controlled.

Prevent and control high cholesterol

Eat right, stay active, live well

22Fitness:

Exercise is the first line of attack against

high cholesterol

Jumping rope improves cardiovascular fitness and burns calories while toning muscle at the same time.

PHOTO: THINKSTOCK.COM/DIGITALVISION/M

IKE POWELL

»Nutrition 18»Recipes 20»Fitness 22


HEALTHY STEPS: Nutrition

BY: KATHY CUNNINGHAM M.ED., R.D., L.D.

A change in dietary guidelinesFoods high in cholesterol not the greatest threat

Some guidelines have not changed. Americans are advised to eat more fruits and vegetables, whole grains and lean protein, for example. But two recom-mendations in particular are not only new, they are game-changing.

The 300 milligrams per day limit of dietary cholesterol has been lifted. Although this change has sparked dis-cussion within the nutrition and public health community, the guidelines are quick to point out that “this change does not suggest that dietary cholesterol is no longer important to consider when building healthy eating patterns.”

Research now shows, however, that the cholesterol we eat has only a small effect on blood cholesterol levels for most people. A meta-analysis published in the American Journal of Clinical Nutrition found no association between saturated

fat and heart disease in prospective stud-ies involving close to 350,000 partici-pants. Another study from Japan actually found an inverse association between saturated fat and stroke. In other words, those who ate more saturated fat had a lower risk of stroke.

Trans fats still tabooBased on these and other findings the DGA revised its advice. Cholesterol-rich foods, like eggs, shrimp and lobster are no longer completely forbidden. One egg, which has 186 mg of cholesterol, will not affect your overall cholesterol if it is part of a healthy eating plan. That does not mean that these foods can be eaten with abandon. The guidelines advise that people consume less than 10 percent of their calories from saturated fat. In general, foods that are higher in

THE 2015 DIETARY GUIDELINES FOR AMERICANS HAVE FINALLY MADE THEIR ENTRY. Updated every five years by the U.S. Departments of

Health and Human Services and Agriculture, the guidelines provide recommendations to promote good health through healthy eating.


dietary cholesterol, such as fatty meats, are also higher in saturated fat.

Trans fats, however, do not get a pass. Trans fats, also called partially hydroge-nated fats, are created when hydrogen is added to liquid vegetable oil, thereby making it solid at room temperature. These types of fats that are found in fried foods, pastries and snacks, for ex-ample, have been found to increase the ratio of unhealthy cholesterol levels. There is no specified limit of trans fats — only that individuals should eat as little as possible.

Added sugars the culpritA guilty finger is now being pointed at another culprit. Refined carbohy-drates may be a greater problem and a greater contributor to heart disease than fats. The DGA recommend that people consume less than 10 percent of calories from refined carbohydrates, such as added sugars. Examples are table sugar, high fructose corn syrup and other sweeteners found in pastries, sugar-sweetened beverages and energy drinks. A study published in the Journal of the American Medical Association: Internal Medicine discovered that those who consumed 17 to 21 percent of cal-ories from added sugar each day had a 38 percent increased risk of dying from cardiovascular disease compared to those who consumed only 8 percent of their calories from sugar.

When not used as energy large con-sumptions of refined carbohydrates can set in motion some less than desirable outcomes. It can convert the glucose or sugar into body fat, which causes weight gain, most likely around the waist. Or it can convert it into fat that is stored in the liver, causing a condition known as fatty liver, which in extreme cases can cause scarring and even liver failure.

Researchers at Harvard Medical School suggest that refined carbohy-drates pose another danger. They may

precipitate low-grade inflammation that sets the stage for atherosclerosis and cholesterol-clogged arteries, the forerunners of heart disease. Foods and drinks containing added sugars are a large contributor.

Although the change in guidelines can be confusing, they reflect advance-ments in scientific and medical knowl-edge, which is always evolving. As Mi-chael F. Jacobson, the president of the Center for Science in the Public Interest so aptly stated, “The advice presented in the 2015 Dietary Guidelines for Ameri-cans is sound, sensible and sci-ence-based. If Americans ate according to that advice, it would be a huge win for the public’s health.”

« Omega-3 fats, such as that found in salmon, may lower triglycerides and reduce inflammation that can lead to atherosclerosis, or plaque.PHOTO: THINKSTOCK.COM/ISTOCK/VICUSCHKA

HEALTHY STEPS: Nutrition

HEALTHY HINTSThere is no exact menu to follow for healthy eating. Below are some general guidelines to help you choose wisely.

n Increase healthy fats. Some fats are actually healthy. Monounsaturated fats like olive oil and avocados can improve LDL cholesterol levels, according to Mayo Clinic, as well as omega-3 fats found in fish, such as salmon and albacore tuna. Walnuts, peanuts, almonds and other nuts and seeds help keep blood vessels healthy. Although nuts are good for you, they are high in calories and should be eaten in moderation. A handful a day will do.n Switch the carbs. You need carbs for fuel, but carbs from whole-grain bread, brown rice, and other whole grains pro-vide fuel as well as much needed nutri-ents. They are also high in fiber which helps prevent fat buildup in the blood. n Eat your veggies. Plant-based foods like fruits and vegetables are antioxidants that squelch the damage from free radi-cals that are linked not only to cardiovas-cular diseases but also to cancer.n Spice it up. People tend to overlook the health benefits of herbs and spices such as turmeric, ginger and garlic. These spices are powerful antioxidants and may lower cholesterol and prevent the buildup of plaque that is linked to heart disease.


HEALTHY STEPS: Recipes

THIS “BUTTONS AND BOWS PASTA” RECIPE FROM THE NATION-AL HEART, LUNG, AND BLOOD INSTITUTE OFFERS A BLEND OF

HEALTHY NUTRIENTS, INCLUDING WHOLE WHEAT PASTA, PEAS AND CARROTS FOR FIBER AND PROTEIN. Vegetables are also a good source of potas-sium, which the body needs to regulate the heart’s activity. Olive oil and garlic are also beneficial for cardiovascular health. The dish is low in sodium and has no cholesterol and only one gram of saturated fat.

The recipe takes only five minutes of preparation time and 20 minutes of cook time.Source: Deliciously Healthy Family Meals, a program of the National Heart, Lung, and Blood Institute (www.nhlbi.nih.gov/health/educational/wecan)

INGREDIENTSn 2 cups dry whole-wheat bowtie pasta

(farfalle) (8 oz.) n 1 tbsp. olive oiln 1 tsp. garlic, minced (about 1 clove) n 1 bag (16 oz.) frozen peas and carrots n 2 cups low-sodium chicken broth n 2 tbsp. cornstarch n 1 tbsp. fresh parsley, rinsed, dried, and

chopped (or 1 tsp. dried) n 1 medium lemon, rinsed, for 1 tsp. zest

(use a grater to take a thin layer of skin off the lemon)

n ¼ tsp. ground black pepper

NUTRITIONAL ANALYSIS (PER SERVING)

* Makes 4 servings; a serving is 2 cups

Buttons and bows pasta

DIRECTIONS 1. In a 4-quart saucepan, bring 3 quarts of

water to a boil over high heat. 2. Add pasta and cook according to package

directions. Drain. 3. Meanwhile, heat olive oil and garlic over

medium heat in a large sauté pan. Cook until soft, but not browned.

4. Add peas and carrots. Cook gently until the vegetables are heated through.

5. In a bowl, combine chicken broth and corn-starch. Mix well. Add to pan with vegetables and bring to a boil. Simmer gently for 1 minute.

6. Add parsley, pasta, lemon zest and pepper. Toss gently and cook until the pasta is hot.

n Calories: 329n Total Fat: 6 gn Saturated Fat: 1 g n Cholesterol: 0 mgn Sodium: 127 mg

n Total Fiber: 9 g n Protein: 13 g n Carbohydrates: 59 gn Potassium: 331 mg


HEALTHY STEPS: Recipes

THIS RECIPE COMBINES BROWN RICE WITH

BELL PEPPERS, CORN, TO-MATOES AND BLACK BEANS. Because brown rice retains its bran and germ, it provides more fiber and nutritional benefits than white rice. It also has a mild nutty flavor.

The bell peppers, beans, corn and tomatoes add not only texture and color, but also potassium and vitamins. A bit of cumin provides a hint of Mexican flavor, while turmeric adds a subtle yellow coloring and unique flavor. This recipe is high in fiber and protein, low in sodium and contains no saturated fats, which contribute to high cholesterol.

A green salad will round out this healthy vegetarian entrée.

Source: American Institute for Cancer Research

INGREDIENTSn 1 tbsp. extra virgin olive oiln 1 medium green bell pepper,

seeded and choppedn 1 medium red bell pepper,

seeded and choppedn 1 medium onion, choppedn 4 cloves garlic, mincedn 16 oz. reduced-sodium vegetable broth

n 1 cup uncooked brown ricen ½ tsp. cuminn 1⁄8 tsp. turmericn 1 can (15 oz.) black beans, drained and rinsed

(or use no salt added)n 2 oz. corn kernels, no salt added canned,

or frozen, thawedn 1 can (4 oz.) mild green chiles, dicedn 1 can (14 oz.) diced tomatoes, drained n Salt and freshly ground black pepper to taste

NUTRITIONAL ANALYSIS (PER SERVING) n Calories: 220n Total fat: 3 g (0 g saturated fat)

n Carbohydrate: 42 g n Protein: 7 g

n Dietary fiber: 6 g n Sodium: 70 mg

South-of-the-border beans and rice

DIRECTIONS 1. In medium pot, heat oil over medium high heat.

Add peppers, onion and garlic and sauté for about 4 minutes.

2. Stir in broth, rice, cumin and turmeric. Bring to boil.

Reduce heat, cover and simmer for 45 to 50 minutes or until rice is tender (do not stir during this time).

3. Then gently stir in beans, corn, chiles and toma-toes. Heat through and let stand 5 minutes.

4. Season to taste with salt and pepper and serve. * Makes 8 servings


EXERCISE SEEMS TO BE A MAGICAL ELIXIR FOR MOST

AILMENTS. That’s because it is medi-cine, according to exercise physiologists. It’s better than a pill. It’s free and has few, if any, side effects. And if you participate regularly, you can reduce the risk of cardiovascular disease, diabetes, bone weakness and several types of cancer. You can even improve your mood.

According to several studies exercise also has an impact on cholesterol levels, and when paired with healthy eating, is often the first line of attack to control cholesterol and fats in the blood.

Although results of studies are mixed, HDL (“good”) cholesterol seems to ben-efit the most from exercise. Levels rise regardless of the type and intensity of the activity. That’s a good thing. HDL is the type of cholesterol that grabs the LDL (“bad”) cholesterol and transports it to the liver for removal from the body.

A meta-analysis of the impact of ex-ercise on cholesterol was published in the journal Sports Med in 2014. The authors reported that on average, HDL cholesterol increased by 4.6 percent. More intensive exercise of longer dura-tions, however, was required to lower LDL cholesterol. Total cholesterol was least likely to be affected by exercise and most often remained unchanged.

Another study called the Atherosclero-sis Risk in Communities Study evaluated the long-term impact of physical activity on cholesterol levels in roughly 9,000 adults between the ages of 45 and 64. The ARIC, which involved patients from four communities across the country, was unique in that it included African Ameri-can men and women.

The baseline examination showed

that the participants were sim-ilar in age, LDL and total cho-lesterol measurements. All were overweight or obese.

The results of the nine-year study showed differences by race and gender. Everyone im-proved their HDL. LDL levels dropped only in women, par-ticularly African Americans. Whites showed decreases in triglycerides, while black women were the only ones to experience a decline in total cholesterol.

The relationship between ex-ercise and cholesterol is not clear. One theory is that exercise spurs the development of enzymes that give a boost to HDL and increase their ability to transfer LDL from the blood back to the liver for dis-posal. Another theory is that ex-ercise increases the size of “bad” cholesterol. At first glance, that seems like a bad thing. However, scientists now be-lieve that small, dense LDL is more prone to penetrate arteries, while large, fluffy LDL is relatively benign.

While the focus has been more on aerobic exercise, studies suggest that strengthening exercises have an impact as well. An interesting finding is that the number of repetitions may be as import-ant as or even more important than the amount of weight lifted. So a three-pound weight might have the same or better impact than a 10-pound weight if you lift it more times.

While exercise can improve choles-terol levels, it can also reduce weight. Reduction in weight, especially if the weight is centered around the waistline,

is key to preventing type 2 diabetes, heart disease and metabolic syndrome, a combination of risk factors that in-clude both cholesterol and triglycerides.

The type of exercise is your choice. According to the American Heart As-sociation, people who engage in 150 minutes a week of moderate-intensity exercise had a 14 percent lower risk of heart disease in comparison to inac-tive adults. Hike it up to 300 minutes a week, and the risk drops even further.

Studies suggest that each 1 mg/dL increase in HDL can reduce the risk of heart disease by at least 2 percent in men and 3 percent in women.

The bottom line is the oft-repeated mantra: Some exercise is better than none; more is better than some.

HEALTHY STEPS: Fitness

Exercise and high cholesterolThe first line of attack

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Brigham and Women’s discovery that taking an aspirin a day prevents heart attacks has had a global impact. Today, we are pioneering the latest advances in heart valve surgery. And new approaches to treating and even reversing heart failure are bringing new hope to millions who had none. Innovations here change the future of medicine, one patient at a time. It all starts here.

Download our white paper or watch our video on “Aspirin and Your Health” at BrighamAndWomens.org/aspirin.

What began as an idea of taking one aspirin a day became a standard that saves lives worldwide.

© 2014 Brigham and Women’s Hospital

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