The Healthy Heart Handbooks for Women, Major Risk Factors

	Major Risk Factors

Cigarette smoking has been described as "the most important individual health risk in this country." Approximately 23 million American women smoke. Although the smoking rate for women dropped 11 percent between 1965 and 1990, women who smoke today are apt to smoke more heavily than they did in the past.

Surprising as it may seem, smoking by women in the United States causes almost as many deaths from heart disease as from lung cancer. Women who smoke are two to six times as likely to suffer a heart attack as nonsmoking women, and the risk increases with the number of cigarettes smoked per day. Smoking also boosts the risk of stroke.

Cardiovascular diseases are not the only health risks for women who smoke. Cigarette smoking greatly increases the chances that a woman will develop lung cancer. In fact, the lung cancer death rate for women is now higher than the death rate for breast cancer, the chief cause of cancer deaths in women for many years. Cigarette smoking is also linked with cancers of the mouth, larynx, esophagus, urinary tract, kidney, pancreas, and cervix. Smoking also causes 80 percent of cases of chronic obstructive lung disease, which includes bronchitis and emphysema.

Smoking is also linked to a number of reproductive problems. Women who smoke are more apt to have problems getting pregnant and to begin menopause at a slightly younger age. Further, cigarette use during pregnancy poses serious risks for the unborn. Babies of women who smoked during pregnancy tend to weigh less at birth than babies of nonsmokers. Smoking while pregnant also increases risks of bleeding, miscarriage, premature delivery, stillbirth, and sudden infant death syndrome, or "crib death." Moreover, young children who are exposed to a parent's cigarette smoke have more lung and ear infections.

There is simply no "safe way" to smoke. Although low-tar and -nicotine cigarettes may reduce the lung cancer risk to some extent, they do not lessen the risks of heart diseases or other smoking-related diseases. The only safe and healthful course is not to smoke at all.

High blood pressure, also known as hypertension, is another major risk factor for coronary heart diseases and the most important risk factor for stroke. Even slightly high levels double the risk. High blood pressure also increases the chances of of developing congestive heart failure and kidney disease.

Nearly 50 million Americans have high blood pressure, and about half of them are women. Older women have a higher risk, with more than half of all women over the age of 55 suffering from this condition. High blood pressure is more common and more severe in African-American women than it is in white women. Use of birth control pills can contribute to high blood pressure in some women.

Blood pressure is the amount of force exerted by the blood against the walls of the arteries. Everyone has to have some blood pressure, so that blood can get to the body's organs and muscles. Usually, blood pressure is expressed as two numbers, such as 120/80, and is measured in millimeters of mercury (mmHg). The first number is the systolic blood pressure, the force used when the heart beats. The second number, or diastolic blood pressure, is the pressure that exists in the arteries between heartbeats. Depending on your activities, blood pressure may move up or down in the course of a day. Blood pressure is considered high when it stays above normal levels over a period of time.

High blood pressure is sometimes called the "silent killer" because most people have it without feeling sick. Therefore, it is important to have it checked whenever you see your doctor or other health professional. Blood pressure can be easily measured by means of the familiar stethoscope and inflatable cuff placed around one arm. However, since blood pressure changes so often and is affected by many factors, your health professional should check it on several different days before deciding if your blood pressure is too high. If your blood pressure stays at 140/90 mmHg or above, you have high blood pressure.

Although high blood pressure can rarely be cured, it can be controlled with proper treatment. If your blood pressure is not too high, you may be able to control it entirely through weight loss if you are overweight, regular exercise, and cutting down on alcohol, table salt, and sodium. (Sodium is an ingredient in salt that is found in many packaged foods, baking soda, and some antacids.)

It may also help to include more fruits and vegetables that are good sources of potassium, and low and nonfat dairy products and some vegetables that are good sources of calcium.

However, if your blood pressure remains high, your doctor will probably prescribe medicine in addition to the above changes, especially if you already have heart disease. The lifestyle. changes described above will help the medicine work more effectively. In fact, if you are successful with the changes you make in your living habits, the amount of medicine you take may be gradually reduced.

While few people like the idea oftaking any medicine for a long time, the treatment benefits are real and will reduce the risk of stroke, heart attack, congestive heart failure, and kidney disease. If you are prescribed a drug to control high blood pressure and have any uncomfortable side effects, ask your doctor about changing the dosage or possibly switching to another type of medicine.

A reminder: It is very important to take a blood pressure medication exactly as your doctor has prescribed it. If you are not sure about your doctor's instructions, call to ask about the amount of medicine you are supposed to take each day, and the specific times of day you should be taking it.

During pregnancy, some women develop high blood pressure for the first time. Between 10 and 20 percent of first-time mothers develop a high blood pressure problem during pregnancy called preeclampsia. Other women who already have high blood pressure may find that it worsens during pregnancy. If untreated, these conditions can be life-threatening to both mother and baby. Since a woman can feel perfectly normal and still have one of these conditions, it is important to get regular prenatal checkups so that your doctor can discover and treat a possible high blood pressure problem.

For women with a type of high blood pressure called isolated systolic hypertension (ISH), there is good news. By treating ISH with a blood pressure lowering drug such as a diuretic, it is possible to reduce the risk of stroke and coronary heart disease. If you know you have ISH and are already doing well on another type of blood pressure-lowering drug, you should not neccesarily switch medicines. But you may want to discuss with your doctor whether or not you have ISH and, if so, what is the best treatment for you.

High blood cholesterol is another important risk factor for coronary heart diseases that you can do something about. All women should keep their cholesterol levels down to lessen the chance of developing heart disease. For those who already have heart disease, it is particularly important to take action to treat elevated blood cholesterol to prevent a future heart attack.

Although young women tend to have lower cholesterol levels than young men, between the ages of 45 and 55, women's cholesterol levels begin to rise higher than men's. After age 55, the gap between women and men becomes still wider. The higher a woman's blood cholesterol level, the higher her heart disease risk. Today, about one-quarter of American women have blood cholesterol levels high enough to pose a serious risk for coronary heart disease.

CHOLESTEROL AND THE HEART

The body needs cholesterol to function normally. However, the body makes all of the cholesterol that it needs. Over a period of years, extra cholesterol and fat circulating in the blood are deposited in the walls of the arteries that supply blood to the heart. These deposits make the arteries narrower and narrower. As a result, less blood gets to the heart and the risk of coronary heart disease increases.

Cholesterol travels in the blood in packages called lipoproteins. Low density lipoprotein (LDL) carries most of the cholesterol in the blood. Cholesterol packaged in LDL is often called "bad" cholesterol, because too much LDL in blood can lead to cholesterol buildup and blockage in the arteries.

Another type of cholesterol, which is packaged in high density lipoprotein (HDL), is known as "good cholesterol." That is because HDL helps remove cholesterol from the blood, preventing it from piling up in the arteries.

All women over the age of 20 should have their blood cholesterol checked. However, the testing process and the steps to improve cholesterol levels will depend on your current health status. The following sections describe the steps for managing cholesterol levels for two types of women: those who do not have heart disease, and those who do have heart disease.

IF YOU DO NOT HAVE HEART DISEASE

Getting Your Cholesterol Checked. Blood cholesterol levels are measured by means of a small blood sample. The blood should be tested for total cholesterol and, if an accurate measurement is available, for HDL-cholesterol as well. You do not have to fast or do anything special before having this blood test.

Understanding the Numbers. A desirable total cholesterol level for adults without heart disease is less than 200 mg/dL (or 200 milligrams of cholesterol per deciliter of blood). A level of 240 mg/dL or above is considered "high" blood cholesterol. But even levels in the "borderline-high" category (200-239 mg/dL) still increase the risk of heart disease.

Before age 45, the total blood cholesterol level of women averages below 200 mg/dL. But between the ages of 45 and 55, women's average cholesterol levels rises to almost 220mg/dL, and to nearly 240 mg/dL for women between the ages of 55 and 64. Women who have a cholesterol level over 240 mg/dL are more than twice as likely to develop heart disease as women with levels below 200 mg/dL.

HDL levels are interpreted differently than total cholesterol levels. The lower your HDL level, the higher your heart disease risk. An HDL level of under 35 is a major risk factor for heart disease. The higher your level, the less risk you incur. A level of 60 or higher is considered protective.

Total and HDL-cholesterol are measured first. Depending on what these initial measurements show and whether you have any other heart disease risk factors, you doctor may want to measure your LDL level as well. For this test, you should have nothing to eat or drink except water for 9-12 hours beforehand.

An LDL level below 130 mg/dL is desirable. LDL levels of 130-159 mg/dL are borderline-high. Levels of 160 mg/dL or above are high. As with total cholesterol, the higher the LDL number, the higher the risk.

Prevention and Treatment. If your tests show that your blood cholesterol levels are in the desirable range, congratulations! To help keep your levels healthy, it will be important to eat a low saturated fat, low cholesterol diet, get regular physical activity, and control your weight. (See the specific suggestions on maintaining healthy blood cholesterol levels in the "Prevention" section of this handbook.) Saturated fat raises your blood cholesterol more than anything else in your diet.

If your blood cholesterol levels are too high, your doctor may recommend a specific treatment program for you. For most people, cutting back on foods high in saturated fat and cholesterol will lower both total and LDL-cholesterol. Regular physical activity and weight loss for overweight persons also will lower blood cholesterol levels.

Losing extra weight, as well as quitting smoking and becoming more physically active, also may help boost your HDL-cholesterol levels. Although we don't know for sure that raising HDL levels in this way will reduce the risk of coronary heart disease, these measures are likely to be good for your heart in any case.

If your new diet and other lifestyle changes do not lower your blood cholesterol level enough, your doctor may suggest that you take cholesterol-lowering medications. If you have other risk factors for heart disease, you will need to lower your cholesterol more than someone without risk factors.

IF YOU HAVE HEART DISEASE

Women who have heart disease should pay even more attention to their cholesterol levels. An individual with heart disease has a much greater risk of having a future heart attack than a person without heart disease. Recent studies show that, even if your cholesterol level is not elevated, lowering it can greatly reduce your risk of a future heart attack and may actually prolong your life.

Getting Your Cholesterol Checked. Since you have heart disease, you will need to have a blood test called a lipoprotein profile. This test will determine not only your total cholesterol and HDL-cholesterol levels, but also your LDL-cholesterol level and levels of another fatty substance called triglycerides. In order to take this test, you should have nothing to eat or drink except water (or cofee or tea with no cream or sugar) for 9-12 hours beforehand.

Understanding the Numbers. Your goal should be to have an LDL-cholesterol level of about 100mg/dL or less, which is lower than for people who do not have heart disease. Depending on what your LDL level is, your next step will be the following:

* If your LDL level is 100 mg/dL or less, you do not need to take specific steps to lower your LDL. But you will need to have your level tested again in 1 year. In the meantime, you should closely follow a diet low in saturated fat and cholesterol, maintain a healthy weight, be physically active, and not smoke. You should also follow the specific recommendations of your doctor.

* If you LDL level is higher than 100 mg/dL, you will need a complete physical examination to find out if you have a disease or condition that is raising your cholesterol levels. You will probably need a diet that is very low in saturated fat and cholesterol. In addition, you will need to be physically active, lose weight if you are overweight, and not smoke.

If in your doctor's judgment, your LDL level starts out too far above the LDL goal of 100 mg/dL or if your LDL level stays too high after lifesytle changes, you may need to take medicine. For many individuals, it is necessary to combine medication with lifestyle changes to get enough of a reduction in LDL-cholesterol. Your doctor can help to decide which combination of cholesterol-lowering activities is right for your.

Overweight women are much more likely to develop heart-related problems even if they have no other risk factors. According to an long-term study of nearly 116,000 women, almost 40 percent of coronary heart disease was attributed to overweight. For the heaviest women, 72 percent of coronary heart disease could be traced to excess weight. The study, also showed that even a modest weight gain of 11-17 pounds after age 18 significantly increases a woman's risk of coronary heart disease.

Overweight also appears to contribute to cardiovascular disease in part by increasing the change of developing other risk factors, such as high blood pressure, high blood cholesterol, and diabetes. However, it also appears that obesity is harmful even in the absence of these conditions. Fortunately, these conditions often can be controlled by maintaining a healthy weight and by getting regular physical activity.

What is a healthy weight for you? Currently, there is no exact answer. Researchers are trying to develop better ways to measure healthy weight. In the meantime, check the "Are You Overweight?" table to find out if your weight is withing the range suggested for people of your height. Weights above the suggested "healthy weight" ranges are thought to be unhealthy for most people.

Those who are currently overweight should take special care not to gain additional pounds, since the more overweight a person is, the higher the chances of developing heart disease.

Research also suggests that body shape as well as weight affects heart health. "Apple-shaped" individuals with extra fat at the waistline may have a higher risk than "pear-shaped" people with heavy hips and thighs. If your waist is a large as the size of your hips, or larger, you may have a higher risk of coronary heart disease.

Physical inactivity increases the risk of heart disease. It both contributes directly to heart-related problems and increases the chances of developing other risk factors, such as high blood pressure and diabetes.

Recent reports from the U.S. Surgeon General's Office and a National Institutes of Health (NIH) expert panel warn that physical inactivity is increasing among Americans--especially among women.

According to the first-ever Surgeon General's Report on Physical Activity and Health, 60 percent of American women don't get the recommended amount of physical activity, while more than 25 percent are not active at all. In part, this sedentary behaviour results from a reliance on modern conveniences, such as automobiles, elevators, and escalators, which make life easier but do little to strengthn or tone the body. But even during leisure hours, many women continue to be physically inactive.

This inactivity can have serious results later in life. besides increasing the risk of heart disease, it makes older women who are not physically active more likely to fall than those who are physically active. And, especially for those with bone loss, falls can lead to fractures and have serious, even life-threatening, consequences.

Fortunately, it doesn't take a lot of effort to become physically active. Both the Surgeon General's report and the report of the NIH Consensus Development Conference on Physical Activity and Cardiovascular Health conclude that as little as 30 minutes of moderate activity on most, and preferably all, days helps protect heart health. examples of moderate activity are a brisk walk, raking leaves, or gardening.

If you prefer, you can divide the 30-minute activity into shorter periods of at least 10 minutes each. If you already do this level of activity, you can get added benefits by doing even more.

To find out more about physical activity and how to get started, see the section on "Becoming Physically Active" .

Diabetes is a serious disorder that raises the risk of coronary heart disease. and stroke. About 75 percent of people who have diabetes die of some type of cardiovascular disease.

Compared with nondiabetic women, diabetic women are also more apt to have high blood pressure and high blood cholesterol. Untreated diabetes can also contribute to the development of kidney disease, blindness, problems in pregnancy and childbirth, nerve and blood vessel damage, and difficulties in fighting infection.

The type of diabetes that develops in adulthood is usually "noninsulin-dependent diabetes mellitus," or NIDDM. This type of diabetes, in which the pancreas makes insulin but the body is unable to use it well, is the most common form of the disease. For unknown reasons, the risks of heart disease and heart-related death are higher for diabetic women than for diabetic men.

While there is no cure for diabetes, there are steps one can take to control it. About 80 percent of all NIDDM diabetics are overweight. It appears that overweight and growing older promote the development of diabetes in certain people. Losing weight and increasing physical activity may help postpone or prevent the disease. For lasting weight loss, engage in regular, brisk physical activity and eat a diet that is limited in calories and fat.

Other Factors

In recent years, we have read and heard much about the connection between stress and coronary heart disease. And many studies do report such a connection for both women and men. For example, the most commonly reported incident preceding a heart attack is an emotionally upsetting event, particularly one that involves anger. There also is evidence that people who become easily emotionally upset are more likely to develop hardening of the arteries. In addition, some common ways of coping with stress, such as overeating, heavy drinking, and smoking, are clearly bad for your heart.

The good news is that sensible health habits can have a protective effect. Regular physical activity not only relieves stress, but can directly lower your risk of heart disease. Recent research also shows that involvement in a stress management program following a heart attack decreases the chances of further heart-related problems.

Strong personal ties may also play an important role in heart disease management and prevention. Studies show that having emotionally supportive relationships lessens the chances of developing heart disease, and prolongs life in both women and men following a heart attack. Religious beliefs and activity also have been linked to longer survival among heart surgery patients. While these findings are promising, researchers will need to study larger groups of women over time to find out more about the link among certain behaviors, stress, and coronary heart disease in women.

Studies show that women who use high-dose birth control pills (oral contraceptives) are more likely to have a heart attack or a stroke because blood clots are more likely to form in the blood vessels. These risks are lessened once the birth control pill is stopped. Using birth control pills also may worsen the effects of other risk factors, such as smoking, high blood pressure, high blood cholesterol, and overweight.

Much of this information comes from studies of birth control pills containing higher doses of hormones than those commonly used today. Still, the risks of using low-dose birth control pills are not fully known. Therefore, if you are now taking any kind of birth control pill or are considering using one, keep these guidelines in mind:

* Smoking and "the pill" don't mix. If you smoke cigarettes, stop smoking or choose a different form of birth control. Cigarette smoking boosts the risks of serious cardiovascular problems from birth control pill use, especially the risk of blood clots. This risk increases with age and with the amount smoked. For women over 35, the risk is particularly high. Women who use oral contraceptives should not smoke.

* Pay attention to diabetes. Glucose metabolism, or blood sugar, sometimes changes dramatically in women who take birth control pills. Any woman who is diabetic, or has a close relative who is, should have regular blood sugar tests if she takes birth control pills.

* Watch your blood pressure. After starting to take birth control pills, your blood pressure may go up. For most women, this increase does not go above normal. But if your blood pressure increases to 140/90 mmHg or higher, ask your doctor about changing pills or switching to another form of birth control. Once off birth control pills, your blood pressure should return to normal within a few months.

* Talk with your doctor. If you have a heart defect, if you have suffered a stroke, or if you have any other kind of cardiovascular disease, oral contraceptives may not be a safe choice. Be sure your doctor knows about your condition before prescribing birth control pills for you.

Over the last several years, a number of studies have reported that moderate drinkers--those who have one or two drinks per day--are less likely to develop heart disease than people who don't drink any alcohol or who drink too much. Small amounts of alcohol may help protect against heart disease by raising levels of "good" HDL cholesterol.

If you are a nondrinker, this is not a recommendation to start using alcohol. And certainly, if you are pregnant, planning to become pregnant, or have another health condition that could make alcohol use harmful, you should not drink. But if you're already a moderate drinker, evidence suggests that you may be at a lower risk for heart attack. This is particularly true for women after menopause.

But remember, moderation is the key. Heavy drinking causes heart-related problems. More than three drinks per day can raise blood pressure, and binge drinking can contribute to stroke. Too much alcohol also may damage the heart muscle, leading to heart failure. Overall, people who drink heavily on a regular basis have higher rates of heart disease than either moderate drinkers or nondrinkers.

Women who drink should have no more than one alcoholic beverage a day (see box below).

Keep in mind, too, that alcohol provides no nutrients--only extra calories. Most alcoholic drinks contain 100-200 calories each. Women who are trying to control their weight may want to cut down on alcohol and substitute calorie-free iced tea, mineral water, or seltzer with a squeeze of lemon or lime.

Homocysteine (pronounced homo-SIS-teen) is an amino acid that is found normally in the body. Recent studies suggest that high blood levels of this substance may increase a person's chances of developing heart disease, stroke, and reduced blood flow to the hands and feet. While it is not known for sure how homocysteine contributes to heart and vessel disease, it is thought that high levels of homocysteine may damage the arteries, make the blood more likely to clot, and/or make blood vessels less flexible.

Individuals vary in their levels of homocysteine. For a few people, genetic factors contribute to high amounts of this substance in the blood. In addition, homocysteine levels may increase with age. For women, homocysteine levels may be higher after menopause than during childbearing years.

Recent research also shows that the level of homocysteine in the blood is affected by the consumption of three vitamins--folic acid, and vitamins B6 and B12. People who consume less than the recommended daily amounts of these vitamins are more likely to have higher homocysteine levels. Recommended daily amounts are as follows: 400 micrograms for folic acid, 2 milligrams for B6, and 6 micrograms for B12.

It has not yet been proven that lowering homocysteine levels will actually help to prevent heart or blood vessel disease. But until more research is done, people may help protect their health by getting enough folic acid, B6, and B12 in their diets.

Good sources of folic acid include citrus fruits, tomatoes, vegetables, whole and fortified-grain products, beans and lentils. Beginning in 1998, the U.S. Food and Drug Administration will require that certain foods contain extra folic acid to help prevent certain birth defects. These foods include enriched breads and rolls, all enriched flours, corn meals, all enriched pasta products, and breakfast cereals.

Foods high in B6 include meat, poultry, fish, fruits, vegetables and grain products. Major sources of B12 are meat, poultry, fish, and milk and other dairy products. (For more on vitamins, see "The Vitamin Factor")

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