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Category:
Published: January 2008
Alexander asks:
"We have a history of heart conditions within my family, but I seem to be okay. What signs should I be looking for if my family has a history of heart attacks before the age of 60?"
Dr. Lemanski:
Alexander, this is an excellent question. A family history of premature heart disease trumps all other known risk factors. It confers additional risk even when other risk factors such as smoking, high blood pressure and high cholesterol are absent. For example, if your mother had a heart attack before the age of 65, or your father before the age of 55, and that parent also smoked, ate high fat foods and was a couch potato, you would think that, perhaps, if you didn't do those things you would still be OK. Unfortunately, this is not always the case. You might never have smoked, you might have eaten sensibly and exercised daily, and you may still have suffered a heart attack. The family history alone should suggest that additional investigation of your risk is needed.
This investigation should begin with a visit to your personal primary care physician or cardiologist. They will take a history, do a physical exam, and perform lab work which can further define your risk. Some symptoms of heart disease you would be asked about include a history of chest pain or chest discomfort and/or shortness of breath, especially with exertion. Such symptoms precipitated by exertion, lasting minutes, and relieved with rest are of clear concern. However, heart disease symptoms, especially in women, may be subtle and require more detailed questioning.
For example, one of my female patients with a family history of premature disease did not have chest pain at all. She had lower jaw discomfort on exertion. While the jaw location seemed atypical, the consistent association of the discomfort with exercise and its relief within several minutes of resting caught my attention. As is the case many times, the electrocardiogram was completely normal. The nuclear stress test, however, was abnormal and the woman went to cardiac catheterization which proved she had a partially-obstructing cholesterol plaque causing her symptom.
Sometimes, an individual with a family history of premature coronary artery disease will have no symptom and may not have other identifiable risks. The LDL or "bad" cholesterol, as well as blood glucose, might be acceptable; the blood pressure may be controlled. Such individuals require advanced cholesterol testing which may include markers of inflammation such as hs-CRP, as well as scrutiny of HDL or "good" cholesterol levels and Triglyceride levels. Stress testing, either stress echocardiography or nuclear stress testing, may be considered. Alternatively, CAC (Coronary Artery Calcium) scoring may identify plaque in coronary arteries in individuals with a family history but no other identifiable risks. While the space allotted to this article does not allow me to describe such tests in detail, you may go to my practice web site for more information.
Joe asks:
"My diet contains a lot of fruit and vegetables with my southwestern cooking, but I eat regular rice and some fatty pork with my diet. What do I have to do to lose an additional 50 pounds which I have accumulated over the past 33 years as a truck driver? My heart seems okay, but I get tired easily and I am too sedentary."
Dr. Lemanski:
Jose, this is a question which vexes many people. The answer may sound deceptively simple: in order to lose weight you will need to burn more calories than you consume. The difficulty, of course, is in the implementation. Many different types of diets will decrease weight by decreasing total calories. My approach is to use a ketogenic diet which helps take the edge off of one's appetite. The Atkins diet and the South Beach diet are two of the more recognizable ketogenic diets. In my practice we use a 1200 calorie ketogenic diet I developed for our CARDIOFIT weight reduction program (see ). In addition to lower carbohydrates, these diets typically have higher protein and our program also includes low saturated fat.
I believe that, to have maximal effect, a weight-reducing diet should be used as part of a structured comprehensive program. Weight Watchers is one example of a structured program that I would recommend. Weight Watchers has group classes, Smart Ones frozen entrees, and their point system is featured for some of the dishes at the Applebee's national restaurant chain. Our CARDIOFIT program, which is another example of a structured program, is physician and dietitian led and meets weekly for 12 weeks. It features not only diet but also behavioral modification and exercise recommendations. Only by making comprehensive changes which result in a change in lifestyle will long-term weight loss be sustained.
In your case, you could begin by modifying your diet to significantly reduce carbohydrate such as fruit and rice. You could modestly increase lean meat including lean center cut pork. A registered dietitian could help you map out such a meal plan, adjusting total calories about 400 calories below your current daily consumption. To increase calories burned you would only need to begin a simple walking program, provided that your back, hips, knees and ankles don't hurt you. If you could start out walking 10 minutes each day the first week and increase by 5 minutes per day per week, within 2 months you would be walking 45 minutes per day. To increase the likelihood of sticking with daily exercise, it is best to walk with a partner. You will be able to gauge how briskly to walk on the basis of your ability to carry on a conversation with your walking partner. You should walk as briskly as possible, while still being able to get a full sentence out without pausing to catch one's breath in mid-sentence; this has been shown to be an accurate way to determine adequate effort. Before beginning any exercise program I would recommend that you discuss you plans with your primary care physician. Sometimes an exercise stress test is the best way to determine adequate and safe effort levels during walking.
In this way, by modestly decreasing total daily calories ingested and increasing calories burned, you should see a slow and steady weight loss over time. In weight loss, slow and steady wins the race. I would shoot for a weight loss of about 2 pounds per week, and in 6 months you could lose the additional weight you have put on over the last 33 years. Good luck!
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