Heart disease: how to lower your risk.

Think heart attacks are just for men? In 1992, 48 percent of fatal heart attacks occurred in women.

Think heart attacks are just for older folks? In 1992, 45 percent of heart attacks occurred in people under 65, and five percent hit people under 40.

Think heart disease is a quick, painless way to go? Two out of three heart attack survivors never make a complete recovery. One out of five survivors is disabled with heart failure. And the heart or artery surgery that more than half a million of us undergo each year is no picnic.

In 1995, 1,250,000 Americans will have heart attacks. Here's how to minimize your chances of being one of them.

In 1969, the American male was Number Two. Only Finnish men were more likely to die of heart disease.

By 1992, American men had dropped to Number 16, behind Germany, England, Argentina, and a dozen other countries. (The Russian Federation was Number One.) American women were Number 13, behind Hungary and Scotland, among others.

The 25-year nose-dive in U.S. heart disease--and stroke--deaths was not due to chance. Coronary bypass operations, clotbusting drugs, and hospital cardiac care units have helped salvage the lives of people who already had clogged arteries. Meanwhile, scientists have been figuring out what increases the risk of those arteries becoming clogged in the first place.

That's where you come in. By reducing your "risk factors," you can lower the odds that you'll suffer a heart attack.

And as a nation, we could go much further. "We could look forward to a heart disease death rate equivalent to pre-affluent Japan's," says William Connor, a heart disease expert at the Oregon Health Sciences Center in Portland. "That's one-eighth of what we have now."

THE WHOLE Picture

To many people, "high cholesterol" means "heart attack." But it's not that simple.

"Cholesterol isn't the only risk factor for coronary heart disease," says Frank Sacks, a cholesterol expert at Harvard Medical School. "You've got to look at the whole picture."

In fact, the government's National Cholesterol Education Program (NCEP) advises physicians to consider half a dozen risk factors in addition to cholesterol when deciding how to treat patients (see "Beyond Cholesterol").

Having two or more of those other risk factors bumps someone with "borderline-high" cholesterol into the "high-risk" category. Doctors use the categories to decide who needs cholesterol-lowering drugs.

"I get `cholesterol neurotics' with cholesterol levels under 200 who push me to put them on drugs to lower it even more," says Sacks. "I tell them they can't focus only on cholesterol."

READ MY LIPIDS

The amount of cholesterol--along with other fatty substances called "lipids"--in your blood may not be the whole picture, but it's a big part. You should get your cholesterol tested at age 20 and every five years afterwards--and every year or two if your numbers put you above the "desirable" range.

Here's what the numbers mean for people who don't have heart disease. Some numbers should be much lower if you've already had a heart attack, coronary bypass, angioplasty, or angina pectoris (chest pain).

TOTAL CHOLESTEROL

* High: 240 or more

* Borderline-high: 200 to 239

* Desirable: below 200

"Total" cholesterol includes both the LDL ("bad") and the HDL ("good") cholesterol in your blood. That's why the NCEP now recommends that doctors automatically test for HDL along with total cholesterol. If HDL is high enough, it may mean your risk is fairly low.

"I've got patients with a total cholesterol in the high 200s, and I won't necessarily put them on drugs," says Sacks. "Not if their HDL is 80 and they have no other risk factors, for example."

But that's unusual. Most people who have high total cholesterol also have high LDL, not HDL. To find out, the NCEP recommends that anyone with high cholesterol get another blood test--for LDL and triglycerides.

Ditto for people with borderline-high cholesterol and low HDL.

To Lower Your Cholesterol: See Steps 2-7 (page 6).

HDL ("GOOD") CHOLESTEROL

* Low: below 35

* Intermediate: 35 to 59

* High: 60 or more

You can think of HDL (high-density lipoproteins) as the cholesterol that's being ferried out of your arteries. The more HDL you've got, the better. An HDL below 35 is a heart attack risk even if your total cholesterol is less than 200. That may be particularly true for women.

"An HDL under 45 is unusual for women," says Margo Denke, a researcher at the University of Texas Southwestern Medical Center in Dallas. "We like to see women at least in the 55 to 60 range."

To Raise Your HDL: See Steps 1-3 & 9b.

LDL ("BAD") CHOLESTEROL

* High: 160 or above

* Borderline-high: 130 to 159

* Desirable: below 130

* Desirable for people with heart disease: below 100

If HDL is the cholesterol that's on its way out of your body, LDL (or low-density lipoproteins) is the cholesterol that clogs your arteries.

"A high LDL may be a prerequisite for coronary heart disease," says Basil Rifkind, a physician at the National Heart, Lung and Blood Institute in Bethesda, Maryland. "In Japan they used to have very low LDL, and even though they also had low HDL and a lot of high blood pressure and heavy smokers, they still had very little coronary heart disease."

More than half of all American men aged 35 or older--and women aged 45 or older--have LDL that's higher than "desirable." On the bright side, researchers know most about how to lower LDL, either by diet or--if necessary--drugs. "If you want to lower LDL, I can tell you what to do, and I know it will nearly always work," says Rifkind.

To Lower Your LDL: See Steps 2-7.

TRIGLYCERIDES

* Very high: above 1,000

* High: 400 to 1,000

* Borderline-high: 200 to 399

* Normal: below 200

"Triglycerides shouldn't get equal billing with cholesterol, HDL and LDL," says Rifkind. "Unlike cholesterol, the NCEP has no program to lower the triglyceride level of the U.S. population to protect against heart disease."

That's because it's not clear whether high triglycerides--or the low HDL that almost always accompanies them--is what raises the risk of heart disease.

That may someday change, though, at least for women. "There are data showing that--more so for women than for men--triglycerides are a risk factor [regardless] of HDL," says physician Norman Kaplan of the University of Texas Southwestern Medical Center in Dallas. In any case, if your triglycerides are 200 or higher, you should lower them.

More often than not, excess weight or bad genes are responsible for high triglycerides. But in some cases, the carbohydrates in a very-low-fat diet can make things worse. "Some people who follow a strict low-fat diet can develop carbohydrate-induced high triglycerides, and that lowers their HDL," says Margo Denke.

Her advice: "If I have people with elevated triglycerides who are already eating low-fat diets, I tell them to eat a quarter cup of nuts a day. That's all the fat they need to lower their triglycerides." About a tablespoon of an unsaturated oil like olive or canola would also do the trick.

To Lower Your Triglycerides: See Steps 2-5 & 9b.

Beyond Cholesterol

So you've had your cholesterol and HDL measured, and maybe your LDL and triglycerides, too. Now what? The next step is to see what other factors may be increasing your risk of heart disease.

Age. It's a risk factor because the older you are, the more likely you are to get a heart attack. "Older" starts at 45 for men and 55 for women (earlier if they undergo premature menopause and don't take estrogen replacement therapy).

Unfortunately, there's a lot of confusion over whether to lower high cholesterol levels in the elderly. That's because the difference in risk between a 45-year-old with high cholesterol and a 45-year-old with lower cholesterol is much greater than the difference in risk between a 75-year-old with high cholesterol and a 75-year-old with lower cholesterol.

So why bother treating 75-year-olds? Because all of them have a high risk. A 75-year-old man is 20 times more likely than a 45-year-old man to die of heart disease within one year. A 75-year-old woman has 30 times the risk of her 45-year-old counterpart. So lowering their risk saves more lives.

"Atherosclerosis is a continuous process that gets worse as we get older," says William Connor. "We should treat it at any age, just as we treat appendicitis at any age."

To reduce your risk: There is an alternative to getting older, but we don't recommend it.

Family History. Almost everyone has a relative who's had--or died of--heart disease. That doesn't count as a risk factor. What counts is a family history of premature heart disease. That means your father, brother, or son had a heart attack before the age of 55 or your mother, sister, or daughter had a heart attack before the age of 65.

To reduce your risk: You can't.

Smoking. The good news the risk of heart disease drops dramatically within the first year after you quit. But there's no going half way; switching to a low-tar or low-nicotine brand doesn't make a whit of difference to your heart.

To reduce your risk: Quit.

High Blood Pressure.

Unless your blood pressure is below 120 (the higher number) and below 80 (the lower number), you have an increased risk of heart attack. But in the NCEP's system, you count high blood pressure as a risk factor only if it's either 140 or above (the higher number) or 90 or above (the lower number) or if you're taking medication to lower your blood pressure.

And, as with high cholesterol, high blood pressure isn't harmless for older people. "A survey in England found that doctors wait for higher and higher blood pressure before they treat older people," says Norman Kaplan. "But older people received the most benefit from treatment.

"Hypertension simply should not be disregarded in the elderly," he adds. "It may be part of aging in the U.S., but if you treat it, you can lower your risk."

To reduce your risk: See Steps 2, 3, 6, 8 & 10.

Low HDL. What gives a person low HDL cholesterol? Genes, cigarette smoking, lack of exercise, and obesity can all play a role. So do drugs like beta-blockers, anabolic steroids, and birth control pills.

Except for genes, all of those can be changed. But, warns Basil Rifkind, "treating low HDL without drugs is difficult. Losing weight and exercise help, but we're often disappointed in the rise of HDL we get through those maneuvers."

To reduce your risk: Se step 1-3 & 9b.

Diabetes. People with diabetes are more likely to die of heart disease than anything else. Having diabetes is especially risky for women.

And it's not just because diabetics tend to have lower HDL and higher LDL than other people. There's something else about diabetes--no one knows what--that makes people vulnerable. The risk is so great, says Rifkind, "that you could argue that most adult-onset diabetics should have cholesterol-lowering drugs as part of their treatment." A recent trial, known as the Scandinavian Simvastatin Survival Study, showed that drugs lowered the risk of heart attacks by 40 percent in diabetics. "This could be an important advance in the treatment of diabetes," says Rifkind.

To reduce your risk: See Steps 2 & 3.

Your Overall Risk

Okay, it's time to tally up your risk factors. If you have high HDL (60 or over), subtract one from your total. Do you have two or more risk factors left?

If so, that bumps you up to a higher risk category. For example, if your LDL cholesterol is "borderline-high" and you're a 60-year-old with high blood pressure, you should be treated as though you had "high" LDL.

Ultimately, it's LDL that doctors use to decide who needs drugs. The NCEP suggests that doctors consider prescribing drugs if your LDL is at least 190 (for people with less than two other risk factors), at least 160 (for people with two or more other risk factors), or at least 100 (for people who already have heart disease). But that's only if a serious attempt at diet and exercise doesn't work (see "How to Lower Your Risk").

And despite the NCEP's efforts, that message hasn't gotten through to most doctors. "Diet and exercise are really the front-line treatments for high cholesterol," says Stephen Havas, a physician at the University of Maryland Medical School who serves on the NCEP's coordinating committee.

"But most physicians don't give a strong enough push for diet, because they're not all that well trained to do it and because the average doctor thinks you can't lower cholesterol by diet alone," he adds. "Drugs should be for special situations like people who have either heart disease or diabetes and whose LDL remains above 130 despite intensive dietary therapy."

Norman Kaplan agrees. "The American attitude is that drugs will cure everything."

RELATED ARTICLE: How to Lower Your Risk

Most of these 13 steps are for everyone over the age of two, not just for people who come back from the doctor's office with a bad cholesterol number. If you do have a bad number, try a little harder.

1. Stop smoking. Quitting today cuts your risk of heart disease within a year, even if you gain weight. It also raises your HDL.

Why do it? To prevent cancer, emphysema, heart attacks, strokes--how many reasons do you need?

2. Lose weight if you're overweight, losing as few as five to ten pounds can make a difference, especially if you're an "apple" (that means you're fatter around your waist than around your hips and thighs) rather than a "pear" (fatter around your hips and thighs). Your waist measurement divided by your hip measurement should be less than 0.9 (for men) and less than 0.8 (for women).

Why do it? To raise HDL, lower LDL and triglycerides, lower blood pressure, and help prevent diabetes.

3. Exercise. It doesn't matter if it's brisk walking, swimming, jogging, cycling, step exercise, aerobics, or any other activity, as long as it raises your heart rate for 30 minutes at a time at least three times a week.

Why do it? To raise HDL, lower LDL and triglycerides, keep off excess weight, keep blood pressure from rising, and help prevent diabetes.

4. Eat less saturated fat. Think you've already cut back? If your LDL is high and you're still eating lean ground beef, chicken thighs, reduced-fat cheeses, 2% fat milk, turkey hot dogs, or light ice cream, you could go lower (see page 8).

Why do it? To lower LDL and triglycerides.

5. Cut back on cholesterol in fads. Eat fewer egg yolks (the biggest contributor for most people). If you're eating a low-fat diet and your LDL is still too high, try cutting back even on lean meats and poultry. Also, order scallops instead of shrimp.

Why do it? To cut LDL and triglycerides.

6. Eat more fruits, vegetables, and other foods rich in soluble fiber. That includes oat bran and beans.

Why do it? Foods that are rich in soluble fiber lower LDL cholesterol modestly. (In contrast, the insoluble fiber in wheat bran is good for constipation.) Eating more fruits and vegetables may also reduce your risk of cancer, and they're rich in folic acid, which may help prevent heart disease (see Step 11).

7. Eat less trans fat. Watch out for margarine (especially sticks), cakes, pies, frostings, and other processed foods made with partially hydrogenated oil. Exception: if a food is low in total fat, it's not going to have much trans.

Why do it? To lower LDL.

8. Eat less sodium and more potassium. Avoid high-sodium convenience foods like frozen pizzas, canned or dried soups, frozen dinners, and potato or pasta mixes. Shoot for 2,400 mg of sodium a day ... or less. Eat more fruits and vegetables to get more potassium.

Why do it? To lower blood pressure (or keep it from rising).

9a. Total fat-cut back. Saturated fats and trans fats should be low in everyone's diet. But what about other fats? It's tough not to cut back when you switch to lower-fat meats, cheeses, etc. Only oils, foods fried in (non-hydrogenated) oils, nuts, avocado, and some salad dressings won't automatically get cut when you cut saturated fat. Most people should limit fatty foods like these because they're high in calories.

Why do it? To lose or maintain weight.

9b. Total fat--Don't go too low. If you have low HDL and high triglycerides and you're eating a very-low-fat diet that's full of high-carbohydrate foods like breads, cereals, pasta, rice, and fat-free ice creams, cakes, and other desserts, replace some of those carbohydrates with a daily tablespoon of oil or quarter cup of nuts. But don't overdo it: Each tablespoon of oil has 120 calories. This strategy is only worthwhile if you don't gain weight.

Why do it? To raise HDL and lower triglycerides.

10. Alcohol-limit yourself to two drinks a day (for men) or one drink a day (for women). People who drink alcoholic beverages--in moderation or even occasionally--seem to have a lower risk of heart disease than people who don't. But that's not a good reason to start drinking ... or to drink more. Even a drink a day may raise the risk of breast cancer in women, and more than two a day increases the risk of high blood pressure in women and men. And there's always the danger of alcohol abuse.

Why do it? To reduce the risk of breast cancer, high blood pressure, and alcohol abuse.

11. Consider taking a multivitamin that contains folic acid. The NCEP is mum on folic acid, probably because the evidence isn't airtight. But people with high levels of the amino acid homocysteine in their blood appear to have an increased risk of heart attacks and strokes. If you get about 400 micrograms a day of folic acid (in supplements) or folates (from foods like fruits, vegetables, and beans), your homocysteine levels are likely to stay low.

But if you're over 65 and you take a supplement that contains folic acid, make sure you also take about 500 micrograms a day of vitamin B-12. That will keep the folic acid from covering up any B-12 deficiency you might have (see cover story, September 1995).

Why do it? It might reduce your risk of heart disease and stroke.

12. Consider taking vitamin E. People who take at least 100 IU (International Units) a day of vitamin E seem to have a lower risk of heart disease. But researchers aren't sure whether it's the E or something else these people do that protects them. The NCEP says there's too little evidence to recommend that people take it.

But, unlike beta-carotene and vitamin C, you can't get 100 IU of vitamin E from your food. So consider taking a supplement. The only known drawback: one study suggested that vitamin E might increase the risk of hemorrhagic stroke, but it's too early to say for sure.

Why do it? It might reduce your risk of heart attack.

13. Ask your doctor if you should take aspirin. It reduces the risk of heart disease in men. Trials are under way to see if it does the same in women. In both men and women who've already had a heart attack, non-hemorrhagic stroke, or transient ischemic attack (ministroke), the benefits of taking aspirin clearly outweigh the risks. But aspirin increases the risk of gastrointestinal bleeding and hemorrhagic stroke, so check with your doctor before you start to take it. The NCEP doesn't advise people to take aspirin, probably because its focus is on how to lower cholesterol.

Why do it? To reduce the risk of heart attack, non-hemorrhagic stroke, and possibly colon cancer.

General reference: Circulation 89: 1329, 1994.