The heart of the matter.

Okay. So you're feeling a little left out.

First you memorized your cholesterol level--just one numer, not too tough. Then friends started asking bout your LDL, you HDL, your total-cholesterol-to-HDL ratio, and your triglycerides.

And the other day, someone laughed when you asked which foods have good cholesterol in them.

Don't despair. You don't have to be a cardiologist to keep up with the latest scoop on diet and heart disease.

Our little question-and-answer refresher course, which starson page 5, is just what the doctor oreded. It's a small price to pay to reduce your risk of becoming one of the more than a million Americans who suffer heart attacks each year.

Q: Is arteriosclerosis the same as atherosclerosis?

A: No. Arteriosclerosis means hardening and thickening of the arteries. To some extent, it occurs in all people as they age.

Atherosclerosis is one kind of arteriosclerosis-the kind that causes most heart disease in the U.S. The Greek word athero means gruel or paste, which refers to the buildup of plaque that clogs arteries. When those arteries are the ones that feed the heart or brain, you're in trouble.

Q: Is the plaque in arteries like the plaque on your teeth?

A: No. Dental plaque is mostly a mass of bacteria. The plaque in arteries is a mixture of cholesterol, fats, calcium, blood-clotting material, and cellular debris.

Q: How can you tell if your arteries are clogging up?

A: Most people can't. Often, the first sign of trouble is a heart attack. Some people have warning signs like angina pectoris--chest pain caused by too little oxygen reaching the heart. It usually occurs during exertion or even emotional excitement. More dangerous is unstable angina, which can vary in intensity and duration and which can occur during rest. But most people have no symptoms until more than three-quarters of one of their coronary arteries is blocked off.

Q: Do other arteries get blocked?

A: Yes. If it's one that feeds the brain, the person suffers a stroke. Blocked arteries in the arms or legs of smokers (peripheral vascular disease) can cause gangrene.

Q: What sets off a heart attack?

A: In a myocardial infarction, one of the arteries that supply blood to the heart muscle--or myocardium--gets blocked. These aren't major blood vessels, like the aorta, which pump blood out of the heart. They are smaller ones that carry oxygen-rich blood to feed the heart muscle. If the plaque completely cuts off the flow of blood--or, more often, if a blood clot gets stuck in an already-narrowed artery--the lack of oxygen damages, and eventually kills, the heart muscle.

Q: Is heart disease a man's disease?

A: No. It has that reputation, though, because premenopausal women are practically immune to it. But heart disease eventually kills more women than any other disease--twice as many as cancer.

Unfortunately, most research has focused on middle-aged men (maybe because it has been carried out by middle-aged men). Investigators are now starting to look at women, however. One distressing finding: when a woman has a heart attack, she is twice as likely as a man to die from it within the first few weeks.

Q: Who gets heart attacks?

A: Your risk depends on several factors, some of which you can control and some of which you can't. You can't change being male (though after age 65 a woman's risk is almost as high), having a family history of heart disease before age 55, and growing older (four out of five heart disease deaths occur in people over 65).

The three most powerful risk factors you can change are:

* Smoking: Smokers have more than twice the risk of a heart attack. Fortunately, the risk drops rapidly when people quit.

* High Blood Pressure (at least 140 over 90): It adds to the heart's workload, and also increases the risk of stroke, kidney failure, and congestive heart failure (that's when the heart loses its ability to pump out all the blood that enters it).

* High Blood Cholesterol: Once it hits 240, your risk doubles. Also risky is "bad" LDL (low density lipoprotein) cholesterol over 130 and "good" HDL (high density lipoprotein) cholesterol below 35 (below 40 for women, says the American Heart Association).

Q: Isn't the ratio of total cholesterol to HDL cholesterol important, too?

A: Yes, but not as important as your individual cholesterol, HDL, and LDL numbers. Even so, when you divide your total cholesterol by your HDL, you have an increased risk of heart disease if the number is above 4.5.

Q: What about being fat?

A: Where you are fat may be more important than how fat you are. Being bigger around the belly (most men) is much riskier than being bigger around the hips and thighs (most women). (See article on page 8.)

Q: Can exercise help reduce the risk?

A: Yes. It raises HDL and, in some people, lowers LDL and triglycerides. It also can lower your blood pressure and help you lose weight...and keep it off.

Q: Does it have to be vigorous?

A: Not necessarily. If you haven't been exercising regularly, a brisk walk (at least three days a week for at least 20 minutes) can improve your cholesterol, triglycerides, and blood pressure, and can help you take a little weight off.

To keep the weight off, though, make it five or six days a week...and for an hour at a time. If you already exercise regularly, walking may not be enough. You may have to jog, swim, or bike.

To raise your HDL significantly, you've got to walk or jog at least twelve miles a week.

Q: How can diet reduce the risk of heart disease?

A: Most diet advice is designed to lower your LDL cholesterol. And you get the biggest bang for your buck by cutting back on saturated fats.

That means red meats, especially ground beef and fatty processed meats like sausage and hot dogs. It also means full-fat dairy products like whole milk, regular cheese, ice cream, and butter. They're the biggest sources in the average American's diet.

But don't ignore the substantial amounts of sat fat in lower-fat foods like 2% fat milk, some "light" cheeses, chicken (especially thighs and wings), and ground turkey with skin.

Q: Should I eat less cholesterol?

A: Yes. The cholesterol in foods raises your blood cholesterol, though not as much as the saturated fat in foods. Some studies suggest, however, that the cholesterol you eat could increase your risk of heart disease independent of its ability to raise the amount of cholesterol in your blood.

So watch out for egg yolks, which are the biggest source of cholesterol. (The whites are fat- and cholesterolfree.) And remember that even lean meat, poultry, seafood (especially shrimp), and, to a lesser extent, full-fat dairy products add cholesterol to your diet...and your blood.

Q: Do hydrogenated oils raise cholesterol?

A: The trans fats that are formed when oils are hydrogenated (hardened) do appear to raise blood cholesterol levels, though not as much as saturated fats do. The problem is that trans fats don't have to be listed separately on food labels, so you can't tell how much a food contains. Until labels are clearer, stick to tub margarines (they have fewer trans than stick margarines), and avoid processed or deep-fat-fried foods (like french fries, fried chicken, pies, doughnuts, and cakes) that contain partially hydrogenated oils.

Q: Are monounsaturated fats better than polyunsaturated fats?

A: Yes. Even though highly polyunsaturated oils (like safflower, sunflower, corn, and soy) lower cholesterol slightly more than largely monounsaturated oils (like olive and canola), monos are less susceptible to oxidation. And oxidized fats appear to be especially good at clogging arteries.

What's more, for decades, people around the Mediterranean have eaten large quantities of olive oil without harm. No populations have used high levels of polys for any length of time. And, finally, in animal studies--which may or may not apply to humans--polyunsaturated oils promote tumors.

Q: Can I eat as much olive oH as I want?

A: Sorry. Most of us can't afford the calories--125 per tablespoon. And don't expect to get all the benefits of a traditional "Mediterranean diet" just by pouring olive oil over a typical--or even a reasonably "heart-healthy"--American diet.

People living in Crete during the 1950s, for example, ate a largely vegetarian diet consisting mostly of pasta, bread, vegetables, olive oil, and some fish. Heart disease was rare on the island...but so were saturated fats, cars (people walked), and obesity.

Q: Can fiber lower cholesterol?

A: Foods rich in soluble fiber appear to, at least slightly. Good sources are psyllium (Metamucil), oat bran, beans (other than green beans), oranges, and baked potatoes with skin. Wheat bran is rich in insoluble fiber, which doesn't lower cholesterol (although it's great at relieving constipation).

Q: Which foods have "good" cholesterol?

A: None. "Good" cholesterol is the kind found in the high density lipoproteins (HDL) in your blood. The higher your HDL count, the lower your risk of heart disease, probably because that's the cholesterol that's on its way out of your body.

Q: How can I raise my HDL?

A: The best way--other than taking a drug like niacin--is to stop smoking, lose weight, or exercise. Weight-loss and exercise together can raise your HDL by 10 to 20 percent. And that can lower your risk of heart disease by five to ten percent.

Q: Doesn't alcohol also raise HDL?

A: Yes. But that doesn't mean it's smart to drink. Alcohol increases the risk of cirrhosis of the liver and cancers of the mouth, voice box, esophagus, liver, and breast. What's more, it's involved in up to half of all traffic fatalities, fires, homicides, and suicides.

Finally, alcohol raises blood triglyceride levels, which are already high in many people with low HDL. So if you don't drink, don't start. And if you already drink, limit yourself to either one (women) or two (men) drinks a day.

Q: Are high triglycerides bad?

A: No one knows for sure. But it's worth trying to lower them if they're above 200 and if you already have heart disease, a family history of premature heart disease, or cholesterol above 240 and HDL less than 35. The most important things you can do: lose weight, eat a heart-healthy diet, exercise regularly, and cut back on alcohol.

Q: Do fish oils prevent blood clots?

A: They might. So might alcohol. High-fat meals, on the other hand, might help clots form. The evidence is still preliminary, though. The best way to prevent clots is to do what 11,000 of the participants in the Physicians' Health Study did--take a regular (325 mg) aspirin every other day. The aspirin-taking doctors had a 44 percent lower risk of having a heart attack.

In other studies, heart disease patients lowered their risk by taking the equivalent of a baby aspirin (80 mg) every day.

Q: How long does it take for diet to lower cholesterol?

A: Four to six weeks. Quick, huh?

Q: I'm on cholesterol-lowering drugs and my doctor says I need surgery. What should I do?

A: Ask him or her if you can first try an all-out effort to unclog your arteries with diet and exercise. Then buy a book like Dr. Dean Ornish's Program for Reversing Heart Disease or Robert Pritikin's The New Pritikin Program. Either will tell you how to follow a very-very-low-fat diet (mostly beans, grains, vegetables, and fruits) and start exercising.

If your doctor (and a second opinion) says that you can't afford to wait for diet to work, make sure you watch your diet after surgery. Many people mistakenly assume that surgery "cures" their heart problems and that they can go back to eating fatty foods.

Q: Short of Pritikin or Ornish, what diet offers the best protection?

A: One with the least saturated fat (less than seven percent of calories) and cholesterol (200 mg or less per day), with low levels of sodium (1,800 mg or less per day), and with plenty of foods rich in soluble fiber.

That means a largely vegetarian diet loaded with beans, grains, fruits, and vegetables. You can, if you want, add nonfat dairy products and small amounts of seafood, skinless chicken or turkey breasts or drumsticks, and pork tenderloin or Select (lean grade) round steak.

But keep it modest--four to five ounces a day--because seafood, poultry, and meat contain cholesterol. They also crowd out plant proteins, which may help lower blood cholesterol.

Q: Do antioxidants help prevent heart disease?

A: Evidence is growing that they do--especially vitamin E. Researchers won't know for sure, though, until clinical trials are completed in another five years or so. Until then, it makes sense to take them, since they appear to be safe.

We suggest 400 mg (400 IU) of vitamin E, 15 mg (25,000 IU) of beta-carotene, and 250 to 500 mg of vitamin C every day. That should cost about $5 a month and be available in a single pill. Just remember that antioxidants don't make up for a fatty, salty diet that's low in fruits and vegetables.