Healthy Cholesterol

High blood pressure and elevated cholesterol were among the first known risk factors for cardiovascular disease. When you have your cholesterol checked it is reported in at least 4 categories:

Triglycerides: Goal <200

Total Cholesterol: Goal <200

LDL (bad cholesterol): Goal <120 [<70>

HDL (good cholesterol): Goal >60

Triglycerides

Triglycerides are often elevated by diets high in simple sugars (cakes, cookies, and candies) as well as simple carbohydrates (breads, pastas, cereals). It is also often elevated in those with low thyroid levels. Triglycerides are lowered by avoiding simple sugars and simple carbohydrates. Fish has also been found to lower triglycerides and that is why fish oil (omega 3) is often recommended as a supplement.

LDL

Bad cholesterol is often elevated by diets high in saturated fat (animal fat) and trans fats. Saturated fats are found in animal fats and diary fat. Trans fats are found in 4% of animal fats, up to 15% of margarines fats, 30% of shortening fats, and 45% in artificially hydrogenated fats. There has been a huge push by the public interest groups to decrease the production of oils with artificial trans fats because of their significant risks. The FDA has also required companies to label the content of trans fats. That is why you have noticed a change in the taste of KFC, McDonald’s French fries, and Oreos.

HDL

This is actually a protective type of cholesterol and the higher it is the better. It is lowered by a poor diet as explained above. The biggest factor found to raise HDL is regular exercise.

The Mediterranean Diet has been described as the best diet to lower cholesterol. This diet is composed of fresh vegetables, no processed or fried foods, fish (not much meat), and olive oil. Unfortunately, diet alone is not the only factor that can cause high cholesterol as genetics can often play a significant role.

There are a few categories of medications that can lower cholesterol but most of them have not been proven to decrease mortality. Statins are one of the few medications that have been proven to do this. It is believed that statins may protect the heart by some other mechanism than lowering cholesterol. Some have suggested that it may stabilize plaques so they are less likely to break off and cause a heart attack or stroke. In fact, going off a statin can be risky as it may cause plaques to become unstable. Unfortunately, statins are not without their risks or side effects.

If you want to avoid a prescription medication, the following supplements have been proven to be effective: fish oil, niacin, and red yeast rice. In fact, red yeast rice functions almost exactly like a statin. All of these supplements have their own risks and side effects as well and so you should discuss with your doctor which medication would benefit you most. Different supplements and medications will target different cholesterol categories and so your cholesterol profile may determine which medications would work best for you.

Healthy Blood Pressure

High Blood Pressure is a big risk factor for cardiovascular disease. High blood pressure not only leads to coronary vessel damage but it affects all small blood vessels (microvascular) and capillaries. Hence, high blood pressure is a risk factor for strokes, heart attacks, kidney failure, etc.. The reason why blood pressure damages small blood vessels is twofold. First, Bernoulli’s principle states that as the diameter of a vessel decreases the velocity of the liquid within the vessel increases. This increase in velocity causes more damage to the lining of the blood vessel because of the second reason; Second, end organs tend to have capillaries that branch off at 90 degree angles which leaves the vessels walls open to repeated damage and thickening. Over time, the repeated damage and thickening leads to plaque formation and decreased blood flow to the organ and subsequently higher blood pressure. If that plaque happens to break away it will completely block the blood vessel and cause an infarct (stroke, heart attack, etc).

So what is a healthy blood pressure? The committee that reviews the various studies on blood pressure and makes the recommendations for physicians to use is known as the JNC (Joint National Committee on the Evaluation and Treatment of Blood Pressure). Their last report (7^th) came out in December 2003. The 8^th report is due out in March of this year. For the average adult the recommended blood pressure is under 140/90. If you have heart disease or diabetes it is recommended to keep blood pressure below 130/80. In fact, the lower the blood pressure, the better as long as it is not too low. It is best to check your blood pressure throughout your normal daily activities and not just at the doctor’s office because the anxiety of the doctor’s office can raise your blood pressure. Caffeine can raise your blood pressure for up to 2 hours while smoking can raise your blood pressure for up to 30 minutes.

How do you lower your blood pressure? Smoking, Caffeine, and stress can all raise blood pressure but not long term unless you are smoking and drinking all day long which some people do. Salt (Sodium) is the big problem most people face with our western diet. Sodium is everywhere! Sodium makes you retain fluid and hence raise your blood pressure. This can be so drastic that if a person with heart failure has a large sodium rich meal (cured ham, brined turkey, Chinese food, Brats with Saurkraut etc) they can put themselves into fluid overload and respiratory failure from fluid filling up in their lungs.

If you have high blood pressure; you can lower your risk for stroke by 20% and heart attack by up to 50% by decreasing your pressure by 10 millimeters of mercury (e.g. 140/90 systolic to 130/80 systolic). The DASH diet is a low sodium diet that you can follow. Exercise temporarily raises blood pressure but long term lowers blood pressure. Relaxation lowers blood pressure as well. If you can’t lower your blood pressure with the above measures, medications may be necessary.

I am more than happy to answer any specific questions you may have on medications. In general thiazides and calcium channel blockers are considered first line agents. However, there may be a compelling indication for another medication. Every medication has its pros and cons, side effects, contraindications, etc. Genetics and race may even play a role in how well your respond to a specific medication. It is best to discuss with your physician which medication is best and most affordable. Fortunately, almost every class of blood pressure medication can be found on the $4 dollar formulary at your local pharmacy.

Heart Health

As cardiovascular disease is the number one cause of death and illness, the heart is probably the most important muscle/organ in the body. The heart serves the role of delivering oxygenated blood to the brain, vital organs, and muscles of the body. The risk of heart disease becomes more of a problem between the ages of 40-60. The heart like the other muscles of the body starts to malfunction because of a poor blood supply (atherosclerosis). In fact, a heart attack is caused by a blockage of a coronary artery that leads to muscle death and potential arrhythmias or sudden cardiac death. The heart is preserved by placing a stent in the blocked vessel or replacing it with a venous graft (CABG- coronary artery bypass graft). The goal of heart health is to prevent the blockage in the first place. So what are the risk factors for coronary vascular disease (CVD)?

In 1948, the National Heart Institute started a landmark study in Framingham, Massachusetts. 5,209 men and women between the ages 30 and 62 were followed every 2 years to identify those who died of heart attacks and the associated risks factors. In 1971, a second generation of 5,124 patients were enrolled. In 2002, the third generation was enrolled and is currently being followed. A couple other diverse groups have also been enrolled in 1994 and 2004. Below are the major findings of the study so far...

1960 Cigarette smoking found to increase the risk of heart disease

1961 Cholesterol level, blood pressure, and electrocardiogram abnormalities found to increase the risk of heart disease

1967 Physical activity found to reduce the risk of heart disease and obesity to increase the risk of heart disease

1970 High blood pressure found to increase the risk of stroke

1976 Menopause found to increase the risk of heart disease

1978 Psychosocial factors found to affect heart disease

1988 High levels of HDL cholesterol found to reduce risk of death

1994 Enlarged left ventricle (one of two lower chamber of the heart) shown to increase the risk of stroke

1996 Progression from hypertension to heart failure described

1998 Development of simple coronary disease prediction algorithm involving risk factor categories to allow physicians to predict multivariate coronary heart disease risk in patients without overt CHD

1999 Lifetime risk at age 40 years of developing coronary heart disease is one in two for men and one in three for women

2001 High-normal blood pressure is associated with an increased risk of cardiovascular disease, emphasizing the need to determine whether lowering high-normal blood pressure can reduce the risk of cardiovascular disease.

2002 Lifetime risk of developing high blood pressure in middle-aged adults is 9 in 10.

2002 Obesity is a risk factor for heart failure.

2004 Serum aldosterone levels predict future risk of hypertension in non-hypertensive individuals.

2005 Lifetime risk of becoming overweight exceeds 70 percent, that for obesity approximates 1 in 2.

2006 The National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health announces a new genome-wide association study at the Framingham Heart Study in collaboration with Boston University School of Medicine to be known as the SHARe project (SNP Health Association Resource).

Over the next several weeks, I will discuss the following risk factors of cardiovascular disease: Hypertension (high blood pressure), Hyperlipidemia (high cholesterol), inactivity, and obesity. Stay Tuned!

Muscle Health

Most people don’t realize how important muscle health is until they reach their 40’s to 60’s. As we age blood flow to our muscles decreases and that is why cardiovascular disease is the leading cause of death. This post, however, is not about heart health. I would like to address the skeletal muscles of the body. Skeletal muscles suffer from poor blood flow as we age and that is why stiffness becomes more of a problem as we get older, particularly after we have been sedentary for some time. Have you ever been stiff in the morning?

Blood flow is important for bringing oxygen to the muscles. Oxygen is required to couple muscle fibers to cause contraction. If this is true you would think decreased blood flow would mean less oxygen which means less ATP and less contraction (stiffness). Well oxygen and ATP are needed even more to uncouple muscle fibers and relax. Let me illustrate it this way…when we die, oxygen no longer reaches the muscles. This leads to decreased ATP in the muscle which causes a release of stored ATP in what is called the sarcoplasm reticulum. This ATP causes coupling of the muscle fibers that are no longer moving. Hence rigor mortis sets in within 3 hours of death and maximizes by 12 hours. So essentially the stiffness that comes with old age is caused by decreased blood flow and inactivity. Rigor mortis actually starts setting in to some degree before we actually die.

How do we prevent rigor mortis from setting in too soon? The formula is simple: improve blood flow to the muscles and keep active. Both of these can be achieved through stretching. Have your ever seen an animal stretch after a period of inactivity? They are increasing blood flow to their muscles just in case they need to sprint, but they are also preventing stiffness. Unfortunately, in our western society we look at retirement as a time to sit back in our recliner and relax. This just speeds up the process of rigor mortis. If you look at eastern societies they spend their retirement in the park doing Tai Chi and keep active.

Not only will stretching prevent stiffness but it can also prevent pain. Myofascial pain and fibromyalgia are becoming more prevalent as well as better understood. Myofascial pain is essentially bands of tightened muscles that are stuck in contraction because of poor blood/oxygen supply. Not only are muscles stiff but they can cause a significant amount of pain. Stretching alone may not be sufficient. Aggressive therapy to break up the bands of muscles may be required to improve the blood flow. This can be achieved through (physical therapy, rolfing, deep tissue massage, trigger point injections, acupuncture). I often recommend that patients get a tennis ball that they get wet and freeze. Then use this ball to work into the tissue. This may be painful at first but will do the job. I also recommend all my fibromyalgia patients and chronic low back pain patients to look into yoga which has been shown in multiple studies to decrease pain.

When I mention Yoga. Many people think of the above picture. I have to explain to them that there are several forms of Yoga. The idea is to improve muscle health through stretching and relaxation both of which can be accomplished by Yoga. This has to become a habit in order to be effective. Rigor mortis does not take a day off, nor should you.

Healthy Sleep

"Early to bed early to rise makes a man healthy, wealthy, and wise..."

-Benjamin Franklin

There is a large body of research going on in the field of sleep and sleep disorders because we are realizing how important good restorative sleep is but we don’t understand how to induce this type of sleep. Sleep disorders are becoming more and more prevalent as are the consequences of poor sleep: obesity, depression and other mood disorders, and chronic pain.

Restorative sleep is important for healing, memory, and mood. Unfortunately, not all sleep is equal. People can go for years sleeping several hours a day without getting much restorative sleep which can lead to the above dire consequences. I have several patients that realize they are not sleeping well and will come to me for help. Thanks to pharmaceutical commercials people are convinced that they need a sleep aid. I have to explain to them that a sleep aid may help you fall asleep but it does not guarantee deep restorative sleep. So what is the key to deep restorative sleep? The best we can suggest is good sleep hygiene.

What is sleep hygiene? The best way to explain this is to illustrate how the body functions. We have a circadian rhythm that is dependent on many environmental factors that allows us to go through sleep and awake cycles. Several hormones are involved in this process, including melatonin and cortisol. Bad habits have wrecked havoc on our circadian rhythm such as: excessive sleep and napping, no sleep schedule, alcohol and caffeine, staying up late watching TV… The key to good sleep is the return balance to the circadian rhythm through good sleep hygiene. Consider the body a machine that requires the right signals and send the right signals that it is time to sleep. Eating just before bed sends the signal “here is energy because we are going to do something.” The body gets confused when you then try to sleep. The following are some suggestions on how to return order and send the right signals. .

Personal Habits

• Fix a bedtime and an awakening time dependent on your age
• Avoid napping during the day (nap=>30 min)
• Avoid alcohol (at least 4-6 hours before bed)
• Avoid caffeine (at least 4-6 hours before bed)
• Avoid heavy, spicy, or sugary foods 4-6 hours before bed
• Exercise regularly (not within 2 hours of bed)

Sleep Environment

• Use comfortable bedding
• Comfortable temperature (cold is best)
• Block out noise and light
• Use bed for sleep and sex only (remember we need to signal the right messages to our body)

Getting Ready For Bed

• Have a routine
• Practice relaxation techniques
• Clear mind of worries (prayer)

If you have tried these techniques and cannot restore order there may be a medical problem that needs to be addresses such as an enlarged prostate that makes you get up several times a night to go to the bathroom, sleep apnea, pain, acid reflux, hot flashes…

It is my goal this week to establish a sleep time and routine, practice relaxation techniques, and pray every night. I suspect that I may have some sleep apnea; which I hope improves with weight loss. I may have to get this checked out.