--- title: "Heart Disease Signs and Symptoms at Sutter Health" description: "Learn what changes you can make to increase your heart health and lower your chances of a heart attack." url: "https://www.sutterhealth.org/health/heart-disease-signs-and-symptoms" --- 1. [Home](https://www.sutterhealth.org/) / 2. [Health and wellness](https://www.sutterhealth.org/health) / 3. Heart Disease Signs and Symptoms # Heart Disease: Signs and Symptoms ## Reduce Your Risk ##### Lifestyle changes can help improve your heart health. [Understanding Cholesterol](https://www.sutterhealth.org/health/what-you-need-to-know-about-cholesterol) Learn how it affects cardiovascular fitness. [Exercise and Your Heart](https://www.sutterhealth.org/health/debunking-myths-about-exercise-and-your-heart) Can working out too much be dangerous? [Make Simple Changes](https://www.sutterhealth.org/health/five-ways-to-lower-your-risk-for-heart-disease) A cardiologist offers guidance on prevention. [4 Vital Health Numbers](https://www.sutterhealth.org/health/four-health-numbers-you-should-know) Understand overall health indicators.  [Heart-Healthy Cooking Tips](https://www.sutterhealth.org/health/heart-healthy-cooking-tips) Easy changes can make a big difference. [Control Hypertension](https://www.sutterhealth.org/health/ways-to-lower-your-blood-pressure-naturally) Try lowering your blood pressure naturally. ## Warning Signs of Heart Attacks Symptoms can vary between men and women. Call 911 or go to the nearest ER if you’re experiencing a medical emergency. ### Signs in Men Males are more likely to have these heart attack symptoms: - Breaking into a cold sweat - Declining stamina - Dizziness or feeling lightheaded - Heart palpitations - Severe chest pain - Shooting pain in one or both arms - Shortness of breath ### Symptoms in Women Females tend to feel these warning signs in cardiac events: - A feeling of unease and discomfort - Chest pain or a feeling of heaviness - Dull pain in the stomach, neck, jaw or back - Declining stamina - Extreme fatigue or fainting - Nausea and vomiting - Shortness of breath ## Heart attacks strike every 40 seconds in the U.S. Heart disease is the leading cause of death worldwide. [Find a Doctor](https://www.sutterhealth.org/find-provider) ## Improve Your Cardiovascular Health Watch our webinars with Sutter doctors to learn tips for better heart health. Edward Yu, M.D., discusses cholesterol’s role in cardiovascular issues. Ron Sinha, M.D., gives advice on achieving better heart health in today’s society. Pei-Hsiu Huang, M.D., shares his expertise on how you can protect your heart health. 1 / 3 1 / 3 Edward Yu, M.D., discusses cholesterol’s role in cardiovascular issues. Ron Sinha, M.D., gives advice on achieving better heart health in today’s society. Pei-Hsiu Huang, M.D., shares his expertise on how you can protect your heart health. ![portrait-of-happy-senior-woman](https://edge.sitecorecloud.io/sutterhealt962c-sutterhealt8fce-production57cc-4860/media/Project/SutterHealth/SutterHealth/Images/people/women/portrait-of-happy-senior-woman.jpg?h=482&iar=0&w=724) ## A Leader in Heart Health Sutter’s advancing the treatment and prevention of heart problems through heart failure research, clinical trials, community involvement and award-winning, comprehensive cardiovascular programs. [Heart and Vascular Care](https://www.sutterhealth.org/services/heart-and-vascular) ```json {"@context":"https://schema.org","@type":"MedicalOrganization","name":"Sutter Health","@id":"https://www.sutterhealth.org/#medicalorganization","url":"https://www.sutterhealth.org","logo":"https://www.sutterhealth.org/static/images/sutter-health-logo.svg","address":{"@type":"PostalAddress","streetAddress":"2200 River Plaza Drive","addressLocality":"Sacramento","addressRegion":"CA","postalCode":"95833","addressCountry":"US"},"areaServed":{"@type":"AdministrativeArea","name":"California"},"sameAs":["https://www.facebook.com/SutterHealth","https://www.instagram.com/sutterhealth/","https://x.com/SutterHealth","https://www.youtube.com/sutterhealth","https://www.linkedin.com/company/sutter-health","https://en.wikipedia.org/wiki/Sutter_Health"]} ``` ```json {"@context":"https://schema.org","@type":"WebPage","name":"Heart Disease Signs and Symptoms at Sutter Health","description":"Learn what changes you 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Risks","thumbnailUrl":"https://cf-images.us-east-1.prod.boltdns.net/v1/static/817826402001/2b9cf6b2-9c11-4ad3-be13-3c47866ec0d0/390a2e32-de79-4610-ba87-bf19bab7eb1b/1280x720/match/image.jpg","uploadDate":"2021-10-04T04:23:49.532Z","embedUrl":"https://players.brightcove.net/817826402001/79bcaa57-54d7-453c-9f1f-8ab3ef7b15de/index.html?videoId=6275431438001","description":"Edward Yu, M.D., PAMF Family Medicine Physician, talks about how cholesterol impacts your risk for heart diseases and the benefits of a healthy lifestyle.","duration":"PT55M39S","transcript":"SUBJECT: My talk is going to be focused\non how cholesterol impacts your stroke and heart attack risk.\nSo, our learning objectives is to give you\na little overview when you get your cholesterol lipid\nprofile, what are the different components that go into them,\nand then introduce to you a risk calculator that\ncan calculate your risk score for strokes and heart attack.\nBut more, the majority of the time,\nwhat I want to spend on this talk\nis to discuss evidence-based, proven interventions\nthat you can use now to lower your stroke and heart attack\nrisk over your lifetime.\nAnd I want to give credit to the American Heart Association.\nThe link is down below.\nThat provided the visuals for me to explain the cholesterol\ncomponent that you will see shortly.\nOn that note, let's just dive right in.\nSo, what is cholesterol?\nCholesterol is a component of a product that\nis made in your liver that assembles it,\nand then it is then passed through\nand put into your bloodstream.\nColossos also a component in food,\nspecifically animal products that\ncontains cholesterol products-- do not have cholesterol in it.\nSo, that's one reason why focusing on plant-based food\nis one intervention which we'll go into.\nNow, cholesterol is an essential ingredient in our body.\nPart of its function is to help maintain the cell\nwall of our cells, and also in is component\nthat goes into the manufacturing of certain hormones\nthat we need in your body.\nSo, I just want to highlight that cholesterol\nis an essential component.\nWe need some, but we certainly don't need a lot of that.\nAll right, so in cholesterol, when you get the cholesterol\nresults, typically, it comes in a lipid profile,\nand I'll show you an example of that later on.\nAnd it's broken down to different components.\nAnd you may have heard of before.\nI want to start with the one that\nis linked with all the bad things that cholesterol can do,\nand that is the LDL cholesterol, or the bad cholesterol.\nThe way I'd explain to my patients, L stands for lousy.\nWell, it actually doesn't, you know?\nIt's actually, LDL stands for low density lipoprotein,\nso the first is low.\nBut I just use the word is lousy, so you want less of it.\nThe lower the better, for bad cholesterol, in general.\nSo, this is the cholesterol component\nthat deposits the cholesterol into the walls of the arteries,\nand then over time, narrows the arteries.\nSo, this is one of the factors among many\nwhy LDL cholesterol, the bad cholesterol,\nis something that we want to tackle.\nThat's one of the main interventions\nthat we do in cholesterol management.\nNow, as opposed to LDL, lousy cholesterol,\nthere's HDL cholesterol, which is the good cholesterol.\nNow, H stands for high density lipoprotein,\nor I call the H highly desirable.\nHD stands for highly desirable.\nSo, what this component of the cholesterol is,\nthis is a marker that your body has synthesized and packaged\nthe cholesterol components to be removed from your body\nto be excreted, to be eliminated from your system.\nSo, that's why when you look at your cholesterol,\nsome people are blessed with an extremely high HDL\ncount, highly desirable, a good cholesterol count.\nIt simply means that that person's body\nis very efficient in packaging and moving\ncholesterol from the LDL part that gets deposited\ninto the cell walls and then metabolizes it\ninto a component where it's packaged to be eliminated\nfrom your body.\nHDL cholesterols don't clog up the arteries.\nHDL cholesterols are those that are\nin the process of being eliminated from your body.\nSo, HDL is good.\nLDL is bad.\nAll right, another component is triglycerides.\nTriglycerides, you can think of it as the oily fatty components\nthat we kind of sometimes see as you thin down the blood that\ngets into it.\nTriglycerides is also the ingredient\nof which when you eat and you metabolize the food,\nit goes into triglycerides to be packaged\ninto various components in the body.\nAnd if you eat in excess of certain calories,\nand in particular, if you eat in excess of sugar\nthan your body wants, typically, your triglyceride levels\nwill go up.\nSo, sometimes you hear people say that triglycerides can also\nbe a marker of your diabetes risk,\nbecause typically, high triglycerides and high blood\nsugar sometimes go hand in hand.\nNot always, but you can sometimes\nsee when people that have a high sugar intake,\ntheir triglycerides tend to be high.\nAnd some people will say, oh, it's a cholesterol problem,\nbut in fact, many of which the contributor is\nexcess consumption of sugar calories,\nbecause when the sugar calories get absorbed in the body,\nsome of it is packaged into triglycerides as a way of being\nstored into your system.\n\nThis kind of blurb here mentions about that.\nSo, a little bit about the anatomy now.\nSo, now you know HDL is the highly desirable,\nLDL is the lousy one.\nThe main thing why we pay attention\nto the LDL cholesterol is that the lousy, or the low density\nLDL deposits cholesterol between the layers\nof the arterial wall.\nAnd this is a healthy arterial wall,\nthis is kind of the LDL particle,\nand it starts depositing in there.\nAnd then over time, you hear about this,\nthe artery wall gets thickened, and then\nit can form into plaque, and then\nit can narrow the arteries, causing\nthe downstream effects that can lead to heart attacks\nand strokes.\n\nSo, this is just an illustrative example of how physiologically\nsome of the cells that package these together,\nbecome foam cells that enlarge.\nAnd some of it, then, when you hear plaque,\nit's basically the cholesterol components\nin the arterial wall.\nAnd the unstable plaque, this is what this is trying to depict,\ncan erupt, and then the lining of the arterial wall\nbecomes disrupted.\nAnd when there's a break in it that's not smooth,\nthe blood components can form a clot around here.\nAnd then if you have a clot, as you can imagine,\nit can sometimes block your artery,\nthen leading to strokes and heart attacks.\nSo, physiologically, that's what happens\nwhen you have a certain type of strokes and heart attack\nis that you have plaque rupture causing a clot formation.\nIt then occludes the blood vessel,\nso that anything beyond the clot no longer has blood supply\nand leads to cell death, which translates\nto-- if it's in the heart, it becomes a heart attack.\nIf it's in the brain, it becomes a stroke.\nSo, that is what--\nso, that is the physiological basis of this.\nThe other reason that we pay attention to this\nis that heart attacks, heart disease\nstill remains one of the leading causes of bad health outcomes\nthat we have in the country.\nHeart disease is the leading cause\nof death, still, for men, women, and people\nof color, in general.\nAnd even with COVID in the past year and a half\ncausing over 600,000 deaths, it's\nstill not even in the top two of leading causes of death.\nIt's still strokes and heart attacks in that.\nAnd this is a visual that across the nation, the higher the red\nyou have, the higher rates of these incidents.\nAnd you can see, there are some geographic variation\nof how this happens.\nSome of it is due to genetic factors, some of it\ndue to environmental factors, and a lot of it due to,\nif you look at us here in California,\nwe generally have lower rates of that.\nAnd some of it may have to do with our values\nand our lifestyle, which I'll go into, that factors in,\nwhy that living healthy lifestyle can\nbe protective against strokes and heart attack, OK?\nBut remember, despite the news of COVID,\nbeside all causes of cancer, heart disease\nstill and remains the number one leading cause of death.\nI mean, it's not the flavor of the month, so to speak,\nbut that's why we continue to focus on that,\nand I'm very glad that all of you have come to this talk\nto learn more about how you can impact this and lower\nyour own personal risk of heart disease and strokes.\nSo, a little bit about your cholesterol number.\nRemember, the total cholesterol is a combination\nof various factors.\nThe three main ones are the HDL good cholesterol,\nthe LDL bad cholesterol, and triglycerides.\nNow, this is not exact, calculating\nthe total cholesterol score, but it comes pretty close.\nSo, that's why there have been people saying,\noh, what should my total cholesterol be is less than 200\nwhere I should be.\nWell, the truth is that we are looking\nat-- what you need to look for is actually\nthe different components of that.\nAnd you will see this in action when\nwe do the risk score calculation is\nthat while the total cholesterol is a number we factor into it,\nwe do need to know the breakdown, specifically\nthe ratio of your good cholesterol\ncompared to your total cholesterol as a way\nto interpret your risk score from a cholesterol standpoint.\nSo, there are cases where people have extremely high HDL\ncholesterol, rendering their total cholesterol above 200.\nHowever, in that situation, their bad cholesterol\nmay be less than their HDL cholesterol,\nand that profile becomes less concerning.\nSo, mistakenly narrow down just to your total cholesterol\nscore.\nWhen you have your total cholesterol score,\nmake sure you know what the breakdown is, specifically\nwhat parts are the HDL and the LDL, primarily.\n\nWhat is here is an example of a patient of mine\nand the views of their cholesterol\nvalue on MyHealth online.\nSo, some of you who are our patients at Sutter\nand you sign up for online access\nand you do blood tests, specific cholesterol, this\nis actually a screenshot of what it will look like.\nNow, here is this patient whose total cholesterol is 189.\nSo, there is a standard range.\nYes, in general, we use less than 200 as a guideline.\nIn this situation, what matters more\nis looking at the breakdown components.\nSo, for this patient, the LDL, in general,\nwe want it below 130, optimally below 100\nfor people that don't have heart disease or strokes and heart\nattacks.\nThis person is OK at 92.\nBut one thing you can see for this particular patient,\ntheir HDL profile is on the low side.\nFor HDL, more is better.\nThe standard is they have 30 or more.\nWell, this patient happens to be less than that.\nSo, that can be a marker-- even though the total cholesterol is\nOK, this is a marker of some concern,\nbecause you look at that, one of the things\nthat I would like you to take a look at\nis your cholesterol to HDL ratio.\nThis is actually-- if you want to look at one number,\nthis would be a good number for you to look at,\nbecause this puts the cholesterol components\ninto context and giving you a sense about, oh, how much\ndo I need to worry?\nIn general, while the reference range is 4.5,\nI use a standard less than 4.5 as the indication\nof a good profile.\nYou can see, this patient, despite a total cholesterol\nless than 200, because the HDL is on the low side\nand triglycerides are a little bit high,\ntheir ratio is on a higher side.\nSo, this person, actually, in my mind,\nis either higher risk for strokes and heart attack\nbecause of these compounds, and I'll\nget into more about that in a minute.\nAnd also, just want to let you know, in MyHealth online,\nyou have the ability to graph the numbers over time\nto see what the trends are.\nSo, this patient's total cholesterol kind of wanders\nup and down.\nThis to see the trend going down over time,\nand this is an indication of the LDL cholesterol, which\nthe bad cholesterol.\nSo, for this person, the LDL cholesterol\nremains pretty steady.\nAnd for this, I'm pretty sure the decline\nin their total cholesterol is due to the fact this person\nprobably did a good--\ndid some work to improve their triglycerides.\nAnd I'm pretty sure this person will have--\nis tied into having higher diabetes risk,\nbecause again, higher blood sugar and higher triglycerides\nsometimes go hand in hand.\nThat's why you may hear your doctor even saying, hey,\nyour triglycerides are high.\n\nCut out on your sugary intake as a recommendation,\nrather than cholesterol.\nThat's where it comes from.\nAgain, today, we're not on a diabetes talk.\nI just want to bring that in, where this interacts here.\nSo, again, take home message here,\nwhen you have your total cholesterol numbers,\nand also sometimes they use lipid profiles\nsynonymous with cholesterol profile.\nThey kind of mean the same thing.\nSo, when you look at that, make sure you put it into context,\nlook at the cholesterol field ratio as a guide,\nand look at what the standard recommendations are.\nI personally use 4.5 or less as a marker of good health.\nThe lower the ratio the better, typically, in these cases.\nAll right, so now I want to broaden this a little bit.\nAnd those of you who follow about risk factors,\nof markers for heart disease will\nknow that there are things beyond just cholesterol\nthat factors into this.\nSo, what you have on the screen here\nare the core common ones that are well\nresearched and validated as inputs to increase your risk.\nWe know in general the male sex is at higher risk than female.\nOlder you are, higher risk.\nThere are certain ethnicities brings you to higher risk.\nWe talked about cholesterol already.\nHigher cholesterol is bad.\nHigher HDL is protective.\nBlood pressure, blood sugar, smoking status\nall factor into that.\nNow, I fully acknowledge there are additional risk factors\nthat people have follows, such as homocysteine,\nLPa, intimal thickness in the carotid artery,\namong other things, and other--\nhigh sensitivity CRP.\nSo, what we have found is that while all those are\ncan be markers of increased risk, the impact of it\nindependently is still not as validated as the ones\nover here.\nSo, what I want people to know is\nthat please start here first.\nUnderstand the components of these\nin factoring your heart attack and stroke risk,\nand get these under good handle, because primarily, these\nare the ones that we have good interventions for,\nit's where you focus on, and don't get too distracted\nwith the other secondary markers.\nI mean, they are always in the news.\nHowever, these secondary markers do not supersede the ones that\nwe know here, and that's the reason why you cannot go wrong\nby focusing on your heart health by looking at cholesterol,\nyour blood sugar, and your blood pressure as the primary\ncomponent of where you are.\nNow, what can you do?\nThere is a risk calculator that you can use,\nand I have the link below.\nAnd after the talk, my team will find out the link to you\nso you can use.\nThis is widely available on the internet,\nwidely used and validated.\nNow, there are some limitations to these,\nwhich I will mention to you.\nBut what I like about this is that it\nputs the established primary risk\nfactors into one calculator to give you a global score.\nSo, it's a situation here where you put these factors--\nthose are asterisks that are components\nyou need to put in there to calculate your risk score.\nSo, let me give you an example of that.\nSo, over here, we put in someone that's\n42 years of age that's female, white race, with a blood\npressure that is borderline, 135 over 85.\nAgain, ideal blood pressure should be below 120 over 80,\nso this person is above that.\nWe call these patients pre-hypertension.\nAnd in fact, according to some stricter guidelines,\nthey call this patients with hypertension already.\nBut in general, let's just use the standard 140 over 90\nas a marker of hypertension.\nThe patient is kind of in the at risk range.\nAnd then the cholesterol, it's above 200.\nHDL is low at 30, and for the LDL, I have what, 38 over here.\nAnd it spits out a global risk score here, 2.4%.\nNow, what this number me is the risk\nof this person having a stroke and a heart\nattack in the next 10 years.\n2.4%, quite low, kind of 1 out of 25 people\nor so, and primarily because this person\nis relatively on the younger side.\nThat's one thing that you don't really\nhear about strokes and heart attack\nin people generally less than 50 years of age,\nbecause again, younger age is a protective factor over here.\nBut what I want to call your attention here is this number\nhere, optimal CV risk factor.\nIn this example, I put in someone\nthat has borderline blood pressures\nand a borderline cholesterol component,\nand you can see if these were all normal,\ntheir risk score would be 0.4%, so basically\n1 out of 200 risk of stroke versus 1 out of 25.\nSo, while this person is low risk,\nelevated blood pressures and abnormal lipids\ndo increase the risk 6 times compared\nto someone that has an optimal profile there, OK?\nSo, yes, while this patient is still considered low risk,\nthis person has an-- compared to optimal standards,\nthis person already has a six-fold increase of risk.\nAnd I think that is, as long as these are modifiable,\nthat's where the intervention can come in to lower\nyour risk over a lifetime.\nOK.\nI want to highlight to you-- this is all the same numbers\nover here, but to illustrate the risk of diabetes and high blood\nsugar in factoring into this.\nSo, everything else in this slide\nis the same as the previous one.\nAnd remember, this rate was 2.4%.\nAll I did was to say this patient has diabetes,\nthe blood sugar is high, OK?\nAnd you can see that risk went from 2.4% to 6.5%,\ncausing its risk up by 2 to three-fold.\nSo, that's why when you look at stroke and heart attack risk,\nyou can't ignore the impact of blood sugar and diabetes\ninto this.\nAnd as you hear now, we're more and more\nlooking at diabetes as a stroke and heart attack disease\nmore so than the complications of high blood sugar causing\namputations or kidney disease.\nThat still happens, but more and more over here,\nparticularly people with high blood sugars\nand higher diabetes, we worry more\nabout their cardiovascular risk factors\nas much or sometimes more so than the damage\nthat high blood sugar can cause to your eyes, to your kidneys,\nand all that.\nThere are different mechanisms to it\nthat as you more and more hear, we're\nlooking to recognize diabetes as a main driver of strokes\nand heart attack, therefore so many interventions.\nAnd that's why you hear the recommendations\nfor people with diabetes that even if they\nhad a pretty good cholesterol, the standard recommendations\nnow is to consider adding a cholesterol-lowering medicine\nfor patients with diabetes.\nAnd the reason is the fact that diabetes almost triples\nyour risk for strokes and heart attack,\neverything else being equal.\nSo, the take home message here is\nthat don't get singular focus on just cholesterol or your blood\npressure or your smoking status.\nIt's really looking at all these factors\nall together in combination that is going to be the key,\nand you can use this risk calculator to do so.\nI want to mention before I move on,\nthere are limitations for this.\nNow, the research that goes behind this risk calculator\nhas been done on a skewed population,\nmeaning it has been mainly for--\nthis was done kind of almost 40, 40 to 50 years ago\nthat accumulated the data into this.\nAnd it's recognized that it may not properly\ncapture risk profiles of people from Southeast Asians,\nfor instance.\nSo, if you belong in that population over there,\nthis risk score calculator sometimes\nundercaptures your risk factors.\nThe medical community kind of knows about that.\nSo, don't be falsely reassured by a low number over here,\nparticularly the Southeast Asian heritage\nin your family or yourself.\nJust to put this in context, low risk is generally 5% or lower.\nHigh risk has a different threshold,\nbut in general, 10% or higher is considered\nhigh risk, so for those of you between 5% and 10%,\nI consider intermediate risk.\nAgain, next time you go in and see your doctor,\nyou can have a discussion about hey,\nI want to assess my risk factors for strokes and heart attack\nusing a risk calculator, and have the doctor ordered\nthe components.\nThey can put them in, OK?\nAll right, now you understand the factors\nthat go into stroke and heart attack risk,\nand you know how to put those numbers into context\nand calculate your risk score.\nWhat can you do?\nWell, we start with kind of the more clinical pharmacologic\naspects of that.\nIndeed, if you are moderate to high risk,\nthere they are treatments and medications that can help.\nAn acronym we use commonly is called ABCS.\nAspirin thins out the blood, reduces\nrisk of clotting of that unstable plaque,\ngetting a blood pressure in a tight control,\ngetting cholesterol under tight control,\nand if you're a smoker, stop smoking.\nThose are the bread and butter interventions\nthat I think most of us do know or are familiar with it.\nIf not, this is a great conversation to have.\nIf you happen to be at high risk,\nthese are inevitably components that your doctor\nor your clinical team will talk to you about.\nMost of us have a sedentary job, that we\nsit at a desk, work long hours, high stress, and struggle\nof getting enough exercise, among other things.\nSo, the way you live your life, I feel,\nhas a huge or even the most important component\nabout your risk of your strokes and heart attack downstream.\nYes, while you can wait until things get bad\nand take a pill for it, I feel very strongly that--\nand I think this is one of the things\nthat I think that in medicine that we\nneed to do a better job of--\nis not to wait to you to be a high risk,\nor you to have formal diabetes, formal high cholesterol,\nor formal high blood pressure to start intervention,\nbecause having good healthy habits\nnow inevitably provides long term\nbeneficial health outcomes by reducing\nyour risk of metabolic factors that contribute to stroke\nand heart attack risk.\nThe metabolic factors are the impacts\nof higher cholesterol, higher blood pressure,\nand higher blood sugar on that.\nSo, what I want to tell you to do\nare those various lifestyle components\nthat you can do right now to understand.\nAnd if you have any habits that are outside of these ranges,\nyou can start knowing what they are start picking\na few leads to make some improvements,\nand the first one is weight.\nA healthy weight, if you don't know your cholesterol numbers,\nyou don't know your blood pressure,\nyou don't know your blood sugar, you actually\ncan use your weight as a rough estimate of what your risk are.\nAs many of you know, being overweight or obese\nis a risk factor for diabetes, among other things.\nSo, if your weight is above target,\ngetting a weight target is one immediate thing\nyou can do to lower your stroke and heart attack\nrisk over our lifetime.\nThe thing I want to point out to you\nis that we use a body mass index.\nThat's what BMI stands for.\nYou Google and internet how to do the calculation.\nThe cutoffs do vary by ethnicity.\nSo, while in general 25 or lower is considered a normal body\nmass index-- again, there are limitations with this.\nBut in general, we use that as a guide.\nBut you have to adjust it for Asians and Southeast Asians,\nbecause genetically speaking, their risk\nfor metabolic disease runs at--\nstarts earlier at a lower weight.\nSo, if you are of that ethnicity,\nyour BMI target should be below 23.\nNow, I know, when you start talking about this, you\nsay, oh my gosh, how am I ever going to get there?\nMy BMI is 30.\nDon't worry.\nThe risk of these is incremental.\nSo that if you are, say, above 30,\nput initial goal to get you below 30 at the initial point,\nbecause we move from the red bracket\ndown to the yellow brackets.\nIn and of itself, it will lower the risk\nas you move your way down to the green brackets over here.\nSo again, we don't necessarily need everyone\nto achieve ideal weight right off the bat.\nIt says just move your weight down.\nIf you're at a higher risk range,\nmove down to a lower risk range as the initial goal\nfor you to have as you work your way down, OK?\nSo all you need, when it's easy for you\nto know what your weight are, so we can get\nyour weight and your height.\nYou can easily calculate a BMI.\nActually, there's a lot of apps that can do that for you,\nand you can use your body mass index\nas a proxy of your overall stroke and heart attack risk\nwith the goal of getting your body mass index close to normal\nas possible.\nNow, how do you do that?\nWell, it starts with healthy nutrition.\nThe food that you put in your body\nis critical in determining your health risks,\nand as I mentioned before, animal protein\nis the one that has cholesterol in its source.\nSo if you look at foods made from plants, and even\nwith fried fruits and plants, they\nwon't have any cholesterol in it.\nBecause plants don't.\nSo, in general, if you move to a plant based diet and more\nof a whole food, meaning less processed food,\nless processed food, more plant based,\ninevitably is more healthy.\nSo I'm not saying that you need to be vegetarian.\nIt's that, if you eat more processed foods,\nand your percentage of food tend to more to fats, proteins,\nand carbs, move towards a diet that's more plant based\nand less processed.\nThat in and of itself will help you.\nIn general, if you follow general guidelines,\nwe do recommend in your meal, at least,\n1/3 of your food by volume comes from a plant.\nThose are fruits and vegetables combined in general.\nIf you don't, that'll be a good goal to have.\nTypically, people need more carbs or processed foods.\nIt's not unusual that people load up a plate of pasta\nand then put some meat sauce or some veggies on the side,\nwhere the pasta component comprises 50% of your meal\nby volume.\nWhat you can do is then shift that ratio, where the carb\nparts is no more than a quarter or a third\nand having the rest of it taken over by a plant based food.\nSo whole-food, plant-based diet is one way to go, OK?\nAnd then red meat is one area that you can now\nlook at as well.\nNot that you have to eliminate all of that, but again,\nred meat tends to be more inflammatory.\nAnd meat has more cholesterol components in it.\nSo by shifting away from that, that is another thing\nyou can do right now.\nAgain, for those who do have it, you\ndon't have to eliminate it completely, but just\ntake less of that.\nSo that's whole food.\nNow, exercise.\nThere are standard guidelines on these as well.\nThe more that you move, the healthier you are,\nand now, these are guidelines for exercise.\nThey have changed, that we're not looking for you\nto break out in a big sweat.\nAnything that makes you move is sufficient to count.\nSo there are guidelines.\nAnd here's a link that you will get\nafter the talk that gives you a little guidelines based on age\nand your health status about how much you should do.\nAnd in general, anything that gets you moving\nis going to be good.\nThe type that helps you most from a stroke and heart attack\narea is cardiovascular.\nThose that get your heart rate up,\nrunning, swimming, biking, long hikes, all those things\ncan do that.\nI just simply put down that there\nare other forms of exercise that you want to also focus on\nover your lifetime.\nDoing strengthening, which typically involves\nsome type of weightlifting, is a good exercise to have,\nparticularly if you want to lose weight.\nLifting weights burns a lot of calories.\nSo sometimes, when people have an exercise program,\nthey sometimes overemphasize the cardiovascular parts\nand don't maximize benefit of using strengthening exercises\nas a way to help with losing weight.\nLifting weights or using weights do help burn a lot of calories.\nSo don't neglect that.\nAnd it helps with bone health, particularly if you're a woman.\nAnd then finally, about flexibility training.\nThis is more applicable for people\nthat have poor ergonomics, have stiff neck and back issues.\nSo having some exercise that focus on flexibility\nis helpful because a more flexible body prevents kind\nof skeletal aches and pains that can\ninterfere with your cardiovascular\nand strengthening exercises.\nSo that's exercise.\nDrinking.\nYou can drink, but don't drink for the sake of drinking.\nAnd one thing I want to emphasize,\nand this one I'm going to go to my visual,\nis about portion sizes.\nAnd oftentimes, people get confused on the portion sizes.\nSo here I am over here.\nSo this is a small wine glass.\nSo a standard drink is five fluid ounces.\nSo I got this.\nThis is basically colored soda water.\nSo this is a small wine glass.\nSo this is five fluid ounces.\nSo we have a standard wine glass.\nThe level of it should be lower.\nBut a lot of people said, oh one drink is one glass.\nBut there are standard definitions\nof that depending on the size of your glass.\nI have a small one.\nSo this is five fluid ounces.\nBut if we have a bigger glass, that drink line\nis going to be much lower.\nAnd that's something you have to keep in mind because portion\nsizes often is a challenge for us in America\nbecause we tend to drink larger portion sizes over here.\nSo a drink is two--\nless than two standard drinks for men and one drink or less\nfor women.\nAnd these are the sizes of it.\nSo don't go by the size--\njust one drink as a one glass or one mug of something.\nIt is specifically specified in ounces\nhow much you should have.\nAnd I would encourage you to take whatever\nglasses you use at home to drink and then pour it\ninto a measuring cup to see how much you're actually\ndrinking to make sure that you adhere to these standards.\nAnd we sometimes neglect the self-care health that we need.\nPaying attention to adequate sleep.\nPaying attention, we talk about eating well, exercising.\nBut then, looking at ways to help\nfueling connection to people.\nSocial connections, joining a club,\ndoing things that you like.\nAnd then spending time in nature, going to hikes,\ngoing to the beach, going to the forest.\nThey may seem like simple things,\nbut having these components as a core part\nof your day-to-day living that connects you back to purpose\nactually has shown to reduce your stress level\nand then in turn reduces inflammatory signals\nin your body and stress signals in your body.\nThat helps to help with your cardiac health over time.\nSo this is one area that they think\ndoes not get as much attention that we do.\nAnd yet, I think this is one of the easiest and most kind\nof work-life balance way of addressing\nphysiologic risk down the line.\nSo again, I encourage you to look\nat these components over here in your day-to-day life\nto address that because the healthy way\nyou live your life reduces inflammatory stress\nsignals that then lower your strokes and heart attack\nrisk down the line.\nLAUREL: All right, Dr. Yu, thank you so much.\nSuch good information in there.\nAnd we have many, many questions for you today.\nWe're going to do our best to get to as many of them\nas we can.\nAnd I am going to group some of them together\nthat are very similar for you.\nSo our first question is about genetics.\nSo if your parents have high cholesterol or heart disease,\nare you destined to get it?\nSUBJECT: Genetics is a factor into your risk factors\nover there, but it's not the only basis of that.\nSo yes, if there is a family history of high cholesterol,\ndiabetes, or high blood pressure,\nit does make you at a high-risk area.\nHowever, that doesn't negate the benefits of the lifestyle\ncomponents I have into it.\nBecause when we look at it, in my mind,\nthe genetic factors can contribution to stroke or heart\nattack risk.\nAnd your lifestyle components of it may have equal if not more\nfactor in the way how you live your life in it.\nSo yes, genetics is a factor.\nBut sometimes it's-- and those you may not modify,\nbut the lifestyle components you can.\nSo don't neglect those.\nThank you.\nLAUREL: Thank you for that information.\nSo our next question is, are there any supplements\nproven to prevent high cholesterol or help lower it?\nSUBJECT: There are plenty of supplements on the market.\nIn fact, the common cholesterol medicine comes from a plant.\n\nRice yeast extract.\nAnd there are a lot of supplements\nthat sell those things as well.\nSo what I would say about supplements\nis that I don't have any objection to people\nusing supplements, but I would not\nrely on supplements as your way out of this.\nHaving-- it goes back to the core basics of how you eat,\nhow you live your life as the core factor.\nBecause supplements are not as studied or not as regulated,\nif you indeed have bad enough, say, cholesterol or blood\npressure which your doctor recommends medications,\nyou're then better off taking a standard FDA-vetted and\nregulated prescription medicine over a supplement.\nSo while supplements are popular,\nand I don't have any objections to people using them,\nis that please don't over rely on supplements\nin place of healthy lifestyle.\nThank you.\nLAUREL: All right, thank you, Doctor Yu.\nSo if you have high cholesterol and you\nmake these lifestyle changes, you reduce\nthat wine at the end of the day and you\nstart eating a more plant-based diet, long\ndoes it take before your cholesterol starts to go down?\nSUBJECT: So the impact on cholesterol\ngenerally starts to set in about four to six weeks' time.\nNow remember, if you are using lifestyle eyes,\nit's not like one and done, just like, all right,\nI'm going to eat well.\nIn six weeks, get my cholesterol checked,\nand after it gets to goal, then I'm\ngoing to go back to where I am.\nSo don't make that mistake because cholesterol and the way\nyour lifestyle and your food impacts\nthat is a continual process that does not change over time.\nSo sometimes when I tell my patients,\nwhen you improve your eating, it's\nmore important that we check it continually\nto confirm that you're consistently\ndoing it and keeping it at a good level.\nBut in general, if you wait for about four to six weeks\nto check that, that's good enough time\nfor your body to reflect the changes due to dietary changes.\nThank you.\nLAUREL: All right, thank you, Doctor Yu.\nSo our next question is, can you have clogged arteries\nwithout having high cholesterol?\nSUBJECT: Clogged arteries can occur\nwith people with quote unquote normal cholesterol\nbecause there are some genetic basis of people where\ncholesterol particles may be just are stickier or more\nprone to plaque formation.\nSo people with normal cholesterol, though rare,\ncan also have clogged arteries.\nSo a good question.\nThank you.\nLAUREL: All right, thank you, Doctor Yu.\nSo Doctor Yu, is there any harm on being on any\nmedications to lower your cholesterol or high blood\npressure for a long period of time, or is that safe to do?\nSUBJECT: So the standard medications\nthat we use for blood pressure for cholesterol\nand for diabetes, for that matter,\nare one of the most well-studied medications with the best\nlong-term outcomes that we have.\nAnd in general, these medicines by and large\nare easily accessible.\nThey are very affordable.\nAnd have very good evidence for it to work.\nSo if you end up being someone that needs medications\nto control it, there is no problem for you\nto continue on it on a long-term basis\nbecause what matters is the impact of these medications\nin your risk factors.\nBecause if you have someone that has, say,\na cholesterol near 300, most likely you're going to need\nmedications to lower that because lifestyle alone\ntypically doesn't--\nlifestyle factors on cholesterol impact,\ntypically we can see up to, in the best cases,\nup to a 30% improvement.\nTypically for cholesterol is more modest.\nWe're expecting between 10% and 20%.\nSo when people have super high cholesterol,\noftentimes lifestyle alone may not be enough.\nAnd you add medications to that.\nAnd if you do, the medicines have-- again,\nthese medicines have been around for many, many decades\nand are among the most well-studied ones\nin terms of its safety and its effectiveness.\nSo I have no problems for people thinking long term\nbecause we've seen time and time again\nthat people stop and the cholesterol goes back up.\nTheir risk scores go back up.\nAnd they end of suffering the consequences of it.\nSo if end up take--\nbeing prescribed on it, I have no problems\nwith you taking it long term.\nNow that being said, is that for instance,\nlet's just say you happen to be an obese patient with diabetes\nthat have to be on cholesterol medicines because of that.\nAnd let's just say you go on aggressive lifestyle changes.\nNow your weight is normal.\nYou're no longer a diabetic.\nIt is possible that then you may be\nable to go off of these medications\nbecause now your risk circumstances have dramatically\nimproved.\nSo keep that in mind as well.\nThank you.\nLAUREL: All right, thank you for that information.\nWe've had a number of people asking about a cardiac calcium\nscore.\nCan you explain what that is and what those results tell us?\nSUBJECT: So a coronary calcium score\nis actually a test that we are using more and more.\nWhat that test is, it's basically\ntaking a scan of your arteries to your heart\nand looking for presence of calcium, which is\na marker for plaque formation.\nIt's called the coronary calcium score.\nNow, the way we use that, and based on guidelines actually,\nis that we use it in context of your risk score.\nSo for instance, going back to that risk calculator\nthat I showed you, let's just say you end up\nbeing intermediate risk.\nSo for this purpose, say you're at between 5% and 7.5%,\nwhich is typically the standard definition\nof intermediate risk.\nShould you be on medication to lower it\nor can you just focus on lifestyle first?\nSometimes then we use the risk the coronary calcium\nscore as an additional factor to drive the decision\nwhether to take medications or not.\nIf you're intermediate risk, your calcium score\nis minimal or zero, that means there's\nno plaque in your arteries yet.\nAnd if so, then I think this will be a safer case\nto say, hey, focus on the healthy lifestyle as a way\nto intervene because there's no plaque yet.\nHowever, if on the calcium score it shows that you already\nhave plaque or high--\nalready had formed plaque already,\nthat means the physiologic is-- the bad physiologic changes\nthat cholesterol can do.\nIt has already started and shown up already.\nAnd technically, if you have a high calcium\nscore in those tests, it is synonymous in having\nearly coronary artery disease.\nNow if that is the case, then those patients,\nthen we favor enough to start on medications early\nbecause there's already plaque.\nThen we want to be more aggressive\nlowering your cholesterol to reduce the chance of it further\nprogressing.\nAnd in some cases, if you take the medicine early on,\nit sometimes can minimize the amount of plaque that you have.\nSo that's how we use a coronary calcium score.\nIf you're already low risk, there is not much value in it.\nAnd if you're already at high risk,\nyou should be on aggressive treatment,\nincluding medications for that already.\nSo the best use of that test typically\nare people in the intermediate risk\nto assess their likelihood to benefit from medications.\nThank you.\nLAUREL: All right, thank you so much, Doctor Yu.\nSo our next question is, are there\nwere any at-home devices that can be used\nto measure your cholesterol?\nSUBJECT: So at-home cholesterol tests have not\nbeen popular or big yet.\nAnd the reason is just you actually\nneed the sub-components of the cholesterol to properly assess\nyour risk factors.\nSo I would not bother.\nUnlike blood sugar or blood pressure,\nfor which there is home devices that you can take,\ncholesterol is something that I would\nrecommend you go to a standard lab to get that assessed.\nThank you.\nLAUREL: All right, thank you, Doctor Yu.\nSo we have a number of questions, really specific\nquestions, about diet.\nSo the first one is about caffeine.\nIs caffeine dangerous?\nIs it OK to have some coffee every day or sodas?\nCan you talk a little bit about caffeine specifically?\nSUBJECT: Sure.\nLike all things, you've got to live life.\nSo everything, in general, in moderation, is OK.\nSo caffeine's impact is more on the blood pressure side\nbecause caffeine is a stimulant.\nIt revs things up.\nAnd, I mean, obviously, that's some of the reasons why\npeople drink it.\nIn excess of that, the main impact that we see\nis raising the blood pressure and then\ninterfering with sleep and other things as well.\nIt's much less so in the cholesterol part.\nSo if you drink caffeine from a standard--\nfrom a typical standpoint, as long as you moderate that,\nI don't have any problems with that.\nThe standard recommendation is to have two--\nless than two standard cups a day on average.\nBut if you are-- again, if you are looking into it,\nwhat you may want to do--\ncaffeine is something you monitor the health--\nthe impact on your body typically\nwill be in your pulse and your heart rate.\nAnd if you are noticing that your blood\npressure and your pulse goes up when\nyou drink a lot of caffeine, then just moderate that back.\nI don't think that you need to eliminate caffeine,\nso to speak.\nPerhaps only if you have a really high blood pressure,\nthen you may want to do so.\nBut for standard people, having some caffeine in general\nis not going to be a problem.\nEverything in moderation.\nThank you.\nAnd soda, OK?\nWell, soda is sugar.\nAgain, going back to what I mentioned about healthy eating,\nyou want to minimize sugar or kind of free sugar\nor refined sugar or processed food intake.\nSo I would not--\nand I-- soda is one easy intervention\nto get rid of in your diet if you can.\nEven with diet soda itself, which has no calories,\nbut it is now believed that the substitute sugar that they use\nmay stimulate appetite.\nSo that while it does not have impact on sugar,\nit makes you eat more, which has a weight component that\nis negative.\nSo again, you can occasionally.\nI don't think we need to worry too much about it.\nBut I would certainly not recommend regular soda use\nbecause, in general, it is not a healthy food.\nThank you.\nLAUREL: All right.\nSo Doctor Yu, there has, I think,\nbeen a debate for a long time about eggs.\nAre eggs OK to eat?\nShould you just eat egg whites?\nIf you eat a whole egg, can you talk a little bit about that?\nSUBJECT: Yes.\nEggs are OK.\nNow, you really want to be careful.\nThe egg component that has the most cholesterol\nindeed is in the egg yolk.\nThe egg white is basically a pretty heavy protein component\nand in general has much less issues with cholesterol.\nBut that being said, unless you eat excessive amounts of whole\neggs over there, I don't-- again,\nit's hard for people to overeat eggs.\nIt's easy for people to overeat carbohydrate calories\nor kind of processed snacks and all that.\nSo I think in context, unless you're\nsomeone that eats six eggs, whole eggs, a day\non an ongoing basis, then we might\nwant to monitor what your cholesterol impact is.\nBut on occasion, having some is not going to be a problem.\nAgain, everything in a proper context.\nSo if you're worried about that, what\nsome people do is just say, all right, could you have any eggs?\nBut if you have eight eggs, making\nan omelet for your family, then you just\ntake two or four to eight yolks out.\nSo you don't need to go overboard avoiding egg yolk.\nEgg in general is a pretty healthy food\nbecause there's no sugar.\nNo sugar in it.\nIt's a pretty healthy source of protein\nand it's pretty satiating as well.\nIt makes you feel full.\nJust don't over salt it, OK?\nAnd unless you eat a lot of it every day,\nI don't think you need to worry too much about eggs or egg\nyolks.\nThank you.\nLAUREL: All right, thank you, Doctor Yu.\nSo Doctor Yu, we've had a few questions regarding statins.\nCan you talk about what they are, their effect?\nThere's been a number of people wondering if they can cause\nearly onset dementia or Alzheimer's.\nCan you talk a little bit about that, please?\nSUBJECT: Yes.\nSo statins have been in the news a lot.\nAnd I think there's some people that\nwere leery about taking them when\nthey're clinically indicated.\nAnd these type of factors come up.\nSo let me share with you about statins over there.\nThe main-- for statins, like any medications, there are side--\npotential side effects from them.\nBut again, statins being one of the most studied medications\nthat we have seen.\nWe know quite well about that.\nSo first off the bat, dementia and memory loss.\nNo.\nStatins actually may help reduce that risk because dementia--\na certain-- most of the dementia and memory issues\nthat people have that is age-related\nare actually related to vascular issues.\nMeaning that with time and age, your arteries to your brain\ngets clogged up or less blood flows through efficiently.\nNow statin has a role to help with that.\nBecause as we mentioned, statin can reduce the plaque build up\nover time, and that can maintain good blood flow to the brain.\nAnd that may have a protective effect\nin decreasing people's risk of strokes and heart.\nSo statin certainly does not cause that at all.\nNow, what statin can do is that there\nare some people that have an inflammatory reaction\nto the statin that causes you to have muscle inflammation\nor muscle aches.\nIt will not be subtle because the effects of statin\nwill be generally all over your body.\nIt won't be isolated to just your arm or your leg.\nThat can happen, but the rates of that are less than one\nin 10,000 in general.\nBut if people have that, then indeed they\nshould not be taking--\nthey cannot take statin.\nThey have to take alternatives.\nSo again, those are pretty noticeable,\neasily identified things.\nSo statins-- and also, some people ask, well,\nstatin damages your liver.\nWell, statins, while it does metabolize through your liver,\nas most of the medicines and of the foods\nwe eat go through the liver as well, and usually--\neven right now, there's no need to continue\nto monitor your liver when you're taking a statin.\nThat was an old recommendation that\nhas since been eliminated because it's\nshown that it really--\nstatin effects on liver are no worse\nthan you drinking two glasses of wine a day.\nSo yes, if you're taking other medicines\nthat are hard on a liver or if you happen\nto be a heavy drinker and you're taking statins over there,\nthat may be the case we want to do an occasional check.\nBut otherwise, if you're--\nif you eat healthy and all that, the liver effects\nare no worse than having-- drinking\ntwo alcoholic drinks a day.\nSo hopefully that answers your questions about statins.\nStatins are one of the safest medicines that we know.\nThat's what proven benefits for stroke and heart attack\nreduction.\nThank you.\nLAUREL: Oh great, thank you so much for explaining\nthat, Doctor Yu.\nAnd unfortunately, we are out of time for our question\nand answer period today.\nI'll turn it back over to you, Doctor Yu.\nSUBJECT: Well again, I appreciate\nall the great questions that you have.\nLet me share my screen again.\nAnd I really appreciate your great questions.\nIt is the focus on your lifestyle that you can do now.\nAnd again, it's over the lifetime.\nIf anything else, remember you can just use your weight\nas a good proxy for things.\nAnd then make sure you pay attention\nto the stress reduction part to help with your--\nto improve your overall health.\nThe next slide has my contact information over here.\nAnd then there are additional resources that we have for you.\nI'll turn it back to Laurel to go through more of that for you\nand close out the program.\nThank you.\nLAUREL: All right, thank you, Doctor Yu.\nAll right, everyone, well, thank you for joining us today.\nIf you are watching our webinars for your wellness program,\nthe wellness code is cholesterol.\nAll right, and if you have any questions about our services\nor doctors at Sutter, our team is here to help you.\nYou can connect with us at sutteremployer.org.\nOn our website you can also learn more\nabout our new metabolic wellness program, which\nhas you use a continuous glucose monitor to teach you\nabout your body so that you can make some healthy lifestyle\nchanges.\nAll right, everyone, thank you again for joining us.\nAnd stay healthy.\nSUBJECT: Thank you, everyone.\nBe safe.\nBye bye."} ``` ```json {"@context":"https://schema.org","@type":"VideoObject","name":"Avoiding Heart Disease In The Modern World","thumbnailUrl":"https://cf-images.us-east-1.prod.boltdns.net/v1/static/817826402001/dccfaa0a-ccf3-4587-8bbe-27e63b8ccdf3/bfff30b4-18b8-4931-a38e-c2683c81a7ff/1280x720/match/image.jpg","uploadDate":"2022-02-20T19:54:24.079Z","embedUrl":"https://players.brightcove.net/817826402001/79bcaa57-54d7-453c-9f1f-8ab3ef7b15de/index.html?videoId=6298230911001","description":"Ron Sinha, M.D., teaches us how to lower our risk for heart disease while maintaining our modern lifestyles.","duration":"PT56M48S","transcript":"RONESH SINHA: Hi, great, wonderful to be here.\nLet's go ahead and get started.\nSo, heart disease is a topic that's\nvery relevant for this month.\nIt is Heart Disease Awareness Month.\nAnd today's talk will be about avoiding heart disease,\nespecially in our modern world.\n\nSo, as a background, I do run corporate wellness programs.\nAnd really, heart disease has become a big focus\nof my lifestyle practice.\nAnd in medical school and medical training,\nI was taught that heart disease was actually\na condition that affected mainly individuals of an older age.\nAnd although that's clearly true,\nwhat I was shocked about after coming to Silicon Valley\nto practice is that I am seeing individuals of all ages,\nincluding much younger ages, that are coming in\nwith early heart disease.\nSo, I remember when I started in my clinic,\neven I was seeing heart attack patients in their 30s\nand young 40s, which was actually quite shocking to me.\nSo, really, during today's presentation,\nI'm going to talk to you about the origins of heart disease.\nWe're going to also talk about what\nare some risk markers that you can focus on, lifestyle\nchanges to help prevent and reverse heart disease,\nand also the role of technology that I use in my lifestyle\npractice, called \"continuous glucose monitors,\" which\nhave really been a game changer in terms of really sensing\nthe impact of nutrition and lifestyle on your body.\nAnd I'll present a couple of case studies\nto show you how we've been using these CGMs in addition\nto an exciting wellness program that we're running right now\nusing these innovative sensors.\nSo let's go out and jump right in.\nSo, I like to teach using case studies.\nSo, let's use Sam, which is basically a fictitious name\nthat I am using here for a case study.\nAnd Sam is a 38-year-old software engineer who eats\na vegetarian diet-- mostly grains,\nvery little vegetables though, so not doing optimal vegetarian\ndiet--\nhas a body mass index or a BMI of 24, which technically would\nfall into the normal range, being less than 25,\nalthough you would adjust that cut off\nfor those of Asian ancestry.\nHe has a normal blood pressure and blood sugar level,\nhas a total cholesterol level of 190.\nAnd we'll talk in detail about cholesterol\nand what the numbers mean.\nHe visits the gym two or three times a week,\nbut is otherwise sedentary, and work stress is high.\nSo this is probably a case scenario that a lot of us\ncan connect with.\nOK, so Sam's wake-up call, at 3:00 in the morning on Sunday,\nSam was woken up with progressive chest discomfort.\nHe took an antacid, didn't get any relief from that,\nand essentially what happened was his wife called 911.\nAnd he was rushed to the emergency room\nwhere he was diagnosed with a massive heart\nattack due to a blockage in a major coronary artery.\nSo, when you look at this diagram of the heart muscle,\nthe coronary arteries are the blood vessels that actually\nfeed and nourish the heart.\nSo, you can see the blow up image of that coronary artery\non the right, in that inset B. And you\ncan see that a plaque buildup in the artery\nand cause that blockage.\nSo this is really the case of Sam having his heart attack.\nNow, I also want to highlight-- because, again,\nin medical training, often we talk about men and heart\ndisease--\nbut I want women especially to be aware of the fact\nthat heart disease continues to be the number one\nkiller in women and men.\nOK, so a typical prototype in this case\nthat I'm using to explain the concept is\nwe have a techie mother of two young kids on a very\nlow-carb diet and practices fasting,\nexercises vigorously doing bootcamps three to four times\na week, work and family stress are very high,\nand gets six or seven hours of sleep a night or less.\nOK, so, I've seen women in this category\ncome in with new onset diabetes, high heart disease risk\nfactors.\nOr in some cases, we end up seeing\nwomen of a fairly young age coming in\nwith their first heart attack or heart disease events.\nNow, the gender differences in symptoms I've gotten\nlined up in this image here on the left.\nI want to highlight a couple these.\nSo you can see with men, men more often\ntend to get that classic chest fullness or squeezing pressure,\noften that can happen with exertion.\nThe pain can spread to the shoulders and neck or the arms,\nsometimes up to the jaw as well, too.\nAnd then that chest discomfort can\ncome along with lightheadedness, fainting, sweating, et cetera.\nI want to contrast that with women, on the right,\nwhere, yes, they can get chest discomfort.\nBut more often than not, they might actually\nget shortness of breath or difficulty breathing.\nThey might get some stomach symptoms,\nlike nausea, maybe vomiting or some dizziness.\nThey can get some back or jaw pain.\nThey can get unexplained anxiety.\nSometimes they feel like they're having a panic attack.\nThey can get the palpitations.\nAnd something they feel like they're\nhaving a mild flu-like illness.\nNow, at the very bottom of this image right here, this graphic,\nyou can see that, for men, the trigger most often reported\nis physical exertion prior to heart attacks.\nSo maybe you were on the treadmill or the exercise bike,\nor during the winter, you're shoveling\nsnow, and all of a sudden that stressor triggers this heart\nattack symptom.\nKeep in mind that for women, they most often\nreport emotional stress.\nAnd that's really what I'm highlighting.\nMore typically, they might have an emotionally stressful\nsituation and then they start getting those symptoms.\nSo again, there is a lot of overlap between this.\nClearly, women can get chest pain, chest discomfort.\nClearly, men can sometimes have emotional stress\nbefore a heart attack.\nBut these are some basic categories\nof differences between genders I want you to be aware of.\nAnd for women, in particular, it's\nimportant to know about the fact that chest pain may not\nbe as common, because women typically\npresent much later to the emergency room with heart\ndisease risk factors or with heart disease symptoms.\nAnd that could be a problem, because when\nit comes to surviving a heart attack\nand having the best outcomes, the quicker you\ncan get to the emergency room, the better.\nAnd because women's symptom are a little bit more vague,\noften they present later than men would.\nSo I'm spend some time on the slide,\nbut I just want you to be aware of that nuance and difference.\nOK, now the evolution of atherosclerosis.\nAtherosclerosis is just a fancy word for the development\nof plaques inside the arteries.\nAnd all I'm showing you in this is that process actually\nstarts in childhood.\nSo from the first decade of life,\nwe've already started depositing the foundation\nof that plaque, which will then evolve throughout life.\nAnd why am I bringing this up?\nBecause I do give talks to schools and to young teens\nand families, and I am actually seeing some teens\nin my practice.\nAnd we are already seeing early heart disease risk\nmarkers in kids and teens.\nBecause the more they are inactive,\nif they're already eating an unhealthy diet, if there's\nfamily risk factors and genetics, that process\ncan start early on.\nSo, if you really want to prevent plaque formation,\nyou've got kids, you've got to start the process\nas early as possible.\nBecause, otherwise, when it comes on later,\nthat plaque formation, it's tougher\nto stabilize and reverse.\nSo, you want this to be a proactive, family-based\napproach to lowering the risk of heart disease.\nNow, there are different ways to think about heart disease.\nAnd this is one analogy that I love.\nI can't recall the name of the cardiologist.\nBut he literally talks about heart disease plaques\nlike being like a pimple.\nNow, in the early days, we'd think\nabout heart attacks being like plumbing,\nlike a clogged artery or a pipe.\nBut that's actually not accurate.\nWhat you want to think about with heart disease is\nthat plaque that forms, it's literally\nlike a pimple that develops inside\nof the inner lining of your blood vessel.\nAnd just like a pimple, it fills up with fat, with lipids,\nand pus, with inflammatory cells inside it.\nSo like I said, that process starts very early in childhood,\ndepending on genetics and lifestyle.\nAnd then what ends up happening is\nwhen a heart attack happens, literally\nthat pimple actually pops.\nIt ruptures.\nSo, with a pimple, you get pus coming out of it.\nWith a plaque, you also get inflammatory cells\nthat pop out.\nAnd then you get, basically, the migration of red blood cells\nand other clotting factors.\nAnd those will instantly block off the blood.\nSo this is not necessarily a process\nwhere you're getting all this deposition of the material\nand it blocks up the artery plumbing.\nYou can start with a very small line\nof a vulnerable plague that's on the lining of the blood vessel.\nAnd if that instantly pops, the fluid's\ngoing to block off the blood vessel.\nAnd that's how a heart attack happens.\nSo, I know this is a little bit--\nnot the most attractive analogy.\nBut these sorts of analogies can really stay in your head.\nBut important to know that it really\nis more of a process that involves really\na small plaque that can rupture and then occlude that artery\nand cause a heart attack.\nNow, some of the root causes that we're going to get into--\nI'm putting two big categories here.\nOne is the process of inflammation.\nAnd inflammation is if you sprained your ankle,\nyou would see a visible inflammation\nwhere your ankle swells up and turns red.\nBut here, we're talking about were\nlow grade inflammation where your immune system becomes\nactivated.\nAnd that immune system, when it's active,\nthose of white blood cells in parts of the immune system\ncan migrate into the plaque and, again,\nfill up that pimple just like it's filling up with pus.\nAnd you can see chronic inflammation is just not linked\nto heart disease alone.\nIt's also linked to diabetes, to Alzheimer's disease,\nall types of the processes.\nThe other process I want you to be aware of\nis insulin resistance.\nAnd I want to talk about that in the next slide.\nBut that is also an epicenter for a lot of the risk\nfactors for heart disease.\nNow, just to make the concept clear,\nI have insulin resistance and inflammation\nin separate diagrams here, but in actuality,\nboth of these things really overlap.\nHaving chronic inflammation can make\nyou more susceptible to insulin resistance.\nHaving insulin resistance makes your body more\nsusceptible to inflammation.\nAnd usually, with heart disease, both of these\nare playing together and really leading\nto the development of that plaque in addition\nto the other chronic health conditions that\nare listed on this slide.\nSo insulin resistance, the way I like\nto describe this is really I call it a carbohydrate parking\nproblem.\nAnd so you can think about carbs in the form of glucose.\nIn the center of this diagram, that's the car\nthat you see in the middle.\nAnd then there's three parking lots.\nYou've got the muscle, liver, and the fat.\nSo ideally, when you consume carbohydrates\nin food, fats in general, you want\nthe carbohydrates predominantly to go to the muscle parking\nlot at the top left.\nAnd it basically gets inside by using the hormone insulin.\nThat's like a parking pass that gets a carbs through the door.\nBut when we see individuals who are becoming insulin\nresistant, what that means is the body is producing insulin,\nbut the muscles are not properly responding to the signal.\nSo if the carbs can't adequately get inside the muscle,\nwhere do they end up going?\nThey can go towards fat formation,\nespecially with the more dangerous stomach or belly fat.\nThey can go to the liver.\nAnd the liver can actually fill up with fat.\nIt actually literally turns those glucose molecules\ninto fat.\nAnd then, the liver also, when it becomes overwhelmed,\nit will inject those extra carbohydrate molecules\nas triglycerides in the form of fat\nor as blood sugar where you become\npre-diabetic or diabetic.\nSo that's where the constellation of insulin\nresistance.\nAnd a high level, we want to teach your body\nto get those carbs moving back towards muscle so we can\ndeflate those fat cells and offload the liver\nso it's not releasing all the extra triglycerides,\ncholesterol, and sugar into the blood.\nNow, what are triglycerides?\nTriglycerides are actually the storage form\nof fat inside your fat cells.\nAnd they are really an early marker of insulin resistance.\nLDL cholesterol gets a lot of press.\nAnd definitely LDL cholesterol is very important.\nWe'll talk about that in a second.\nBut really, in my clinic and practice,\nI see a lot of individuals with borderline to high\ntriglycerides.\nAnd often, they don't realize the linkage\nbetween triglycerides and heart disease.\nHigh triglycerides can be and early\ntrigger to atherosclerosis, and it\ncan lead to the formation of a more dangerous form of LDL\ncalled Type B. Think of B as standing for bad cholesterol.\nSo within LDL cholesterol, the Type B\nis the more dangerous one.\nWe'll talk about that in the coming slides.\nBut just know that high triglycerides\ntrigger the formation of more of that Type B LDL.\nHigh triglycerides also drive down the HDL cholesterol.\nAnd this diagram right here shows you triglycerides, again,\nthey fill up the fat cells, kind of like a big beach ball.\nWhen they inflate with triglycerides,\nthat's when we increase body fat.\nReally, through adequate lifestyle changes,\nwhat we want to do is we want to take that ball of fat,\nwe want to squeeze it, deflate it,\nget the fats to get inside your blood.\nAnd ideally, those free fatty acids\nthat you can see in that blood vessel,\nwe want it to travel to your muscle\nso you can burn that for energy.\nSo that's the process lipolysis, the breakdown of fat.\nThat's how we lose body fat and lower heart disease risk.\nBut many of us might be having the reaction go the other way.\nWe're actually forming more triglycerides.\nSo we really want to reverse that reaction.\nSo LDL, again to highlight, basically,\nyou've got the Type A, which is the larger LDL particle.\nAnd larger might sound like it's more dangerous,\nbut actually it's less dangerous than the Type\nB, which are the boats.\nAnd you can see this diagram, this is the image from my book.\nYou've got the larger boat that's floating along.\nSo lipoprotein particles are basically\nboats that carry cholesterol.\nAnd they float through your bloodstream.\nSo the larger one is a little bit more innocent\nas it floats through that bloodstream.\nBut the Type B tends to dock on the blood vessel wall,\nand then, again, it can cause damage and plaque formation.\nOK, so that's how we break down Type A and Type B.\nI've kind of broken these details down here, too.\nBut, again, the big meta picture I want to talk to you about\nis the fact that when triglycerides get up higher,\nespecially above 150, our body does\ngenerate more of those dangerous Type B LDL boats.\nA standard cholesterol is not going\nto break down Type A and Type B. I'm not\nsaying everybody has to get advanced cholesterol test,\nbut in my individuals who have high triglycerides and other\nrisk factors, I might do a more advanced lipid profile to see\nwhat the breakdown of the Type A and Type B\nis and also look at the particle numbers, which is also\nknown as LDL P.\nNow, healthy cholesterol, what we call the HDL cholesterol,\nwhat that does is it actually removes cholesterol\nfrom the artery wall and transports it to the liver.\nWe call that reverse cholesterol transport.\nHDL also can have an anti-inflammatory effect.\nAnd again, we want to reduce inflammation of the artery wall\nso we're not generating plaque formation.\nIt can keep the blood thinner, so it doesn't quite as readily.\nIt can also help relax those blood vessels.\nAnd then, I'll keep saying this over and over,\nbut often you will see the high triglycerides and low HDL\ncome together.\nThey tend to be inversely proportional.\nSo the higher the triglycerides, it tends to push that HDL down.\nOK, so now let's put this into practical application.\nWe're coming back to Sam's cholesterol profile.\nThis is our young general and that ended up\nhaving the heart attack.\nSo you can see the cholesterol tests.\nAnd I put his sample result and the target levels.\nSo let's look at the first row together, OK?\nI'm actually going to use my pen here\nso we can highlight some of these things.\nAll right, so we're going to start right here\nwith the total cholesterol.\nSo we see the total cholesterol here of 190.\nNow, typically laypeople will say\nthat if the total cholesterol is less than 200, its normal.\nIf it's about 200, it's abnormal.\nThat's not true.\nSome people with really good cholesterol profiles\ncan have a total cholesterol above 200,\nbecause they have more of the healthy cholesterol.\nOn the other hand, like Sam, individuals who don't have\nmuch healthy cholesterol and they're insulin resistant,\nthey're total cholesterol might be less than 200.\nSo really, the big picture point here\nis, really, total cholesterol is not very useful.\nObviously, if you're getting up into the 250,\n260, 300 category, that's going to flag\nthat some of the other cholesterol particles are high.\nBut in general, in this particular case,\nnot very important.\nThe LDL cholesterol is right here.\nYou can see that the result is 108.\nNow, most labs will see it at less than 100\nis normal and greater than 100 or even 130 is abnormal.\nBut I would tell you that that's not really--\nit's a limited way of looking at the cholesterol panel.\nYou've got to look at the big picture here.\nSo we want to focus in more on the additional numbers\nthat we're going to talk about and the ratios.\nNow the HDL, which we refer to as the healthy cholesterol,\nyou can see that that is 32, OK?\nAnd in males, the target levels, we want that to be above 40.\nIn women, we want that to be above 50.\nSo, clearly, the healthy cholesterol here is low.\nNow, the triglycerides, which we talked about earlier,\nwe would like that to be less than 100.\nI call that ideal.\nMost lab reports will say than less than 150.\nAnd we can see that Sam's triglycerides\nis at the 250 level.\nNow, here are the numbers that can really\ngive us a broader snapshot picture of the cholesterol\nprofile rather than looking at the absolute numbers we\ndiscussed earlier.\nAnd these are ratios.\nSo the first is a total cholesterol to HDL ratio.\nSo, you take the total, you divide by the HDL.\nAnd here, the ratio is 5.9.\nIdeally, we'd like to see that be less than 4.0.\nThe other ratio that I really want you to pay attention to--\nbecause this is not typically on a cholesterol profile.\nIt's listed as part of the results--\nis the triglyceride to HDL ratio.\nAnd typically, we want that to be less than 3.\nAnd we can see, in Sam's case if we divide the triglycerides\nof 250 by a 32, it's 7.8.\nAnd that's very significantly elevated.\nAnd this is a ratio that often gets missed.\nIf you are your doctors are knocking attention to ratios\nand just focusing on total cholesterol and LDL here,\nyou might think that Sam's cholesterol profile doesn't\nlook that terrible.\nBut these ratios tell us that he was at high risk.\nAnd this ended up being a signal for plaque formation and heart\nattack.\nSo, we really want to get that triglyceride to HDL\nratio less than 3, the lower, the better.\nWhen my patients are really in great metabolic shakes\nwith low risk of heart disease, they're\ncan be below 2, sometimes 1 to 1 or less than 1,\nbecause of really elevated HDL and brought the triglycerides\ndown.\nSo, a lot of these additional points\nI've kind of summarized here at the bottom.\nI'm spending time on the cholesterol profile,\nbecause I think it's really important to understand how\nwe should be viewing cholesterol profiles\nwhen we're assessing for heart disease risk.\nAnd, again, the advanced diagnostic tests,\nI don't recommend doing this in everyone.\nI can tell from a really good looking cholesterol profile\ndone with the standard lab that, OK, the ratios look good,\nnothing to worry about.\nI don't need to get an advanced lipid product done.\nBut in some cases, if it's borderline,\nthere's family history, there's other elements,\nI might get a additional marker for inflammation called the HS\nC-Reactive Protein.\nI might do the advance lipid profile\nto look at the particle size and numbers.\nIf there is a early family history\nof heart disease in a first-degree relative,\nmeaning like a parent or a sibling,\nI make get an additional test called the Lp little a.\nNow, that's usually included in the advanced lipid profile.\nBut that is a cholesterol marker that\ncan often signal an earlier risk for heart disease.\nAnd then, in some cases, I might also\nget a coronary calcium scan, which\nI would explain right now.\nSo, what is a coronary calcium scan?\nSo, basically, calcium is a surrogate marker\nfor plaque formation in the arteries.\nSo, you can again see here, on the right diagram,\nI'm showing the coronary artery blown up.\nAnd then, if you look to the right of that,\nthis is actually a CAT scan, a CT scan or an X-ray image.\nAnd those white, bright spots there\nare actual calcium deposits.\nAnd that calcium is basically an indicator\nof the existence of plaque.\nAnd the higher the score, the more that\nis indicative of a more significant plaque\nwhich might actually signal a future risk of heart disease.\nThis is not something I get in every patients.\nJust like the advanced lipid profiles,\nI might get this in select individuals\nfor an intermediate to high risk for heart disease.\nSo, somebody who, based maybe on age, diabetes, blood pressure,\nfamily history, we might get this coronary calcium\nscan to give us more information.\nNow, the calcium itself doesn't necessarily\nmean that you're at a very high risk for heart disease.\nBecause often what happens is when you develop a plaque,\nit's kind of like developing some scar\ntissue over that plaque, it's kind of like a scarred pimple.\nBut it is an indicator that there was some injury\nof that blood vessel wall.\nSo we have to really intensify lifestyle modifications.\nSo, this can really help for the risk stratify individuals.\nSome of my patients that are resistant to going\non cholesterol or blood pressure medications,\nif this test comes back and we see plaque\nformations that scores even low to medium to high,\nthen we are going to basically be\nmore aggressive about lifestyle plus medications.\nSo, I actually did a very detailed blog post\non coronary calcium scans.\nSo, you can refer to that.\nBut if this is something you're thinking about,\ntalk to your doctor and see if this\nmight be a test that would be useful in your individual case.\nNow, I talked earlier insulin resistance\nand how it can cause more fat storage in the belly, the belly\nfat.\nSo, really, when we think about body composition,\nrather than just focusing exclusively on weight and body\nmass index, it is important to know where\nthat weight is distributed.\nSo, using a waist-based measurement,\nlike waist-to-hip ratios or waist circumference\nis a good way for you to assess whether you might\nbe at risk for insulin resistance\nor you might already have insulin resistance.\nAnd that's a metric we want to really improve over time.\nSo, the weight-to-height ratio is a good way\nto adjust for the fact that individuals that are tall,\nthey're going to be expected to have a wider waist point.\nSo, weight-to-height ratio, you can see\nis literally your waist circumference over your height.\nAnd that ratio should be less than 0.5.\nSo, for example, if you're 70 inches tall,\nyour waist circumference should be less than 35 inches,\nhalf of that 70 inches.\nSo a nice, simple rule of thumb to use.\nAnd when my patients are making progress\nthrough their lifestyle changes, I'll often ask them,\nare your pants getting looser, how's that waistline feeling,\nrather than fixating on how many pounds did you lose.\nBecause this is really the more inflammatory type\nfat around the belly that can really\ntrigger inflammation and insulin resistance.\nOK, so, some signs and risk factors for insulin resistance.\nWe talked about the waist circumference.\nWe've talked about the triglycerides, a combination\nof high triglycerides and HDL.\nI've stratified by gender, as well, too.\nElevated blood glucose, either based on a fasting glucose test\nand/or an A1C test.\nThe A1C is your composite score.\nThat composite percentage shows your average\nof just the last two or three months.\nHigh blood pressure.\nThere are specific conditions that\nwill raise our risk of insulin resistance, like gout,\nfatty liver, Polycystic Ovarian Syndrome or PCOS,\na skin condition called acanthosis nigricans,\nor gestational diabetes, which is diabetes during pregnancy.\nAnd then there are some ethnic groups\nthat comparatively have a higher risk of insulin resistance\nand early heart disease.\nAnd I've listed those here in the box, as well.\nOK, now here is an example of an individual where I actually\nused a Continuous Glucose Monitor.\nSo these are abbreviated CGM.\nSo any time I say CGM throughout this presentation,\nI'm referring to these sensors.\nAnd this is an incredible tool in really\nhelping this individual reverse their metabolic dysfunction.\nSo, you can see the way the sensor works.\nOn the arm, basically, you would--\nso, these sensors have to be prescribed.\nAnd then, you would basically apply the sensor to your arm\ntypically.\nAnd then, as you can see, in this case,\nit's individuals using a reader.\nBut you can actually use your smartphones.\nEvery time I want to see my glucose,\nI'd wave the phone of my arm.\nAnd I can see my glucose response to diet,\nexercise, stress, and sleep.\nSo, I know this is a bit of a busy table,\nbut I just wanted to show that before the CGM--\nand again, I'm going to use my handy pen since there's\nlot of numbers here.\nSo, again, before CGM, the total cholesterol-- again,\ndon't get misled by that.\nYou might look at this and go, wow, 180 is good.\nBut in this case, you'll see this person did not\nhave a good cholesterol.\nSo, this is very misleading right here.\nThe LDL you might say is good because it's less than 100.\nBut when you have more small, dense, Type B LDL,\nit tends to falsely lower--\nit drives down the LDL.\nSo, it looks mysteriously normal,\nbut this is actually not a good LDL.\nThis is mostly Type B.\nThe HDL, my goodness, is 18, one eight, right?\nThat's a very low level of healthy cholesterol.\nAnd then, look at this whopping high triglyceride.\nIf you look at the ratios, 10.4 on the cholesterol to HDL.\nRemember, we want that to be less than 4.\nAnd look at this triglyceride to HDL ratio.\n23, goodness gracious, less than 3 is what we.\nSo, 23 is huge.\nAnd this A1C of 8.3 makes this individual a type 2 diabetic.\nWeight here 188, OK.\nAfter just three months of wearing the continuous glucose\nmonitor sensor, look at the change of the numbers.\nOne thing I want to highlight is you\nmight think that, oh, my goodness, his LDL right here\nwent up.\nBut actually, it's a good increase in LDL,\nbecause now this individual is forming more of the Type A LDL\nparticles.\nLook at the HDL, in three months, from 18 to 40.\nTriglycerides have dropped below 100, which is\nwhere I love the numbers to be.\nThe ratio of 4.2 looks good.\nThis was the greatest thing.\nI love this.\nA tenfold decrease in the triglycerides to HDL ratio,\nfrom 23 to 2.3 right here.\nA1C is completely out of diabetes range, less than 5.6,\nand a nice drop in weight about 165 pounds.\nSo, in some of my individuals, I can do this without a sensor.\nBut again, getting real-time feedback,\nthis individual was able to make unbelievable changes.\nThis is surely somebody who would have gone out\nto develop diabetic complications,\npotentially a heart attack, potentially a stroke,\nall these things.\nAnd in three months, we were able to fix that.\nI'll tell you more about the program,\nbut we are doing limited pilots using these glucose sensors.\nSo, I would encourage you to join our wait list.\nAnd the link is right here at the bottom\nat sutteremployer.org/mwp, if you're interested in joining\nour next program.\nNow, when we talk about nutrition, a healthy plate\ntypically just to simplify things,\nI like the bowl or plate-type approach to this.\nAnd really, just to simplify things,\nrather than doing all this obsessive counting,\nwhenever I have my lunch, dinner, or whatever meals,\nI'm looking to fill that bowl or plate up\nwith colorful, mostly non-starchy plants.\nSo you can see a selection of those right here.\nOne corner of that's going to be some fibrous grains, just\na corner of that.\nA sliver of healthy fats, and we'll\ntalk about healthy fats, and then some healthy proteins\nin the other corner.\nAnd now, vegetarian proteins I put in on the right\nbecause I do see a growing number\nof vegetarians in my practice.\nAnd often, they're struggling with protein sources.\nSo I put a list of really good quality vegetarian protein\nsources.\nThis is also something I've got a dedicated blog post on,\nbut it's absolutely possible for a vegetarian\nto get really good plant-based sources of protein\nto really help with metabolism, muscle growth, all\nthat good stuff.\nNow, the way I sort of work this diet here,\ntoo, is on days where I've done a lot of endurance workouts\nand my muscles need more carbs, but my dial up\nthe amount of grains, healthy grains or healthy carbohydrates\nand starchy vegetables.\nOn days where I'm stuck in back to back Zoom meetings,\nI didn't get to exercise, my muscles don't\nhave much of a demand for energy,\nI'll be much more restrictive with my carbohydrate intake\nsince my muscles are mostly sedentary.\nAnd then if I do some weightlifting and things\nlike that, I might consciously be increasing my protein intake\njust a bit based on this.\nSo this is a rough construct but intuitive\nwhere you can actually tailor some of these things\ndepending on your physical activity levels\nand just your overall body's needs.\nNow, I know you probably know this already,\nbut I do find when I talk to patients\nabout the types of plants that they're consuming,\nmany are just eating two or three different colors,\nand that's it.\nThey'll have a banana in the morning.\nThey have bagged greens.\nThey're getting plenty of greens because if you\ngo to any grocery store, they are filled with bagged greens.\nBut they're really not getting these other colors\nconscientiously.\nSo I want you to really think about how you eat the rainbow.\nEat more vegetables and fruit.\nIf you have insulin resistance--\nI'm a big fruit fan.\nI'm not anti-fruit all, but some of my patients\nwho have insulin resistance, they\ncan be very reactive to things like overripe bananas.\nOr if they're making a smoothie with berries and bananas\nand all types of fruits, like a tropical smoothie,\ntheir sugar goes through the roof.\nThey're better off eating and chewing their fruit\nthan drinking it through smoothies and other blendables.\nBut this is really key to keep in mind.\nChoose more crunchy and leafy vegetables.\nGet at least six to eight servings.\nAnd again, those color wheels are\nso important because each of these different colors\nhas different antioxidant anti-inflammatory actions\non the body.\nSo next time you go to the grocery store\nor if you're doing online grocery delivery,\nbe a little bit adventurous and add different types of colors\nto your plate.\nIt could be something as simple as maybe I'll\ndo purple carrots this time.\nMaybe try eggplant.\nPurple is one color that has incredible benefit.\nA lot of us are maybe getting blueberries,\nbut I would encourage you to really get some more\npurple foods into the diet.\nI tend to find that's a real color that's\nlacking in most of our diets.\nNow, I talk about carb copycats.\nSo a lot of us are struggling with insulin resistance\nand weight issues.\nSo getting creative around how you can introduce carbs\nto be disguised as grains is a really powerful way\nto lower sugar and really improve metabolism.\nBut I remember back when I wrote the book and I was doing this,\nI would have to teach people in the clinic\nhow to make cauliflower rice.\nBut the good news is now you can go to any grocery\nstore in the frozen and often in the fresh section,\nyou'll find pre-riced cauliflower, which\nis a great rice substitute.\nYou can do zoodles, spaghetti squash,\nlots of different options out there\nwhere you can really lower the amount of carbs in your diet\nthrough these sorts of innovative approaches.\nNow, the big question about saturated fat,\nI'm sure every time you look at headlines,\nyou see something different.\nIs saturated fat good for you?\nIs it bad for you?\nIs it going to affect my cholesterol?\nI wish I had a simple answer that would\naddress the entire audience.\nBut really, the answer is it depends.\nIt depends on your genes.\nThere are certain genes that make us much more, what I call,\nsaturated fat sensitive.\nSo some of my patients that consume red meat,\nthey're LDL cholesterol goes through the roof.\nThey are not very--\ntheir genes basically are not allowing them to metabolize\nthose fats properly.\nSo if they go on a high-fat, keto-style, carnivore diet\nand they are having a lot of butter, eggs, and red meat,\nwe see their cholesterol go through the roof.\nAnd I would say that's a concern.\nWe want to definitely tapering down the amounts of those fats\nand really focus on more healthy fats, which\nwe'll talk about in a second.\nSo I know this question might come up,\nbut really, I don't have a straight answer for you.\nI wouldn't say that, hey, everybody\nis going to avoid saturated fat, or the other extreme about it\nis, well, you might have to do some personal dietary\nexperimentation followed by some lab testing\nto see how your body responds to saturated fat.\nA general message for you, though,\nis I'd like you to diversify your fat intake.\nKey message is that the evidence-based heart\nhealthy fats are ones like monounsaturated fats\nlike olive oil, avocados, nuts, and seeds,\nthe omega-3s that come from marine fish\nsources, plant-based products, flax seeds, leafy greens.\nWhatever your approach is, I think\nit's important to get those sorts of fats into the diet.\nYou absolutely want to eliminate the hydrogenated trans fats,\nlimit the seed-based Omega-6 inflammatory oils\nlike safflower, corn, sunflower, canola, et cetera.\nAnd then use well-sourced saturated fat\nin moderation, virgin coconut oil,\na little bit of grass-fed ghee, a little bit of butter\nif you want.\nThe one thing I will tell you about saturated fat\nis based on the studies, if you're\nusing high-quality saturated fat,\nin most cases when it comes to heart disease,\nit looks like saturated fat is fairly neutral\nunless you're somebody that's very sensitive like we talked\nabout.\nBut I have not seen any studies that\nshow that saturated fat is heart protective.\nThat's a really key point.\nThe ones that I mentioned at the like the olive oil,\nespecially, the marine-based Omega-3s, those\nhave been shown in studies to have\nsome heart-protective effect.\nBut we haven't seen that.\nSo that's why regardless of what approach you're following,\nI want you to get those heart-healthy fats\nin your diet.\nOtherwise, there are types of carnivore and keto-style diets\nthat really go hard on saturated fat,\nbut they're not doing a good job in\nencouraging these other healthy anti-inflammatory\nheart-healthy fats.\nNow, another thing for you to be aware of\nis the role of gut health when it comes to cholesterol.\nSo LPS or lipopolysaccharide is an actual endotoxin\nthat is on the cell wall of gram-negative bacteria.\nAnd these are bacteria that actually colonize our gut.\nAnd the interesting thing is that increased toxin,\nthat LPS from your gut tissues, they can actually\nraise our LDL levels.\nNow, the reason I'm telling you this\nis because some people that have digestive gut issues,\ntheir body is producing a lot of this toxin because\nof that bacteria, and that can actually increase LDL levels.\nSo some of my patients that were struggling with their LDL\nlevels, and they're doing diet, they're doing exercises,\nthey're eating more fiber, it wasn't until they fixed\ntheir gut issues-- and I'm not a gut expert--\nbut until they fixed their gut health issues,\nthen we saw the LDL actually drop down.\nSo that's why I'm kind of highlighting this slide here.\nSo gut bacteria, also, when you've\ngot the right type of bacteria in your gut,\nit can really help with the metabolism and removal\nof cholesterol from your body.\nAnd I put a couple of mechanisms about how this happens.\nBut basically, those little guts, those tiny bacteria\ninside your stomach, they can actually\nconsume, digest, and remove some of that extra cholesterol\nfrom your body.\nMany of us that are not eating diverse diets,\nlike I said the one-dimensional sort of plant-based diet,\nreally eating one or two different types of colors,\nwhen you start diversifying the foods in your diet,\nyou'll grow the right type of bacteria,\nand they will help your body remove cholesterol\nfrom the body.\nSo I put a list here of prebiotic foods.\nYou want to eat a variety of these.\nAnd prebiotics are basically foods\nthat will feed and populate a higher diversity of bacteria.\nSo I put a whole list of those here.\nThe probiotic foods are actually the bacteria themselves.\nSo these are foods that contain the bacteria that you\nwant to populate your gut.\nSo I put different categories.\nSo for example, fermented dairy, yogurt, kefir,\nthe Indian lassi--\nnot that sweetened mango lassi that you get in restaurants,\nalthough that's delicious-- hopefully, more homemade\nlassis, yogurt-based drink.\nEven cheeses are fermented dairy sauces.\nUnder East Asian foods, I put a list of typical things\nthat you can use.\nUnder Indian foods as well, too.\nBut the disclaimer is you want to get\nthese really through natural foods if you can.\nNow that probiotics have become very trendy,\nthere are a lot of foods out there, a lot of types of drinks\nand shakes you can buy at the grocery store that\nsay probiotic rich, but they're also rich in sugar,\nand that sugar is going to make insulin resistance worse.\nSo really be careful about what your sources are\nprobiotics are coming from.\nReally try to get it through natural sources.\nAnd hopefully, if you're eating a very diverse diet--\nit's very common for me, by the way, when I make salads,\nI will actually add sauerkraut or kimchi to my salad.\nAnd it actually adds a tremendous amount of flavor\nto my salad.\nI like it better than the usual salad dressing that people use.\nBut these are great ways to really populate\nthat gut bacteria.\nNow, we get a lot of questions about cholesterol supplements.\nPeople love to supplement the heck out\nof all their medical issues.\nAnd I'm not anti-supplements, but they play a minuscule\nto no role at all in terms of lowering\nthe risk of most conditions.\nI really want you to pay attention to that.\nBut let me go through a few of the supplements\nhere that we have the most research behind them.\nSo fiber, you want to get fiber through foods first.\nMaybe you can try psyllium husk fiber\nif you want to add on more fiber to the diet.\nBut really try to get it through a rich, diverse array\nof fiber-rich foods.\nThe second is plant sterols and stanols.\nThese are plant-based oils that can\nhelp reduce LDL cholesterol.\nThis can be a way to maybe take the edge off that elevated LDL\ncholesterol, but there's really no vigorous rigorous studies\nthat show that plant-based sterols actually lower\nthe risk of heart disease.\nBut again, it can take the edge off LDL\nmodestly in terms of lowering that number.\nNow, Omega-3s, they don't really lower heart disease risk\nmuch in most individuals.\nAnd I'm talking about the Omega-3 supplements, right?\nAgain, if they come through marine resources and fish\nin particular, it does look like it\nhas some heart-protective effect from that.\nI always get questions about garlic supplementation.\nLarge studies show that there is pretty much no benefit.\nBut garlic is a good anti-inflammatory food\nthat might have other benefits.\nAgain, get it from food, not from supplements.\nNow, red yeast rice is one that comes up a lot.\nAnd what red yeast rice basically is is\nit actually has a chemical inside it called monacolin K,\nand it basically acts like a statin called lovastatin.\nSo it's literally like taking a small dose of statin.\nBut the problem with red yeast rice\nis there is a lot of variability in the quality\nand the amount of that active ingredient, and in some cases,\nit can cause toxicity.\nSo I find it paradoxical that somebody's\ntrying to take a supplement that's got statins in it.\nWhy wouldn't you just take a low dose\nof statin, which is regulated and we know\nexactly how much statin you're getting in the body?\nJust because it sounds nice and natural like red yeast rice,\nit doesn't mean it's good for your body.\nIn this case, it can cause liver toxicity.\nAnd then tea extracts and supplements, be very careful\nwith these.\nA lot of people try to supplement these,\nand they can cause potential liver toxicity.\nOK, now cholesterol medications, they\nare indicated in appropriate risk individuals\nif your lifestyle doesn't get you to goal.\nSo heart disease is, again, usually due to high cholesterol\nplus other factors like glucose, high blood pressure,\ninactivity, sleep issues, stress issues, excess body weight.\nSo medications are just one part of this.\nI put a couple of categories of drugs, LDL drugs that\nare more targeted towards lowering LDL,\ntriglyceride drugs, but I want to get down\nto the bottom bullet point where drugs without lifestyle changes\nhad a minor impact on lowering overall heart disease risk.\nAnd I'm saying that message to you\nvery clearly because I see lots of patients\nthat see me for consultations.\nThey had one or two heart attacks,\nand they were taking statins the whole time.\nAnd because their numbers magically look so good,\nthey felt like they don't have exercise as much,\nand they don't have to do the lifestyle stuff.\nBut these drugs do not come close to what\nlifestyle can do when it comes to lowering heart disease risk.\nExercise, a couple of quick points.\nInterrupting prolonged sitting is really, really important.\nWhen we're sitting for more than 30 to 45 minutes at a time,\nthat can actually trigger inflammation in the body.\nSo you can get increased cytokine-based inflammation.\nIt also elevates body fat, raises sugar,\ncan raise blood pressure.\nAll these factors can actually result from prolonged sitting.\nAnd many of us that are in back to back meetings\nthroughout the day now, really taking opportunities\nto sit, to stand, to do all types of different positions\ncan be very useful and important.\nSo your goal in general is to do what's called exercise\nsnacking where you snack on movement every few minutes\nthroughout the day, and this can really\nshift your metabolism so your body is\nburning more fat and cholesterol rather than storing it.\nRemember, lipolysis is the breakdown of fat,\nand regular movement throughout the day\ncan trigger more lipolysis so that fat cell empties out\nsome of the extra fat.\nLipogenesis is storage of that fat.\nAnd when we're in sedentary throughout the day,\nthat's what ends up happening.\nSo again, I said for at least 4 to 5 minutes of movement\nevery 30 to 45 minutes if you can.\nNow, the right aerobic exercise dose-- so many of us\nare doing aerobic level activity,\nbut some of my patients are on the other end of that spectrum.\nIf they measure their heart rate, many of my patients\nwere wearables like Fitbit and Apple watches,\nand I find that their heartbeat is too high.\nThe optimal dose to protect your heart,\nto facilitate weight loss and help with insulin resistance\nis really a zone that we call moderate.\nAnd there's different ways you can calculate it.\nI like using the Maffetone heart rate or the MAF heart\nrate developed by Dr. Phil Maffetone.\nAnd really, it's a very simple equation.\nIt's 180 minus your age, OK.\nSo if you're 40 years old, your upper limit is going to be 140.\nSo 80% to 85% of your workouts should really\nbe pushing that ceiling of 140, again, if you're 40 years old,\nand maybe once a week or so, you can do more anaerobic-based\nHIIT-type training.\nNow, some of you might argue, no,\nI've read HIIT training three, four, or five days a week\nis better.\nIt saves me time.\nAnd for some individuals, maybe that works,\nbut I find that people that do excessive HIIT training also\nhave increased hunger-- that's been shown through studies.\nAnd they have increased injuries unless they're athletic\nand they've got a strong core and they're really\ndoing a lot of things to really prevent injury.\nBut really, this aerobic dosage is super, super\nimportant to make sure you're getting enough\nof that type of exercise.\nAnd this shows you that exercise,\nthere is dose-dependent effect.\nSo you can see on the left-- let me just use my pen here\nso I can highlight.\nThis is really important because I often\nhave this discussion in the clinic with my patients.\nBut here on the y-axis, you see all-cause mortality or death\nrates, and here on the x-axis is basically\nthe amount of exercise.\nAnd when we look at all this together,\nwhen you're sedentary, clearly, you\ncan see mortality and death rates are higher.\nAs you get physically active, you\ncan see it's dropping down, which is good.\nWe want mortality to go down, mortality to go down.\nSo the optimal amount of exercise is somewhere in here.\nNow, some people that keep doing more and more and more\nexercise, they're training for triathlons\nand running marathons and just going non-stop,\nwe see that excessive endurance-based exercise\ncan increase fibrosis or scarring of that heart muscle.\nIt can cause arrhythmias, which are abnormal heart rhythms.\nIt can lead to more coronary artery Calcification\nso there is a point in which excessive exercise can actually\nhave an opposite effect and actually increase\nthe rate of heart disease.\nSo really keep that in mind.\nOK, fasting we get a lot of questions\nso let me cover a couple of quick things here for fasting.\nSo some tips on Time Restricted Eating or TRE\nor intermittent fasting, whatever you want to call it--\nso first, you ask yourself when do you start and stop eating.\nThat's your eating window.\nAnd I tell people try to shave one\nto two hours from your baseline.\nSo you can go straight to a 14/10 or a 16/8.\nSo that first number is the fasting interval,\nand the second number is the--\nI'm sorry the first one is yes, the fasting.\nThe second number is the feeding window.\nSo a 16/8 basically means that you're fasting for 16 hours,\nand you're basically eating during the 8-hour window.\nSo just trying to end eating earlier, for most individuals,\nfinishing by 7:00, 7:30 PM, it works well.\nLater meals are linked to higher heart disease\nrisk, increased glucose, and inflammation.\nSo I have some individuals that I've seen in the clinic,\nand they're eating around 9:00, 9:30, or 10:00 PM.\nThat is not good for inflammation and insulin\nresistance.\nYou want to really pull that back earlier.\nMore is not always better for fasting, especially for women.\nYou want to really personalize that interval.\nI've done a lot of work, a little bit of research,\nand looked at the data on fasting.\nAnd really, people that are excessively fasting\ncan often lose muscle mass, and there can be other side effects\nto that.\nSo there is a proper dose of fasting that most of us\nshould pay attention to.\nAnd I did a detailed blog post on that that's\nlinked here at the bottom here.\nIt's bit.ly/sinhafasting.\nSo information in this individual,\nI just want to focus on one specific number.\nI've already hammered you with a lot of cholesterol information,\nbut this is an individual that made some really great changes\nin diet, and you can see the triglycerides got much better.\nBut there is one test I want you to pay attention to here\nis this C-Reactive Protein.\nI mentioned earlier that's a marker for inflammation.\nNow, with lifestyle changes, you see\nthat this C-Reactive Protein dropped from 10.6 to 3.6.\nSo that's a good improvement.\nBut there was one change in particular\nthat completely normalized this individual's level\ninflammation.\nAnd what was that intervention?\nThat was meditation.\nAnd I see this in my patients.\nA lot of times, we just obsess over diet and exercise so much.\nAnd we don't realize that when our system,\nour emotional system is basically revved up,\nwhen chronic stress is constant in the background,\nit can rev up our immune system and cause increased inflation.\nThat's why chronic high levels of stress\nare an independent risk factor for heart disease.\nSo literally doing mindfulness-based practices\nfor this individual completely normalized that\nC-Reactive Protein.\nSo I want you to be aware that.\nThe other direct effect of stress\nis stress can absolutely raise blood sugar.\nIt can raise blood sugar in some cases more than eating sugar.\nSo this is an individual from our Metabolic Wellness Program,\nand I wanted to highlight the fact\nthat this individual throughout the two-week course of wearing\nthis sensor had not seen any abnormal blood sugars at all.\nAnd let me use my pen here again so I can make this point here.\nSo basically, you can see here, the glucose levels\nfrom the sensor were pretty stable throughout\nthe whole time she wore this.\nBut then what happened?\nShe has a single heated discussion with her in-laws,\nand all of a sudden, the glucose went up into this zone,\ninto the 170s.\nShe had never seen anything go up that high\nthroughout the course of this program.\nAnd this tells you that that emotional stress,\nthat cortisol, it can trigger the liver\nto produce more glucose.\nSo this is going to happen episodically for some of us.\nBut if you're constantly in conflict and stress\nwith your family, during work, because of life circumstances,\nknow that the metabolic impact, again, can be very significant.\nAnd as I mentioned earlier, if you're\ninterested in joining our program, the link is down here.\nAnd you can join the wait list for this.\nBut this, again, this along with the C-Reactive Protein,\nI hope helps quantify the effect of stress\nit can have on inflammation and on insulin resistance.\nSo here, remember that diagram I showed you\nin the beginning of the inflammation and insulin\nresistance?\nThese two cases show directly quantitatively how\nstress can actually lead to both of those conditions.\nSo really important to keep that in mind.\nEmotional stress and heart disease,\nwe covered this already.\nSo stress and sleep tools and resources,\nI put some of my links.\nI've got some instructional videos\non my blog that tell you how to help manage stress\nthrough breathing.\nI've also got an e-book that helps with sleep issues\nas well, too.\nAnd through Sutter Health, we also\noffer health education classes, courses on mindfulness,\nand things that can really help you manage stress and also\nimprove your sleep.\nNow, smoking I want to say a couple of things\nabout because some of my patients during the pandemic\ndid resort to increasing, restarting smoking,\nor doing social smoking.\nThe smoking really is the strongest reversible risk\nfactor for heart disease.\nIt can have effects on lipids.\nIt can increase blood clotting.\nAll these factors can really raise plaque formation\nand accelerate that process with increased heart disease risks.\nAnd one final point I want to make about smoking\nis even one cigarette daily is deadly.\nMany of my patients who are social smokers\nsince think they're off the hook,\nbut I want to highlight this last bullet here\nwhere smoking one cigarette daily\nhas half the risk of someone who smokes 20 cigarettes daily,\nnot 1/20 of the risk.\nSo it's not mathematical on that scale.\nIt's basically one cigarette enough\ncan cause that to perpetuate an increased risk,\nespecially if you're already insulin resistant.\nSo if you're smoking at any degree,\nplease quit altogether if you can.\nAnd you can reach out to your health care team\naround resources and support to help you quit.\nOK, so I wanted to leave enough time for questions and answers.\nSo we are going to move on to that.\nAnd because I know we're going to get questions\nabout our metabolic program, I'm just\ngoing to keep this slide up here,\nwhich has the link for joining our wait list along\nwith some fast facts on the program itself.\nAll right, so let me go ahead and stop sharing here,\nand we can jump in to questions.\nAnd I'd like to introduce Laura [INAUDIBLE] who's\ngoing to help be moderator for a long list of chat questions.\nI don't envy your job right now, Laura,\nbut I know you're going to do a great job as always.\nLAURA: Oh, thank you so much, Dr. Sinha.\nAnd thank you for all that information.\nWe do have many, many questions for you today.\nSo we're going to do our best, everybody, to get to as many\nof them as we possibly can.\nAll right, Dr. Sinha, for our first question,\nis it possible for someone to find out\nif they have a clogged artery before they\nhave a heart attack?\nRONESH SINHA: OK, really good point.\nSo like I said, so for the clogged artery, the only way\nyou can tell if the artery is clogged, and god forbid,\nif you have a clogged artery, you're\ngoing to have symptoms of that already, right?\nWhat you're really trying to identify\nis those vulnerable plaques.\nRemember, you want to identify that pimple before it pops.\nAnd basically, one of the best ways\nto do that if you're at intermediate risk\nis to basically get a coronary calcium scan.\nI don't recommend that in everyone,\nbut that is one way to visualize if that's happening.\nAnother indirect way that you can\ntell if you might have a blocked artery\nis if you're somebody that is developing chest pain\nor shortness of breath with exercise,\nthen talking to your doctor about getting a stress test.\nWhat they'll do is they'll have you basically exercise\non a treadmill, and based on the EKG\nor if we're doing an echocardiogram and ultrasound,\nwe can see changes that take place that would give us\nan idea that you have an artery that's\npossibly getting squeezed or getting tighter\nas you exercise.\nSo those are two ways we can get a bit more visual dynamic\nfeedback.\nLAURA: Great, thank you so much.\nOur next question is, does a woman's risk\nfor developing heart disease increase during menopause?\nIf so, can it be minimized with hormone replacement therapy?\nRONESH SINHA: Yeah, great question,\na very controversial area.\nSo the first thing is although there are some studies\nto indicate that menopause might increase heart disease risk,\nif you really do a deeper analysis,\nit's all over the map.\nIt's conflicting because clearly during menopause, women\nare also aging, and there's a lot of age-related risks\nthat occur with that.\nNow, something specific that can happen with menopause\nis your lipid profile might change because\nof the hormonal changes.\nSo sometimes the LDL cholesterol might go up a little bit.\nThe healthy cholesterol might go down.\nBut I would say based on available studies,\nit doesn't look like menopause significantly raises risk\nindependently, but the age itself\ndoes raise risk on top of that.\nNow, with hormone replacement therapy,\nagain, lots of conflicting studies.\nSome studies-- earlier, we used to think that it lowered risk.\nNow really what we're finding with hormone\nreplacement therapy is it's probably more neutral.\nThere are some studies that showed\nthere might be a slightly elevated risk of heart attack\nor stroke.\nBut even that's being questioned.\nSo really, the approach to hormone replacement therapy\nis if you're having symptoms that are really affecting\nyour quality of life, talk to your doctor\nabout going on a temporary course of hormone replacement\ntherapy.\nBut again, the big meta picture here\nis hormones and menopause, conflicting data\nthat out there.\nIf you want to lower risk, focus on all the things\nwe've talked about around diet, lifestyle, stress, sleep,\nall those things.\nThose are far more important.\nLAURA: Great, thank you, Dr. Sinha.\nOur next question is regarding alcohol consumption.\nCan you talk about alcohol consumption\nas it relates to heart health?\nRONESH SINHA: Yes.\nOK, so what I will tell you is when you look and do\na deeper analysis of the studies around alcohol, many of us\nhave grown up thinking alcohol is protective.\nIf I drink a glass of red wine, it's\ngoing to protect me against heart disease.\nAnd I'll tell you, most of the studies that were done on this\nare absolute garbage because the problem\nis in most of the studies, when you're\nassessing alcohol intake, these are usually\nwhen you try to basically do a deeper analysis,\nyou find that a lot of individuals\nwho have lower heart disease risk,\nit's because of that population of people that are drinking\nthose one to two drinks.\nSo often, this can be a healthier population that tends\nto be more health promoting.\nSo a lot of people that are drinking a glass of wine\nor two in the evenings, they tend\nto be individuals also that might be exercising and eating\nhealthier foods.\nThey're more health conscious.\nSo when you actually look at those lifestyle factors\nand confounders, in most studies,\nyou don't see a significant protective effect from alcohol.\nSo my bottom line advice to you is\nif you enjoy alcohol in moderation\nand you don't have any contraindications\nbased on your health, you can continue drinking\nin moderation.\nIf you don't drink alcohol, I would never\nrecommend that you start drinking alcohol to protect\nyourself against heart disease.\nThat's not going to be a good strategy.\nAnd there is not evidence to back that up.\nLAURA: Great, thank you so much, Dr. Sinha.\nSo our next question is about genetics.\nWhat role does that play with heart disease?\nRONESH SINHA: Yes, so with genetics,\nanywhere from about 40% to 60%.\nSo it can play a significant role.\nBut the good news is when I see patients\nat the clinic that have had one or two family\nmembers that have heart disease, often, they get very nervous.\nThey're like, oh, my God, am I going\nto go get a heart attack at age 40 or 50?\nBut you have to keep in mind that those genes,\nthey're kind of like apps on your phone.\nThey don't get turned on unless your adverse lifestyle has\nan influence on that.\nSo often when I ask patients about their parents\nor grandparents that might have had early heart disease,\nI ask them, were those parents overweight?\nWere they consuming an ideal diet?\nAll these things are really important because most\nof the time when they look back, their parents\nmight have been smokers.\nMaybe they weren't exercising.\nMaybe they were eating a moderately unhealthy diet--\nI'm sorry.\nNot modern, but a Western unhealthy diet.\nSo if we can get our individual to reverse\nsome of those lifestyle patterns,\noften we see that they don't develop heart disease\nat a premature age.\nSo genetics does play a strong role,\nbut lifestyle can trump a lot of that genetic risk, which\nis what you want to focus on.\nLAURA: Great, thank you so much, Dr. Sinha.\nSo Dr. Sinha, what causes your heart to rapidly beat,\nand is this something that's dangerous\nand that you should talk to your doctor about?\nRONESH SINHA: Yeah, so rapid heart beats\ncan come from various causes.\nFirst, I want to answer the last part of it.\nYes, you should talk to your doctor about that.\nRapid heart rate can come from caffeine intake.\nIt can come from anxiety, stress, severe dehydration.\nIt can be medications or supplements.\nSo if you're having it once in a while, not a concern.\nBut if it's happening more often or you\nhave symptoms that are going along with that,\nthen definitely talk to your doctor about rapid heart beats\njust to make sure there's nothing serious.\nThey can check an EKG, do testing\nlike for thyroid disease.\nWhen you're thyroid is overactive,\nit can cause palpitations.\nBut they can do a more thorough workup\nto see what the cause of that rapid heart rate might be.\nLAURA: Great, thank you.\nSo Dr. Sinha, can your body actually recover,\nreverse the signs of heart disease\nafter decades of overeating, drinking, not exercising?\nBut if you are doing all of those things\nand then turn the corner and start exercising and eating\nhealthy diet, can you reverse those effects?\nRONESH SINHA: That's a really good question.\nThe good news is our body, thank goodness,\nis incredibly forgiving.\nSo at any stage when you come into this with whatever\nstage you're at, we find that the minute\nyou can incorporate these lifestyle changes,\ntake a couple inches at the waist line, start exercising,\nyou can actually-- what you end up\ndoing is, for example, my patients that have calcium\non their coronary scan, you may not\nmake that calcium disappear.\nBut the whole game with this plaque\nis whether you make the plaque disappear or not,\nyou want to scar it and stabilize it.\nAnd that's what lifestyle does.\nWhen you're managing stress, you're eating properly,\nyou're exercising, often what happens is that plaque,\nthat pimple gets scarred over.\nThe pimple may not disappear, but as long\nas it becomes inactive and it's not going to blow,\nit's not going to explode or pop,\nthat's really the goal that you're looking for.\nSo to answer your question, the earlier\nwe can intervene, the better.\nThat's why I mentioned that, hey, already\nwatch your kids' habits.\nIf they're sitting in front of a computer on a screen all day\nand if they're eating garbage foods,\nyou want to get on top of that now.\nBut even if you present at 35, 40, 45, 50,\nand you've already got existing risk factors or a high calcium\nscore, at any stage, you can intervene\nto really slow down or stop that progress\nso it doesn't turn into a catastrophic premature event.\nLAURA: Great, thank you, Dr. Sinha.\nWe've had lots of questions regarding the Metabolic\nWellness Program.\nCan you further explain that?\nI know you have a slide on that.\nRONESH SINHA: Oh, yeah.\nSorry.\nLet me jump back into these slides again here.\nYeah, yeah, absolutely.\nSo this program right here is basically it is a 12-week--\nand you can see my slide?\nLAURA: Yes.\nRONESH SINHA: OK, so it's a 12-week guided program,\nand we use a glucose sensor.\nAnd really, what we're doing is it\ncan often be difficult to get your hands on a glucose sensor.\nSo our team is the one that prescribes the sensor for you,\nand we get the sensor in your hands.\nWe teach you how to put the sensor on,\nand we teach you how to actually interpret the data\nand make lifestyle changes based on this.\nSo it's super cutting edge because most\nof the time, these sensors have been used exclusively\nin diabetics on insulin.\nBut we teach how to use it in the context of your daily life.\nSo really, this program is designed\non the proper use of the sensor, interpreting your data.\nAnd then we have a team, myself included.\nI lead some of the health education sessions.\nWe've got some functional medicine practitioners,\na great dietitian that does sessions on ketogenic diets,\non fasting, on anti-inflammatory things, stress, sleep.\nSo we've got a nice comprehensive line of resources\nthat help support people's metabolic health while they\ntrack it using the sensor.\nWe have limited space with each pilot.\nSo if this is something you're interested in,\nI would go to that link and just enter the wait list.\nAnd there's also a video that tells\nyou more about the program itself\nwith some additional information on that web page.\nSo something to keep in mind."} ``` ```json {"@context":"https://schema.org","@type":"VideoObject","name":"Heart Disease: Differences Between Men and Women","thumbnailUrl":"https://cf-images.us-east-1.prod.boltdns.net/v1/static/817826402001/1b7bdea2-bbd7-49d1-8f35-44ca83188a92/7e3ea0dc-e314-45d6-a2c5-1076050e2d90/1280x720/match/image.jpg","uploadDate":"2021-03-10T18:35:20.886Z","embedUrl":"https://players.brightcove.net/817826402001/79bcaa57-54d7-453c-9f1f-8ab3ef7b15de/index.html?videoId=6238626905001","description":"Pei-Hsiu Huang, M.D., offers his expertise in lifestyle changes you can make to protect your heart health.","duration":"PT37M39S","transcript":"PEI-HSIU HUANG: Thank you for taking the time\nto join us today while we talk about cardiovascular disease\nin women.\n\nOK.\nSo we are near the end of February 2021,\nand this will mark the close of the 57th annual American Heart\nMonth.\nAnd this is important to take into account\nbecause heart disease has claimed countless lives\nover the years, and even most recently has claimed\nover 800,000 lives each year.\nHeart disease continues to be the leading\ncause of death in the US, prior to COVID, of course.\nAnd more people die of heart disease\nthan all cancers combined.\n\nHere is a different depiction split\ninto male and female deaths.\nIf you look at the bold, blue wedges,\nthey represent heart disease, which include ischemic heart\ndisease where the blood supply to the heart muscle\nis affected.\nLooking at the slide, about 22% of women--\nbasically, one in five-- deaths are due to heart disease.\nAnd while the proportion of cancer deaths is similar,\nbreast cancer--\nwhich is also very much in the forefront\nwith a lot of attention and initiatives--\ncauses a relatively small percentage of total cancer\ndeaths, as you can see here.\nAnd this all in all is about four times less\nthan the deaths caused by heart disease.\nSo historically, heart disease was\nthought to be a man's problem.\nBack in the 1950s and a lot of men\nwere smoking, a lot of people had heart attacks.\nAnd when the mortality started to be tracked a little bit more\ncarefully, you noticed that in 1984, the blue\nand the red lines cross.\nAnd for many years thereafter, note\nthat more women die from heart disease than men.\nAnd the deaths for women continued\nto rise, despite an improvement in the death rate in men.\nAnd this is kind of peculiar because around this time,\nthis is when a lot of transformative developments\nin understanding of ischemic heart disease were made.\nAngiography was already being performed to identify blockages\nin the coronary arteries.\nMedicines that were developed to break up\nclots in the coronary arteries were already\nbeing used to treat patients with heart attacks.\nAngioplasty, which was first utilized\nin patients in the late 1970s was now\nbeing routinely used to treat patients with heart attacks.\nAnd in 1994, the FDA approved the first coronary stent\nfor use in the United States.\nSo despite all this, why did the female mortality\nremain so high?\nI'll come back to this in a little bit.\nFirst, I want to talk about Jane.\nHere's Jane.\nShe is a bit of a heavyset person.\nAnd four years ago-- she has chronic back pain.\nSo four years ago she was undergoing evaluation\nto have back surgery.\nAnd at that time, she told her doctor\nthat her father had had a heart attack when\nhe was 54 years old.\nSo she had an electrocardiogram done,\nand it was a little abnormal, but some other tests were fine.\nSo she underwent back surgery.\nShe went through it without an issue.\nSubsequently, she was diagnosed with high blood pressure.\nSo following that, she had some really nondescript chest\ndiscomfort, and just made her feel a little bit uneasy.\nShe said it was kind of difficult to describe\nexactly what it feels like.\nSometimes that the discomfort would shoot her back.\nOccasionally when she walks around,\nshe had some shortness of breath.\nAnd she was thinking, well, because her father had a heart\nattack when he was 54, she was kind of worried about it.\nSo Jane went through tests.\nShe went through tests, and she went through more tests.\nShe initially, saw a cardiologist\nand had an echocardiogram, stress test,\nhad a heart monitor done, none of which\nreally showed anything.\nShe continued to have symptoms.\nAnd so a year later, she had another stress test.\nThis time it was a little bit abnormal,\nbut the cardiologist thought, well,\nmaybe that's just artifact.\nWell, a few years after that, she\ncontinued to have chest discomfort\nand had another echocardiogram and another stress test.\nNothing was found.\nSo she had another echo, and finally another cardiologist\nsaid, you know, forget the stress test,\nwe just can't find anything.\nLet's just do a coronary angiogram.\nSo she went through and had a coronary angiogram\nand didn't really find much.\nIf you look on the sides, the panel on the left--\nlet's see, where is it?\n\nHere we go.\nThe panel on the left really shows not too much in terms\nof everything's pretty smooth.\nThere's no obvious blockages.\nThe panel in the middle, these blood vessels\nlook pretty smooth.\nThe panel on the right here, the blood vessels\nlook a little small, but there is no pinches or no blockages\nanywhere.\nSo what do we do with her?\nThe treatment, in this case, pretty much\nwas more of the same, but at least more decisively\nso because, at least now, her doctor\nknew that, her cardiologist knew that she\ndidn't have a blockage.\nAnd so she just went through lifestyle changes,\ntried to lose some weight.\nShe ended up going through bariatric surgery.\nAfter, she was diagnosed with diabetes.\nAnd then she went through some other testing\nfor some other symptoms, but never really completely figured\nout exactly what it was.\n\nNow, what we just described, this scenario\nis actually pretty commonly encountered and one\nthat potentially illustrates some of the differences in how\nwomen present with ischemic heart disease compared to men.\n\nSo it's important to recognize what increases someone's risk\nfor developing cardiovascular disease because 90% of heart\nattacks and other heart disease events\noccur in people with at least one of these risk factors--\nI would say the traditional risk factors.\nI group them in my head in two separate categories-- number\none, the nonmodifiable ones such as age.\nCan't really change that.\nCan really change which family you were born in to.\nAnd the rest of them are more modifiable-- things\nsuch as blood pressure, cholesterol, diabetes,\nand lifestyle issues with regards to smoking,\nwhat you eat, stress level, physical activity.\nAnd while a lot of these risk factors\nare the same ones that we pay attention to and mend,\nthese risk factors tend to occur more frequently\nor even have greater impact than the risk\nof cardiovascular disease.\nFor example, high blood pressure occurs more often\nin women over the age of 60.\nIt has a stronger affect to the risk of developing\nheart disease than men.\nAnd as far as cholesterol, after the fifth decade,\nwomen generally tend to have a little bit higher cholesterol\nlevel than men.\nAnd while we often focus on the level of bad cholesterol--\nthe so-called LDL--\nit turns out that for women, having\na low HDL, a low level of good cholesterol,\nis more strongly associated with the risk of developing heart\ndisease.\nSo as far as obesity, this is an epidemic in the United States\nand around the world.\nAnd with obesity, that goes hand in hand\nwith developing metabolic syndrome.\nIn fact, it is one of the components\nof metabolic syndrome, which is really\na combination of obesity, high blood pressure, diabetes,\nand having cholesterol issues.\nAnd metabolic syndrome tends to occur more commonly\nafter menopause.\nSo smoking doesn't really have the same effect\nin men as in women.\nIt turns out that women, even smoking as few as one\nto two cigarettes a day, have a stronger--\nit almost doubles their risk of developing a heart attack\nin the future.\nSo those are how the risk factors are common with men--\nor different-- or affect women differently.\nNow, women have unique risk factors\nthat largely are related to hormonal changes that occur\nduring the woman's lifetime.\nFor example, a younger age at menarche\nis associated with a higher risk of cardiovascular disease.\nAnd while cardiovascular disease is\nunusual in premenopausal woman without any risk factors,\nthe postmenopausal state seems to increase\nthe risk of heart disease.\nBut it's hard to know exactly why it does that\nand how much it does that.\nWhat we do know is that from the many studies,\nsuch as the Women's Health Initiative and the HRT, two\nstudies, that hormone replacement therapy does not\nseem to be protective against the increased risk.\nAnd, in fact, can itself increase\nthe risk of heart attack, stroke, and forming clots.\nPolycystic ovarian syndrome is really\nstrongly associated with developing diabetes\nand metabolic syndrome.\nAnd that in itself can increase your cardiovascular risk\nas well.\nAnd then pregnancy complications--\nthere are the issues encountered during pregnancy.\nIf someone has a history of pre-eclampsia,\nwhich is a hypertensive condition that involves\nmultiple organs during pregnancy,\nthe risk of developing heart disease in the future\nis double.\nAnd if at any time during the pregnancy\na woman has high blood pressure or diabetes,\nthat increases the risk of having high blood pressure,\ndiabetes later on in life after pregnancy,\nand thus the risk of developing cardiovascular disease\nhas also increased.\n\nSo symptoms-- it is probably the case\nthat women with ischemic heart disease more often than not\nhave classic anginal symptoms.\nAnd the classic anginal symptoms are this.\nWe call it typical angina, and tends to have all three\nof these characteristics in terms of being severe, being\nbrought on by some sort of activity, exertion,\nand it resolves with rest or taking\na little bit of nitroglycerin.\nAnd it's usually described as heaviness, pressure, tightness.\nYou may have heard on TV people saying, oh,\nthe classic heart attack, the hand over the chest.\nThere's an elephant sitting on my chest.\nAnd it's usually in the center.\nSometimes it goes to the left.\nI would say off in the left neck and the arm.\nAnd it's accompanied a lot of times by shortness of breath.\nYou may feel a little bit nauseated or have sweaty skin.\nAnd some of these symptoms will often\nbe found to have some sort of severe blockage in at least\none or more of their coronary arteries.\nBut studies showed that women, even\nthough they experience angina--\nand sometimes even more frequently than men--\nas they age, may describe the symptoms a little bit\ndifferently.\nAnd it's not only in the descriptive words that\nare used to communicate with the physicians,\nbut women are more likely to have symptoms that occur\nat rest and with exercise.\nSo it's not necessarily predictable.\nSometimes women may have these anginal symptoms\nthat occur during sleep.\nThe intensity of the pain may vary over time.\nAnd these symptoms, much like the one\nthat Jane had described, it doesn't always\nraise suspicion of someone having heart disease.\nAnd so this may be why studies have\nshown that women are significantly less\nlikely to have diagnostic testing such as stress\ntesting or coronary angiogram, or even\nundergo angioplasty or bypass surgery even\nwhen they're admitted to the hospital for chest\npain or a heart attack.\nAnother study showed that women only had coronary angiography\nabout half as often despite the fact\nthat, when they were admitted to the hospital,\nthere were symptoms of angina.\nThey had angina as frequently with more debilitating symptoms\nthan men.\nAnd as you can imagine, this leads to delays in treatment\nand even lack of appropriate treatment in many cases.\nSo to complicate things more, it's been shown that up to 60%\nof women with heart disease symptoms\nhave no severe flow limiting blockages on the angiogram\nwhen they have one, just like Jane.\n\nIf you look at more carefully, though, at these women,\nat those coronary arteries, there is one study--\nseveral studies, actually-- looked at it very carefully,\nsome with a special ultrasound catheter.\nYou can see that the coronary plaque in some of those women\nwere deposited a little bit more differently\nthan they are in men.\nThey tend to be more uniform and more evenly distributed\nor diffusely distributed into many of the coronary branches.\nSo this led to the description of\nthe potential different patterns of plaque distribution\nwith men compared with men.\nSo women tend to have smaller coronary arteries.\nAnd they don't necessarily have a discrete stenoses.\nIf you remember Jane's angiogram,\none of her blood vessels looked kind of small.\nIt looked pretty uniformly small all the way down.\nAnd so compare that with men, where it's lumpy,\nbumpy and you see this--\nright in the middle of the blood vessel right there--\ndiscrete blockage.\nAnd women tend to have more soft plaque, less calcium.\nAnd a lot of this ends up affecting the microscopic blood\nvessels and cause dysfunction of flow\nthrough those microscopic blood vessels.\nThose are blood vessels that you cannot stent,\nyou cannot bypass.\nAnd as a result of effecting those blood vessels,\nyou also can cause a coronary artery to spasm.\nAnd so those are the various ways\nthat plaque and coronary flow differ.\nBut the research that's been done in this area,\nyou have a better understanding.\nAnd now you can imagine that the full extent of disease in women\nmay not really be recognized.\nLet's go back and take a look at Jane's angiogram.\n\nLet's see.\n\nSo the inset, right here, if you take\na look at this particular blood vessel,\nperhaps Jane had a lot of diffuse plaque buildup.\nI mean, this vessel is clearly a lot smaller\nthan the other ones.\nBut you don't see any discrete blockage.\n\nSo if you can't see what you're treating,\nhow do you know you have something to treat?\nAnd I think it's been described that this is probably\na large part of what contributed to the big differences\nin the rate of death among men and women\nbetween the late '90s and early 2000s, if you go back and look\nat that mortality slide in the beginning.\nAll right, let's switch gears a little bit.\nLet's talk about Anne.\nShe's very healthy.\nShe's 43.\nAnd pretty much going about her business,\nand one day woke up having pretty severe chest discomfort\nright in the middle, and it radiated,\nit spread over to both arms.\nShe fell a little bit short of breath, a little sweaty,\nwent to the hospital.\nAnd then she had an electrocardiogram that really\ndidn't show all that much.\nBut when her blood test came back,\nshe had one specific blood test called the troponin I level.\nIt is supposed to be pretty low--\n0.4 is well above the upper range.\nIt's definitely abnormal.\nSo because of this she underwent coronary angiography.\nAnd what was found is the right coronary artery, which\nis the panel on the left, didn't really have too much.\nBut if you look at the left coronary artery,\nin the panel on the right, you can see that this particular\nblood vessel down the front-- and I'll let you take a look\nat it a bit more carefully--\nit looks completely diseased all over the place.\nIt is very different than the blood vessel on the left panel.\nAnd even the other branches over on the right panel--\nthat's the left anterior descending artery.\nAnd that's specifically where the electrocardiogram\nmight have shown changes.\nSo the cardiologist who did this thought that, hey,\nwe've got to get this taken care of-- she's having chest pain--\nand ended up putting a stent in.\nAnd the stent is almost like a pit in a python type of look.\nThe stent is a little too big compared to the blood vessel,\nbut given what was there to begin with, not\ntoo bad of a result.\nAnd so what do you do with something like this?\n\nYou put some on medicines, and over the next 10 years--\nliterally 10 years--\nAnne continue to have random episodes of chest pain\nand had a lot of atypical features,\nsort of like the ones we talked about in the past.\nThey come and go.\nThe intensity would vary.\nSometimes it would occur at night when she was sleeping.\nAnd it was pretty random, no real pattern to it.\nAnd to the point that her cardiologist had written\nin multiple notes that he thought\nthat the chest pain she was experiencing was,\nquote, \"noncardiac chest pain.\"\nAnd through the 10 years, just to check\nbecause she's had a stent already, just\nto check to see what else is going on,\nshe ended up having four different stress tests.\nAnd finally, the last one that she had\nshowed an abnormal finding.\nSo she was referred back to get another cardiac\ncatheterization.\nAnd take a look at the cornea arteries pretty carefully\nthis time.\nThe panel on the left, if you take a look\nat the right coronary artery right here,\nit looks actually bigger and smoother.\nAnd if you look at the panel on the right,\nthe blood vessel that was really heavily diseased 10 years ago,\nthis one that has a stent right about here,\nlooks pretty normal.\n\nTake a look at that.\nAnd if you compare 10 years ago to today--\nso here's 10 years ago.\nIf you look at this blood vessel down the front\nhere, compared to today it looks like a completely different\nperson.\nAnd so what exactly happened to Anne?\nI think, in this case, she probably\nhad a bit of plaque buildup.\nShe probably ended up having just vasospasm.\nSo what you're seeing right here is blood vessels\nare not exactly like lead pipes.\nThey're like soft rubber hoses, and they\ncan constrict and shrink and dilate and get bigger\nbased on how much blood flow is needed.\nAnd in some cases, if there's some sort\nof issue with the mechanism that causes\nthe blood vessels to shrink and dilate,\nyou can have a vasospasm.\nAnd sometimes it occurs in one blood vessel.\nSometimes it occurs in some other blood vessels.\nAnd this is probably what happened in Anne\nbecause her blood vessels look completely normal.\nAnd this is a procedure that I had done.\nAnd I put an IVUS done there, this Intravascular Ultrasound\ncatheter.\nIn fact, she had no plaque at all.\nAnd so her heart attack 10 years ago\nwas due specifically to vasospasm, and not\nnecessarily a \"true heart attack\"\nin the classic sense of the [INAUDIBLE] blood vessel.\nIn any case, so Anne just ended up\ncontinuing on with medical management.\nShe was treated with medicines that\nwas promoting blood vessel dilation to try to prevent it\nfrom constricting.\nAnd she has actually done pretty well.\nSo both the patients that we discussed actually\ndid quite well after their medicines were increased.\nAnd actually, eventually even Jane's symptoms\nimproved after she lost weight and had her medicines really\naggressively increased.\nAnd now their doctors, their cardiologists\nhad a better idea of what disease was actually there\nto need treatment, I think that they actually received\nmore appropriate treatment.\nAnd that's just across the board,\nhow that people have a little better understanding of what\nsort of disease women have, even if they don't\nhave the classic, just discreet severe blockage\nin a coronary artery.\nI think more women are being diagnosed and started\non appropriate therapies.\nSo treatment for these type of cases--\nif you have a severe blockage, then you\ngot to consider opening a blockage up\nto restore blood flow to the heart muscle.\nAnd that could involve putting a stent in or going\nthrough a bypass surgery if you have complicated\ndisease or multiple blockages.\nBut beyond that, that should be in addition to--\neveryone needs to be on what we call a guideline directive\nmedical therapy.\nSo you need to be on good medicines\nto prevent progression of disease.\nAnd these medicines, even in the absence of severe blockages,\ncan actually sometimes potentially\neven reverse plaque, as some studies potentially suggest.\nAnd along with guideline directed medical therapy,\nhaving a good diet, exercising--\nthe current recommendation is 30 minutes, 5 days a week.\nAnd if you smoke, that's a huge risk for having continued heart\ndisease.\nAnd these things are often enough to improve symptoms.\n\nSo now that doctors, like I said,\nwere able to identify people and treat them appropriately,\nyou're starting to see that as the number of deaths in women\npeaked in or about the year 2000,\nthe general trend followed the general trend of the reduction\nin deaths in males, in men such that in 2014,\nfor the first time in 30 years, the number of women\ndying from cardiovascular disease is now less than men.\nSo now like it or not, men are dying more again.\nSo unfortunately, we have seen an uptick in the rates of death\ndue to cardiovascular disease.\nAnd I'm not sure that's fully explained at this point.\nSo a lot of this is attributed to,\nI think, public awareness of a lot of the new research that\nhas been done, really plays a role\nin improving the outcomes for women.\nAnd part of this public awareness\nwas this very large initiative that I'm\nsure everyone's heard about, not only\nthe February American Heart Month but American Heart\nAssociation in 2004, launched a large initiative called\nGo Red for Women.\nAnd the point of this was to increase awareness\nabout women's heart health.\nAnd it's had significant impacts to the point\nwhere now, I think over 50% of women\nare aware that heart disease is actually\nthe leading cause of death.\nAnd breast cancer had been taking a lot of press,\nand it's not really a competition.\nBut these are issues that everyone--\nall of these issues need to be taken seriously.\n\nThat's a brief discussion about cardiovascular disease\nin women and the things that a cardiologist\nshould be paying attention to and\nthe things that the general public need to be aware about.\nSo I'll stop here, and I'll take any questions.\n\nOK, so here's a question.\nThe question is, can some chest tightness and/or shortness\nof breath indicate COPD as well?\nAnd if so, wouldn't that eventually translate\ninto heart issues?\nAnd what type of doctor should be seen in this instance?\nAnd what type of tests should be run?\nSo, absolutely.\nI think heart and lungs sometimes,\nit's difficult to separate out what's causing what.\nAnd hang on a sec.\nThat scrolled off the screen.\nSo absolutely can indicated COPD.\nBut oftentimes, people with COPD have had some risk factors\nto develop that as well.\nSo if there is concern, then I would certainly\nstart with your primary care physician,\nexpress the concerns, and what sort of tests can be run.\nThe first test that can be run to determine whether or not\nyour have COPD is just a lung function test.\nWe call it a pulmonary function test.\nAnd it will allow you to measure how well your lungs move air.\nAnd if it looks like there is any obstruction,\nthen it's potentially hinting at you might\nhave some issues with that.\nSo a primary care doctor can definitely start that process.\n\nSo it says, the internet says, occasional flutter feeling\nlasts a few seconds is normal.\nIs that always true?\nThat's hard to say because everyone\nwill have some abnormal heart beats at some point.\nIf you hook all of us up to a heart rhythm monitor,\nwe're all going get an extra beat or early beat or a skipped\nbeat every once in a while.\nI think if that happens occasionally,\nyou should mention it to your doctor just\nto make sure that there is nothing else\ngoing on because it depends on what else is associated too.\nAnd occasionally, some people may have a heart rhythm issue.\nSo I think, depending on what it is that you're feeling,\nwhat it is that you're describing to your doctor, that\nwould determine whether or not more testing is needed.\n\nAll right.\nHere's another question-- you talked about a pain\nin the left arm.\nWould a sharp, stabbing pain in the left\nshoulder down that arm that lasts few seconds be\na good description?\nI think if you're having that, and if you're\nhaving that frequently, it's something\nthat you might want to check with your doctor about,\nand see if more testing is needed.\nCertainly, it would be more of an atypical type of description\nbased on the traditional definition of anginal chest\npain, but certainly something that should not be ignored\nif you feel like it's abnormal.\n\nAll right.\nSo here here's another question--\nbeen frequently feeling a pulse heartbeat flutter-type feeling\nin my throat.\nShould I be concerned?\nThat's also a difficult one because it\ndepends on how often you're feeling it\nand what the circumstances are.\nAnd that's something I believe that you need to speak\nwith your doctor about.\nPerhaps a heart rhythm monitor may be needed.\nSometimes if you have some extra beats or skipped beats,\nthat can feel like it's the throat\nand feel like it's a bit of a flutter.\nAnd if you have that often, I think it's worth checking out.\n\nAll right.\nAre there any guidelines for working out?\nAbsolutely.\nThe American Heart Association itself puts out--\nhas a recommendation of exercising 30 minutes a day,\n5 days a week at a minimum.\nSo that's sort of minimum passing grade.\nAnd working out doesn't necessarily\nmean running a marathon or biking 50 miles\nor something like that.\nIt just means a brisk walk, something to stay active.\nAnd that's really what the American Heart Association\nis trying to get people to dd to stay active.\n\nCan you explain what normal blood pressure is?\nWell, so technically speaking, with the recent,\nI guess, guideline updates, the normal blood pressure\nis 120 over 80.\nAnd the top number is 120.\nWe call that the systolic number.\nAnd the bottom number is the diastolic number,\nand it should be under 80.\nAnything above that, you start getting into what\nwe call stage one hypertension.\nAnd what that means is, stage one\ndoesn't necessarily always necessitate\nyou starting to take medicines.\nBut it does really mean that you just\nneed to start paying attention to your blood pressure\nand tracking it carefully.\nSo if that's you, it would be helpful to figure out\nhow to track your blood pressure in some way.\n\nAll right.\n\nSo usually we are told that if we have high cholesterol,\nyou have a high risk for cardiovascular disease.\nI also heard that the criteria to look at\nis the number for the bad cholesterol, not\ntotal cholesterol.\nIn other words, as long as you have your number\nfor the good is very good, you shouldn't\nworry about that much.\nIs that correct?\nSort of.\nAs we were talking about earlier, a lot of times\nwe focus on the bad cholesterol number.\nBut I think, it really is a combination of both\nbecause, particularly in women, the good cholesterol level\nseems to be more predictive of the risk of developing\ncardiovascular disease than the bad cholesterol number.\nBut in either case, men or women,\nif you have a low good cholesterol number and, on top\nof that, a high bad cholesterol number,\nthat's not necessarily going to be good for you.\nSo that's something that can be changed with change and diet.\nGood cholesterol is generally associated with--\nyou can change that by exercising more, smoking,\nand stuff like that would certainly cut that out\nand that can help your cholesterol profile.\n\nWhat kind of food are recommended\nto keep your heart healthy because I think\nprevention is better than cure?\nAbsolutely.\nPrevention is always better than cure.\nUnfortunately, all the cures that we have-- quote unquote,\n\"cures\" are mostly band aids for stuff.\nThere's really no absolute cure for heart disease.\nAnd so in terms of foods, the recommendation\nis really just a balanced diet.\nAnd there's been more focus recently\non foods that have a lower glycemic index because it's\nthought to lead to lower risk of developing diabetes.\nAnd I know there's more of a focus on vegetables\nand plant-based stuff as well.\nI think, generally speaking, any one of these trends,\nhaving a balanced diet across the board,\nnot too much of one thing versus another,\ncutting out saturated fats and things like that,\nand eating more vegetables in general\nis just going to be good for you.\n\nHa!\nIs wine really good for your heart?\nSo the studies are mixed.\nAnd I think the consensus is that moderate drinking\nis actually good and lowers your risk of death.\nBut I think you have to take that with a grain of salt.\nYou can't just take that as, I should drink moderately.\nAnd because it's thought that if you drink moderately,\npeople who do that-- have, say, a glass of wine with dinner\nevery day--\ntended to have other healthier lifestyle choices as well.\nSo I'm not sure that that alone lowers the risk of--\nis good for your heart, necessarily.\nBut it's that along with all the other things that come with it\nthat's good for your heart.\n\nIs it true that genetics plays a significantly larger role\nin diet and lifestyle?\nWell, I would say that we're not at the point yet\nof understanding just how much of a role genetics play.\nI think we are at the point of being able to identify genes\nare associated with disease, but just because you have a gene\ndoesn't always mean-- depending on the disease and stuff--\ndoesn't always mean that you're going to develop the disease.\nAnd so I usually give advice that if you have a family\nhistory of heart disease, if you have,\nsay, your parents both had heart attacks before they were 50,\nyou probably have some genetics that if you\nadd on top of that, bad habits such as smoking,\neating way too much salt, you don't exercise,\nthat doesn't help the situation out at all.\nSo control what you can control.\nAnd the rest, unfortunately, right now we just\nhave to see what the research and studies show.\n\nOK.\nI think we're probably close to wrapping up here.\n\nAll right.\nWell, thank you.\nI want to thank everyone for taking time out their lunch\nhour to join us.\nAnd I thank you very much for your patience\nthrough all the technical difficulties that--\nthese heart health resources, here's some information\nthat if you're in the Sacramento region\nand need some cardiologist, advice, give your primary care\ndoctor a call, and we're happy to help you out.\nAll right.\nWell, thank you very much.\nIt's a great way to close out the 57th American Heart Month.\nAnd we'll see you in the future."} ```