■ Blood sugar of 100 mg/dL or more
If you have metabolic syndrome, you should calculate your risk
score and risk category as indicated in Steps 2 and 3 on the
previous page.
You should make a particularly strong effort to reach and maintain
your LDL goal. You should emphasize weight control and physical
activity to correct the risk factors of the metabolic syndrome.
— 34 —
Your LDL Goal
The main goal of cholesterol-lowering treatment is to lower your
LDL level enough to reduce your risk of heart disease or heart
attack. The higher your risk category, the lower your LDL goal
will be. To find your personal LDL goal, see the table below:
If You Are in This Risk Category _ _ _ _ _ _ _ _ _ _ _Your LDL Goal Is High Risk _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Less than 100 mg/dL
Next Highest Risk or Moderate Risk _ _ _ _ _ _ _ _ _ _ _ _ Less than 130 mg/dL
Low-to-Moderate Risk _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Less than 160 mg/dL
Recent studies have added to the evidence suggesting that for
people with heart disease, lower LDL cholesterol is better. Because
these studies show a direct relationship between lower LDL
cholesterol and reduced risk for heart attack, it is now reasonable
for doctors to set the LDL treatment goal for heart disease patients at
less than 70 mg/dL—well below the recommended level of less
than 100 mg/dL. Doctors may also use more intensive cholesterol-
lowering treatment to help patients reach this goal.
If you have heart disease, work with your doctor to lower your LDL
cholesterol as much as possible. But even if you can’t lower your
LDL cholesterol to less than 70 mg/dL because of a high starting
level, lowering your LDL cholesterol to less than 100 mg/dL will still
greatly reduce your risk.
— 35 —
How To Lower Your LDL
There are two main ways to lower your LDL cholesterol—through
lifestyle changes alone, or though medication combined with
lifestyle changes. Depending on your risk category, the use of
these treatments will differ.
Because of the recent studies that showed the benefit of more
intensive cholesterol lowering, physicians have the option to start
cholesterol medication—in addition to lifestyle therapy—at lower
LDL levels than previously recommended for high-risk patients.
For information on the updated treatment options and the best
treatment plan for your risk category, see the fact sheet, “High
Blood Cholesterol: What You Need To Know,” available on the
NHLBI Web site or from the NHLBI Health Information Center.
(See “To Learn More” on page 119.)
Lifestyle Changes. One important treatment approach is
called the TLC Program. TLC stands for “Therapeutic Lifestyle
Changes,” a three-part treatment that uses diet, physical activity,
and weight management. Every woman who needs to lower her
LDL cholesterol should use the TLC Program. (For more on the
TLC approach, see page 70.) Maintaining a healthy weight and
getting regular physical activity are especially important for
women who have metabolic syndrome.
Medication. If your LDL level stays too high even after making
lifestyle changes, you may need to take medicine. If you need
medication, be sure to use it along with the TLC approach. This will
keep the dose of medicine as low as possible and lower your risk
in other ways as well. You will also need to control all of your
other heart disease risk factors, including high blood pressure,
diabetes, and smoking.
— 36 —
C H O L E S T E R O L - L O W E R I N G M E D I C I N E S
As part of your cholesterol-lowering treatment plan, your doctor
may recommend medication. The most commonly used medicines
are listed below.
Statins. These are the most commonly prescribed drugs for people
who need a cholesterol-lowering medicine. They lower LDL levels
more than other types of drugs—about 20 to 55 percent. They also
moderately lower triglycerides and raise HDL. Side effects are
usually mild, although liver and muscle problems may occur rarely.
If you experience muscle aches or weakness, you should contact
your doctor promptly.
Ezetimibe. This is the first in a new class of cholesterol-
lowering drugs that interferes with the absorption of cholesterol
in the intestine. Ezetimbe lowers LDL by about 18 to 25 percent.
It can be used alone or in combination with a statin to get more
lowering of LDL. Side effects may include back and joint pain.
Bile acid resins. These medications lower LDL cholesterol by
about 15 to 30 percent. Bile acid resins are often prescribed
along with a statin to further decrease LDL cholesterol levels.
Side effects may include constipation, bloating, nausea, and gas.
However, long-term use of these medicines is considered safe.
Niacin. Niacin, or nicotinic acid, lowers total cholesterol, LDL
cholesterol, and triglyceride levels, while also raising HDL cholesterol.
It reduces LDL levels by about 5 to 15 percent, and up to 25 percent
in some patients. Although niacin is available without a prescription,
it is important to use it only under a doctor’s care because of possibly
serious side effects. In some people, it may worsen peptic ulcers or
cause liver problems, gout, or high blood sugar.
Fibrates. These drugs can reduce triglyceride levels by 20 to 50
percent, while increasing HDL cholesterol by 10 to 15 percent.
Fibrates are not very effective for lowering LDL cholesterol. The
drugs can increase the chances of developing gallstones and
heighten the effects of blood-thinning drugs.
— 37 —
Overweight and Obesity
A healthy weight is important for a long, vigorous life. Yet
overweight and obesity (extreme overweight) have reached
epidemic levels in the United States. About 62 percent of all
American women age 20 and older are overweight—about
33 percent of them are obese (extremely overweight). The more
overweight a woman is, the higher her risk for heart disease.
Overweight also increases the risks for stroke, congestive heart
failure, gallbladder disease, arthritis, and breathing problems,
as well as for breast, colon, and other cancers.
Overweight in children is also swiftly increasing. Among young
people 6 to 19 years old, more than 16 percent are overweight,
compared to just 4 percent a few decades ago. This is a
disturbing trend because overweight teens have a greatly
increased risk of dying from heart disease in adulthood.
Even our youngest citizens are at risk. About 10 percent of
preschoolers weigh more than is healthy for them.
Our national waistline is expanding for two simple reasons—we
are eating more and moving less. Today, Americans consume
about 200 to 300 more calories per day than they did in the
1970s. Moreover, as we spend more time in front of computers,
video games, TV, and other electronic pastimes, we have fewer
hours available for physical activity. There is growing evidence
of a link between “couch potato” behavior and an increased risk
of obesity and many chronic diseases.
It is hard to overstate the dangers of an unhealthy weight. If you
are overweight, you are more likely to develop heart disease
even if you have no other risk factors. Overweight and obesity
also increase the risks for diabetes, high blood pressure, high
blood cholesterol, stroke, congestive heart failure, gallbladder
disease, arthritis, breathing problems, and gout, as well as for
cancers of the breast and colon.
— 38 —
Each year, an estimated 300,000 U.S. adults die of diseases
related to obesity. The bottom line is that maintaining a healthy
weight is an extremely important part of heart disease
prevention. It can help to protect your health—and may even
save your life.
Should You Choose To Lose?
Do you need to lose weight to reduce your risk of heart disease?
You can find out by taking three simple steps.
Step 1: Get your number. Take a look at the box on page
41. You’ll notice that your weight in relation to your height gives
you a number called a “body mass index” (BMI). A BMI of 18.5
to 24.9 indicates a normal weight. A person with a BMI from
25 to 29.9 is overweight, while someone with a BMI of 30 or
higher is obese. Those in the “overweight” or “obese” categories
have a higher risk of heart disease—and the higher the BMI, the
greater the risk.
Step 2: Take out a tape measure. For women, a waist
measurement of more than 35 inches increases the risk of heart
disease as well as the risks of high blood pressure, diabetes,
and other serious health conditions. To measure your waist
correctly, stand and place a tape measure around your middle,
just above your hip bones. Measure your waist just after you
breathe out.
Step 3: Review your risk. The final step in determining
your need to lose weight is to find out your other risk factors for
heart disease. It is important to know whether you have any of
the following: high blood pressure, high LDL cholesterol, low
HDL cholesterol, high triglycerides, high blood glucose (blood
sugar), physical inactivity, smoking, or a family history of early
heart disease. Being age 55 or older or having gone through
menopause also increases risk. If you have a condition known
— 39 —
as metabolic syndrome (see page 34), your risk of heart disease
is particularly high. If you aren’t sure whether you have some of
these risk factors, ask your doctor.
Once you have taken these three steps, you can use the
information to decide whether you need to take off pounds.
Although you should talk with your doctor about whether you
should lose weight, keep these guidelines in mind:
■ If you are overweight AND have two or more other risk
factors, or if you are obese, you should lose weight.
■ If you are overweight, have a waist measurement of more
than 35 inches, AND have two or more other risk factors,
you should lose weight.
■ If you are overweight, but do not have a high waist
measurement and have fewer than two other risk factors,
you should avoid further weight gain.
— 40 —
ARE YOU AT A healthy WEIGHT?
Body Mass Index
Here is a chart for men and women that gives the BMI for various heights
and weights.*
B O D Y M A S S I N D E X
21
22
23
24
25
26
27
28
29
30
31
4’10” 100
105
110
115
119
124
129
134
138
143
148
5’0”
107
112
118
123
128
133
138
143
148
153
158
5’1”
111
116
122
127
132
137
143
148
153
158
164
5’3”
118
124
130
135
141
146
152
158
163
169
175
5’5”
126
132
138
144
150
156
162
168
174
180
186
5’7”
134
140
146
153
159
166
172
178
185
191
198
HEIGHT
5’9”
142
149
155
162
169
176
182
189
196
203
209
5’11” 150
157
165
172
179
186
193
200
208
215
222
6’1”
159
166
174
182
189
197
204
212
219
227
235
6’3”
168
176
184
192
200
208
216
224
232
240
248
* Weight is measured with underwear but no shoes.
What Does Your BMI Mean?
Normal weight: BMI = 18.5–24.9. Good for you! Try not to gain weight.
Overweight: BMI = 25–29.9. Do not gain any weight, especially if your waist measurement is high. You need to lose weight if you have two or more risk factors for heart disease and are overweight, or have a high waist measurement.
Obese: BMI = 30 or greater. You need to lose weight. Lose weight slowly—
about 1/2 to 2 pounds a week. See your doctor or a nutritionist if you need help.
Source: “Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report,” National Heart, Lung, and Blood Institute, in cooperation with the National Institute of
Diabetes and Digestive and Kidney Diseases, National Institutes of Health, NIH Publication 98-4083, June 1998.
— 41 —
Small Changes Make a Big Difference
If you need to lose weight, here is some good news: a small
weight loss—just 5 to 10 percent of your current weight—will
help to lower your risks of heart disease and other serious
medical disorders. The best way to take off pounds is to do so
gradually, by getting more physical activity and following a heart
healthy eating plan that is lower in calories and fat. (High-fat
foods contain more calories than the same amount of other foods,
so they can make it hard for you to avoid excess calories. But be
careful—”low fat” doesn’t always mean low in calories. Sometimes
extra sugars are added to low-fat desserts, for example.) For some
women at very high risk, medication also may be necessary.
To develop a weight-loss or weight-maintenance program that
works best for you, consult with your doctor, a registered dietitian,
or a qualified nutritionist. For ideas on how to lose weight safely
and keep it off, see “Aim for a Healthy Weight” on page 81.
Physical Inactivity
Physical inactivity raises your risk of heart disease—more than you
might think. It boosts your chances of developing heart-related
problems even if you have no other risk factors. It also increases
the likelihood that you will develop other heart disease risk
factors, such as high blood pressure, diabetes, and overweight.
Lack of physical activity leads to more doctor visits, more
hospitalizations, and use of medicines for a variety of illnesses.
Yet most women aren’t getting enough physical activity.
According to the Centers for Disease Control and Prevention,
60 percent of Americans are not meeting the recommended
levels of physical activity. Fully 16 percent of Americans are not
— 42 —
active at all. Overall, older people are less likely to be active than
younger individuals, and women tend to be less physically active
than men. Physical inactivity is especially common among African
American and Hispanic women.
For women, physical inactivity also increases the risk of osteoporosis,
which in turn may increase the risk of broken bones. This is worrisome,
because women tend to become less physically active as they get older.
Fortunately, research shows that as little as 30 minutes of moderate
activity on most, and preferably all, days of the week helps to protect
your health. This level of activity can reduce your risk of heart
disease as well as lower your chances of having a stroke, colon
cancer, high blood pressure, diabetes, and other medical problems.
Examples of moderate activity are taking a brisk walk, raking leaves,
dancing, light weightlifting, house cleaning, or gardening. If you
prefer, you can divide your 30-minute activity into shorter periods of
at least 10 minutes each. To find out about easy, enjoyable ways to
boost your activity level, see “Learn New Moves” on page 92.
Diabetes
Diabetes is a major risk factor for heart disease and stroke. More
than 65 percent of people who have diabetes die of some type of
cardiovascular disease. Diabetic women are at especially high risk
for dying of heart disease and stroke. Today, 7 million women in the
United States have diabetes, including an estimated 3 million women
who do not even know they have the disease.
— 43 —
A N N
“I wasn’t aware of my risk factors, such as
being diabetic and having a family history
of heart problems.”
The type of diabetes that most commonly develops in adulthood is
type 2 diabetes. In type 2 diabetes, the pancreas makes insulin,
but the body cannot use it properly and gradually loses the ability
to produce it. Type 2 diabetes is a serious disease. In addition to
increasing the risk for heart disease, it is the #1 cause of kidney
failure, blindness, and lower limb amputation in adults. Diabetes
can also lead to nerve damage and difficulties in fighting infection.
The risk of type 2 diabetes rises after the age of 45. You are
much more likely to develop this disease if you are overweight,
especially if you have extra weight around your waist. Other risk
factors include physical inactivity and a family history of diabetes.
Type 2 diabetes also is more common among American Indians,
Hispanic Americans, African Americans, Asian Americans, and
Pacific Islanders. Women who have had diabetes during
pregnancy (gestational diabetes) or have given birth to a baby
weighing more than 9 pounds are also more likely to develop type
2 diabetes later in life.
Symptoms of diabetes may include fatigue, nausea, frequent
urination, unusual thirst, weight loss, blurred vision, frequent
infections, and slow healing of sores. But type 2 diabetes
develops gradually and sometimes has no symptoms. Even if you
have no symptoms of diabetes, if you are overweight and have
any of the risk factors for type 2 diabetes, ask your doctor about
— 44 —
getting tested for it. You have diabetes if your fasting blood
glucose level is 126 mg/dL or higher.
If you have diabetes, controlling your blood glucose (blood sugar)
levels will help to prevent complications. Because diabetes is so
strongly linked with heart disease, managing diabetes must include
keeping certain factors under control (See “The ABCs of Diabetes
Control” on page 47.). Recommended levels of blood pressure
and blood cholesterol control are lower for people with diabetes
than for most others. Not smoking, being physically active, and
taking aspirin daily (if your doctor recommends it) also are
important ways to prevent heart disease if you have diabetes.
Some people do not yet have diabetes but are at high risk for
developing the disease. They have a condition known as
“prediabetes,” in which blood glucose levels are higher than
normal but not yet in the diabetic range. But new research shows
that many people with prediabetes can prevent or delay the
development of diabetes by making modest changes in diet and
level of physical activity (See “Preventing Diabetes” on page 48.).
People who are prediabetic also have a 50 percent greater
chance of having a heart attack or stroke than those who have
normal blood glucose levels. If you are prediabetic, you’ll need
to pay close attention to preventing or controlling blood pressure,
high blood cholesterol, and other risk factors for heart disease.
— 45 —
“ A T T H E T I M E , I T N E V E R O C C U R R E D
T O M E T H A T I C O U L D B E H A V I N G
A H E A R T A T T A C K . I T H I N K A B O U T
H E A R T D I S E A S E E V E R Y
D A Y N O W . ”
—Sharon
— 46 —
T H E A B C s O F D I A B E T E S control
If you have diabetes, three key steps can help you lower your
risk of heart attack and stroke. Follow these ABCs:
A is for the A1C test, which is short for hemoglobin A1C. This test measures your average blood glucose (blood sugar) over the last
3 months. It lets you know if your blood glucose level is under control.
Get this test at least twice a year. The number to aim for is below 7.
B is for blood pressure. The higher your blood pressure, the harder your heart has to work. Get your blood pressure measured at
every doctor’s visit. The numbers to aim for are below 130/80 mmHg.
C is for cholesterol. LDL, or “bad” cholesterol, builds up and clogs your arteries. Get your LDL cholesterol tested at least once a year.
The number to aim for is below 100 mg/dL. Your doctor may advise
you to aim for an even lower target number, for example, less than 70.
Be sure to ask your doctor these questions:
■ What are my ABC numbers?
■ What should my ABC target numbers be?
■ What actions should I take to reach my ABC target numbers?
To lower your risk of heart attack and stroke, also
take these steps:
■ Be physically active every day.
■ Follow your doctor’s advice about the type of physical activity
that’s best for you.
■ Eat less salt and sodium, saturated fat, trans fat, and cholesterol.
■ Eat more fiber. Choose fiber-rich whole grains, fruits,
vegetables, and beans.
■ Stay at a healthy weight.
■ If you smok