Cardiovascular Disease

Vascular disease can cause narrowing of the blood vessels supplying the heart, causing a heart attack (myocardial infarction), or narrowing of vessels to the brain, causing a stroke. Risk factors include family history, smoking, male sex, other vascular disease, hypertension, diabetes, obesity, inactivity, high low-density lipoprotein (LDL) cholesterol level ( > 130 mg/dL), and low high-density lipoprotein (HDL) cholesterol level ( < 40 mg/dL). An individual’s 10-year risk of vascular disease can be approximated by using the Framingham Risk Score and should be discussed with your physician.

Vigorous exercise reduces cardiovascular risk, but a significant reduction can also be accomplished by brisk walking 3 or 4 times per week for 30 to 45 minutes. Reducing the fat content of food to less than 30% of overall calories decreases cardiovascular risk as well. The Complete and Up-to-Date Fat Book: A Guide to the Fat, Calories and Fat Percentages in Your Food, by Karen J. Bellerson, and Eater's Choice: A Food Lover's Guide to Lower Cholesterol, by Ronald S. and Nancy Goor are excellent resources that list the fat content of many foods.

High-Sensitivity C-reactive Protein

High-sensitivity C-reactive protein (CRP) is a marker in the blood that measures inflammation. Many illnesses and conditions can cause an elevated value (eg, a viral infection, arthritis, etc). However, in the absence of a temporary problem, chronically elevated values are thought to be associated with an increased risk of cardiovascular disease such as heart attacks and strokes.

An average of two measurements is best to assess the usual level. Low, average, and increased risk are defined as less than 1, 1 to 3, and greater than 3 mg/dL. It is important to remember that CRP is just one of several factors that assess the risk for cardiovascular problems.

Daily aspirin therapy reduces the risk associated with elevated CRP levels. A healthy diet may reduce CRP levels.

Aspirin and Cardiovascular Disease

Findings of some studies suggest that daily aspirin use (1 adult aspirin every other day or 1 baby aspirin daily) reduces the incidence of stroke and heart disease. Many large trials have shown that aspirin benefits all patients who have known vascular disease, as well as patients who have risk factors for vascular disease but have not had a heart attack or stroke. Benefits of aspirin therapy must be weighed against the risks. Reasons not to take aspirin include bleeding disorders, the use of blood thinners, allergy to aspirin, uncontrolled hypertension, and ulcer disease. It is important to discuss with your physician whether aspirin therapy makes sense for you.

Coronary Calcium Scoring

Measuring calcium in the coronary arteries provides an indirect indication of possible artery blockage of the heart. Newer computed tomographic (CT) scans can calculate the amount of coronary calcium and create a measure of heart attack risk relative to that of the general population.

This screening test is most valuable for people at intermediate risk for heart disease, as those with high risk are already receiving maximal therapy. It is used mostly to predict problems in the future rather than to diagnose an immediate heart problem.

Cardiac Stress Tests

Stress testing of the heart assesses the heart in the here and now. Various methods (standard, nuclear, and echocardiographic) are used to determine if the heart is getting enough blood. The recommendations for who should get a stress test vary widely: some guidelines suggest routine testing every 4 years for middle-aged people, others recommend it for individuals with cardiac risk factors, and still others restrict it largely for people with cardiac symptoms. Approximate heart attack risk can be calculated by using the Framingham Risk Model.

Abdominal Aortic Aneurysm Screening

Abdominal aortic aneurysms are 5 times more common in men than in women. Other predisposing factors include hypertension, smoking history, and family history. The current recommendation is to screen men with a history of smoking once between the ages of 65 to 75 years and men older than 60 years with a family history.

Hypertension

Hypertension, or high blood pressure, is defined by the Joint National Committee on Hypertension as a blood pressure exceeding 140/90 mm Hg in the sitting position. It may be predominantly diastolic (bottom number >90) or systolic (top number >140). Borderline hypertension is defined as a blood pressure ranging from 130/85 to 139/89 mm Hg. In 95% of individuals, there is no discernible cause. An average of readings taken over weeks in a relaxed setting is more important than isolated elevations. Diastolic pressures tend to rise until age 45 or 50 years and then level off. Diastolic pressures that average above 85 are associated with an increased risk of coronary disease in middle-aged men. Isolated systolic pressures above 160 are a risk factor for stroke, particularly in the elderly.

Untreated hypertension is a major risk factor for vascular disease and can lead to heart attack, stroke, peripheral artery disease, and aortic aneurysm.

Predisposing Factors Family history, overweight, high salt intake, high alcohol intake, and stress may dispose an individual to hypertension. Nonsteroidal anti-inflammatory drugs (eg, ibuprofen [Motrin or Advil] and naproxen sodium [Aleve]) may elevate blood pressure and may block the blood pressure–lowering effects of angiotensin-converting enzyme (ACE) inhibitors (eg, lisinopril, enalapril maleate, and ramipril).

Treatment of Hypertension Weight loss (if overweight), aerobic exercise, stress reduction, and limiting alcohol, caffeine, and salt intake (the latter to <2 g/day) can reduce blood pressure in some individuals. However, medication is usually recommended when blood pressures consistently exceed 140/90 mm Hg, despite lifestyle modifications. The choice of medication is an individual decision and should be discussed with one’s physician.

Cholesterol

High LDL cholesterol and/or low HDL cholesterol levels are important risk factors for vascular disease. The total level is less important than the fractions that comprise it.

LDL Cholesterol Higher LDL (bad) cholesterol levels are associated with an increased incidence of vascular disease in many studies. Individual goal LDL cholesterol level depends on individual risk for vascular disease and should be discussed with one’s physician. For example, patients with known coronary artery disease and/or diabetes should aim for a goal LDL cholesterol level of less than 70 mg/dL. For many patients, a goal LDL cholesterol level of less than 130 mg/dL is reasonable. Dietary changes are recommended as the initial therapy, including avoidance of foods high in cholesterol and fat such as eggs, milk (other than skim milk), cream, ice cream, butter, cheese, red meat, organ meats, the majority of fast food, and many desserts. Saturated fats are usually found in foods that come from animals (meat, milk, etc). “Tropical” vegetable oils (palm and coconut) and hydrogenated oils (solid margarine) are also rich in fat. Switching to monounsaturated oils (olive and canola oils) lowers fat intake.

Medication may be considered when LDL cholesterol level remains above one’s individual goal, despite dietary modification and regular exercise, or when 2 or more of the following risk factors are present: known vascular disease, male sex, family history of premature coronary heart disease, cigarette smoking, hypertension, HDL (good) cholesterol level less than 40 mg/dL, diabetes, and severe obesity.

HDL Cholesterol A low HDL (good) cholesterol less than 40 mg/dL is a separate risk factor for coronary heart/vascular disease. Conversely, levels greater than 60 mg/dL are protective. The best ways to raise HDL cholesterol level are to increase aerobic exercise and to stop smoking. It is also increased by a small amount of daily alcohol and by certain medications (eg, estrogen therapy and the vitamin niacin).

Cholesterol Medications The most effective and most commonly used cholesterol-lowering medications are the statins (Lipitor, simvastatin [Zocor], Crestor, and pravastatin sodium [Pravachol]), which are very well tolerated. Any mild gastrointestinal intolerance usually subsides over time. They occasionally cause muscle inflammation or liver abnormalities. Blood tests are generally performed 1 to 3 times a year to ensure correct dosing and stable liver function.

Diet

Five to nine servings of fruits and vegetables per day supply enough vitamins for most people. This diet provides the required vitamins and adequate fiber to ensure health. Use vegetables as snacks.

A high-fiber diet is associated with a 45% reduction in heart disease risk and a 30% reduction in the risk of developing diabetes. Diets high in fruits and vegetables help prevent cardiovascular disease, stroke, cancer, and diabetes.

Trans-fatty acids and saturated fats should be avoided and replaced with monounsaturated and polyunsaturated fats.

Overweight and Obesity

Obesity, a chronic disease that is increasing in prevalence, is now considered a global epidemic. Obesity is associated with a significant increase in mortality and risk of many disorders, including diabetes, hypertension, high cholesterol, heart disease, stroke, gallstones, osteoarthritis, sleep apnea, cancer, and many others. Weight loss is associated with a reduction in obesity-associated problems. Screening for overweight and obesity should include measurement of body mass index (BMI) and waist circumference and evaluation of overall medical risk.

The best way to lose weight is through increasing physical activity and reducing caloric intake. An individualized plan should be formulated with one’s physician. It is important to choose a plan that is realistic. Weight Watchers and the online program called My Food Diary (http://www.myfooddiary.com) are good ways to keep track of caloric intake, outputs, and weight goals. For those with an iPhone, the Lose It application offers similar information.

Weight loss medications are rarely used, as many have undesirable adverse effects and are not as effective as diet and exercise. Weight loss surgery is reserved for severely obese patients or those with significant weight-related problems for whom diet and exercise are not effective.

Weight loss for those who are overweight provides enormous health benefits. A 7% weight reduction decreases the progression of borderline blood glucose levels to diabetes by 58%. Innumerable other benefits are achieved by weight reduction.

To lose 1 pound per week, you must reduce caloric intake or burn off 500 calories per day. Weight Watchers has the best track record for persistent weight loss. Helpful online assistance includes My Food Diary.

Approximate caloric expenditures are given in parentheses for the following types of exercise: running 8 mph (13 calories/minute), walking 2 mph (3 calories/minute), walking 4 mph (6 calories/minute), housecleaning (864 calories/90 minutes), shopping (325 calories/90 minutes), yard work (555 calories/90 minutes), and sitting at rest (2 calories/90 minutes).

Vitamins and Supplements

Many people take supplemental vitamins and minerals in doses higher than the recommended dietary allowances (RDAs). Fat-soluble vitamins (A, D, E, and K) are stored and may cause problems when taken in excess. Multivitamins generally contain safe amounts.

Water-soluble vitamins are readily excreted in the urine and generally cause no problem when taken in excess. Those who take large doses of pyridoxine hydrochloride (vitamin B6) can develop nerve problems (eg, numbness). Large doses of vitamin C can predispose to kidney stones. Niacin (nicotinic acid) in excess can cause flushing, itch, and liver problems.

Recommendations for vitamins and supplements seem to change from day to day. It is clear that obtaining vitamins and nutrients from a diet rich in fruits and vegetables is the most beneficial for your health.

With the exception of pregnancy and certain conditions (eg, alcoholism, stomach surgery, kidney disease, etc), the current recommendations for supplements in people with an adequate diet beyond that found in a standard multivitamin are as follows:

• Vitamin A and beta-carotene supplements should not be used because of possible deleterious effects such as increasing the risk of lung cancer in smokers.
• Excessive vitamin E is not effective in preventing cancer, dementia, or stoke. All-cause mortality was increased in patients taking 400 units per day or more. Therefore, high-dose vitamin E is not recommended.
• High doses of vitamin C have not been proven to have a health benefit. Whether it helps to prevent eye disease is not clear.
• Treating elevated levels of homocysteine with folic acid, vitamin B6, and vitamin B12 has not been proven to reduce cardiac risk.
• Vitamin B12 deficiency causes serious disease, including dementia. Routine B12 supplements for the elderly are advisable and are usually fully supplied in a multivitamin. Higher doses are not associated with any health problems.
• Vitamin D deficiency is very common and is associated with osteoporosis. We suggest 1000 units per day as a supplement. More is advisable for patients with osteoporosis and for older patients. Calcium supplementation seems to offer more improvement in osteoporosis than increased dietary calcium.
• Supplemental calcium is helpful in treating and preventing osteoporosis and may improve cholesterol levels and decrease the risk of colon cancer.
• Diets high in folate (folic acid) are associated with a decreased risk of colon cancer and colon polyps, a benefit not reproduced by folate pills alone. However, folate deficiency is common and is prevented by taking 400 µg of folate daily, an amount usually supplied in a multivitamin.
• Similarly, antioxidant vitamins (vitamins A, C, E, and beta-carotene) are associated with health benefits when obtained through the diet and with only mixed results when taken as supplements.

Cancer Risk

Dietary and vitamin recommendations for cancer prevention vary from one study to the next. A diet low in animal fat may protect against breast and colon cancer. A high-fiber diet may decrease the risk of colorectal cancer. Foods rich in vitamin A and beta-carotene may protect against cancer. Obesity is linked to an increased incidence of breast cancer.

Smoking

Smoking is responsible for 90% of lung cancer in the United States. A smoker’s risk of developing lung cancer is 10 to 30 times greater than that of a nonsmoker. In addition, all forms of tobacco and smoking are major risk factors for mouth and throat (particularly in heavy drinkers), larynx, esophagus, pancreas, and bladder cancers.

Breast Cancer

Breast cancer accounts for 24% of all cancer in women. One in 11 women will develop the disease. The chance of having breast cancer at age 50 years is 1 in 50. Risk factors include a sister or mother with breast cancer (2-3 times greater risk, higher if the disease is in both breasts), early onset of menstrual period, late menopause, never having been pregnant, and certain types of fibrocystic disease. Studies show an increased risk in postmenopausal women receiving hormone therapy.

Approximate breast cancer risk can be calculated using the Gail model (http://www.cancer.gov/bcrisktool/). Current recommendations suggest a routine mammogram for women between ages 35 and 40 years and every 1 to 2 years starting at age 40 years. All guidelines recommend monthly breast self-examination and a yearly breast examination by a physician. Self-examination should be done 7 to 10 days after each menstrual cycle begins. Menopausal or postmenopausal women should do a self-examination on the first day of each month.

Colorectal CancerRisk factors include age older than 50 years, family history of colon cancer, previous history of colon cancer or polyps, inflammatory bowel disease (ulcerative colitis or Crohn disease but not irritable bowel syndrome), cigarette smoking, and a diet high in fat and red meat. Recommendations for preventing colon cancer include a high-fiber diet. After age 50 years, a full colonoscopy should be performed by a gastroenterologist every 3 to 10 years in addition to annual fecal occult blood tests. The frequency of colonoscopy depends on one’s level of risk. Complications from the procedure are rare and will be discussed by the gastroenterologist.

Melanoma Melanoma risk factors include fair complexion, tendency to burn, intermittent heavy sun exposure, family history, and certain dermatologic conditions. Try to avoid excessive sun exposure, especially between 10:00 AM and 3:00 PM, when UV rays are strongest. Use protective clothing and a 15 sun protection factor (SPF) sunscreen or higher, with repeated applications. Avoid indoor sunlamps, tanning parlors, and tanning pills. Prostate Cancer

Prostate Cancer While the lifetime risk of prostate cancer in men is 17%, only 3% of men die of it. More than 80% of all prostate cancer cases occur in men older than 65 years. Prostate examination and a prostate-specific antigen (PSA) test should be performed annually after age 50 years and earlier in those with specific risk factors

The PSA is a screening test that has to be used in appropriate context, as there are many false positives and some false negatives. Even when cancer is subsequently noted on a biopsy specimen, it is not clear whether all cancers found would have eventually gone on to cause problems. However, along with the digital rectal examination, it offers the best we have at present for prostate cancer screening.

Acceptable PSA values (usually 2.5-4 units) vary depending on age, race/ethnicity, size of the prostate gland, and other factors. A change of more than 0.75 units per year (or less in some cases) can indicate the possibility of cancer.

The rectal examination itself can cause a slight elevation in PSA level (approximately 0.3 units), which quickly resolves. An increase of approximately 0.8 units can occur after ejaculation, which resolves over 48 hours, and can occur after trauma (eg, bike riding) and with infection.

Screening usually starts after age 50 years in white men and at age 40 to 45 years in black men, men with a family history, and men with other predisposing conditions.

Cervical Cancer The Papanicolaou (Pap) smear is very effective in screening for cervical cancer. This test should be performed in all sexually active women and in all women older than 18 years on an annual basis. Screening recommendations vary for those older than 65 years. The biggest risk factor is human papillomavirus (HPV) infection. Other risks include a history of sexually transmitted disease, multiple sexual exposures at a young age, and cigarette smoking. The HPV vaccine (Gardasil) is now available to girls and women aged 9 to 26 years to prevent 70% of the HPV strains known to cause cervical cancer.

Mental Health

Depression, anxiety, bipolar disorder, panic disorder, eating disorders, substance abuse, and postpartum blues, among others, are extremely common mental health problems. All of these are considered medical conditions and can lead to significant psychological and physical distress, and all are very much treatable. Treatment is often through the combination of behavioral changes, exercise, counseling, or medication. Referral to a specialist is sometimes necessary. It is important to report any symptoms to your physician and to discuss means of improving mental health. In many instances, getting stress or moods under control can greatly improve overall physical health and sense of well-being.

Osteoporosis

Osteoporosis and osteopenia (pre-osteoporosis) are much more common in women than in men, particularly among white women. Other risk factors include thin body, small bones, lack of weight-bearing exercise, smoking, excessive alcohol or coffee consumption, vitamin D deficiency, low calcium intake, fair skin, prior hysterectomy, family history of osteoporosis, early menopause, and never having been pregnant. General prevention recommendations include weight-bearing exercise, smoking cessation, and prudent use of alcohol. In general, daily calcium intake should be between 1200 and 1500 mg for premenopausal women and 1500 mg for postmenopausal women. Because there is a limit on how much calcium can be absorbed at any single time, it is more effective to take the calcium in divided doses. Specific goals depend on one’s risk and should be discussed with one’s physician. Excellent dietary sources of calcium include milk (300 mg/serving), yogurt (245 mg/serving), and cheese (300 mg/serving). Lower-fat products are preferred. Calcium supplementation is often needed to meet the goals. A Tums 500 tablet provides 500 mg of calcium. Estrogen therapy can be a help in preventing osteoporosis.

Vitamin D deficiency is an important risk factor for osteoporosis, and vitamin D level is easily tested in the blood. (Please see the subsection regarding vitamin D supplementation in the Vitamins and Supplements section.)

Screening for osteoporosis is simple with a noninvasive test called a dual-energy x-ray absorptiometry (DEXA) scan and should be performed at the time of menopause (or sooner if there are enough risk factors) and then every 1 to 5 years depending on the results or therapy.

The first-line treatment for osteoporosis and for many cases of osteopenia is the class of medications called the bisphosphonates (Fosamax, Boniva, and Actonel) in addition to exercise, calcium, and vitamin D supplementation. An individualized program to prevent fracture risk should be formulated with your physician.

Caffeine

Caffeine can cause a rapid or an irregular heartbeat, anxiety, and breast cyst enlargement. Two cups per day is prudent, and more than 5 cups is generally excessive. Average caffeine contents per cup are given in parentheses for the following beverages: brewed coffee (60-80 mg), instant coffee (30-120 mg), decaffeinated coffee (2-5 mg), brewed tea (20-90 mg), instant tea (25-50 mg), iced tea (67-76 mg), and 1 ounce of chocolate (4-35 mg).

Alcohol

Moderate consumption is the equivalent of no more than 2 drinks per day (2 beers, 2 glasses of wine, 2 measured glasses of spirits, or 2 measured mixed drinks) for men and no more than 1 drink per day for women. Higher intakes are associated with serious risks, including liver disease, hypertension, stroke, various cancers, and the exacerbation of depression, anxiety, and other mental health problems. It is important to discuss one’s alcohol consumption with one’s physician.