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I am a believer in the efficacy of healthy lifestyle choices for the primary and secondary prevention of coronary heart disease (CHD). As a result, I make a serious effort to eat healthy, exercise effectively, manage stress, avoid cigarette smoke, and keep a positive attitude. Looking back on my life, I would love to tell you that my commitment to healthy living was the result of native intelligence, but it was not. Instead, it was born out of need. For the first 33 years of my life, healthy living took a back seat to other, seemingly more important things that took my time and interest: my family, work, and community. Besides, I had always been healthy. Serious diseases such as heart disease and cancer happened to other people.
Sure, there were things that could have been improved. My cholesterol was too high, I could stand to lose a few pounds, and my exercise regimen was sporadic. There would be time, I thought, to improve my numbers and my health in the future. But I was wrong.
In 1977, I underwent coronary bypass surgery. I was 32 years old. My wife and I had not yet celebrated our 10th wedding anniversary. My daughter was 6 years old; my son was just 4.
That experience became the motivating force for me to understand the impact of lifestyle habits on health and to take action to improve them.
In retrospect, it was a hard way to learn important lessons. What I had to be taught for rehabilitation I could have learned for prevention.
It was a hot afternoon in July 1977, and for the second time in a week I was seated in the office of a prominent cardiologist in Tacoma, Washington. I was bewildered as to why I was there.
Five days earlier, I had been to see my family doctor about what I thought was a bronchial problem. For about a month, I had experienced shortness of breath and a low-grade but nagging chest pain as I warmed up to play tennis. The pain was dull, more like a feeling of fullness or pressure. By the end of the warm-up, it would usually disappear. I ignored the pain, hoping it would just go away. But one day, it remained with me through 2 hours of play. It was then that I decided to call him.
“I've got a problem in my lungs, probably a touch of bronchitis,” I told him. He asked me to come in right away. I had seen him just 4 months earlier for an annual physical and the results then were excellent, so I was not expecting anything more than a short visit and perhaps a prescription.
The examination indicated that my lungs were fine. The results of an electrocardiogram, however, were not. A previous electrocardiogram had been performed just 4 months earlier, and the results then had been normal. The results now, however, were drastically different. “Joe, the test indicates a possible obstruction of the coronary artery,” my doctor said. “I want you to see a cardiologist immediately, today.” So, 3 hours after my “routine” examination, I found myself undergoing a thorough cardiac examination and an exercise stress test. I did not take seeing a cardiologist lightly. But I did not believe there was anything seriously wrong, either; I was certain it was a mistake.
Like the electrocardiogram, the results of the stress test indicated a problem. I subsequently had coronary angiography that indicated three arterial blockages ranging from 50% to 95%. “You have CHD,” the cardiologist said. “I recommend coronary bypass surgery be done within the next few days. At this moment you are a heart attack statistic just waiting to happen.”
The shock of his words hit me like a slap in the face. This couldn't happen to me. I was not prepared to hear what he had to say; I had difficulty understanding. He was speaking about a heart problem—my heart problem!—that psychologically I could not accept. Thoughts of escape filled my mind. “Just get up and leave,” I told myself. “It's all a mistake. You're not supposed to be here.” Once safely back in my world, I reasoned, I would surely awaken from this horrible nightmare.
As I continued to listen numbly to the doctor, I was confused. Like most people, I knew something about the workings of the heart and the coronary arteries, but the information was chiefly of the Biology 101 variety. It was not that information about the heart and heart disease was not available. The American Heart Association, among others, had produced and disseminated a tremendous amount of it. But, quite frankly, it had been of remote interest to me. Such information, indeed the subject itself, was simply not relevant to my life. What did blocked arteries or heart attacks have to do with me, a young guy in the prime of life?
Unknowingly, I had succumbed to the “what I don't know won't hurt me” syndrome. In reality, what I didn't know could not only hurt me, it could kill me.
Such information was simply outside the realm of my everyday life. But it all changed for me on that July afternoon. As the diagnosis sank in, the age of innocence and ignorance ended for me. I was gripped by pure stomach-churning fear. At 32 years old, I had felt a kind of immortality that only the young experience. The concept of death had been a remote one. I pictured it at the end of a long life, after years of accomplishment, fulfillment, and joy. Old age was something that I looked forward to sharing with my wife. I had never contemplated the idea of death taking me in my prime.
On that July day, the alarm clock of reality rang. I realized that not only could death happen now, but also it probably would happen now, the result of a time bomb located inside my chest. A decision was made to undergo coronary bypass surgery.
A week after surgery, I went home to recover, elated simply to be alive and with my family again. But I was very concerned about my future. Surgery had circumvented the immediate problem—having a heart attack—but had not stopped the disease. Bypass did not “cure” me. As my doctor counseled, “You had heart disease the day before surgery, you had heart disease the day after surgery, and you have it today as well. The surgery took away the pain but it did not remove the disease. Only a change in your lifestyle habits can reduce your future heart attack risk.”
This knowledge was complicated by the prediction of another doctor, a nationally known lipid specialist. I saw him after the surgery for advice on how to manage my cholesterol. “Should I change my diet, maybe increase my exercise?” I asked. “Don't bother,” was his reply. “You have an aggressive form of CHD at a very early age. Frankly, I'd be surprised if you live to be age 40. The chances of seeing your children graduate from high school are slim.”
While his bedside manner was harsh, I had to acknowledge that he might be right. For a week or two I was depressed, unable to see a clear path or take decisive action. Then my wife put it all into perspective: “His prediction is not predestination,” she said. “It's true, you can't change the cards you were dealt. You have aggressive heart disease at a young age. But you can change the way that you play those cards. And we are going to do everything possible to eat healthier and exercise more effectively to even up the odds.”
And that is what we have done. How has it worked? In 2009 I celebrated the anniversary of my bypass surgery by hiking on Mount Rainier with my wife. Now 33 years after the surgery, I am one of the longest-lived bypass survivors in the country. My current biometric measurements—cholesterol, weight, and blood pressure—show that I'm in better health now than in 1977. As a result, I have experienced the joy of seeing my daughter and son graduate from high school, college, law school, and graduate school; of walking my daughter down the aisle and making a toast at my son's wedding; of celebrating 42 years of marriage; of gathering with family at my 65th birthday; of holding our grandchildren; and of experiencing a 25-year career of writing and speaking on cardiac health. None of this would have happened without practicing healthier lifestyle habits.
No one has the ability to influence patient behavior more than physicians do. How many anecdotes have we heard about the heart patient who continues to smoke because “my doctor never told me to stop”? So, while it is easy to become enthralled with the science of cardiac health—new medications, robotic surgery, and coronary inflammation, for instance—helping the patient create a healthier lifestyle is the core issue. It is ﬁne to give the patient a 4-inch-thick study on cholesterol, but what does he do when he goes to the refrigerator? The science of healthy living needs practical application for it to help patients.
If I were a doctor counseling patients on primary or secondary prevention of CHD, here is what I would advise based on my 33 years of managing my heart disease successfully.
Responsible for more than 500,000 deaths annually, smoking has historically been the single most preventable cause of death in the United States. According to the American Lung Association, if a person starts smoking before age 20, each cigarette costs about 20 seconds of life. For a two-packs-a-day smoker, this means throwing away more than 8 years of life. Most people assume that the greatest health risk from smoking is cancer. And while it is true that smoking leads to more than 150,000 cancer deaths each year, the impact of smoking on the risk of heart disease is much greater. Smoking contributes to about 40% of all cardiac deaths. Smokers are twice as likely as nonsmokers to have a heart attack and are five times more likely to die from sudden cardiac death.
But I would stress to my patients that there is hope for those who give it up. Research shows that within 2 to 3 years of quitting, former smokers reduce their risk of heart attack and stroke to levels similar to those of people who never smoked. And within 5 years of quitting, former smokers have a 50% to 70% lower risk of heart attack than current smokers. The bottom line is that if you are not a smoker, don't start. If you are a smoker, get into a smoking cessation program.
There is considerable evidence that chronic stress may directly penalize cardiovascular health by raising cholesterol and blood pressure, promoting coronary inflammation, and triggering sudden cardiac death. While much more study needs to take place, there is great consensus about the indirect impact of daily stress: it can destroy healthy lifestyle habits.
Most people today are not stressed by “big-ticket” items such as the Iraq war or their 401(k). Instead, most chronic stress comes from the fact that we are out of time. We simply do not have the time to do all the things we need or want to do. One woman in a corporate seminar recently told me, “I'm answering e-mails at 9:00 pm, doing my laundry at midnight, and grocery shopping at 6:00 am, and then I drive my kids to school and go to work. I do a lot of different things during the day, but because I'm always short of time, I don't feel that I do any of them well.”
When people are stressed like this, it makes no difference how much they know about healthy living—and we know a lot!—a candy bar still becomes lunch, exercise is skipped, and cigarettes are smoked. If we have learned anything in the past 20 years of health messaging, it is this: cognitive understanding does not automatically lead to behavior change. If it did, we would be a nation of nonsmokers.
If I were a doctor, I would drive home the point that while stress cannot be reduced, it can be managed successfully with techniques such as deep breathing, regular exercise, and meditation. Stress management is a key to dietary and exercise compliance.
“If exercise could be packaged into a pill,” said Dr. Robert Butler, former director of the National Institute on Aging, “it would be the single most widely prescribed and beneficial medicine in the nation.” With physical activity ranking so high on the list of smart things to do for your heart and health, you would think most Americans would have gotten the message to exercise regularly. If you judged us by our appearance—jogging shoes, biking pants, and warm-up suits—you would think the country was in the middle of a fitness boom.
Think again. The reality is that Americans do not exercise. As one doctor told me, “We just buy exercise stuff!” According to government data, about half the adult population admits to being sedentary, and of those who claim to exercise, fewer than 15% do it often enough or hard enough to produce cardiovascular beneﬁts. Dr. Jeffrey Koplan, former director of the Centers for Disease Control and Prevention, said, “Physical inactivity, along with overweight, accounts for more than 300,000 premature deaths each year in the United States.”
This is a tragedy for heart health, as regular physical activity confers so many benefits. It strengthens the heart, boosts high-density lipoprotein cholesterol, reduces blood clotting, lowers blood pressure, aids in weight loss, maintains muscle strength, and helps to manage stress. A balanced exercise program should include daily physical activity (such as walking the dog), weight training for building strength, ﬂexibility exercises (such as stretching or yoga) to prevent injury, and, most important, aerobic exercise to promote cardiovascular endurance and fat burning. Physicians should encourage patients to ﬁnd a form of exercise that they like and will do. Brisk walking, jogging, aerobic dance, swimming, stair stepping—it doesn't matter what the exercise is as long as it is done regularly.
If I were a doctor, I'd spend less time with patients on the formula of exercise—such as taking an exercise pulse, determining training rate, debating duration, and such—and more time preaching regularity. Getting patients to do something every day trumps what specific exercise is practiced. A key point is to encourage the patient to exercise with a partner. Most people are much more faithful to regular exercise with a partner than when on their own.
Perhaps nothing is more important for cardiac health than eating a healthy, balanced diet. But the American diet is the antithesis of healthy eating. About 34% of calories consumed come as fat, much of it saturated and trans fats; 24% as refined sugar (which translates to about 150 pounds per year for adults); and 5% as alcohol.
There are also problems with what we do not eat: some 40% of adults eat no fruit, 80% eat no whole grains, and 40% eat no vegetables. (Actually, the vegetable number is worse, as it seems that half of those claiming to eat vegetables list French fries as the only vegetable eaten!)
The Surgeon General's Report on Nutrition and Health characterized Americans as “gobbling their way to the grave.” It identiﬁed a causal link between the typical American diet and five of the 10 leading causes of death: CHD, cancer, high blood pressure, stroke, cirrhosis of the liver, and the nation's leading ailment, obesity.
There are many reasons behind such an unhealthy dietary pattern. Our fast-paced, out-of-time lifestyle has moved people away from shopping and cooking. Instead, they often eat on the run and settle for what is available, quickly, from restaurants, take-out places, and food stores. Many people have simply traded nutrition for convenience. “And when you add in what choices are available,” according to Dr. Kelly Brownell, an obesity expert at Yale University, “the problem is compounded. We live in a toxic environment for making healthy food choices.”
If I were a doctor, I would keep the nutrition message simple: moderate fat intake and when you eat fats, make them healthy ones such as olive oil; minimize unhealthy saturated and trans fats; center your diet on fruits, whole grains, and vegetables; eat cardioprotective foods such as oatmeal, ﬁsh, and nuts; eat lean meat; stay away from sugary desserts, soft drinks, and high-sodium foods; drink water; have an occasional glass of wine; choose low-fat and fat-free dairy products; and choose whole foods over processed foods.
From a practical standpoint, this can be accomplished with three actions. First, don't crash diet. It is a game for fools. Fads such as high-protein diets might help you lose a few pounds in the short run, but they are ineffective for a lifetime. Consider this: we have had more than 60 years of quick weight-loss diet books. If any one had worked—if the cabbage soup diet had worked!—we would be a nation of skinny folks.
Second, eat real foods. We struggled in our house to eat healthy foods after my surgery, but these foods were often bland and tasteless. So we began to drift back to tastier, but unhealthier, foods. Then I came upon a piece of information that changed our thinking. Data show that most American families prepare 12 recipes 80% of the time. So, if you can identify your 12 favorites and learn how to reduce their fat, sugar, and salt—but only to the point that taste remains—you get the best of both worlds: familiar recipes that are healthier.
Let's suppose that it is Sunday morning and your family likes French toast. The traditional recipes call for mixing whole milk with salt and four whole eggs, dipping in the bread, and frying in bacon fat. Instead, use fat-free milk, skip the salt, and use one whole egg and three egg whites. Then fry in a nonstick pan. Top with a little tub-margarine and maple syrup, and your family will love it, yet it is healthier than the original version.
Finally, talk to the patient about portion size. Eating for heart health is not just about speciﬁc foods. It is also about how much is eaten. Unfortunately, we are eating a lot more than in the past. Restaurant meals and processed foods have become “super sized.” Dinner plates now look like hubcaps. Most people have little understanding of portion size. A simple way to estimate healthy portions is to use your palm, fist, and thumb as a guide:
In this fast-paced society, the day can get away from you. Under time pressure, the best-intended plans for healthy eating can go awry. What I have found, however, is that by eating a healthy breakfast, I can meet a good part of my nutritional needs even if the rest of the day gets derailed. I eat oatmeal topped with berries (strawberries, blueberries, or blackberries), chopped almonds or walnuts, and nonfat milk. It is a simple and easy way to get soluble ﬁber, antioxidants, vitamin D, omega-3 fatty acids, and calcium—a great nutritional start on the day. If I were a doctor, my advice would be, “Whatever you eat for the day, make certain you have a healthy breakfast.”
Helping the patient create a positive mindset is critical to long-term success. Patients who approach lifestyle change with hope and optimism do much better than those with a negative outlook. That is why my latest book—Positive Mind, Healthy Heart—was written. It is a collection of motivational stories, quotes, and anecdotes to help inspire patients to stick with the program. One morning I was still in bed, trying to decide if I was going to exercise that day. I just didn't feel like it. But a read a simple quote: “There are no gold medals for the 95-yard dash.” That moved me to make a positive decision, and 10 minutes later I was out the door.
Making healthy changes to benefit cardiovascular health is simple—not easy, but simple. Many patients can become discouraged, particularly if they have a lot to change or feel pressure to do it all at once. Advise them to make changes just for today. Don't fret about yesterday; it's over and you can't call it back. Don't be concerned with tomorrow, as it is not yet here. Instead, make a commitment to live healthy just for today. Pretty soon, the days will add up to weeks, months, and years, and changes will become habits. That's what I've done for 33 years … one day at a time.