Be knowledgeable. Be well. Be healthy.
High cholesterol PLANT-BASED FOODS — GOOD MEDICINE
PREVENTION METHODS FITNESS TIPS AND HEALTHY RECIPES
STRESS AND HEART DISEASE
A POSSIBLE LINK TO HIGH CHOLESTEROL
2 Be Healthy | Spring 2016
Publisher Melvin Miller Health Editor Karen Miller Senior Editor Yawu Miller Art Director Daniel Goodwin Production Caleb Olson Proofreader Rachel Reardon For advertising opportunities Please contact Karen Miller at (617) 936-7800 or firstname.lastname@example.org
Be Healthy is published by Banner Publications, Inc. 23 Drydock Ave. Boston, MA 02210 Volume 4 • Number 1 Spring 2016 Be Healthy is printed by TC Transcontinental Printing, 10807, Mirabeau, Anjou (Québec) H1J 1T7 Printed in Canada COVER PHOTO: THINKSTOCK.COM/ISTOCK PAGE 3 PHOTO: THINKSTOCK.COM/ ISTOCK/RALWEL
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 recommend that you take advantage of screenings appropriate for your age, sex, race and risk factors and make timely visits to your primary care physician.
Peripheral arterial disease: Common, but often undetected
Recipe: Buttons and bows pasta
Spring 2016 The issue
High cholesterol By the numbers
Heart attack and stroke Stress and heart disease Peripheral arterial disease Prevention Metabolic syndrome
10 11 12 14 16
Nutrition Recipes Fitness
18 20 22
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The issue: High cholesterol
High cholesterol: Common and silent
Cholesterol not really a villain CHOLESTEROL 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. 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. 4 Be Healthy | Spring 2016
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 peripheral arterial disease. The LDL does not have affinity for a particular artery. All arteries — regardless of their location — are fair game. The reason it is so strongly linked to heart attacks is because of the devastating outcome. Heart disease is the number one killer in this country.
Stats High 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 activities. 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 attacked and it can result in amputation if the legs are afflicted.
Testing High 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 triglycerides. Generally, desired readings are
The issue: High cholesterol
PHOTO: ERNESTO ARROYO
Pradeep Natarajan, M.D., M.MSc specializes in preventive cardiology at the Massachusetts General Hospital Corrigan Minehan Heart Center.
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The issue: High cholesterol
Prevention and treatment With the exception of a genetic predisposition 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 exception. “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 guidelines The medical profession has made a recent major shift regarding the effect of diet on 6 Be Healthy | Spring 2016
The lipid panel tests for total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides.
SCREENING RESULTS It 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, schedules 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.
Below 200 200-239 240 and above
Below 100 Optimal 100-129 Near optimal 130-159 Borderline high 160-189 High 190 and above Very high
Below 40 Poor – a major risk for heart disease 40-59 Better 60 and above Best – considered protective against heart disease
Below 150 Desirable 150-199 Borderline high 200-499 High 500 and above Very high
Desirable Borderline high High
Source: National Heart, Lung, and Blood Institute
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 clearcut. Total cholesterol could test as normal, but include higher than desired LDL. To get a better look, some health providers perform additional calculations to determine 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, according to the American Heart Association. Screening should begin at 20, according 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.
The issue: High cholesterol
A CLOSER LOOK
Total 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.
A risk factor is a characteristic that increases the likelihood of developing 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.
Total cholesterol/HDL ratio
Non-HDL (Total cholesterol minus HDL)
No race is spared. But risk factors may vary among groups.” — Dr. Pradeep Natarajan Massachusetts General Hospital
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 warning might have backfired. “We told people not to eat any fat,” said Natarajan, “but they continued to eat refined carbohydrates.” Unfortunately, one bad habit replaced another. Sugar-sweetened beverages and foods like white rice can produce cholesterol and triglycerides. The modified warning does not apply to all fats. Trans fats are still taboo. Unsaturated 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
COMPLICATIONS The buildup of plaque called atherosclerosis, which is attributed to cholesterol, is linked to several life-threatening conditions. n Angina (chest pain) n Heart attack n Stroke n P eripheral arterial disease (buildup of plaque in the legs)
the National Heart, Lung, and Blood Institute 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 exceeding 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, diastolic 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 favorably among all cardiologists. While the test still applies to people with known risk factors for heart disease, it now advises 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
RISK FACTORS THAT CANNOT BE CONTROLLED n F amily history: It can run in families, particularly if genetic nA ge: The risk increases with age n S ex: Occurs in both genders, but men typically have lower HDL levels than women nR ace: Occurs in all races, but is more frequent in Mexican American males and African American females RISK FACTORS THAT CAN BE MODIFIED nU nhealthy diet: Diets high in trans fats and added sugars have been linked to high cholesterol n P hysical inactivity n Obesity n L arge waist circumference n Smoking
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 findings from the Framingham Heart Study, which included no people of color. “It opens up an avenue of discussion,” he explained. “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 compound. 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. baystatebanner.com/news/be-healthy | Be Healthy 7
By the numbers: Cholesterol
13% The percent of U.S. adults that have total cholesterol of 240 or higher
Less than one-half of adults with high LDL get treatment
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People with high total cholesterol have twice the risk of heart disease.
25% The percent of U.S. adults that have high triglycerides
The number of U.S. adults that have high LDL (“bad”) cholesterol
Less than one-third of adults with high LDL have it under control
Focus:High cholesterol Common, but often preventable »Heart attack and stroke 10 »Stress and heart disease 11 »Peripheral arterial disease 12 » Prevention 14 »Metabolic syndrome 16
“ PHOTO: STEVEN ADAMS PHOTOGRAPHS
I want to talk to more women and change the picture of a cardiac patient.” — Melissa Blount
Stress may have aggravated Melissa Blount’s high cholesterol, which resulted in a 95 percent blockage in one of the arteries in her heart.
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FOCUS: High cholesterol
Heart attack and stroke Major complications from cholesterol HEART ATTACK BY FAR THE MOST FEARED OUTCOME OF HIGH CHOLESTEROL IS A HEART ATTACK.
Blood flow through a clear artery.
10 Be Healthy | Spring 2016
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 nutrients 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 disease. 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 prevent 80 percent of all strokes.
SYMPTOMS n P ain or discomfort in the jaw, neck or back n F eeling weak, light-headed or faint n C hest pain or discomfort n P ain or discomfort in arms or shoulder n S hortness of breath n E xtreme fatigue (common in women)
UNCONTROLLED BLOOD PRESSURE IS MORE FREQUENTLY CORRELATED TO STROKE, BUT HIGH CHOLESTEROL DOES ITS FAIR SHARE OF DAMAGE. The same mechanism
Obstructed blood flow through a partially clogged artery.
n S udden numbness or weakness of face, arm or leg, especially on one side of the body n S udden confusion, trouble talking or understanding speech n S udden trouble seeing in one or both eyes n S udden trouble walking, dizziness or loss of balance or coordination n S udden severe headache with no known cause
ILLUSTRATIONS: CALEB OLSON
That fear is realized every 43 seconds in the U.S., according to the Centers for Disease 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 cholesterol, 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.
FOCUS: High cholesterol
Stress and heart disease A possible link to high cholesterol MELISSA BLOUNT, 46, HAD IT ALL. A LOVING HUSBAND, A BEAUTIFUL DAUGHTER AND A PROMISING CAREER IN CLINICAL PSYCHOLOGY. There was one thing
PHOTO: STEVEN ADAMS PHOTOGRAPHS
missing, though — a baby sister or brother for Safiya, her only child. Her efforts to have another child several 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 relatively 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 pregnant or nursing.” The drugs may cause birth defects, and the risks outweigh the benefits. Blount preferred natural alternatives 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 grandmother 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 exercise. 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 escalated 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 subsequent catheterization (test to diagnose heart disease) found a 95 percent blockage 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
Melissa Blount and her daughter Safiya.
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. baystatebanner.com/news/be-healthy | Be Healthy 11
FOCUS: High cholesterol
Peripheral arterial disease Common, but often undetected NOWADAYS THE WORD “PAD” BRINGS TO MIND A TABLET OR NOTEBOOK OR SOME OTHER ELECTRONIC DEVICE. But to the medical commuIt 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 favoritism. 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 situation is that the symptoms come and go. Most often people experience claudication, 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 adequate supply of blood to the muscles. The demand for oxygen — and the pain — decrease with rest. Claudication is characterized by its consistency. 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 12 Be Healthy | Spring 2016
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 pressure, 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 undiagnosed. Initially, it is painless. The first sign that the problem even exists is often the lack of pulses in the leg, but an examination 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 angiogram — 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.
Readings of less than 1.0 indicate narrowing 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 lifestyle and taking medications to control cholesterol, blood pressure and glucose. A daily aspirin is often recommended to prevent clots. Other situations require a more aggressive 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 medicine and surgical interventions are insufficient, amputation is required. But there is good news. Researchers from the Harvard T.H. Chan School of Public Health studied the impact of certain risk factors on the incidence of PAD. They followed 45,000 male health professionals for 25 years and found that four risk factors — high cholesterol, smoking, diabetes and high blood pressure — were
nity, it means peripheral arterial disease, a blockage of arteries in the limbs and organs.
FOCUS: High cholesterol
A common symptom of PAD is claudication, or pain in the leg, usually during exercise.
SYMPTOMS OF PAD
PHOTO: USED WITH PERMISSION OF MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED.
n P ainful cramping in hip, thigh or calf muscles after physical activities n L eg numbness or weakness n S ores or wounds on the toes, feet, or legs that wonâ€™t heal n S hiny skin on the legs n C hange in color of the skin of legs nA lower temperature of one leg compared to the other leg n S lower growth of toenails and slower hair growth on feet and legs n E rectile dysfunction, especially among men who have diabetes
ANKLE-BRACHIAL INDEX The 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 pressure (top number) of the arteries near the ankle by the systolic blood pressure in the arms. Blood pressure ankle Blood pressure arm
the major culprits behind PAD. Having just one of these factors doubled 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 conditions. Time was also a factor. The longer the man smoked or had diabetes or high cholesterol, the higher the risking of developing PAD. These results suggest that PAD can be prevented. Lifestyle changes to prevent the four risk factors or adherence to a medication regime can reduce the risk of not only PAD, but also stroke and heart disease.
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
Treat risk factors
Some arterial disease
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
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FOCUS: High cholesterol
Prevention of high cholesterol It’s possible to eat your way to good health 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 effective as desired in reducing cholesterol levels, medication — in conjunction with healthy lifestyles — is prescribed.
BMI: BODY MASS INDEX Obesity 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)
BMI 18.5-24.9 25-29.9 30 or more
Definition Healthy Overweight Obese
x 703 Waist Size Men Women
Desired Measurement Less than 40 inches Less than 35 inches
Smoking Cigarette smoking might provide a “buzz” from that quick jolt of nicotine, but it wreaks havoc on your health. Cigarette 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 cardiovascular 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 structure and function of blood vessels making them fertile ground for atherosclerosis, the buildup of plaque attributed largely to cholesterol. 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 actually puts more nicotine into the bloodstream than do cigarettes. Although it is 14 Be Healthy | Spring 2016
chewed rather than inhaled studies suggests 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 (1-800-7848669) for information and help quitting.
Obesity Correlating a few extra pounds to cholesterol 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 association 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 reverse 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 increase in HDL cholesterol and an average 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 cardiovascular disease and type 2 diabetes, and is linked to high cholesterol levels.
Healthy eating It is hard for many people to eat healthy foods for many reasons. Time and money
FOCUS: High cholesterol
AT A GLANCE Healthy lifestyles can help improve the levels of cholesterol in the blood. You want to increase your HDL and lower your LDL and triglycerides.
levels should be higher
triglyceride levels should be lower
« The chemicals in cigarette smoke damage the linings of arteries, which can promote the buildup of plaque.
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 National Heart, Lung, and Blood Institute are recommended choices. Both emphasize 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 individual healthy eating plan.
Exercise Next 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 moderate-activity aerobic exercise can raise HDL cholesterol levels and lower triglycerides. 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 muscle-strengthening exercises. It’s hard to get going, and 150 minutes a week sounds insurmountable. Ten minutes a day is a good start. baystatebanner.com/news/be-healthy | Be Healthy 15
FOCUS: High cholesterol
A combination of disorders 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. The name is uncommon but the syndrome 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 conditions that occur together, thereby increasing the risk of heart disease, stroke and diabetes. Abnormal levels of cholesterol and triglycerides are smack in the middle of it. The five conditions are low HDL cholesterol, 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 Institute defines the syndrome as the simultaneous existence of three or more of the conditions. Most threatening is that, although a person can have three or more of these disorders lurking, there’s a high probability that he or 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. » 16 Be Healthy | Spring 2016
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 average 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.
n L arge waist circumference » 35 inches or higher for women » 40 inches or higher for men nH igh triglyceride level — at least 150 mg/dL, or if on treatment for high triglycerides nR educed HDL cholesterol in mg/dL » Less than 40 for men » Less than 50 for women n I ncreased blood pressure — at least 130/85 or if taking blood pressure medications n E levated fasting blood sugar — at least 100 mg/dL or on medications to control high glucose The good news is that aggressive lifestyle changes can often prevent the incidence 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 includes 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 glucose 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 illnesses. 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.
ILLUSTRATION: CALEB OLSON
TRAITS OF METABOLIC SYNDROME
Healthy Steps Eat right, stay active, live well » Nutrition 18 » Recipes 20 » Fitness 22
Jumping rope improves cardiovascular fitness and burns calories while toning muscle at the same time.
Prevent and control high cholesterol
PHOTO: THINKSTOCK.COM/DIGITALVISION/MIKE POWELL
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.
Exercise is the first line of attack against high cholesterol
22 baystatebanner.com/news/be-healthy | Be Healthy 17
HEALTHY STEPS: Nutrition
CUNNINGHAM M.ED., R.D., L.D.
A change in dietary guidelines Foods high in cholesterol not the greatest threat 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. Some guidelines have not changed. Americans are advised to eat more fruits and vegetables, whole grains and lean protein, for example. But two recommendations 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 discussion within the nutrition and public health community, the guidelines are quick to point out that â€œthis change does not suggest that dietary cholesterol is no longer important to consider when building healthy eating patterns.â€? 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 18 Be Healthy | Spring 2016
fat and heart disease in prospective studies involving close to 350,000 participants. 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 taboo Based 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
HEALTHY STEPS: Nutrition « 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
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 hydrogenated 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 example, 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 culprit A guilty finger is now being pointed at another culprit. Refined carbohydrates 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 calories 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 consumptions 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 carbohydrates pose another danger. They may
HEALTHY HINTS There 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 provide fuel as well as much needed nutrients. 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 radicals that are linked not only to cardiovascular 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.
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 advancements in scientific and medical knowledge, which is always evolving. As Michael 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 Americans is sound, sensible and science-based. If Americans ate according to that advice, it would be a huge win for the public’s health.” baystatebanner.com/news/be-healthy | Be Healthy 19
HEALTHY STEPS: Recipes
Buttons and bows pasta THIS “BUTTONS AND BOWS PASTA” RECIPE FROM THE NATIONAL 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 potassium, 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)
INGREDIENTS n 2 cups dry whole-wheat bowtie pasta (farfalle) (8 oz.) n 1 tbsp. olive oil n 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
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 cornstarch. 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. * Makes 4 servings; a serving is 2 cups
NUTRITIONAL ANALYSIS (PER SERVING)
n Calories: 329 n Total Fat: 6 g n Saturated Fat: 1 g n Cholesterol: 0 mg n Sodium: 127 mg
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n Total Fiber: 9 g n Protein: 13 g n Carbohydrates: 59 g n Potassium: 331 mg
HEALTHY STEPS: Recipes
South-of-the-border beans and rice THIS RECIPE COMBINES BROWN RICE WITH BELL PEPPERS, CORN, TOMATOES 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
n 1 cup uncooked brown rice n ½ tsp. cumin n 1⁄8 tsp. turmeric n 1 can (15 oz.) black beans, drained and rinsed
n 1 tbsp. extra virgin olive oil n 1 medium green bell pepper, seeded and chopped
(or use no salt added)
n 1 medium red bell pepper,
n 2 oz. corn kernels, no salt added canned,
seeded and chopped
or frozen, thawed
n 1 medium onion, chopped n 4 cloves garlic, minced n 16 oz. reduced-sodium vegetable broth
n 1 can (4 oz.) mild green chiles, diced n 1 can (14 oz.) diced tomatoes, drained n Salt and freshly ground black pepper to taste
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 tomatoes. Heat through and let stand 5 minutes. 4. Season to taste with salt and pepper and serve.
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.
* Makes 8 servings
NUTRITIONAL ANALYSIS (PER SERVING) n Calories: 220 n 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
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HEALTHY STEPS: Fitness
Exercise and high cholesterol EXERCISE SEEMS TO BE A MAGICAL ELIXIR FOR MOST AILMENTS. That’s because it is medicine, 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 benefit 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 exercise 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 durations, 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 Atherosclerosis 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 American men and women. The baseline examination showed 22 Be Healthy | Spring 2016
that the participants were similar in age, LDL and total cholesterol measurements. All were overweight or obese. The results of the nine-year study showed differences by race and gender. Everyone improved their HDL. LDL levels dropped only in women, particularly African Americans. Whites showed decreases in triglycerides, while black women were the only ones to experience a decline in total cholesterol. The relationship between exercise 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 disposal. Another theory is that exercise increases the size of “bad” cholesterol. At first glance, that seems like a bad thing. However, scientists now believe 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 important 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 cholesterol 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 include both cholesterol and triglycerides. The type of exercise is your choice. According to the American Heart Association, people who engage in 150 minutes a week of moderate-intensity exercise had a 14 percent lower risk of heart disease in comparison to inactive 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.
PHOTO: THINKSTOCK.COM/PHOTODISC/RYAN MCVAY
The first line of attack
What began as an idea of taking one aspirin a day became a standard that saves lives worldwide. 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.
© 2014 Brigham and Women’s Hospital
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Cancer can be conquered. Dana-Farber can help. To learn more about cancer prevention, screenings and treatment, call 866-408-3324 or visit www.dana-farber.org/community.