Do your heart good


Lifesaving news for every woman and the man who loves her


Ask women how they protect themselves and they'll tell you about locking their doors, driving defensively and what kinds of airplanes are the safest. They'll tell you about regular mammograms and they'll tell you about not using products with a broken seal. Even so, most women are leaving their most vulnerable spot unguarded: their hearts.

And when we undertook two surveys--one survey of our readers and one of women nationally--we found that women aren't even aware that their heart health is an area that's begging for protection. And we found that our doctors aren't doing nearly enough to educate us about how vulnerable our hearts are and the essential steps we should be taking to protect them.

The good news: There's plenty that we can do. Read on to learn what you need to know.

We need to realize that heart disease is the number-one threat to our lives. Women worry about breast cancer. But for every woman who dies of breast cancer, five die of heart disease. And most women aren't even aware that they should be concerned about heart disease. Only a third of the public and 37% of our readers were aware that their risk of dying from a heart attack is greater than their risk of dying from breast cancer.

Beyond that, many women think that heart disease is like Monday Night Football or Steven Seagal movies--sort of a guy thing. But beginning at meno-pause, women's rate of heart disease slowly rises. By age 75 it's the same as that of men. Yet of our respondents age 75 and older, only 33% of American women and 58% of readers knew that. Women who mistakenly think they're immune to heart disease may not go out of their way to prevent it.

For years, scientists didn't suspect that women were prone to heart disease. This gave doctors, and even women themselves, an excuse to ignore heart-disease symptoms, notes Bernadine Healy, MD, cardiologist, former director of the National Institutes of Health and renowned women's health advocate. But now the truth is out and women need to know it.

Women do indeed get heart disease and they do die of heart attacks--but usually about 10 years later in life than men do. Exception: Women with diabetes can have a heart-disease risk higher than a nondiabetic man's throughout their lives. Other women whose risks may shoot up more quickly than their peers are women who've experienced early menopause or have had a surgical removal of their ovaries.

We need to get a head start on heart health. Women can't afford to wait for doctors to raise the subject of heart disease before we start trying to reduce its threat. A surprising number of Ameri-can women (59%) said that their doctors haven't talked to them about heart disease. That includes a substantial number (44%) of women over age 60, whose risk is the highest.

"This is not acceptable," says Columbia University internist Marianne J. Legato, MD, co-author of The Female Heart (Simon and Schuster, 1991). Women at high risk need to hear about it. And younger women shouldn't wait until they're at risk to start thinking about heart disease. The earlier women start on a healthy lifestyle, the better, says Dr. Legato. That means the agenda for your next doctor's appointment is clear: If your doctor doesn't raise the heart-disease subject, take the initiative and ask for a review of your risk factors.

To know our risk, we need to know the cholesterol number that matters most. American doctors deserve kudos for being scrupulous about two basic measures of heart-disease risk. At routine examinations, the vast majority of women say their doctors are checking blood pressure (93% nationally; 90% of reader respondents) and weight (92% nationally; 88% of reader respondents).

The bad news: Many women and doctors are overlooking cholesterol checks, an essential measure of heart-disease risk. One-quarter of our readers told us their doctors have not recommended they get their cholesterol checked!

Even worse: If women are getting their cholesterols checked and find out they have a total cholesterol over 150,they're not coming away with the number they most need to know--their total cholesterol/ HDL ratio. That's according to 41% of our reader respondents. "You can't beat that ratio for predicting heart-disease risk--it's better than total cholesterol, HDL, LDL or even triglycerides," says Prevention advisor William Castelli, MD, medical director of the Framingham (MA) Cardiovascular Institute.

To find your ratio, you divide your total cholesterol number by your HDL number. Your ratio should be 4.0 or below.

Looking at your total cholesterol and HDLnumbers together, in the form of the ratio, is essential because in women, a high HDL can make up for a high total cholesterol, says Dr. Healy. Remember that HDL is the "good" cholesterol, admired for its ability to herd "bad" LDL out of the body. Especially before menopause, women tend to have much higher HDL than men (testosterone may suppress HDL). That can make their total cholesterol look really awful. Dr. Healy offers the example of a woman with total cholesterol of 240, which is risky for a man and could be for a woman. "But if her HDL is 85, then her cholesterol level is actually good!" she says. If doctors and women don't pay attention to HDL, a woman might end up taking a cholesterol-lowering medication that she doesn't really need.

Conversely, "low" total cholesterol doesn't guarantee women immunity from heart disease. A woman with a total cholesterol under 200 might assume she's safe if she doesn't know that she has low HDL--and she may not do enough to improve her heart-disease profile.

Wondering where you stand? Ask your doctor. "Don't get into the situation where you're told, 'Your numbers are O.K., I looked at them,'" says Dr. Castelli. Bring your doctor the "Women's Cholesterol Worksheet" on p. 87.

We need to know what's happening around our waists. Virtually no physicians measure a woman's waist/hip ratio (WHR). Those missing measurements mean docs are overlooking some important information. WHR has been shown to be a better way to judge who's at risk for heart disease than weight alone. Even people who aren't overweight can have an increased heart-disease risk if their weight is all located around their middles.

Among the public, only 8% have doctors who measure the waist and hips; among our readers, the figure is a scant 2%. Some doctors say that they don't need to wrap a tape measure around every patient to clarify whether that person has that dangerous pattern of central obesity or not. In the most obvious cases, "eyeballing it" may be enough. But just as your doctor puts you on the scale to get a precise reading on your weight, a precise reading on your WHR is important, too.

If your doctor isn't checking WHR at all, grab a tape measure and record the following:

Waist (in inches): ( )

Hip (in inches
at widest part): ( )

WHR (divide waist
measurement by
hip measurement): ( )
Your target is a ratio of 0.8 or below.

Risk of heart disease rises steeply in women whose ratio is above 0.8.

The good news, says Dr. Castelli, is that it's not so hard to change a waist/hip ratio. "I've seen people's waist/hip ratios reverse even after losing just 5 pounds," he notes.

After menopause, we need to consider HRT for heart health. Very few of the women we surveyed knew that hormone-replacement therapy (HRT) reduces women's risk of heart disease. Less than a third of our readers (31%) consider it very important for heart health. "I certainly was surprised by that lack of information about the benefits," says Dr. Healy.

Fact is, the incidence of heart disease and death in postmenopausal women who take estrogen is almost half that of women who have never used it.

Research shows that estrogen can reduce blood pressure, keep blood-vessel walls from collecting plaque, and prevent blood vessels from constricting. Some scientists speculate that these benefits may prove to be even more important than estrogen's well-documented effect on cholesterol levels: It can raise HDL and lower LDL by as much as 15%.

The experts also acknowledge that HRT is not right for every woman. The decision must be based on a careful evaluation of each individual's risk factors for heart disease and other health considerations.

Even when women do decide to take HRT, they must be closely supervised by a knowledgeable physician. Dosages and form often need adjustment for women to maximize benefits and minimize side effects.

Women need to ask their partners for heartening support. Of course, it helps to have the support of your "significant other" in addressing these heart-health issues. Yet our survey found that women are more likely to give this kind of support than to receive it. (See "Who Supports Whom?" on p. 163.)

Our experts saw two possible reasons for the discrepancies: One may be that many women tend to be more "other oriented" than men are, says Prevention advisor Redford Williams, MD, professor of psychiatry and director of the Behavioral Medicine Research Center at Duke University Medical Center, Durham, NC.

Another is possibly caused by the incorrect assumption by both husbands and wives that women aren't vulnerable to heart disease, suggests psychotherapist Mary Nakata, lifestyle counselor at the Pritikin Longevity Center, Santa Monica, CA. "Women may not be asking for the support that they need." Either way, the point is that a spouse's loving support can improve heart health, says Dr. Castelli. Partnering up is especially important when someone already has heart disease, he says. "We've learned that when you can only get one or the other partner into the clinic, you won't be as successful as when the whole family hears the information together and realizes that the lifestyle changes are something they have to do together."

Where can you start? "Make an appointment to talk with your husband about your own heart health," suggests Dr. Williams. "It sometimes can be hard to engage a husband in any dialogue about this sort of thing. A woman can say, 'I want to set a time that we can talk about this health thing. When is good for you?'"

Then ask specifically for what you need. If your husband is always bringing ice cream into the house, Dr. Legato suggests saying something like, "'My cholesterol is terrible, and I have a real problem resisting your ice cream. Can you help me out with this?' Engage him in collaboration," she explains. "If women would spell out what they want, that would be a whole new exercise for most of them."

It may work. Or it may not. Ultimately, Dr. Legato says, women can't afford to wait for someone else to save them. "We have to take care of ourselves. If we wait for our spouses or someone else to rescue us, it won't happen," she says. "Do your own risk assessment, learn about heart disease, and change your behavior. Even without a spouse's support, those things are not that hard to do."

Women must learn to defuse anger. "Anger is probably as much of a risk factor for coronary disease (in women and in men) as cholesterol, smoking, high blood pressure, and a sedentary lifestyle," says Prevention advisor Redford Williams, MD, professor of psychiatry and director of the Behavioral Medicine Research Center at Duke University Medical Center, Durham, NC. In our national poll, more than half of women reported being angry often or occasionally in the previous 2 weeks. Fifty percent of reader respondents reported the same thing.

It's not the occasional moment of rage that ruins your heart--it's when you regularly explode outward or hold it inside and stew--responses that 21% of our readers reported. That can send levels of stress hormones like cortisone and adrenaline, as well as blood pressure, into the stratosphere.

Dr. Williams suggests you learn to disarm that anger by asking yourself three questions:

(1) Is the situation that's causing my anger important to me? A "no" answer can knock out a lot of anger right from the start. If the answer is yes, go on to the next question.

(2) Is my anger appropriate to the objective facts of the situation? Again, a "no" may remove a lot of anger right away. But maybe it is appropriate: "If blizzard conditions mean you're going to spend the next 3 nights at the Newark airport and miss Christmas with your family--any jury would rule you have a right to be angry," says Dr. Williams. If the answer is yes, go on to the next question.

(3) Is there anything I can do to modify the situation that's causing my anger? Confront the situation in an assertive way. Don't blow up at the ticket clerk--that won't eliminate the blizzard. But if the ticket clerk won't let you call ahead to tell your family, you can insist on seeing his manager. "Don't explode," says Dr. Williams. "Ask for what you want."

Women must recognize and seek treatment for depression. Depression is dangerous to the heart in both men and women, according to research. But women take note: Research has shown that women are more likely to suffer depression than are men.

Some 36% of our reader respondents reported recent feelings of depression; nationally, 34% reported them. If depression persists, it's vital to get help. "Depression is as treatable as a broken leg, but first the illness must be recognized," says Dr. Williams. "Depression is a persistent sadness, blueness, lack of energy, or guilt or blame. The emotions are often accompanied by changes in biological functions, like a lack of interest in sex, or changes in sleeping and eating patterns," he says. If such symptoms interfere with your daily activities for a period of 2 weeks or more, your depression is serious enough to warrant medical attention.

Treatment doesn't necessarily mean medication. Studies show that cognitive/behavioral therapy ("talk therapy" that helps you learn new, positive and realistic ways to think ) can work just as well as pharmacological therapy, says Dr. Williams.

Women's hearts need friends and confidants. You've heard of cocooning. You've heard how concerns about safety are keeping people tucked away in their homes, isolated from others. Some research has turned up a link between loneliness and increased heart-disease risk. That's a risk that the women we surveyed won't really have to worry about. The vast majority have a confidant with whom they can share their innermost feelings. Having a confidant not only reduces heart-disease risk, it even improves the prognosis for people who already have heart disease, says Dr. Williams. Only 14% of women in the general public said they don't have a confidant, and 6% of Prevention readers said they don't.

Doesn't matter who the confidant is, says Dr. Williams. The most common answer among our readers was spouse (47% ), followed by a friend (45%) or a family member (25%).

If you don't already have a confidant, it is possible to grow one. "Be a good listener," suggests Dr. Williams. "When someone tells you her back hurts, don't immediately respond by saying, 'Let me tell you about my ankle!'" Instead, he says, "Acknowledge their feelings--say, 'Back pain really can be awful. Tell me more.' If you're a good confidant, that will make her more likely to be a confidant for you."

PHOTO (COLOR): A woman and man kissing and stroking each other

DIAGRAM: Heart disease versus breast cancer: Most women underestimate heart-disease risk, thinking that breast cancer is the greatest threat to their lives. In fact, heart disease claims five times as many women's lives. Source: NCI, based on NCHS public use files, 1992

DIAGRAM: What do doctors do? Doctors are doing a good job at checking two heart-disease indicators: blood pressure and weight. But our surveys found that doctors are overlooking two critical indicators of risk: cholester ol and waist/hip ratio

DIAGRAM: Taking action: There is plenty a woman can do to reduce heart-disease risk. Our survey shows that a majority of survey respondents are already trying to improve heart health with diet and exercise. But women mig ht benefit from also recognizing the risk-reduction potential of hormone-replacement therapy (HRT)

DIAGRAM: Who supports whom? The women in our surveys were more likely to be concerned about their spouse's heart health than their spouses seemed to be about theirs. Women can benefit from a spouse's loving support and m ay just need to ask for it

SOURCES: William Castelli, MD, medical director, Framingham (MA) Cardiovascular Institute; Bernadine Healy, MD, dean, Ohio State University College of Medicine, Columbus, cardiologist, former director of the National Institutes of Health, and author, A New Prescription for Women's Health (Penguin Books, 1995); Marianne J. Legato, MD, internist and specialist in women's health, Columbia University, New York, NY, and co-author, The Female Heart: The Truth About Women and Coronary Artery Disease (Simon and Schuster, 1991) and What Women Need to Know (Simon and Schuster, 1997); JoAnn Manson, MD, co-director of women's health, Brigham and Women's Hospital, Harvard Medical School, Boston; Mary Nakata, MPH, MFCC, lifestyle counselor, Pritikin Longevity Center, Santa Monica, CA; Dean Ornish, MD, director, Preventive Medicine Research Institute, Sausalito, CA; Redford Williams, MD, professor of psychiatry and director, Behavioral Medicine Research Center, Duke University Medical Center, Durham, NC, and co-author, Anger Kills (Times Books, 1993).


By Cathy Perlmutter with Susan C. Smith, Ed Slaughter and Toby Hanlon

This article is based on the results of two surveys. Our national survey, conducted by Peter D. Hart Research Associates, polled a representative, randomly selected sample of American women age 18 or older (1,002 in all) by telephone in September 1996. The reader survey was published in the October 1996 issue of Prevention. The numbers in this report are based on a sample of 1,200 questionnaires, taken randomly from the 5,228 questionnaires returned. Our thanks to all.

If there's one word women need to know when it comes to heart health, it's "action!" A striking one-quarter of reader respondents who experienced heart-attack symptoms didn't seek immediate medical attention.

"I was particularly concerned about these results," comments Bernadine Healy, MD. "Your study shows that women still minimize symptoms, even the most compelling ones."

The classic symptom of heart disease for both men and women is heaviness, tightness or discomfort in the chest. That may be accompanied by shortness of breath or sweating. The discomfort may radiate into the neck, shoulders or the stomach. For women, a heart attack may also be indicated by any of the following:

* Chest discomfort that occurs during mental stress or when resting. (In men, chest discomfort is most likely to occur during physical exertion.)

* Nausea and pain, often just under the breastbone. This can be aside from or along with chest discomfort. The nausea is not relieved by antacids or burping. There may even be vomiting.

* Any of these accompanied by weakness in the chest, arms or shoulders or unusual fatigue that may worsen with activity.

* Go directly to the emergency room if you're short of breath or have an excruciating chest pain that you've never felt before.

* Call your physician if you have other symptoms. Be as specific as possible about what you're feeling and where the feeling is. Don't dismiss what you're feeling just because the answer to the question, "are you having chest pains?" is no. Other feelings can also indicate a heart attack. Your doctor needs to know what those sensations are.

He or she can tell you what the next step should be. "If you can't reach any doctor on the telephone within a few minutes, go to an emergency room, says Dr. Healy. True, if it turns out to be nothing serious, you might experience a little embarrassment. But if it is a heart attack, you just might save your life. Ask yourself, "What would I do if I were a man having these symptoms?" Similarly, if a female friend tells you about her symptoms, ask, "What would I do if she were a man and telling me this?"

Take this worksheet to the doctor's office when you get the results from your cholesterol test. The test you'll need is a "serum lipid panel," an analysis that is done from a blood sample drawn at your doctor's office or lab.

Note: These target numbers are at levels that may prevent heart disease, not reverse it.

Test Your Target Your # Date

Total cholesterol 150 or below ( ) ( )

HDL cholesterol (see total/HDL) ( ) ( )

Total/HDL ratio 4.0 or below ( ) ( )
(divide total cholesterol by HDL)
FOR WOMEN WHOSE TOTAL/HDL RATIO IS OVER 4.0, ask your doctor to check your triglyceride level. (This may mean returning to your doctor's office for another blood test.) Triglycerides can provide vital information in some cases. If a woman's total/HDL ratio is bad and her triglyceride level is high(over 150), it might help the doctor diagnose a newly recognized pattern of symptoms called "syndrome X," or "polymetabolic syndrome." "To put it bluntly, these women are galloping toward a heart attack," says William Castelli, MD. "A particularly dangerous type of fat particle called the 'small dense beta VLDL particle,' tends to clog up their arteries. They need to know that they're susceptible, because they must be especially careful about staying on a prudent diet." The good news about high triglycerides--and syndrome X in general--is that lifestyle changes can eliminate its risk. "Most of these women would be cured by losing 15 pounds around the waist!" says Dr. Castelli.

FOR WOMEN AT MENOPAUSE OR WOMEN WITH RISK FACTOR FOR HEART DISEASE, especially new risk factors (like weight gain), get your cholesterol numbers retested every year if your readings are less than optimal.

FOR HEALTHY WOMEN UNDER 50 WITH NO RISK FACTORS and good readings, have cholesterol rechecked every 4 to 5 years.

Once you've filled out the worksheet, if any of the key numbers don't hit their target, don't feel bad--feel challenged! "Exercise and diet work terrifically to reduce your risk factors, even after menopause," says William Castelli, MD.

Another incentive: "Women seem to be able to reverse heart disease more easily than men do," says Dean Ornish, MD "Their bodies respond to changes in diet and life style more dramatically than men's."

Focus first on the basics. The obvious steps may make the biggest difference. (For how great of a difference, "Taking Action" on p.89.)

* If you smoke, quit. Smoking is the number-one risk factor for heart disease. Women who smoke are two to four times more likely to get heart disease than women who don't. Smoking lowers HDL and quitting is a proven way to raise it, notes JoAnn Manson, MD, co-director of women's health at the Brigham and Women's Hospital in Boston.

* If you're overweight, lose weight. Even if your ideal weight is miles away, a little bit can make a big difference, says Dr. Castelli. You've read on page 00 how he's seen waist/hip ratios reverse when obese people lost just 5 pounds. "I've also seen people who lost just 5 to 25 pounds get dramatic improvements in their blood pressure, blood sugars, HDL and LDL. I've even seen people go off blood pressure and diabetes medication by losing a relatively small amount of weight!"

* Get regular aerobic exercise. "You don't need to be a marathon runner," says Dr. Manson. Her new research indicates that 3 hours a week of moderate-intensity exercise, like brisk walking, can reduce heart-disease risk by 40%. "It's probably best to divide up the 3 hours so that you exercise at least 30 minutes every day," she adds. Although it's not conclusive, new research suggests that exercise may reduce women's risk more than it reduces men's risk! Exercise keeps weight down and HDL up.

* Eat less fat, especially saturated fat. Your daily diet should contain no more than 25% of calories from fat. Switching to a low-fat diet not only helps your cholesterol levels-it also helps you lose weight.

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