Running

Considered one of the most time-efficient exercises, running is an excellent way to get fit. The average adult burns about 100 calories per mile (or about 700 per hour at a moderate pace), and you can see a vast improvement in aerobic fitness in a matter of weeks. But when other responsibilities are running your life, and time for a trek is in short supply, here's how to make the most of your mileage:

• Invest in some intervals: Instead of just hitting the road at a steady stride, mix up your pace with short and fast intervals. Run full-blast for about 30 seconds, and then jog or even walk for another minute. Your overall distance may be less, but you'll get a more intense workout in less time. If you're running on a curved track, run the straight-aways at full speed and jog the curves; if you're running on a street, sprint for several telephone poles and walk for a few more.
  
• Include hills: You'll get more from your workout by choosing a hilly course, or at least including hills in your runs. Elite runners often sprint up a hill for about 30 seconds, and jog down. (Don't run down hills, because it increases risk of injury.) If you're running on a treadmill, you can include inclines every few minutes to get a better workout.
  
• Wear ankle weights: If you're in good shape and want to really challenge yourself, wear ankle weights and run up and down the steps of a high school stadium or bleachers. But do this with caution, because there's added stress on your joints.
  
• Be a softie: If possible, avoid running on hard surfaces like asphalt and concrete sidewalks; softer surfaces such as grass, a dirt track or indoor tracks at health clubs reduces risk of shinsplints and knee pain.
  

Study: Half of Overweight Adults May Be Heart-Healthy, Defying Conventional Wisdom

You can look great in a swimsuit and still be a heart attack waiting to happen. And you can also be overweight and otherwise healthy. A new study suggests that a surprising number of overweight people -- about half -- have normal blood pressure and cholesterol levels, while an equally startling number of trim people suffer from some of the ills associated with obesity.

The first national estimate of its kind bolsters the argument that you can be hefty but still healthy, or at least healthier than has been believed.

The results also show that stereotypes about body size can be misleading, and that even "less voluptuous" people can have risk factors commonly associated with obesity, said study author MaryFran Sowers, a University of Michigan obesity researcher.

"We're really talking about taking a look with a very different lens" at weight and health risks, Sowers said.

In the study, about 51 percent of overweight adults, or roughly 36 million people nationwide, had mostly normal levels of blood pressure, cholesterol, blood fats called triglycerides and blood sugar.

Almost one-third of obese adults, or nearly 20 million people, also were in this healthy range, meaning that none or only one of those measures was abnormal.

Yet about a fourth of adults in the recommended-weight range had unhealthy levels of at least two of these measures. That means some 16 million of them are at risk for heart problems.

It's no secret that thin people can develop heart-related problems and that fat people often do not. But that millions defy the stereotypes will come as a surprise to many people, Sowers said.

Even so, there's growing debate about the accuracy of the standard method of calculating whether someone is overweight. Health officials rely on the body mass index, a weight-height ratio that does not distinguish between fat and lean tissue. The limits of that method were highlighted a few years ago when it was reported that the system would put nearly half of NBA players in the overweight category.

A number of experts say waist size is a more accurate way of determining someone's health risks, and the study results support that argument.

Dr. Robert Eckel, a former American Heart Association president and professor of medicine at the University of Colorado, said the new research may help dismiss some of the generalizations that are sometimes made about weight and health.

Study co-author Judith Wylie-Rosett emphasized that the study shouldn't send the message "that we don't need to worry about weight." That's because half of overweight people do face elevated risks for heart disease, explained Wylie-Rosett, a nutrition researcher at Albert Einstein College of Medicine in New York.

But, for those without elevated risks, losing weight "might be important only from a cosmetic perspective," she said.

To arrive at the estimates, scientists analyzed nationally representative government surveys involving 5,440 people age 20 and over, and extrapolated to calculate nationwide figures.

The new study, appearing in Monday's Archives of Internal Medicine, used government surveys from 1999 to 2004 that included lab tests and height and weight measurements. Participants reported on habits including smoking and physical activity.

In all weight categories, risk factors for heart problems were generally more common in older people, smokers and inactive people. Among obese people who were 50 to 64, just 20 percent were considered healthy compared with half of younger obese people.

The results underscore how important exercise is for staying healthy, even for people of healthy weight, Wylie-Rosett said.

The authors noted that fat tissue releases hormones and other substances that affect things like blood vessels, cholesterol and blood sugar. The results suggest this interaction varies among overweight and obese people, the authors said.

The results also add to mounting evidence that thick waists are linked with heart risks.

Among people of healthy weight in the study, elevated blood pressure, cholesterol and other factors were more common for people with larger waists or potbellies. This often signals internal fat deposits surrounding abdominal organs, which previous research has shown can be especially risky.

Similarly, among overweight and obese adults, those in the "healthy" category tended to have smaller waists than those with at least two risk factors.

Dr. Lewis Landsberg, a Northwestern University obesity expert, noted that the research didn't look at heart disease, and that not everyone with high risk factors develops heart problems.

Still, he said, the study shows that waist measurements can help assess health.

Reaching the Limits of Exercise

• Improving Oxygen Delivery
  
• Dealing With the Sense of Effort
  
• Putting It Together
  

When your mind and body tell you, "I can't take another step or complete another rep," do you listen to your body or push beyond it, thinking, no pain, no gain? There is no right answer, but learning why you feel you've reached your limit will help move you to a higher fitness level.

Improving Oxygen Delivery

Cells break down sugars and fats to create energy, and they do that most efficiently when oxygen is present. This is called aerobic metabolism, a process that goes on perpetually throughout our bodies. Without oxygen, cells can still burn calories for energy — called anaerobic metabolism. But parts of the body can only function for short bursts of time under anaerobic conditions before energy production declines.

Oxygen delivery has long been considered the most important factor that limits exercise.

Oxygen in the air must make its way to individual muscle cells. After the lungs deliver the oxygen to the blood, the heart and the arteries move the oxygen-rich blood to the contracting muscles.

The lungs, heart, and arteries have maximal capacities. Once the maximal capacity of any one of these three components is reached, the muscles won't get any incremental increase in oxygen no matter how much they crave it. To keep the muscles contracting, the cells switch to anaerobic metabolism. In this state, the cells produce lactic acid, which causes muscle pain and fatigue.

The more athletically fit you are, the more efficiently your body delivers oxygen to your muscles. To increase your exercise capacity you want to maximize the oxygen delivery. This starts with getting more oxygen deep into the lungs. Be aware of your breathing as you exercise. Inhale through your nose, reaching a natural pause, then take another short inhale, and slowly let the air exhale through your mouth. As exertion increases, this becomes a challenge, because the increased oxygen demand will cause you to breathe faster. Try to stick with the technique even at the quicker breathing rate.

The heart can increase the amount of blood pumped to the arteries in two ways: by increasing the rate of heart contractions and by expanding the volume of blood that is pushed out with each heartbeat. With fitness training, the heart will enlarge over time so that it can push more out, but cranking up your heart rate is the predominant way that your heart does its part to improve oxygen delivery.

When an inactive person tries to exercise vigorously (NOT recommended), heart rate rises very quickly and hits the maximal rate within several minutes. Unlike your breathing, you can't voluntarily tell your heart rate to slow down. To achieve a more gradual heart rate rise during exercise, you need to improve your overall fitness. With improved physical conditioning, you increase both exertional effort and exercise time without a racing pulse.

During exercise, the walls of normal arteries relax to allow the heart to pump blood with less resistance, increasing blood flow and oxygen delivery to the working muscles. There are no specific techniques to improve artery function, but you can harm it. Smoking makes arteries stiffer by impairing their ability to relax. In addition, studies show that lower LDL cholesterol and triglycerides and higher HDL cholesterol are associated with healthier arteries.

Dealing With the Sense of Effort

When you are exercising and you reach the point where you feel you cannot move another muscle, your brain is perceiving "exercise effort." This sense of exercise effort is related to both the duration of time you have exercised and the level of power output. This sense of effort is an unpleasant sensation that causes you to decide to stop exercising when it becomes intolerable. Like any painful or unpleasant sensation, your willingness to put up with the sense of effort is subjective and influenced by cognitive and emotional factors. People vary widely in how much "exercise effort" they can stand.

The nerve pathways involved in perception of effort are connected to both the skeletal muscles and the muscles that control breathing. Our brain will sense that the effort is coming from one or the other, or both at the same time. Without stopping your exercise activity, you can quickly lessen the unpleasant sense of effort by temporarily slowing down. The reason is that power output has a much more dramatic affect on sense of effort than does length of time doing the exercise. Small decreases in power output rapidly diminish sense of effort and allow you to continue exercising. This relationship is true for both breathing and skeletal muscle performance. So if you are running or pedaling on a bike, slow down a little to relieve the sense of effort. And then increase your pace again after a few minutes.

Stronger, conditioned muscles are much more able to use oxygen efficiently (aerobic metabolism). It is when muscles run out of oxygen and are operating without it (anaerobic metabolism) that lactic acid is created, which reinforces the sense of effort. By strengthening your muscles, you will decrease the point at which your brain perceives the effort sensation.

Putting It Together

A progressive exercise session, where you start at a lower power output and gradually increase your effort, enables you to think about the limiting factors I described. During your walk, pick up your pace a little and think about your breathing — in through your nose twice and out through your mouth. If you can, check your heart rate, either by wearing a heart rate monitor or feeling your pulse. Stay at the faster pace until the sense of effort kicks in. The sense of effort is not chest pain or some other pain — that kind of pain should make you stop immediately. But the sense of effort is a sensation you will need to get beyond to reach a higher level of fitness.

Lower Your Blood Pressure With Exercise

• How Exercise Helps
  
• What's the Best Exercise?
  
• Exercise Precautions
  
• Exercise and Blood Pressure Medications
  

Regular exercise is a great way to prevent high blood pressure or hypertension. But did you know it's also one of the best means of lowering high blood pressure? It may even help you avoid having to take medication to bring your numbers into the normal ranges.

How Exercise Helps

Your blood pressure is determined by the force your heart produces in your arteries when it pumps blood through your body and by the tension of the artery walls. High blood pressure occurs when the blood pushes against artery walls with too much pressure.

Persistently high blood pressure puts a strain on the arteries, which can cause them to harden, become clogged or to weaken. This in turn increases the risk of heart disease and stroke.

Here's how exercise can help. The cells lining our artery walls contain chemicals that determine the degree of tension of the arteries. Exercise training keeps these cells — called vascular endothelial cells — healthy. Healthy endothelial cells release more chemical "relaxers" and inhibit the production of chemical "tighteners." With less resistance in the arteries, your heart can pump more efficiently and blood flows more easily.

What's The Best Exercise?

There is no "best" way to exercise to help lower blood pressure. The old "no-pain-no-gain" regimen of high-intensity activity aimed at pushing the heart and lungs to their limits is long gone. In 1995, experts unveiled a kinder, gentler approach: 30 minutes or more of moderate-intensity activity done on most — but preferably all — days of the week.

Brisk walking and leaf-raking joined jogging and swimming as acceptable activities. With this no-sweat version, you don't even have to be active for 30 minutes straight. Segments of 10 to 15 minutes are fine. The emphasis on moderate activity was aimed, in part, at getting people who wouldn't exercise to increase their daily physical activity.

Today, 30 minutes of moderate intensity exercise remains a good start. But the new goal, set by the Institute of Medicine is to perform 60 minutes of more vigorous exercise to raise your heart rate to a moderate intensity level.

In general, you should vary your daily workout with a combination of cardiovascular (aerobics) and resistance training. Also you want to stretch after each exercise session. To lower blood pressure, spend more time on aerobics. Some resistance training is fine but don't strain. Do more repetitions at lighter weights to prevent your blood pressure from temporarily spiking up.

Exercise Precautions

Since high blood pressure is a risk factor for heart disease and stroke, you should ask your doctor for advice about an exercise routine that is right for you. In general, if you don't have other risk factors for heart disease and you don't take blood pressure medication, no special precautions are necessary.

To insure that you stick with it, start slowly and gradually work up to longer and more intense exercise sessions. If you do experience chest pain, shortness of breath, dizziness or cold sweats, don't push through it. Contact your doctor; he or she may want to order a stress test before giving you the go-ahead to restart your program.

Exercise and Blood Pressure Medications

If you are taking one or more medications for high blood pressure, you can still exercise but you need to check with your doctor first. Depending upon the class of medication, you may need to take some extra precautions:

• Thiazide diuretics, such as hydrochlorothiazide and chlorthalidone, are first-line drugs to treat hypertension. But they can alter the levels of certain chemicals in your blood, especially potassium. Most diuretics cause the kidneys to eliminate potassium, which lowers the amount in the blood. Your doctor may want to check your potassium level if you plan to start a vigorous exercise program. Bananas, tomatoes and citrus fruits are good sources of potassium.
  

  Thiazide diuretics also lower blood volume slightly so you may be more prone dehydration with exercise. If you plan to do vigorous or prolonged exercise routines, talk with your doctor about lowering the dose of the thiazide diuretic and adding a blood pressure medicine with a different action. Some people, especially older women, are at risk of developing a very low blood sodium concentration. This situation will be made worse if you just re-hydrate with plain water rather than a sports drink.
  

• Beta blockers, such as atenolol, metoprolol and labetalol, and the calcium channel blockers verapamil and diltiazem slow the heart rate. When doing aerobic activity, don't be concerned if your heart rate (pulse) does not reach the recommended target heart range for moderate intensity exercise.You are still getting the benefits of exercise. Not reaching a target heart rate is not a reason to change the dose of beta blocker unless you are a competitive athlete.
  

Burn Those Calories

Any increase in the amount of physical activity you do is a step in the right direction. Burning more calories with shorts walks and climbing the stairs can help maintain a healthy body weight. And losing weight, even if you only increase your exercise a little, will help lower blood pressure.

If you're already somewhat active, try adding more exercise to your routine. Adding activities that burn an extra 100 calories per day can make a difference. Increase that to 300 calories per day and the weight-loss benefits really start to kick in.

Here are some examples of activities that will burn 300 calories per hour:

• Walking briskly (at a 4-mile per hour pace)
  
• Gardening
  
• Doubles tennis
  

Study: To Sleep Better, Perchance to Live Longer

Shakespeare once called sleep the "balm of hurt minds." Bodies, too, apparently. People with the severe form of apnea, which interferes with sleep, are several times more likely to die from any cause than are folks without the disorder, researchers report in Friday's edition of the journal Sleep. The findings in the 18-year study confirm smaller studies that have indicated an increased risk of death for people with apnea, also known as sleep-disordered breathing. "This is not a condition that kills you acutely. It is a condition that erodes your health over time," Dr. Michael J. Twery, director of the National Center on Sleep Disorders Research, said in a telephone interview. People with such disorders "have been sleep deprived for perhaps very long periods of time, they are struggling to sleep. If this is happening night after night, week after week, on top of all our other schedules, this is a dangerous recipe," said Twery, whose center is part of the National Heart, Lung and Blood Institute. The institute estimates that 12 million to 18 million people in the U.S. have moderate to severe apnea. The condition is not always detected because the sufferer is asleep when the problem occurs and it cannot be diagnosed during a routine office visit with a doctor. Researchers tested the patients for sleep-disordered breathing in the laboratory and then followed them over several years. For people with apnea, their upper airway becomes narrowed or blocked periodically during sleep. That keeps air from reaching the lungs. In some cases, breathing stops for seconds to a minute or so; the pauses in breathing disrupt sleep and prevent adequate amounts of oxygen from entering the bloodstream. "When you stop breathing in your sleep you don't know it, it doesn't typically wake you up," Twery said. Instead, it can move a person from deep sleep to light sleep, when breathing resumes. But the overall sleep pattern is disturbed, and it can happen hundreds of times a night. He said that a person typically will have four or five cycles per night of light sleep, deep sleep and REM (rapid eye movement) sleep, when most dreams occur. More deep sleep comes early in the night with more REM sleep closer to waking up. This pattern helps control hormones, metabolism and levels of stress. The institute, part of the National Institutes of Health, says apnea has been linked to a greater risk of heart disease, high blood pressure, stroke, diabetes and excessive daytime sleepiness. In the new report, the Wisconsin Sleep Cohort followed 1,522 men and women, ages 30 to 60. The annual death rate was 2.85 per 1,000 people per year for people without sleep apnea. People with mild and moderate apnea had death rates of 5.54 and 5.42 per 1,000, respectively, and people with severe apnea had a rate of 14.6, researchers said. Cardiovascular mortality accounted for 26 percent of all deaths among people without apnea and 42 percent of the deaths among people with severe apnea, according to the researchers led by Terry Young of the University of Wisconsin, Madison. In the same issue of the journal Sleep, a separate study of 380 adults between 40 and 65 in Australia came to a similar conclusion. This study found that after 14 years, about 33 percent of participants with moderate to severe sleep apnea had died, compared with 6.5 percent of people with mild apnea and 7.7 percent of people without apnea. "Our findings, along with those from the Wisconsin Cohort, remove any reasonable doubt that sleep apnea is a fatal disease," said lead author Dr. Nathaniel Marshall of the Woolcock Institute of Medical Research in Sydney, Australia. Apnea often is treated with a device that delivers continuous positive airway pressure through a mask over the nose and/or mouth. The U.S. study found that patients using this device had reduced death rates. There has been debate over whether to use airway pressure to treat patients who are not sleepy in the daytime, the report noted. The U.S. researchers noted that while theirs was a large study, 95 percent of the participants were white and most had adequate income and access to health care. "It is likely that our findings may underestimate the mortality risk of SDB in other ethnic groups or the lowest socio-economic strata where there is poor awareness and access to health care," they said. The U.S. research was supported by the National Institutes of Health. The Australian study was supported by the Australian National Health and Medical Research Council.

Burning Topics

• Genetic Testing Predicts Who Will Have Side Effects from Statin Drugs
  
• Low Levels of Good Cholesterol (HDL) Are Linked to Poor Memory
  
• Cipro and Similar Antibiotics Can Cause Tendon Pain or Rupture
  
• A Better Cholesterol Test
  
• Diabetes Rate Climbs to 8% of Americans
  

Genetic Testing Predicts Who Will Have Side Effects from Statin Drugs

Researchers have identified a gene that makes some people more likely than others to have side effects from cholesterol medicines called "statins." A study describing the findings was published online by the New England Journal of Medicine on July 23.

Statin cholesterol drugs occasionally cause muscle pain and weakness (myopathy), which can be severe. Commonly prescribed statins include atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), simvastatin (Zocor), pravastatin (Pravachol) and rosuvastatin (Crestor). Approximately one out of every 10,000 patients who take a middle-range dose of a statin drug experience this side effect each year. It occurs much more frequently in people who take a high dose of a statin.

Researchers wanted to see if some people were genetically predisposed to this serious reaction. They compared the genes of 85 people who were taking a statin and developed myopathy with the genes of 90 people who did not experience myopathy while taking a statin. Both groups of patients were similar in terms of sex, age, estimated kidney function. The groups were also alike in terms of other medicines that they took regularly.

A gene on chromosome 12 appears to control how much statin enters the liver. Eighty-five percent of the general population have two normal copies of this gene, but 15% of people have a variation in one or both copies. Sixty-six or almost 80% of the people who had muscle symptoms had the variation for at least one of their genes. Because the gene is present in so many of the patients who have myopathy, it is very likely that this gene is predisposing people to have this painful drug reaction. The researchers calculated that if a person has one copy of the gene with the variation, then the risk for myopathy is roughly quadrupled compared with people who have two normal copies of the gene. If a person has two copies of the gene with the variation, then the risk is about 17 times normal.

Using genetic tests to predict a person's response to a medicine is called "pharmacogenomics." Genetic testing is likely to be requested in the future before a statin is started, or before the dose of a medicine is increased. In this way, people who have one or two copies of the gene variation can avoid statins (especially at a high dose).

Low Levels of HDL ("Good" Cholesterol Are Linked to Poor Memory

If your high-density lipoprotein (HDL) levels are low in middle age, your memory may be poorer than it normally would be. This is the finding of a study that was released online on June 30 by Arteriosclerosis, Thrombosis and Vascular Biology: Journal of the American Heart Association.

Researchers gave 3,673 middle-age people a short-term memory test when the study began. The average age of the participants at that time was 55. Participants listened to a list of 20 words, then were asked to write down as many as they could remember. The group was re-tested five years later. Cholesterol was measured at the time of each memory test.

Word-recall tests are not a perfect measure of memory, yet the study results are interesting. The initial memory test showed that people who had a low HDL (less than 40 milligrams per deciliter, mg/dL) scored 27% lower on their word-recall test compared with people who had HDL levels above 60 mg/dL. Most people in the study did not have significant changes in their HDL levels between the first and second tests. Five years after the first test, people with low HDL scored on average 53% lower on the memory test compared with people who had high HDL levels. In other words, the relationship between low HDL and poor memory was "magnified" as the group aged.

This study shows that there is a connection between HDL and memory, but not that low HDL causes poor memory. Statins can improve HDL, but aren't recommended if HDL is your only cholesterol abnormality. Boost your HDL level by making healthy changes in your lifestyle instead. Regular exercise helps your HDL level. The kinds of fats that you eat in your diet also matter: Reduce saturated fats and trans fats (which are found in hydrogenated and partially-hydrogenated vegetable oils) in your diet, and eat monounsaturated fats, such as olive oil, canola oil and peanut oils.

Cipro and Similar Antibiotics Can Cause Tendon Pain or Rupture

A group of antibiotics that are commonly prescribed for bacterial infections, such as urinary tract infections, pneumonia and skin infections, can cause curious but damaging side effects — tendonitis and tendon rupture. On July 8, the U.S. Food and Drug Administration (FDA) issued a new online alert to doctors and the public that went beyond an earlier notice about this concern. The new alert warned that these side effects may be more common than originally recognized.

The medicines in question are in the drug family known as fluoroquinolones. They include ciprofloxacin (Cipro, Proquin), levofloxacin (Levaquin), moxifloxacin (Avelox), gemifloxacin (Factive), norfloxacin (Noroxin) and ofloxacin (Floxin).

During treatment or within several months of their use, the drugs can trigger inflammation and, in some cases, rupture of a tendon. The most commonly affected tendon is the Achilles tendon, which is located at the back of the ankle. A ruptured Achilles tendon requires surgery to fix the damage. Other tendons that have been affected by these medications include the rotator cuff of the shoulder, the biceps tendon in the arm, and tendons in the hand and thumb. People are at greater risk of this side effect if they are over age 60, have had a heart, lung, or kidney transplant, or are taking corticosteroids, such as prednisone.

If you notice pain, swelling or redness in your ankle, shoulder or hand within three months after you have taken one of these antibiotics, stop using the medication, avoid exercising the painful area and contact your doctor.

A Better Cholesterol Test.

In the July 19 issue of Lancet, experts propose a new way for doctors to monitor your cholesterol levels and more accurately predict your heart-attack risk. They suggest measuring the concentration of protein particles in your blood called "apolipoprotein B100" (ApoB)and "apolipoprotein A1" (ApoA1). They may be more important to your heart risk than is cholesterol itself. To travel through your bloodstream, cholesterol combines with certain proteins to form particles called "lipoproteins." The two main types of lipoproteins are "low density" and "high density." They are also known as your "bad" cholesterol (LDL) and "good" cholesterol (HDL). Technically, LDL and HDL aren't themselves cholesterol. They are the small bundles that form and carry cholesterol through the body. ApoB is one of the proteins on LDL particles. HDL packages cholesterol with different proteins, including ApoA1.

The ratio of ApoB protein to ApoA1 protein is very closely linked to heart attack risk. In a study that measured LDL, HDL, ApoB and ApoA1 levels, researchers compared 9,345 people who had heart attacks with 12,120 individuals who were of similar age and gender, but who hadn't had heart attacks. The ratio of ApoB to ApoA1 predicted heart attack risk better than did the ratio of LDL to HDL, or total cholesterol to HDL.

Within the next few years, doctors may begin to report your cholesterol results differently, with a new focus on your ApoB to ApoA1 ratio. Medicines that lower LDL also reduce ApoB proteins, so treatments will not change. The other good news is that ApoB and ApoA1 can be measured with a random blood sample; they do not require a fasting test.

Diabetes Rate Climbs to 8% of Americans.

On June 24, statisticians from the U.S. Centers for Disease Control and Prevention(CDC) estimated that the total number of Americans with diabetes had climbed to 24 million in 2007, an increase of 3 million since 2005. The new number equals 8% of the U.S. population, including Americans of all ages. The rate of diabetes among mature adults is even more alarming. Almost 25% of Americans age 60 or older had diabetes in 2007. About 57 million people have pre-diabetes, a condition that makes you more likely to develop diabetes. People with pre-diabetes have mild elevations in blood sugar caused by resistance to the effects of insulin. Diabetes runs in families, but most experts agree that this increase in diabetes is due to poor weight control, poor diet and not enough exercise among Americans.

How Do You Know If You're Fit?

• Defining Fitness
  
• Using METs To Gauge Fitness
  
• What Is the Right Amount of METs for Me?
  
• Raising Your METs
  
• Bottom Line
  

We all know that keeping physically active and exercising regularly are good for your health. Thirty minutes of moderate-intensity exercise most days of the week:

• Lowers blood pressure
  
• Decreases the risk of heart disease
  
• Helps prevent type 2 diabetes
  
• Reduces the risk of certain types of cancer
  
• Adds to bone strength
  
• Assists in weight control
  

Regular exercise also improves your chances of living longer with more stamina. But how do you know if you are getting enough exercise? This is where fitness comes in.

Defining Fitness

We often use the term fit to describe someone who looks healthy and trim with muscular definition. But the more technical definition refers to cardiovascular fitness. The level of cardiovascular fitness is determined by how efficiently the heart, lungs, blood vessels and red blood cells supply muscles with oxygen during sustained exercise, along with the ability of the muscles to use that oxygen. It is also known as cardio-respiratory fitness or aerobic fitness.

Defining fitness more precisely means taking some measurements of bodily functions. In special fitness laboratories, technicians can get the most accurate assessments by measuring maximum oxygen consumption (VO2 max for short) during strenuous exercise. This requires breathing through a mask that measures the volume of air inhaled and the concentration of oxygen in the exhaled air while cycling on a stationary bike or running on a treadmill. It's a complicated and expensive procedure, and so is usually limited to research or training elite athletes.

Using METs To Gauge Fitness

An easier way to gauge cardiovascular fitness is to measure it in metabolic equivalents (METs). One MET is the amount of oxygen used when you are completely inactive, such as sitting still or sleeping. Average healthy but non-athletic middle-aged men and women have peak exercise capacities in the range of 8 to 10 METs; marathon runners can have values as high as 18 to 24.

The easiest way to find out where you currently stand is to go to a gym and ask to get on an exercise machine that displays your MET level. Many models of treadmills, elliptical trainers and rowing machines have built in MET calculators. If an exercise machine with a MET display is not available, you can estimate your exercise intensity level in METs according to the type of physical activities you do. For example, walking at 3 miles per hour puts your level at about 3.5 METs. Jogging at a pace of 5 miles per hour (12-minute miles) brings the intensity level to 8 METs.

Tables listing different physical activities and their associated intensity levels are readily available.

What Is the Right Amount of METs for Me?

Similar to maximum heart rates adjusted for age, exercise researchers have developed a simple to use calculation to find out your target MET level:

• For women, MET level = 14.7 - (0.13 x your age in years)
  
• For men, MET level = 14.7 - (0.11 x your age in years)
  

For example, a 45-year-old woman has a target MET level of almost 9 METS.

Hitting your target METs or higher indicates very good to excellent cardiovascular fitness. Falling under 100% is associated with diminished health status.

In the August 4, 2005, issue of the New England Journal of Medicine, researchers from Rush University Medical Center in Chicago reported results of an eight-year study on 5,721 women healthy enough to walk on a treadmill. They recorded each woman's exercise capacity in METs. Women whose exercise capacity at the start of the study in 1992 was less than 85% of the predicted value for their age were twice as likely to have died over the next eight years compared with those who achieved 85% or better.

High fitness, hitting your target METs or higher, is clearly good. Medium, greater than 85% but less than 100%, is okay, but you should aim for improvement. Low fitness, less than 85% of your target, means you need to start exercising more.

Raising Your METs

Unlike some measures of health, fitness and exercise capacity are not set in stone. No matter where you are today, you can boost it with regular physical activity that challenges your body. That means working your body hard enough to speed up your heartbeat and breathing. Any increases in exercise intensity and the time you spend doing it will move you in the right direction.

A recent University of Florida study suggests some answers to the duration and intensity questions. Researchers recruited almost 500 sedentary women and men for an exercise experiment. All were asked to walk for 30-minute sessions at different intensities and frequencies:

• Moderate intensity — 45% to 55% of their maximal heart rate
  
• High intensity — 65% to 75% of their maximal heart rate
  
• Moderate frequency — three to four times a week
  
• High frequency — five to seven times a week
  

After two years, all the subjects who followed their exercise prescriptions improved their cardiovascular fitness. Those who walked at moderate intensity for 30 minutes five to seven times a week and those who walked at high intensity three to four times a week had substantially greater fitness improvement over the low intensity, low frequency group. No surprise, the group that stuck with high intensity and high frequency did the best.

Bottom Line

Thirty minutes of dedicated exercise at moderate intensity most days of the week is likely to achieve your target MET level. Doing higher-intensity workouts on fewer days also works, but people stick with this one less often. To know for sure that you are hitting your target, measure your METs now and track your progress during the coming weeks.

Taking Care of Your Teeth

Teeth for a Lifetime

Brushing

Flossing

Other Cleaning Tools

Teeth for a Lifetime

Thanks to better at-home care and in-office dental treatments, more people than ever before are keeping their teeth throughout their lives. Although some diseases and conditions can make dental disease and tooth loss more likely, most of us have a good deal of control over whether we keep our teeth into old age.

The most important thing you can do to maintain good oral health is to brush and floss your teeth regularly.

Most mouth woes are caused by plaque, that sticky layer of microorganisms, food particles and other organic matter that forms on your teeth. Bacteria in plaque produce acids that cause cavities. Plaque also leads to periodontal (gum) disease, a potentially serious infection that can erode bone and destroy the tissues surrounding teeth.

The best defense is to remove plaque daily before it has a chance to build up and cause problems. Brushing removes plaque from the large surfaces of the teeth and, if done correctly, from just under the gums. Flossing removes plaque between teeth.

Brushing

Most of us learned to brush our teeth when we were children and have kept the same technique throughout our lives. Unfortunately, many of us learned the wrong way. Even if we learned the correct method, it's easy to become sloppy over the years. Brushing correctly isn't instinctive. Getting the bristles to remove plaque without damaging your gums is a little trickier than you might think.

There are different ways to brush teeth, and your dentist or dental hygienist can show you the method that he or she feels would be best for you. The modified Bass technique is among the most popular for adults and is very effective in removing plaque above and just below the gum line. Children, however, may find it difficult to move the toothbrush this way. A dentist or dental hygienist can explain to your child the best way to brush. Parents should supervise their children's oral hygiene until age 9 or 10.

Here are a few general pointers about brushing:

• Brush at least twice a day — Many oral health professionals recommend brushing just before going to bed. When you sleep, saliva decreases, leaving the teeth more vulnerable to bacterial acids. Teeth should also be brushed in the morning, either before or after breakfast, depending on your schedule. After breakfast is ideal so food particles are removed. But if you eat in your car, at work or skip breakfast entirely, make sure you brush in the morning to get rid of the plaque that built up overnight.
  

• Brush no more than three times a day — Brushing after lunch will give you a good mid-day cleaning. Remember, though, that brushing too often can cause gums to recede over time.
  
• Brush lightly — Brushing too hard can cause gums to recede. Plaque attaches to teeth like jam sticks to a wooden spoon. It can't be totally removed by rinsing, but just a light brushing will do the trick. Once plaque has hardened into calculus (tartar), brushing can't remove it, so brushing harder won't help. Try holding your toothbrush the same way you hold a pen. This encourages a lighter stroke.
  
• Brush for at least two minutes — Set a timer if you have to, but don't skimp on brushing time. Longer is fine, but two minutes is the minimum time needed to adequately clean all your teeth. Many people brush for the length of a song on the radio. That acts as a good reminder to brush each tooth thoroughly.
  
• Have a standard routine for brushing — Try to brush your teeth in the same order every day. Some oral health professionals feel that this helps patients remember to brush all areas of their mouths. If you do this routinely, it eventually will become second nature. For example, brush the outer sides of your teeth from left to right across the top then move to the inside and brush rights to left. Repeat the pattern for your lower teeth.
  
• Always use a toothbrush with "soft" or "extra soft" bristles — The harder the brush, the greater the risk of harming gum tissue.
  
• Change your toothbrush regularly — As soon as the bristles begin to splay, the toothbrush loses its ability to clean properly. Throw away your old toothbrush after three months or when the bristles flare, whichever comes first. If you find your bristles flaring much sooner than three months, you may be brushing too hard. Try easing up.
  
• Choose a brush that has a seal of approval by the American Dental Association — Oral health-care professionals say, "It's not the brush, it's the brusher," meaning that the exact type of brush you use isn't nearly as important as your brushing technique and diligence. Any approved brush will be a good tool, but you have to know how to use it.
  
• Electric is fine, but not always necessary — Electric or power-assisted toothbrushes are a fine alternative to manual brushes. They are especially useful for people who are less than diligent about proper brushing technique or for people with physical limitations that make brushing difficult. As with manual brushes, choose soft bristles, brush for at least two minutes and don't press too hard or you'll damage your gums.
  
• Choose the right toothpaste for you — It can be overwhelming to face the huge number of toothpaste choices in the average supermarket. Remember, the best toothpaste for you may not be the best toothpaste for someone else.
  

Toothpastes don't merely clean teeth anymore. Different types have special ingredients for preventing decay, plaque control, tartar control, whitening, gum care or desensitizing teeth.

Most toothpastes on the market today contain fluoride, which has been proven to prevent, stop or even reverse the decay process. Tartar-control toothpastes are useful for people who tend to build up tartar quickly, while someone who gets tooth stains may want a whitening toothpaste. Whitening toothpastes will remove only surface stains, such as those caused by smoking, tea or coffee. To whiten teeth that are stained at a deeper level, talk with your dentist.

Your needs will likely change as you get older, so don't be surprised if your hygienist recommends a type of toothpaste you haven't used before. Look for the ADA seal of approval, which assures that the toothpaste has met the standards set by the American Dental Association. Once these conditions are met, choose the toothpaste that tastes and feels best. Gel or paste, wintergreen or spearmint — these work alike, so let personal preference guide your decision.

Some people find that some toothpaste ingredients irritate their teeth, cheeks or lips. If your teeth have become more sensitive or your mouth is irritated after brushing, try changing toothpastes. If the problem continues, see your dentist.

How To Brush
Modified Bass brushing technique:

• Hold the head of the toothbrush horizontally against your teeth with the bristles part way on the gums.
  
• Tilt the brush head to about a 45-degree angle, so the bristles are pointing under the gum line.
  
• Move the toothbrush in very short horizontal strokes so the tips of the bristles stay in one place, but the head of the brush waggles back and forth. Or use tiny circular motions. This allows the bristles to slide gently under the gum. Do this for about 20 strokes. This assures that adequate time will be spent cleaning away as much plaque as possible. Note: this is a very gentle motion. In healthy gums, this should cause no pain. Brushing too vigorously or with large strokes can damage gum tissue.
  
• Roll or flick the brush so that the bristles move out from under the gum toward the biting edge of the tooth. This helps move the plaque out from under the gum line.
  
• Repeat for every tooth, so that all tooth surfaces and gum lines are cleaned.
  
• For the insides of your front teeth, where the horizontal brush position is cumbersome, hold the brush vertically instead. Again, use gentle back and forth brushing action and finish with a roll or flick of the brush toward the biting edge.
  
• To clean the biting or chewing surfaces of the teeth, hold the brush so the bristles are straight down on the flat surface of the molars.
  
• Gently move the brush back and forth or in tiny circles to clean the entire surface. Move to a new tooth or area until all teeth are cleaned.
  
• Rinse with water to clear the mouth of food residue and removed plaque.
  
• You can clear even more bacteria out of your mouth by brushing your tongue. With your toothbrush, brush firmly but gently from back to front. Do not go so far back in your mouth that you gag. Rinse again.
  

  Flossing

  Many people never learned to floss as children. But flossing is critical to healthy gums and it's never too late to start. A common rule of thumb says that any difficult new habit becomes second nature after only three weeks. If you have difficulty figuring out what to do, ask your dentist or dental hygienist to give you a personal lesson.
  
  

Here are a few general pointers about flossing:

• Floss once a day — Although there is no research to recommend an optimum number of times to floss, most dentists recommend a thorough flossing at least once a day. If you tend to get food trapped between teeth, flossing more often can help remove it.
  
• Take your time — Flossing requires a certain amount of dexterity and thought. Don't rush.
  
• Choose your own time — Although most people find that just before bed is an ideal time, many oral health professionals recommend flossing any time that is most convenient to ensure that you will continue to floss regularly. Choose a time during the day when you can floss without haste.
  
• Don't skimp on the floss — Use as much as you need to clean both sides of every tooth with a fresh section of floss. In fact, you may need to floss one tooth several times (using fresh sections of floss) to remove all the food debris. Although there has been no research, some professionals think reusing sections of floss may redistribute bacteria pulled off one tooth onto another tooth.
  
• Choose the type that works best for you — There are many different types of floss: waxed and unwaxed, flavored and unflavored, ribbon and thread. Try different varieties before settling on one. People with teeth that are closely spaced will find that waxed floss slides more easily into the tight space. There are tougher shred-resistant varieties that work well for people with rough edges that tend to catch and rip floss.
  

How To Floss

How you hold the floss is a matter of personal preference. The most common method is to wind the floss around the middle fingers then pull it taut and guide it with your index fingers. You also can wind it around your index fingers and guide it with your thumb and middle fingers or simply hold the ends of the floss or use a floss-guiding tool. (If you have a fixed bridge, a bridge threader can help guide floss under the bridge for better cleaning.) How you hold the thread is not as important as what you do with it. If you can't settle in on a good method, ask your dentist or hygienist for suggestions.

• Hold the floss so that a short segment is ready to work with.
  
• Guide the floss gently between two teeth. If the fit is tight, use a back-and-forth motion to work the floss through the narrow spot. Do not snap the floss in or you could cut your gums.
  
• Hold the floss around the front and back of one tooth, making it into a "C" shape. This will wrap the floss around the side edge of that tooth.
  
• Gently move the floss toward the base of the tooth and up into the space between the tooth and gum.
  
• Move the floss up and down with light to firm pressure to skim off plaque in that area. Do not press so hard that you injure the gum.
  
• Repeat for all sides of the tooth, including the outermost side of the last tooth. Advance the floss to a clean segment for each tooth edge.
  

Other Ways To Clean Between the Teeth

Many people have larger spaces between their teeth and need additional tools, called interdental cleaners, to remove food particles and bacterial plaque adequately. You may have larger spaces that need extra care if you have had gum surgery or if you have teeth that are missing or out of alignment.

Small interdental brushes are tiny bristle or filament brushes that can fit between teeth and come in a variety of sizes and handle designs. These brushes clean better than floss when the gum tissue does not completely fill the space between your teeth. These little brushes also can help people with orthodontic bands on their teeth to remove bacterial plaque from around the wires and brackets.

Another tool for cleaning between teeth is wooden interdental cleaners. These long, triangular strips of wood can be softened and used to clean between teeth.

You can find these interdental cleaners at most drugstores and grocery stores. Your dentist or dental hygienist can show you how to use these cleaners to remove plaque between your teeth.

Other Cleaning Tools

To supplement your at-home brushing and flossing, your dentist or hygienist may suggest one or more of the following:

• Oral irrigators — These electrical devices pump water out in a slim steady or pulsating stream. Although they do not seem to remove plaque that is attached to the tooth well, they are very effective at flushing out food and bacteria byproducts in periodontal pockets or that get caught in orthodontic appliances. They are particularly useful for delivering medication to hard-to-reach areas. For example, prescription antibacterial rinses can be sprayed into gum pockets with an oral irrigator. Irrigators should be used in addition to brushing and flossing, not as an alternative.
  

• Interdental tip — These soft, flexible rubber nibs are used to clean between the teeth and just below the gum line. Plaque and food debris can be removed by gently running the tip along the gum line.
  
• Mouthwashes and rinses — As with toothpaste, your choice of mouthwashes or rinses will be guided by your personal mouth care needs. Over-the-counter rinses are available to freshen the breath, add fluoride or kill plaque bacteria that cause gingivitis. Some mouthwashes are designed to help loosen plaque before you brush. Ask your dentist or hygienist to recommend the type of rinse that would be best for you. If you need to avoid alcohol, read ingredient labels carefully. Many over-the-counter mouthwashes contain significant amounts of alcohol. In some cases, the dentist might prescribe a stronger fluoride or antibacterial rinse.
  

High Cholesterol

What Is Cholesterol? What Causes Excessive Cholesterol? Using Cholesterol To Measure Heart Disease Risk Understanding Triglycerides

Cholesterol And Triglyceride Levels Factors That Affect Cholesterol Levels Medications To Lower Cholesterol Levels

What Is Cholesterol?

Cholesterol may already be familiar to you as a risk factor for coronary-artery disease. But cholesterol is also vital to good health. Cholesterol is a type of a lipid, a soft, fat like substance that serves as a source of fuel and contributes to cell structure, the manufacturing of hormones and other biological functions. Cholesterol is manufactured by the liver. (In fact, your body manufactures all the cholesterol you need from other fats in your diet; you don't need to consume any cholesterol to maintain health.) You can also get cholesterol from consuming animal foods, such as meat, eggs and dairy products.

Too Much

Although cholesterol is vital to a variety of life-sustaining functions, too much cholesterol in your blood is a major risk factor for heart disease. Excessive cholesterol can cause buildup of atherosclerotic plaque. Accumulation of plaque in arteries can block blood flow and lead to a heart attack.

What Causes Excessive Cholesterol?

To understand how excessive cholesterol occurs, consider how cholesterol travels in your body. Cholesterol doesn't dissolve in water. Therefore, to circulate through your blood (which is mostly made up of water), cholesterol and triglycerides (another lipid in the blood) combine with proteins to form lipoproteins.

There are four types of lipoproteins, each differing in the ratio of cholesterol and triglycerides to protein. The main types are low-density lipoprotein (LDL) and high-density lipoprotein (HDL).

LDL cholesterol, the so-called "bad" cholesterol, is transported to sites throughout the body where it's used to repair cell membranes or make hormones. LDL cholesterol can accumulate in the walls of your arteries, just as hard water promotes a buildup of lime inside the plumbing of your house. Cholesterol deposits, however, are spotty, rather than evenly coated, throughout the arteries.

HDL, the so-called "good" cholesterol, is transported to the liver, where it's altered and removed from the body. In a sense, HDL is the clean-up crew that sops up excess cholesterol from the tissues and disposes of it before it can do any damage. In fact, there is no good cholesterol. It is the lipoprotein HDL that is "good," not the cholesterol it carries. But laboratories measure HDL cholesterol rather than HDL itself.

Using Cholesterol To Measure Heart Disease Risk

No single cholesterol or ratio of cholesterol numbers provides an absolute standard for measuring heart-disease risk. Your lipid profile includes the following measurements: total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides.

Total cholesterol, LDL cholesterol, and HDL cholesterol reflect a dynamic process — cholesterol is deposited in the walls of blood vessels and then taken away. The total cholesterol level is the crudest look at this process; the LDL and HDL numbers give a more detailed look at the two-way traffic inside your blood vessels. Ideally, LDL cholesterol levels should be less than 100 milligrams per deciliter (mg/dL). An HDL cholesterol level under 40 mg/dL is low; a level of 60 mg/dL or above is excellent.

Understanding Triglycerides

Like cholesterol, triglycerides are lipids that circulate in your blood. Triglycerides are used by the body to transport and store fat. The relationship between high triglyceride levels and heart disease is complex; clearly, however, high triglyceride levels aren't good for health. High triglyceride levels accompanied by low HDL levels appear to be especially worrisome.

Cholesterol And Triglyceride Levels

Here is information for interpreting cholesterol and triglyceride levels, based on guidelines recently issued by the National Cholesterol Education Program Expert Panel.

LDL Cholesterol Less than 100 Optimal 100 to 129 Near optimal 130 to 159 Borderline high 160 to 189 High 190 or greater Very high

Total Cholesterol Less than 200 Desirable 200 to 239 Borderline high 240 or greater High

HDL Cholesterol Less than 40 Low 60 or greater High

Triglycerides Less than 150 Optimal

Factors That Affect Cholesterol Levels

Factors that affect cholesterol levels include diet, exercise and genetics.

Diet

Significantly large amounts of saturated fat and trans fat in your diet can increase your cholesterol levels, more so than anything else you eat. Saturated fat is found in animal foods such as meat, fish, poultry and whole-milk dairy products, such as cream, milk, ice cream and cheese. Saturated fat is also found in butter, lard and coconut, palm kernel and palm oils. Your body easily turns saturated fat into cholesterol, which ends up in the walls of your arteries.

Trans fats are fats that start out as liquid vegetable oils, and then are transformed by a chemical process (hydrogenation) into solids at room temperature. This process turns healthy vegetable oils into unhealthy fats that raise LDL cholesterol and lower HDL cholesterol.

If you are trying to modify your diet to improve your lipid profile, focus on reducing the amount of saturated fat and trans fat in your diet rather than the absolute amount of cholesterol.

Exercise

Regular aerobic exercise reduces your blood levels of triglycerides and increases your levels of beneficial HDL cholesterol.

Genetics

Your genes can affect your cholesterol levels. Because of abnormal genes inherited from their parents, some people lack certain cell receptors that are needed for removing LDL from the blood. In this condition, called familial hypercholesterolemia, people can have extremely high levels of LDL cholesterol. This results from inheriting one bad gene (these people are called heterozygotes) or two bad genes (called homozygotes). Heterozygotes can develop premature coronary-artery disease, usually in their 40s to 60s, whereas homozygotes can die of heart attacks in their teens or 20s. There are also milder forms of hypercholesterolemia, which generally produce moderate elevations of cholesterol and proportionally increased risk of premature heart attacks.

Medications To Lower Cholesterol Levels

Reducing your cholesterol and other levels of blood fats should begin with lifestyle changes, such as following a low-fat diet and controlling weight, but a number of drugs can lower total cholesterol, LDL and triglyceride levels, while increasing beneficial HDL levels. If your cholesterol levels are high despite dietary changes, talk to your doctor about how to reduce them with these lipid-lowering medications:

Drug Category: Statins
How They Work: Statins block the production of cholesterol.
Some Common Agents: Lovastatin, pravastatin, simvastatin, fluvastatin, atorvastatin, cerivastatin

Drug Category: Niacin
How They Work: Niacin reduces the liver's ability to produce very low-density lipoprotein, the precursor of LDL.
Some Common Agents: Nicotinic acid, niacin extended-release (Niaspan), niacin (Slo-Niacin)

Drug Category: Fibrates
How They Work: Fibrates activate an enzyme that speeds the breakdown of triglycerides in the blood.
Some Common Agents: Clofibrate (Atromid), gemfibrozil (Lopid), fenofibrate (Tricor)

Drug Category: Bile acid sequestrants
How They Work: These drugs bind with bile acids (which are made from cholesterol) in the intestines and remove them in the stool. More cholesterol is then used by the liver to make bile acids.
Some Common Agents: Cholestyramine, colestipol

Drug Category: Cholesterol absorption blockers
How They Work: They decrease total serum and LDL cholesterol levels by inhibiting absorption of cholesterol from the intestinal tract.
Some Common Agents: Ezetimibe (Zetia) is currently the only one approved from this category.

Lifestyle Changes

The lifestyle choices to keep your heart healthy are similar to what you should do to help prevent many other diseases, such as diabetes and certain types of cancer. If you have coronary heart disease or are at high risk to develop it, you should do the following:

• Eat plenty of vegetables and fruits while avoiding trans fats and saturated fats.
  
• Keep blood pressure in the normal range, ideally with a systolic blood pressure of less than 120 millimeters of mercury (mm Hg).
  
• Don't smoke.
  
• Get your low-density lipoprotein, or LDL (bad), cholesterol under 100 milligrams per deciliter (mg/dL) and perhaps as low as 70 mg/dL. This usually requires medications such as a statin drug.
  
• Maintain a healthy weight.
  
• Strive to keep your blood sugar levels normal.
  
• Manage stress.
  
• Become more physically active, and make daily exercise a priority at an intensity level recommended by your doctor.
  

High LDL cholesterol is one of the major risk factors for heart disease, and the risk increases as the bad cholesterol level rises. Other major risk factors are smoking, high blood pressure and diabetes. Your cholesterol level is determined by your genetic makeup and the amount of saturated fat and cholesterol in the foods you eat. The liver manufactures cholesterol, so even if you never eat cholesterol, your body can make all it needs.

Several factors contribute to high blood cholesterol:

Diet: Reduce your blood LDL cholesterol level by eating less fat, particularly saturated fat (as found in whole milk, cheese and meat). Low cholesterol foods are important, too. Studies have shown that your total cholesterol and your bad cholesterol levels may begin to drop two to three weeks after you begin your lower you intake of fat, calories and cholesterol.

A healthy diet:

• Contains healthy fats. Once you've cut way back on saturated fats and trans fats (the unhealthy fats), you can start adding healthy fats to your diet. Healthy fats are polyunsaturated and monounsaturated.
  
• Contains healthy sources of carbohydrates. Eat more whole grains — foods like whole-wheat bread, brown rice and oatmeal — to help lower cholesterol, improve blood sugar and insulin levels, control weight, protect the heart, guard against diabetes and keep your digestive system healthy.
  
• Relies on healthy sources of protein. For a healthier heart, cut back on red meat and switch to fish. Why? The good fats in many types of fish help protect the heart against erratic rhythms and may prevent blood clots. The American Heart Association now recommends that people eat fish (especially fatty fish) at least two times per week. Beans, nuts and seeds are also excellent sources of protein.
  
• Includes plenty of fruits, vegetables and whole grains. These foods have more powerful effects on your health than most pills.
  
• Tastes great. If it doesn't, you probably won't stick with it for long.
  

Weight control: Obesity increases triglyceride and total blood cholesterol levels, blood pressure and the risk of developing diabetes.

Exercise: Regular exercise may help a person control weight, lower blood pressure and increase the level of high-density lipoprotein, or HDL (good), cholesterol.

Genetic factors: Lowering your LDL cholesterol levels through diet often is not enough to reach your goal. Many people are genetically programmed to produce cholesterol in the liver no matter how strictly they follow a diet. They require cholesterol-lowering drugs to get their levels in shape.

Sex/age: Coronary heart disease is the leading cause of death and disability for both men and women in the United States. Traditionally, coronary heart disease has been associated much more with older men than women. However, today, the importance of lifestyle changes is recognized for both sexes at all ages.

Alcohol: In some people, modest amounts of alcohol can increase the amount of good cholesterol (HDL). Modest intake means two or fewer drinks per day for men and one drink per day for women. There is good evidence that moderate alcohol intake lowers the risk of coronary artery disease, whether or not the protection is due to increasing HDL levels. However, alcohol provides "empty calories" that can add to your weight. Because drinking can have serious adverse effects, present guidelines do not recommend drinking alcohol as a way to prevent heart disease.

Smoking: Smoking damages the heart by raising blood pressure, damaging blood vessels, promoting the buildup of fatty plaque in arteries, lowering levels of "good" cholesterol, making the blood more likely to clot and depriving the heart of oxygen. Quitting smoking is the best thing you can do to prevent a heart attack.

Stress: Stress can increase chemicals within the body that may increase the risk of a heart attack. These fight-or-flight stress hormones, such as cortisol and epinephrine, excite the heart and make it work overtime.