CARING FOR YOUR HEART (Heart Risk Assessment)

A SELF TEST

• Inheritance
• Diabetes
• High blood pressure
• Obesity
• High Cholesterol
• Smoking
• Physical Inactivity
• Stress

WHAT IS YOUR RISK OF HEART DISEASE
Think of the people you know who have had a heart attached and then think about those who have not. Do you know of someone who smokes like a chimney, does not watch his/her weight, eats whatever he/she likes and is still going strong at 83? And do you also know of someone who looked after himself, kept his weight down, exercised regularly, did not smoke and suffered a heart attached long before retirement age?

When you think about people like these, you may conclude that it's hard to assess the risk of having a heart attack, right? Wrong . At least, mostly wrong. Yes, there are surprise heart attached and surprise survivors, but these are the exceptions rather than the rule. When we look at large populations, we can see how the actual risk adds up for the average person by counting the number of risk factors, such as having diabetes, high cholesterol, high blood pressure, smoking and not getting enough exercise.

But what about shortcuts? Every so often, you read about some new discovery that seems to promise instant protection from heart disease such as walnut, fish oil or grape fruit juice. And yes, it is true that these things may all be able to help. But there is no magic pill or magic food that can work on its own. Heart disease is a complicated condition and preventing it requires paying attention to all the established risk factors.

This following quiz will help you to assess how well you are doing with regard to some of the risk factors contributing to heart disease. For each question, circle the option that best describes you. At the end, we suggest a few steps you can take to reduce your risk of heart disease or to keep it low.

WHAT IS YOUR RISK?

Here are the risk factors that are beyond your control.

1. What is your sex and for women, the status of your hormones?
   1. I am a man or a woman before menopause with diabetes
   2. I am a post-menopausal woman
   3. I am a pre-menopausal woman
      
      
2. How many of your close relatives (parents, grandparents, uncles, aunts, siblings) suffered heart attacks before the age of 65?
   1. Quite a few of them
   2. More than one
   3. One
   4. None

   Here are the risk factors within your control:

3. What is your total cholesterol level?
   1. Over 240 mg/dl
   2. 220 to 239 mg/dl
   3. 200 to 219 mg/dl
   4. Under 200 mg/dl
      
      
      
4. What is your High Density Lipoprotein (HDL) cholesterol (the “good” cholesterol) Level?
   1. Under 35 mg/dl
   2. 35 to 42 mg/dl
   3. 43 to 50 mg/dl
   4. Over 50 mg/dl
      
      
5. What is your systolic blood pressure  (the higher number)?
   1. Higher than 160 mm Hg
   2. 141 to 160 mm Hg
   3. 121 to 140 mm Hg
   4. 120  mm Hg
      
      
6. What is your diastolic blood pressure (the lower number)?
   1. Higher than 100 mm Hg
   2. 90o 100 mm Hg
   3. 80 to 89 mm Hg
   4. 79  mm Hg lower
      
      
7. Do you smoke cigarettes and, if so, how many?
   1. More than a pack a day
   2. Half a pack to one pack a day
   3. Less than half a pack a day or smoke a pipe
   4. Do no smoke at all or do not chew tobacco

8. When it comes to physical activity, how do you rate yourself?
   1. Sedentary (sitting idle most of the time)
   2. Occasionally active
   3. Moderately active on most days
   4. Very active on most days
      
      
9. How thick is the roll of fat when you pinch your side at your waistline?
   1. As thick as my wrist, or thicker
   2. Between the size of my thumb and the size of my wrist
   3. About the size of my thumb
   4. Smaller than the size of my thumb
      
      
10. How is excess fat distributed on your?
    1. I look like an apple (wider at the waist than around the hips)
    2. I look like a pear ( wider below the waist, in the buttocks and thighs)
    3. I do not have much excess fat
       
       
11. What kind of stress do you experience and how often?
    1. I am often under stress
    2. I feel tense and rushed most of the time
    3. I feel tense and rushed occasionally
    4. I am generally pretty calm
    
    

HOW DID YOU RATE?
Let's first look at the factors you may not be able to do much about.

QUESTIONS 1 AND 2 (Gender and Family History)
In the general population men have a higher risk of developing heart disease than women who are of child bearing age. After menopause, when hormone (estrogen) production drops off,  a woman's risk may become as high as that of a man's. for people who have diabetes, however, the relative risks are a little different. For one thing, having diabetes increases the risk of heart disease for both sexes. And women with diabetes are just as likely to develop heart disease as men with diabetes, even before menopause.

A family history of heart attacks may increase your risk of heart disease. But if there is also a family tendency to have high cholesterol or high blood pressure or to be overweight, there are steps you can take to break out of the family pattern.

So, if your answers for questions 1 and 2 appear to put you at a higher risk, do not assume there is nothing you can do. If you scored only C's and D's on question 3 through 11, your total risk may be quite low.

Now let's look at the factors that you can do something about:

QUESTIONS 3 AND 4 (Blood Cholesterol)
Cholesterol comes in two main types: High-Density Lipoprotein (HDL) Cholesterol, the “good” kind and Low-Density Lipoprotein (LDL) Cholesterol, the “bad” kind. HDL cholesterol plays an important role in lowering the level of LDL cholesterol in the blood. High levels of total cholesterol especially LDL cholesterol and low levels of HDL cholesterol can contribute to the build up of blockages (plaques) in the arteries, thus narrowing the opening through which blood flows. When plaque builds up in the tiny neat arteries that supply blood to the heart muscles, the heart does not get enough oxygen to do its work and the result can be angina (chest pain). Even small plaques can rupture, which can result in a total blockage of blood flow through the artery. If heart muscles have no other source of blood than the blocked artery, they will die and the individual will have a heart attack. If an artery supplying blood to the brain gets blocked, the result is a stroke. Fortunately, total cholesterol levels can be brought down through changes in diet such as reducing the amount of saturated fat you eat. Total cholesterol also usually comes down as people lose weight. If those two measures do not work, talk to your doctor about medicine to reduce cholesterol levels.

Changing your diet cannot improve your HDL level, but there are other ways you can raise it. If your HDL is too low (30 to 40 mg/dl), you may be able to bring it up by losing weight or by increasing your physical activity. HDL cholesterol is naturally higher in women before menopause and in those who take hormones after menopause.

QUESTION 5 AND 6 (Blood Pressure)
Systolic blood pressure is the pressure while the heart is actually pumping and diastolic blood pressure is the pressure between beats. Both numbers are important. Blood pressure goes up when the blood vessels do not stretch as far as they should to accommodate the flow of blood. When blood vessels lose flexibility, the heart has to work harder, which strains the heart itself and also creates wear and tear on the arteries.

High blood pressure can always be brought down and often by things you can do yourself. For most people, blood pressure drops sharply as they lose weight. For others, it responds well to a reduction in dietary salt and other forms of sodium. Consuming more potassium from bananas and other fruits and vegetables can also help lower blood pressure. If these measures do not work, there is a wide choice of drugs that can be life-savers, provided you take them.

QUESTION 7 (Smoking / Tobacco use)
Avoid smoking or chewing tobacco at all cost. Tobacco use is one of the main causes of heart attacks, killing many more people than lung cancer or other lung diseases. How? By constricting the arteries, speeding up the heart and adding to the blockage of blood vessels. How to quit? It is not easy, but many people succeed by following smoking cessation programmes and/or using a nicotine patch or nicotine gum. You need to follow the directions for nicotine products exactly. If you have any doubts or questions, please check with your doctor.

QUESTION 8 (Physical Activity)
There is good news for people leading sedentary lifestyle and others who do not enjoy moving their bodies: You don't need to "work out," jog, or even go for long brisk walks to reduce your risk of heart disease. Although these are probably the best options, you can get many of the same health benefits by moving at a moderate intensity for a total of about thirty minutes a day. Such movement might include walking to the store, mowing the lawn, cleaning windows, climbing stairs, or dancing. Anything that moves your body will do. It does not have to be all at once, but you will need to keep track of your activity to make sure it adds up to thirty minutes a day.

QUESTION 9 AND 10 (Body Fat)
How much you weigh may not be as important as what that weight is made up of. A 300-pound man could be in great shape if he has a muscular structure. A 150-pound man could still be too fat if he has more fat than muscle on his body. The pinch test tells you how much excess fat you are carrying around.

Excess fat is considered especially harmful if you have "male­pattern obesity," that is, if you are shaped more like an apple than a pear. Women who carry their excess fat around the buttocks and thighs, rather than around the waist, are considered somewhat better off than apple-shaped women.

QUESTION 11 (Stress)
Excessive stress plays a smaller role in the onset of heart attacks and strokes than many people think. However, there are two exceptions: If you are constantly seething with anger and hostility, your risk may go up. And if you often feel rushed and anxious, you are less likely to look after yourself in other ways. You may even be tempted to smoke, drink, or turn to junk food in an attempt to relieve your stress. The solution? Read on.

Adding it up

Did you get a lot of C's and D's? Congratulations.
What about A's and B's? Well obviously it is a good idea to start thinking about making some changes, especially if you have A's and 8's in questions 3 through 7, where we put the three major risk factors: cholesterol levels, high blood pressure and smoking. Individually, each of these factors is serious enough. If you have more than one, then alarm bells should ring because the damage can accumulate quickly. It may help you to think of it in this way:

• High total cholesterol = increased risk;
• High cholesterol + high blood pressure = double that risk;
• High cholesterol + high blood pressure + smoking = quadruple that risk.

Now for the good news. All these risk factors can be tackled at once, through the changes described below.

The "Hot Four" behaviours
Entire books have been written on each of the risk factors we have described in this brochure. However, you can make a big difference in your life by paying close attention to only four types of behaviours. If you take these four steps every day and also quit smoking or using tobacco, your general health will improve and your score in the heart risk quiz will slip comfortably downward in the alphabet, as those A's and 8's turn into C's and D's.

1. Cut down on saturated fat and transaturated fat
Saturated fat can raise levels of blood cholesterol and increase your risk of heart disease if eaten in excess. Choosing low­ fat or non-fat dairy products, removing skin before eating chicken and eating red meat in moderation are all ways to cut back on saturated fat in your diet.

Recent research suggests that transaturated fats, or hardened unsaturated fats, are even worse for you than saturated fat. Transaturated fats are found in hard margarines, solid vegetables ghee, most commercial baked goods and foods that have been deep-fried in vegetable ghee. Transaturated fats are created when vegetable oils are "hydrogenated," or hardened, to make them firmer and more resistant to becoming rancid. Using the softer tub margarines on toast and using liquid vegetable oils for cooking and baking will help cut down on your transaturated fat consumption.

2. Eat more vegetables and whole grains
There is increased evidence about the benefits of eating vegetables and whole grains. It is not just the fibre in these foods (which has been shown to lower blood cholesterol levels) or the fact that when you fill up on vegetables and whole grains, you tend to eat less meat. We now know that there are many compounds in plants that can promote health by helping the body fight off both heart disease and cancer. For example, vegetables rich in vitamin C and E provide antioxidants that are believed to help prevent damage to the insides of the arteries. Folic acid, found in such food as beans, spinach and orange juice, appears to prevent the build up of a substance called homocysteine, which can also damage arteries. And many fruits and vegetables are excellent sources of potassium, which can help control blood pressure.

So take a minute to think about your eating habits. Do you eat at least five serving of fruits or vegetables a day? Do you eat a variety of vegetables, including orange and dark green ones? Do you eat bread made with whole grains? If not, think about how you could add fruits, vegetables and whole grains to your diet, preferably prepared without a lot of added fat.

3. Get active
For most people, getting more active cannot hurt. And in almost all cases, it will help. People who are really active can stay younger and healthier. Their bodies act much younger than the bodies of people their age who do not exercise. Activity can also help you control your weight, blood cholesterol, blood pressure and level of stress and it makes you more cheerful. As an added bonus, activity also helps you control your blood sugar level.

While you are thinking about it, take a quick inventory of your usual physical activity. Do you exercise vigorously for 20 minutes at least three times a week? Or do you keep track of your moderate activity throughout the day? Do you add at least 30 minutes of brisk walking or other moderate activity to your daily routine? If you know you have been slacking off on exercise, think about how and when you could do a little more and mark your next "exercise appointment" on your calendar.

4. Beat the stress, learn to relax
Life is competitive and everyone has their share of problems. Very often stress is not caused by the problems themselves but comes from the way we respond to difficult situations. You can help yourself by setting realistic targets and planning your day.

We all "wear out" and need time to "unwind" and regain our ability to deal with problems. Take a little time out of your busy schedule for yourself and do what you really enjoy. You also need regular breaks. Plan your holidays well and learn to enjoy life.

Working with your doctor
As you can see, there is a lot you can do by yourself. But there is also a lot you can do where you will need your doctor's help. Prescription drugs for blood pressure and cholesterol control can be life-savers. Your doctor can- advise you about using small doses of aspirin to help prevent formation of blood clots. Your doctor' can also advise you on safe and useful amounts of physical activity.

This booklet will help to assess how much at risk
you are of having a heart attack, and what healthy behaviours
you can adopt to reduce these risk factors. Please contact
your physician for further detailed information.

For further information, please contact:

Section of Cardiology
Aga Khan University Hospital, Karachi
Private Wing, Second Floor
P.O.Box 3500, Stadium Road
Telephone : 92-21-4864701
Fax: 92-21-4934294, 4932095
Email: cardiology@aku.edu
Website: www.aku.edu