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Prevention: A Personal Project

Preventing heart disease, by and large, means making changes in the way we live. For each individual, a healthy heart requires a personal action plan. But where does one begin? A complete medical checkup is a sensible first step. With the help of your doctor or other health professional, you can find out if you have any cardiovascular disease risk factors, and if so, work out a practical treatment plan. Even if you don't have any risk factors now, you can discuss ways to lessen your chances of developing them. Good communication with your health professional is very important. Choose someone you trust who will listen to your questions, answer them fully, and take your concerns seriously.

But while advice from a health professional is important, the final responsibility for heart health lies with each woman. Only you can make the kinds of lifestyle changes--changes in eating, drinking, smoking, and exercise habits--that will help protect against cardiovascular diseases. To learn about the many organizations and reading materials available to help you, see "Resources for a Healthy Heart." In the meantime, keep reading. The self-help suggestions that follow can help you get started on a personal program for a healthy heart.

Self-Help Strategies for a Healthy Heart

Kicking the Smoking Habit

There is nothing easy about giving up cigarettes. But as hard as quitting may be, the results are well worth it. In the first year after stopping smoking, the risk of coronary heart disease drops sharply. It then gradually returns to "normal"--that is, the same risk as someone who never smoked. This means that no matter what your age, quitting will lessen your chances of developing heart disease.

Quitting will also save you money. Over 10 years, a two-pack-a-day smoker can spend more than $7,500 on cigarettes. And that price tag doesn't take into account the extra costs of smoking-related illnesses, such as doctors' bills, medicines, and lost wages.

Take some time to think about other benefits of being an ex-smoker. Check the reasons that apply to you in the box that follows. Add any others you think are important. This is an important first step in kicking the smoking habit--figuring out for yourself what you have to gain.

Many women fear that if they stop smoking they will gain unwanted weight. But you do not have to gain a lot of weight. Here are the facts:

• The average weight gain for ex-smokers is only about 5 pounds.
• Only about 3 percent of women gain a lot of weight (more than 20 pounds) after quitting.

Weight gain may be partly due to changes in the way the body uses calories after smoking stops. Also, some people eat more when quitting because they substitute high-calorie food for cigarettes. Choosing more foods lower in calories and boosting your exercise level will help guard against weight gain. And if you do gain some weight, you can work on losing it after you have become comfortable as a nonsmoker. When you think about the enormous health risks of smoking, the possibility of putting on a few pounds is not a reason to continue.

Getting Ready to Quit

Once you decide to stop smoking, a few preparations are in order. Set a target date for quitting--perhaps the first day of a month. Don't choose a time when you know you will be under a lot of stress. To help you stick to your quit date, write the date on the contract that follows and have someone sign it with you. And don't forget to list how you'll reward yourself for becoming an ex-smoker.

Consider asking your contract cosigner--or another friend or family member--to give you special support in your efforts to quit. Plan to get in touch with your supporter regularly to share your progress and to ask for encouragement. Give your "cheerleader" a copy of your list of "Why I Want to Quit" so that he or she can remind you of your goals. If possible, quit with a spouse or a friend.

Breaking the Habit

Surviving "Day One." On the evening before your quit day, "clean house." Throw away all cigarettes, matches, and lighters and give away your ashtrays. Plan some special activities for the next day to keep you busy, such as a long walk, a bike ride, a movie, or an outing with a good friend. Ask family members and friends not to offer you cigarettes or to smoke in front of you. Your goal is to get through that first important day smoke-free. If you succeed on the first day, it will help give you the confidence to succeed on the second--and on each day after that.

Know yourself. To quit successfully, you need to know your personal smoking "triggers." These are the situations and feelings that typically bring on the urge to light up. Some common triggers include drinking coffee, finishing a good meal, watching television, having an alcoholic drink, talking on the phone, or watching someone else smoke. Stress can also be a trigger. Make a list of the situations and feelings that particularly tempt you to smoke. Especially during the first weeks after quitting, try to avoid as many triggers as you can.

Find new habits. Replace "triggers" with new activities that you don't associate with smoking. For example, if you always had a cigarette with a cup of coffee, switch to tea for awhile. If you always smoked at the table after dinner, get up as soon as the meal is over and go out for a walk. If you're feeling tense or angry, try a relaxation exercise such as deep breathing to calm yourself. (Take a slow, deep breath, count to five, and release it. Repeat 10 times.)

Keep busy. Get involved in projects that require you to use your hands: needlework, gardening, jigsaw puzzles. Try out new physical activities that make smoking impossible, such as swimming, jogging, tennis, or aerobic dancing. When you feel the need to put something in your mouth, have low-calorie substitutes on hand, such as vegetable sticks, apple slices, or sugarless gum. Some people find it helpful to inhale on a straw or chew on a toothpick until the urge passes.

Know what to expect. During the first few weeks after quitting, you may experiences some temporary withdrawal symptoms, such as headaches, irritability, tiredness, constipation, and trouble concentrating. These symptoms may come and go, and be stronger or weaker on different days. While these feelings are not pleasant, it is important to know that they are signs that your body is recovering from smoking. Most symptoms end within 2 to 4 weeks.

Two things to help you. Nicotine chewing gum and a nicotine patch are both available by prescription. The gum and the patch can help you stay off cigarettes by lessening your withdrawal symptoms. They give you nicotine at a lower, more even dose than your cigarettes did. Gradually, you should chew fewer pieces of the gum each day until you stop using it altogether. Similarly, you gradually use patches with a lower dose of nicotine. Nicotine gum and the nicotine patch are not for everyone--talk to your health professional about using them. Pregnant women, nursing mothers, and people with serious heart problems cannot use them safely. But for those who can, both the gum and the patch can help one "over the hump" and on the road to smoke-free living.

More help is available. There are a number of free or low-cost programs available to help you stop smoking. They include programs offered by local chapters of the American Lung Association and the American Cancer Society (see "Resources for a Healthy Heart"). Other low-cost programs can be found through hospitals, health maintenance organizations (HMOs), workplaces, and community groups. Some programs offer special support for women.

Be good to yourself. Get plenty of rest, drink lots of fluids, and eat three balanced, healthful meals per day. If you are not as productive or cheerful as usual during the first several weeks after quitting, don't feel guilty. Give yourself a chance to adjust to your new nonsmoking lifestyle. Ask your friends and family to give you lots of praise for kicking the habit--and don't forget to pat yourself on the back. You are making a major change in your life, and you deserve a lot of credit.

If You "Slip"

A "slip" means that you have had a small setback and smoked a cigarette after your quit date. Don't worry. It doesn't mean that you've become a smoker again. Most smokers "slip" three to five times before they quit for good. But to get right back on the nonsmoker track, here are some tips:

Don't get discouraged. Having a cigarette or two doesn't mean you have failed. It doesn't mean you can't quit smoking. A slip happens to many, many people who successfully quit. Keep thinking of yourself as a nonsmoker. You are one.

Learn from experience. What was the trigger that made you light up? Were you driving home from work, having a glass of wine at a party, feeling angry at your boss? Think back on the day's events until you remember what the specific trigger was.

Take charge. Make a list of things you will do the next time you are in the particular situation--and other tempting situations as well. Sign a new contract with your support person to show yourself how determined you are to kick the habit. Reread your list of all the reasons you want to quit. You're on your way.

Getting Physical

Regular exercise can help you reduce your risk of coronary heart disease. Exercise helps women take off extra pounds, helps to control blood pressure, lessens a diabetic's need for insulin, and boosts the level of "good" HDL-cholesterol.

Some studies also show that being inactive boosts the risk of heart attack.

Exercise has many other benefits. It strengthens the lungs, tones the muscles, keeps the joints in good condition, and helps many people cope better with stress.

While many physical activities are fun, only regular, brisk exercise will improve heart health. This is called "aerobic" exercise and includes jogging, swimming, jumping rope, and cross-country skiing. Walking, biking, and dancing can also strengthen your heart, if you do them fast enough and long enough. Choose an activity that you think you will enjoy and that will fit most easily into your schedule.

Most people do not need to see a doctor before they start a gradual, sensible exercise program. Some people, however, should get medical advice. For example, if you have heart trouble or have had a heart attack, if you are over 50 years old and are not used to energetic activity, or if you have a family history of developing heart disease at a young age, check with your doctor before you start.

Once you get started, keep these guidelines in mind:

Go slow. Before each exercise session, allow a 5-minute period of stretching and slow exercise to give your body a chance to "warm up." At the end of your workout, take another 5 minutes to "cool down" with a slower, less energetic exercise pace.

Listen to your body. A certain amount of stiffness is normal at first. But if you hurt a joint or pull a muscle or tendon, stop exercising for several days to avoid more serious injury. Most minor muscle and joint problems can be relieved by rest and over-the-counter painkillers.

Pay attention to warning signals. While exercise can strengthen your heart, some types of activity may worsen existing heart problems. Warning signals include sudden dizziness, cold sweat, paleness, fainting, or pain or pressure in your upper body just after exercising. If you notice any of these signs, stop exercising and call your doctor immediately.

Keep at it. Unless you have to stop exercising for a health reason, stay with your exercise program. If you feel like giving up because you think you're not going as fast or as far as you "should," set smaller, short-term goals for yourself as well as grander ones. If you find yourself becoming bored, try exercising with a friend. Or switch to another activity. The health rewards of regular, brisk exercise are well worth the effort.

Eating for Health

The health of your heart has a lot to do with the food you eat. Changing your eating habits according to the Dietary Guidelines for Americans lessens your risk of heart disease in three ways:

• It helps reduce high blood cholesterol levels.
• It helps control high blood pressure.
• It helps take off extra pounds.

As a bonus, the kinds of eating habits that are good for your heart may also help prevent certain types of cancer and a number of other health problems.

Lowering Blood Cholesterol

Reducing your blood cholesterol level can greatly lessen the chances of developing coronary heart disease. One major study showed that each 1 percent reduction in blood cholesterol produced a 2 percent reduction in the number of heart attacks. This means that if you lower your blood cholesterol by 25 percent, you may cut your risk of heart attack in half.

For most people, blood cholesterol can be lowered by eating less saturated fat, less total fat, and less cholesterol. Cutting down on the fat in your diet also protects your heart another way--by helping you cut back on calories and take off extra pounds.

Today, about 37 percent of the calories in the average American diet come from fat--about 13 percent from saturated fat and 24 percent from monounsaturated and polyunsaturated fat. To lessen your chances of getting coronary heart disease, the total fat in your diet should be no more than 30 percent of the total calories you take in each day. Your 30 percent "fat allowance" should be divided up this way:

• Saturated fat should make up less than 10 percent of total calories.
• Polyunsaturated fat should be not more than 10 percent of total calories.
• Monounsaturated fat should make up 10 to 15 percent of total calories.

In addition, you should eat less than 300 mg of cholesterol per day. This eating pattern is recommended for all healthy Americans ages 2 and over*, and especially for those who want to lower their blood cholesterol levels. Use the guide to choosing low-saturated fat, low-cholesterol foods on page 68-69. If you follow this diet for 3 to 6 months and your blood cholesterol does not drop to a normal level, you may need to cut back still more on saturated fat and cholesterol.

Fat-Finding

Now, let's get practical. Which foods belong to which categories?

Saturated fat is found mainly in foods that come from animals. Whole milk dairy products such as butter, cheese, milk, cream, and ice cream all contain high amounts of saturated fat. The fat in meat and poultry skin is also loaded with saturated fat. A few vegetable fats--coconut oil, cocoa butter, palm kernel oil, and palm oil--are also high in saturated fat. These fats are sometimes found in cookies, crackers, coffee creamers, whipped toppings, and snack foods. Because fats are invisible in many foods, it is very important to read food labels.

Remember: Saturated fat boosts your blood cholesterol level more than anything else in your diet. Eating less saturated fat is the best way to lower your blood cholesterol level.

Unsaturated fat actually helps to lower cholesterol levels when you use it in place of saturated fat. One type of polyunsaturated fat, which is found in many cooking and salad oils, such as safflower, corn, soybean, cottonseed, sesame, and sunflower oils, and in margarine. Another type is monounsaturated fat, which is found in olive and canola oils.

Cholesterol is found only in foods that come from animals. Egg yolks and organ meats (liver, for example) are very high in cholesterol. Meat and poultry have similar amounts of cholesterol.

Now You're Cooking

Planning and cooking meals aimed at reducing blood cholesterol don't have to be complicated. Here are a few suggestions:

• Choose fish, poultry, and lean cuts of meat, and remove fat from meats and skin from chicken before eating. Eat up to 6 ounces per day.
• Broil, bake, roast, or poach foods rather than fry them.
• Cut down on sausage, bacon, and processed high-fat cold cuts.
• Limit organ meats such as liver, kidney, or brains.
• Instead of whole milk or cream, drink skim or low-fat milk. Try low-fat yogurt in place of sour cream. Use low-fat cheeses. Sherbet or low-fat frozen yogurt can be a delicious replacement for ice cream.
• Instead of butter, use margarine or liquid vegetable oils high in unsaturated fats. All fats and oils should be used sparingly.
• Eat egg yolks only in moderation. Egg whites contain no fat or cholesterol and can be eaten often.
• Eat plenty of fruits and vegetables, as well as cereals, breads, rice, and pasta made from whole grains (for example, rye bread, whole wheat spaghetti, bran cereal). These foods are good sources of starch and fiber, and usually contain no cholesterol and little or no saturated fat.
• Liquid vegetable oils are a good choice for sautéing vegetables, browning potatoes, popping corn, and for making baked goods, pancakes, and waffles. Use small amounts.
• Many store-bought baked goods, snacks, and other prepared foods have hidden saturated fats because they are made with lard, butter, cream, coconut oil, or palm oil. Get in the habit of reading product labels, and choose products that are lowest in fat and saturated fat. New baked goods have been developed which contain no cholesterol and very little fat. But keep in mind that they may be high in calories.

For more meal ideas, see "Recipes for a Healthy Heart" and "Meal Planning: A Change of Heart" at the back of this handbook.

Controlling Blood Pressure

More than half of American women will develop high blood pressure at some point in their lives. Women who have the highest risk include those who are black, have a family history of high blood pressure, are overweight, or have "high-normal" blood pressure. To help keep blood pressure under control, take these steps:

• Lose weight, if you are overweight.
• If you drink alcohol, have no more than one drink per day--that means no more than 12 ounces of beer, 5 ounces of wine, or 1 1/2 ounces of hard liquor.
• Exercise regularly. A regular aerobic exercise program--for example, brisk walking, bicycling, jogging, or swimming--helps weight control and is good for your entire cardiovascular system.
• Use salt in small amounts, if at all, in cooking and at the table. Try seasoning foods instead with pepper, garlic, ginger, minced onion or green pepper, and lemon juice. Keep in mind that sodium, an ingredient in salt, is "hidden" in many foods such as cured meats, cheese, canned vegetables and soups, frozen dinners, prepared snacks, and condiments such as catsup, soy sauce, pickles, and olives. Check product labels for the amount of sodium in each serving, or buy products labeled "no sodium," or "reduced in sodium."
• While salt substitutes containing potassium chloride may be useful for some individuals, they can be harmful to people with certain medical conditions. Ask your doctor before trying salt substitutes.
• If your doctor prescribes medication, take it regularly as directed.

Losing Weight: Four Ways to Win

If you are overweight, taking off pounds can lower the chances of developing cardiovascular disease in several ways. First, since being overweight raises the risk of heart disease, losing weight will directly lower your risk. Secondly, weight loss will also help reduce the risk of developing diabetes and help control it. Third and fourth, shedding pounds can lower both high blood pressure and cholesterol. In fact, if your blood pressure or blood cholesterol count is not too high, weight loss along with other changes in your diet may be the only treatment you will need. But even if medication is required, the more healthful your weight, the less medication you may need.

In a society so concerned about thinness, it may be hard to listen to yet more advice about the need to take off pounds. But too often, women are pressured to lose too much weight and for the wrong reasons: to look better in trendy clothes, to attract male attention, to have today's super-slim athletic look. The aim here is not to promote the false and discouraging idea that "thin is beautiful," but to show the link between reasonable weight and good health--especially the health of your heart. Weight loss is advised only to reach a healthy weight, not to drop to an extreme level.

Taking off pounds-and especially keeping them off--can be quite a challenge. Here are some suggestions for making weight loss an easier, safer, and more successful process:

Eat for health. Choose a wide variety of low-calorie, nutritious foods in moderate amounts from each food group. Make sure that these foods are low in fat, since fat is the richest source of calories. To make every calorie count cut out snack foods that are high in calories but provide few other nutrients. If you have a lot of weight to lose, ask your doctor, a nutritionist, or registered dietitian to help you develop a sensible, well-balanced plan for gradual weight loss. To lose weight you will need to take in fewer calories than you burn. That means that you must either choose food with fewer calories or boost your physical activity--and preferably, do both.

Keep milk on the menu. Don't cut out dairy products in trying to reduce calories and fat. Dairy products are rich in calcium, a nutrient that is particularly important for women. Instead, choose low-fat, lower-calorie dairy products. For instance, if you are used to drinking whole milk, gradually cut back to 2 percent milk, move to 1 percent, and then perhaps to skim milk. This way the calories are reduced while the amount of calcium remains the same.

Beyond dieting. To keep the pounds off, change your basic eating habits rather than simply "go on a diet." Keep a food diary of what, how much, when, and why you eat to help you understand your eating patterns and what affects them. Learn to recognize social and emotional situations that trigger overeating and figure out ways to cope with them. Set short-term goals at first.

Forget the fads. Tempting as their promises are, fad diets are not the answer. Most provide poor nutrition and cause a number of side effects, especially those with less than 800 calories. Although fad diets can give quick and dramatic results, much of the weight loss is due to water loss. The weight returns quickly once you stop dieting.

Steer clear of diet pills. Studies show that most diet medicines have troublesome side effects and don't work for long-term weight loss.

Get a move on. Although physical activity alone won't take off many pounds, exercise can help burn calories, tone muscles, and control appetite. (It will also give you something to do when you feel that familiar urge for a slice of chocolate fudge cake.) Even moderate activity, such as brisk walking, will burn up calories and help control weight.

Ask for support. Tell your family and friends about your weight-loss plans and let them know how they can be most helpful to you. You might also want to join a self-help group devoted to weight control. These groups provide companionship, support, and practical suggestions on changing eating habits and long-term weight loss.

Other Prevention Issues

Hormones and Menopause

Should menopausal women use "hormone replacement therapy"?

There is no simple answer to this question.

Menopause is caused by a decrease in estrogen and other hormones produced by a woman's ovaries. It happens naturally in most women between the ages of 45 and 55, and it also occurs in any woman whose ovaries are removed by an operation. As estrogen levels begin to drop, some women develop uncomfortable symptoms such as "hot flashes" and mood changes. Hormone replacement therapy--a term for prescription hormone pills that are taken daily--can be used to relieve these symptoms. Some women are prescribed pills that contain only estrogen. Others take estrogen combined with a second hormone called progestin.

Estrogen pills have several important benefits. They can help you feel more comfortable as your body adjusts to lower estrogen levels. They also help to prevent osteoporosis, a thinning of the bones that makes them more likely to break in later life. Many studies also have found that estrogen pills help protect women from developing coronary heart disease, but more research is needed before we will know this for sure.

Estrogen therapy also has risks. It may increase the chances of developing gallbladder disease, and it may worsen migraine headaches. It may also increase the risk of breast cancer. But by far, the biggest risk of taking estrogen pills is cancer of the uterus. Women on estrogen therapy after menopause are up to six times more likely to develop uterine cancer than women not on this treatment. It is important to point out that women are much more likely to die of coronary heart disease than from uterine cancer. Still, the cancer risk exists and must be taken seriously and discussed with your doctor.

Because of the risk of uterine cancer, some doctors now prescribe estrogen in combination with the hormone progestin. When progestin is taken along with estrogen, the risk of cancer of the uterus is reduced. While this is good news, we don't yet know how this newer "combo" treatment affects other aspects of women's health. We don't know, for example, whether the progestin-estrogen combination is a safe and effective way to prevent heart disease. We don't know whether the combined hormones are as successful as estrogen alone in protecting women from osteoporosis. Finally, we don't yet know whether this combination will boost the risk of breast cancer. Studies are now under way to find answers to these important questions.

In the meantime, a woman and her doctor must decide whether the benefits of hormone therapy are worth the risks. If you are considering this treatment, you will need to consider your overall health and your personal and family history of heart disease, uterine and breast cancer, and osteoporosis.

If you are now on hormone therapy, check with your doctor to be sure you are taking the lowest possible effective dose. At least every 6 months, you and your doctor should discuss whether you need to continue treatment. Be alert for signs of trouble--abnormal bleeding, breast lumps, shortness of breath, dizziness, severe headaches, pain in your calves or chest--and report them immediately. See your doctor at least once a year for a physical examination.

The Aspirin Question

You may have heard that taking aspirin regularly can help prevent heart attacks. Is this a good idea for you? Maybe.

A recent study of more than 87,000 women found that those who took a low dose of aspirin regularly were less likely to suffer a first heart attack than women who took no aspirin. Older women appeared to benefit most: those over age 50 had a 32 percent lower risk of heart attack, while women overall had a 25 percent lower risk. While earlier research has shown that aspirin can help prevent heart attacks in men, this was the first study to suggest a similar benefit for women.

Other recent research suggests that only a tiny daily dose of aspirin may be needed to protect against heart attacks. One study found that for both women and men, taking only 30 mg of aspirin daily--one-tenth the strength of a regular aspirin--helped prevent heart attacks as effectively as the usual 300 mg dose. The smaller dose also caused less stomach irritation.

While these recent reports are encouraging, more study is needed before we can be sure that aspirin is safe and effective in preventing heart attacks in women. What is known for sure is that you should not take aspirin to prevent a heart attack without first discussing it with your doctor. Aspirin is a powerful drug with many side effects. It can increase your changes of getting ulcers and stroke from a hemorrhage. Only a doctor who knows your complete medical history and current health can judge whether the benefit you may gain from aspirin outweighs the risks.

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