What are her key heart-health issues?
Individualized management—recommended by NCEP/ATP III guidelines— should focus on reversing the metabolic defects of insulin resistance: hypertension, obesity, glucose intolerance, and dyslipidemia.
At present, Judy’s 10-year risk of a cardiac event is 4% by Framingham risk scoring, but it is likely to increase if the metabolic syndrome is not addressed.
How to preserve healthy HDL levels
Diet and regular aerobic exercise are recommended by the NCEP/ATP III guidelines, especially for obese patients with metabolic syndrome. However, dietary changes do not raise HDL cholesterol. In fact, dieting to lose weight will almost certainly lower HDL levels. That’s because people who eat a diet very low in fat tend to replace the fat calories with carbohydrates, and a low-fat, high-carbohydrate diet will reduce all cholesterol fractions—but HDL cholesterol will decrease disproportionately.6
Recommend complex carbohydrates and moderate fat intake
To avoid excessive reduction in HDL cholesterol, any weight-loss diet should involve moderate fat intake (35% of total calories) and emphasize monounsaturated fats such as olive or canola oil, along with complex carbohydrates found in fruits, vegetables, and whole grains.7 After weight loss is stabilized, HDL cholesterol tends to increase somewhat, but may not return all the way to baseline.
INTEGRATING EVIDENCE AND EXPERIENCE
New guidelines on how to intervene
Most women who die suddenly from coronary heart disease had no previous symptoms, and that makes prevention all the more important.
Though it hasn’t been long since the first woman-centered recommendations on preventing cardiovascular disease,19 our understanding of preventive interventions has improved enormously. Thus, the American Heart Association convened a new expert panel to review and, where necessary, revise the original guidelines.20 Here are some of the highlights.
Forget “haves” and “have-nots”
Lori Mosca and the other members of the expert panel observe that “the concept of CVD as a categorical, ‘have-or-have-not’ condition has been replaced with a growing appreciation for the existence of a continuum of CVD risk.”20
For example, the low-risk category (<10% risk of a coronary heart disease event in the next 10 years, according to the Framingham Risk Score for women) would include women with optimal levels of risk factors and a heart-healthy lifestyle, as well as women with metabolic syndrome but no other risk factors. In contrast, women with established coronary heart disease, diabetes mellitus, or chronic kidney disease would fall into the high-risk group (>20% risk). Those with multiple risk factors or markedly elevated levels of a single risk factor fall somewhere in between.
The 5 lifestyle laws
Women are advised to consistently:
- eat plenty of fruits and vegetables, whole grains, and low-fat or nonfat dairy items
- avoid smoking and smokeless tobacco
- perform at least 30 minutes of moderate-intensity activity, such as brisk walking, most days
- achieve and maintain a body mass index between 18.5 and 25.9 kg/m2 and a waist circumference less than 35 inches
- consider omega-3 fatty acid supplementation, especially if risk is high. The guidelines extol the benefits of fish, which contain omega-3 fatty acids, but warn against consumption of fish likely to contain unsafe levels of mercury (shark, sword-fish, king mackerel, and tilefish) by gravidas and women of reproductive age.
BP and cholesterol control
- Blood pressure. Maintain at or below 120/80 mm Hg through lifestyle approaches, or drug therapy when BP is 140/90 mm Hg or higher.
- Dietary fat and cholesterol. Keep saturated fat intake to less than 7% of calories, and cholesterol below 200 mg/dL with high risk or elevated LDL.
- LDL-cholesterol. Use drug therapy (preferably statins) if risk is high and LDL is below 100 mg/dL. Add lifestyle adjustments if risk is high and LDL cholesterol is at or above 100 mg/dL.
What not to take to prevent CVD
The guidelines warn against prescribing—or continuing—estrogen-progestin therapy to prevent CVD. Nor should other forms of menopausal hormone therapy, such as unopposed estrogen, be prescribed or continued unless new findings indicate a beneficial role.
Also discouraged are antioxidant vitamin supplements to prevent CVD.
Look for depression
Especially women with CVD should be referred or treated when depression is found, as it can hamper a woman’s efforts at prevention.
The full text of the guidelines can be viewed at
http://circ.ahajournals.org/cgi/content/full/109/5/672.
Regular exercise raises HDL
One way to avoid an overall reduction in HDL levels with weight loss is to prescribe exercise in conjunction with it. Regular exercise is an excellent way to raise HDL cholesterol levels. Studies suggest that, for women, the volume of exercise is more important than intensity. Thus, women should strive to walk 7 to 14 miles per week or otherwise expend approximately 1,200 to 1,600 Kcal.8,9
Regular exercise is recommended as one of the NCEP/ATP III therapeutic lifestyle changes that directly benefit cardiovascular health and blood pressure and help the individual maintain optimal body weight. Although exercise raises HDL levels, it does so more easily in men than in women. HDL cholesterol increases in men with both intensity and volume of exercise.10 Women appear to derive slightly less of a benefit, perhaps because their HDL levels are already generally higher.