Preventing Heart Desease

Preventing Heart Disease

Scientists now know far more about the major controllable risk factors for coronary artery disease (CAD) than for most other diseases. A risk factor merely increases the probability that you will develop CAD; it doesn't guarantee that you will develop it, nor does its absence (or even the absence of all risk factors) guarantee that you won't have a heart attack. For healthy people, the following steps have been shown to help reduce the risk factors for CAD. Keep in mind that reducing one risk factor may help reduce others. Exercising, for example, can help you control your weight, as can efforts to lower your cholesterol level through a low-fat diet.

1 Quit smoking. This is perhaps the single most effective step you can take. Anywhere from 20 to 40% (100,000 to 200,000 every year) of all CAD deaths in the U.S. are directly attributable to smoking. It more than doubles your chance of eventually having a heart attack and increases the chance of dying from it by 70%; it is also the leading cause of sudden cardiac death. The good news: Quitting smoking quickly reduces your CAD risk; within five to ten years of quitting, your risk of heart attack declines to a level similar to that of people who never smoked, regardless of how long you smoked.

2 Reduce your blood cholesterol. For every 1% reduction in high blood cholesterol, there's a 2 to 3% decline in the risk of heart attack.

3 Avoid or control hypertension. High blood pressure is a risk factor for stroke and heart attack. For every one-point reduction in diastolic blood pressure, there's a 2 to 3% decline in the risk of heart attack. If you can reduce your blood pressure by making the appropriate lifestyle changes—including limiting intake of sodium, calories, and alcohol—the coronary benefits are likely to be particularly great.

4 Stay active. Exercise protects against CAD by helping the heart work more efficiently, reducing blood pressure, raising HDL cholesterol, decreasing the tendency of blood to form clots, moderating stress, helping the body use insulin, and helping people maintain a healthy weight. Sedentary people who begin a regular program of exercise reduce their risk of a heart attack by 35 to 55%. Low-intensity activities, such as gardening or walking, if done regularly and over the long term, can decrease the risk of heart attack.

5 Maintain a healthy weight. About one in three American adults is obese (weighing at least 20% above the "suggested" weight for their height), which doubles their risk for CAD at a given age. Obesity also increases the risk for diabetes, hypertension, and high blood cholesterol, which further worsen the risk for CAD.

6 Avoid or control diabetes. Type 2 diabetes (non-insulin-dependent), which afflicts more than 14 million Americans, is an important risk factor for both CAD and hypertension. Diabetic men have two to three times the risk of having coronary heart disease than those without diabetes. Weight control and exercise can improve the utilization of blood sugar and prevent or slow down the onset of diabetes—and reduce the incidence of heart disease.

7 Consider a drink a day. There's a growing consensus that light to moderate alcohol consumption—that is, two drinks or less a day for a man, one drink for a woman (a drink is defined as 12 ounces of beer, 4 ounces of wine, or 1.5 ounces of 80-proof spirits) can help prevent heart attacks. However, drinking more than that can increase the risk of heart attack and stroke, as well as cirrhosis, cancer, and accidents.

8 Consider low-dose aspirin. The recommended regimen—a baby aspirin (81 milligrams) daily or half a regular aspirin (160 milligrams) very other day—can lower the risk of heart attack by about one-third by reducing the ability of platelets in the blood to stick together and thus form a clot. It is particularly advisable if you have an elevated risk of CAD. Aspirin can have side effects and isn't right for everyone, so be sure to consult with your physician first.

Note on diet: Although eating a healthful, low-fat diet is not generally considered a separate preventive measure, cutting back on fat, particularly saturated fat, and eating foods that provide complex carbohydrates clearly plays a role in many of the listed measures, such as controlling cholesterol, blood pressure, and body weight.

In addition, there has been accumulating evidence that a high intake of antioxidant vitamins—particularly vitamin E—helps reduce the risk of CAD. (See 14 Keys to a Healthy Diet.)

Monitoring Your Blood Pressure

Blood pressure is indicated by two numbers, each referring to how high in millimeters the pressure of the blood in your arteries can raise a column of mercury (Hg). The first number, the systolic pressure, represents the force of blood during a heartbeat. The second number, the diastolic, indicates the pressure between heartbeats. Blood pressure measurements for establishing hypertension now reflect equal emphasis on systolic and diastolic pressure, whereas previously only diastolic. Levels above 140/90 mm Hg are generally thought to require medical treatment, often beginning with the lifestyle measures given below.

Seven Steps to Control Blood Pressure

• Lose weight if you are overweight—even a small drop in weight can lower blood pressure significantly. In some overweight people, a loss of as little as 5 to 10 pounds can make antihypertensive drugs unnecessary.
• Limit your daily alcohol intake to less than two drinks daily.

• Exercise regularly.

• Don't smoke.

• Keep your sodium intake under 2,400 milligrams per day (the amount in 6 grams of salt—a little more than a teaspoon).

• Maintain an adequate dietary intake of potassium, calcium, magnesium, and dietary fiber, which may help prevent or lower high blood pressure.

• Reduce your intake of saturated fat and cholesterol, which can help you reduce weight and is beneficial for overall cardiovascular health

How to Lower Your Cancer Risk

How to Lower Your Cancer Risk

The newspapers and other media are rife with reports that this or that food or chemical or environmental factor—everything from canaries to toasters—causes cancer. But most reports are given out of context, and it's easy to lose sight of the big picture and of the scientific progress that's been made in understanding and preventing cancer.

Cancer does not kill as many people as heart disease, but it still claims 560,000 American lives a year. Four major cancers (lung, colorectal, breast, and prostate) account for slightly more than half of these deaths. Some kinds of cancer (stomach, cervical, and uterine) have dramatically declined in this country, both in incidence and as a cause of death, while others are rising, or seem to be rising. For example, breast and prostate cancer may be occurring more often, or may simply be accurately diagnosed more frequently. (In fact, the number of new cases of prostate cancer has begun to drop, at least for white Americans.) Some other cancers appear to be occurring more frequently because the population is aging.

People often wonder when the "cancer breakthrough" will occur: when will researchers unlock the secret and find the cure? The dramatic breakthroughs we all yearn for—a cancer vaccine, perhaps, or a miraculous cure for all kinds of cancer—may or may not materialize. But enormous progress has been made, and insight into the origins and causes of cancer is growing.

Many of us worry too much about possible cancer promoters that are actually negligible. And at the same time, we may pay too little attention to simple but effective measures we can take to protect ourselves. Important measures for preventing cancer are already at hand.

How does cancer occur?

Genetics has something to do with cancer, though the picture is far from clear. Genes control every aspect of our body chemistry and the growth of cells; some genes may promote cancer, others may protect against it. There is a puzzling interplay of environmental, life-style, and genetic factors, and it's still uncertain where environmental and life-style influences actually come in. Generating energy, which is the basic process of all life, produces unstable molecules known as free radicals that can damage genetic material. This is a normal, everyday process, and most damage is immediately repaired. But sometimes the repair process fails. Exposure to our own hormones, to infectious organisms that have penetrated our immune defenses, and to environmental toxins can also create free radicals that scramble genetic codes and eventually damage cells. If cells are damaged, cell growth may produce tumors rather than copies of healthy cells. It's estimated that three-quarters of all cancers occur largely because of external influences, not our genes.

What you can do

1 Don't smoke. Tobacco use causes more cancer here and in the rest of the world than anything else. The longer you smoke, and the more you smoke, the likelier it is to be lethal. Besides lung cancer, smoking increases the risk of cancer of the bladder, cervix, mouth, throat, pancreas, kidney, and stomach. It may also promote colon and even breast cancer. About 3 million people die of smoking-related causes every year around the world, and that number will rise to 10 million in the next century if the number of smokers continues to increase. Passive smoking (inhaling other people's smoke) causes thousands of deaths a year.

If all tobacco users in this country quit, total deaths from cancer would eventually drop by at least one-third. Lung cancer would become a rare disease, rather than the major cancer killer of both American men and women that it now is.

2 Eat more fruits, vegetables, and whole grains. Diet causes about one-third of all cancer cases, almost as many as tobacco use. Having a diet that consists predominantly of fruits, vegetables, and grains (the current recommendation is at least five servings of fruits and vegetables a day) is the most important factor currently identified in the prevention of cancer through diet. The evidence for this is overwhelming: study after study has confirmed that people who have the highest intakes of fruit and vegetables have the lowest rates of most cancers. Fruits and vegetables contain large amounts of antioxidant vitamins (C and E), as well as folacin, carotenoids, and dietary fiber, which are all important in preventing cancer. Many phytochemicals (plant chemicals) have been shown to have cancer-fighting potential in laboratory studies—and many are still waiting to be discovered.

3 Eat less animal fat. A diet high in animal fat, especially from red meat, has shown up in several studies as a risk factor for prostate and colon cancer. A high-fat diet is also suspected of being a factor in breast cancer, although recent research suggests there is no link. Countries with high-fat diets do have the highest rates of breast and prostate cancer, but other factors could be at work.

4 Don't cook meats at very high temperatures, especially over an open flame. This creates compounds known to promote certain cancers—for example, polycyclic aromatic hydrocarbons (PAHs), which form when meats are charcoal-broiled. An occasional barbecue is probably not harmful. You're better off to steam, braise, bake, poach, stew, or microwave than to barbecue.

5 Limit you alcohol intake. Moderate alcohol intake can help prevent heart disease. ("Moderate" means no more than one drink daily for women, two for men.) But too much alcohol can cause cirrhosis of the liver and liver cancer. Especially when combined with smoking, heavy drinking also contributes to cancers of the mouth, throat, and esophagus, for example. Thus, some experts still say that drinking no alcohol is best.

6 Be active. In the past ten years, studies have suggested that exercise helps prevent breast and prostate cancer, and there's solid evidence it can prevent colon cancer. It's hard to say what level of activity is needed; but moderate activity starting early in a woman's life seems to protect against breast cancer.

7 Control your weight. Being significantly overweight puts you at risk for such diseases as stroke and heart disease, and probably also for some cancers (uterine and postmenopausal breast cancer in women; colon and prostate cancer in men). No one is sure why obesity might boost the risk of cancer. Nevertheless, this is still another reason to maintain a healthy weight.

8 Limit your exposure to the sun. Use a potent sunscreen when you are in the sun. Cumulative sun exposure is responsible for most skin cancers, which account for about 2% of cancer deaths.

9 Limit workplace exposure to chemicals. For people who work with cancer-causing chemicals, such as asbestos, benzene, and formaldehyde, this is a serious problem. However, extensive exposure to such chemicals is uncommon among the population at large.

What about pesticides?

Food is a complex mixture of natural ingredients, not all of them benign. Plants themselves produce pesticides to ward off attack from animals and microorganisms. Our bodies are equipped to defend themselves against most of the potentially harmful elements in foods, just as we have chemical defenses against other kinds of low-level toxins. But it's man-made pesticides that cause the most worry. Humans have been consuming natural pesticides for thousands of years, and we may have ways of protecting ourselves from them, whereas we might be less able to fend off synthetic chemicals. Much remains to be learned about pesticide residues in foods. As yet, there's no evidence that they are a significant cause of cancer.

Should You Drink Alcohol foy Your Heart?

Should You Drink Alcohol for Your Heart?

A recent, widely publicized study in the New England Journal of Medicine has led a lot of drinkers to congratulate themselves, and a lot of nondrinkers to wonder if they should start. "Drinking is good for your heart," the newspaper headlines announced, "and the more you drink, the better."

This was a well-designed study funded by the National Institutes of Health. It tracked the drinking habits of 38,000 men—all healthy at the beginning of the study—over 12 years. Men who drank at least three or four days a week had fewer heart attacks than those who drank less. It didn’t matter what they drank—beer, wine, or spirits—or whether they drank it with meals. The positive news didn’t end there. From the point of view of preventing heart attacks, drinking every day was better than drinking occasionally, and three drinks were better than one. Should you say hooray and head for the liquor store?
We don’t think so. Whether, when, and how much you should drink is a complex question, and the answer should be based on your current state of health, medical history, family history, age, sex, and other factors. If ever there was a double-edged sword, it’s alcohol. It benefits people (and society) in some ways and devastates them in others. It is associated with some 100,000 deaths a year from disease and injury—more than the number of deaths from heart disease (estimated at perhaps 80,000) that it may prevent. And alcohol-related deaths occur mostly among the young.

Before you embrace alcohol as heart medicine, here are some Q & A’s to consider.

Does alcohol protect the heart? If so, how?

Dozens of studies have found that moderate or light drinkers have a lower risk of heart disease—30 to 50% lower—than nondrinkers. There is hardly any argument about this now. Furthermore, researchers have found that even when moderate drinkers do have a heart attack, they have a lower risk of dying than teetotalers or heavy drinkers, and older people who drink moderately have a lower risk of heart failure.
Alcohol raises blood levels of HDL ("good") cholesterol—which removes cholesterol from the bloodstream—and thus helps prevent hardening of the arteries (atherosclerosis). Alcohol also reduces the stickiness of platelets in the blood and thus helps prevent the blood clots that cause heart attacks. Consequently, some people compare alcohol to aspirin as a way to prevent clot formation or break up clots. And, yes, both can be helpful, if taken in small doses. But unlike aspirin, alcohol is intoxicating and potentially addictive. The point is that alcohol is only one of several things that may protect your heart. You can reduce your risk of heart disease without drinking at all.

How clear is the evidence about the protective effect?

The evidence so far is very clear. Yet there has never been a large-scale, long-term, well-designed clinical trial testing the effect of alcohol. No matter how carefully conducted, nearly all the studies, including the one mentioned in the first paragraph, have been observational. That is, they followed groups of drinkers and nondrinkers and compared their health over time—a valuable kind of research, but never definitive. Remember, when the evidence about hormone replacement therapy (HRT) and its benefits for women’s hearts—evidence gleaned from observational studies—was tested in controlled clinical trials, the benefits vanished. Indeed, HRT turned out to do some harm.

It is hard to separate alcohol from all the other factors that affect heart disease risk (that is, "control" for those factors) in a study. For instance, moderate drinkers may have healthier habits to begin with—and thus be less likely to have heart disease. Similarly, women taking HRT tended to lead healthier lives and be better educated and more well-to-do, which may have accounted for their lower risk.

What other health benefits, if any, does alcohol have?

Even as little as one drink a week may protect against ischemic stroke (the most common type). Some research also suggests that moderate drinking may cut the risk of developing dementia, including Alzheimer’s disease.

Is wine a better choice than beer or spirits?

It’s almost certainly the alcohol that’s protective, so it doesn’t matter much which beverage you drink. Nevertheless, how you drink the beverage may be important. Beer and wine tend to accompany food—and food slows the absorption of alcohol, which is good. Furthermore, people who drink at meals, especially in the company of others, tend to keep intake moderate. Heavy drinkers usually drink outside of meals. It’s true that wine (red or white) contains certain phytochemicals that may protect against heart disease or even cancer—and nonfermented grape juice also contains these compounds. Beer and spirits, made from grains and other plants, have phytochemicals of their own. Wine may simply seem healthier than other drinks because wine drinkers tend to be better educated and more prosperous than other drinkers, which means they tend to have better diets and better health care.

Isn’t it wine that protects the French from heart disease—even though they eat so much cheese, meat, and butter?

Wine is only a small part of the picture. This is the famous "French paradox"—the French diet generally includes relatively high amounts of animal fat, but the French have lower rates of heart disease than Americans. Most important, though, the French tend to consume fewer calories and to be more active. And while the French have a lower death rate from heart disease, French life expectancy is only a year longer than that of Americans. In any case, wine consumption has been falling in France for decades, and half of all adults don’t drink at all. It would be unwise to conclude from all this that drinking wine will make up for a diet high in calories and saturated fat.

What is "moderation"?

This is a tricky question, and it varies according to your age and sex. The official definition of a "drink" is 12 ounces of beer, 4 to 5 ounces of wine, and 1.5 ounces of 80-proof spirits. Most people are surprised to learn that these all contain the same amount of pure alcohol, about half an ounce (a little more in the spirits). Moderate intake is no more than one drink per day for a woman, on average, or two drinks for a man. Most studies have found that people who drink this much have the lowest overall mortality rate—lower than nondrinkers, occasional drinkers, and heavy drinkers.

But, in fact, the studies diverge. The new one described in the first paragraph found higher intakes beneficial. Other studies have found lower intakes to be best. Moreover, if it’s healthy for a man to have up to 14 drinks a week, can he drink six on Friday and six on Saturday and abstain the rest of the week? Probably not—binge drinking appears to be harmful. What about body size: is it okay for a tall man who weighs 200 pounds to drink more? What about an athletic woman that same size? Or a man 5'4" and thin? Even one drink can be too much for a very small woman. Obviously, size can sometimes trump gender, or at least confuse the issue. And age comes into play, too, since alcohol affects older people more (see below).

Another problem: Portion inflation occurs not only on your plate, but in your glass. Many bars and restaurants do not serve standard-sized drinks, and what’s served as one drink actually may be the equivalent of two or even three. Most people are pleased to be served generously—but you can’t take half your drink home in a doggy bag, as you can your entree. If you ordinarily serve wine or spirits at home without measuring, it might be instructive to measure and see how close you come to the standard serving sizes. That will give you some idea, too, of how much you’re getting in a restaurant.

Why are the guidelines different for men and women?

Alcohol affects men and women differently. A woman will get more intoxicated than a man from the same amount of alcohol. Women tend to be smaller, with a lower percentage of water and a higher percentage of body fat. Since alcohol is distributed through body water and is more soluble in water than in fat, blood alcohol concentrations (BACs) in women tend to be higher. In addition, the stomach enzyme that breaks down alcohol before it reaches the bloodstream is less active in women. Alcohol also carries additional health risks for women, since heavy drinking boosts the risk of osteoporosis. Women are more prone to suffer liver damage from heavy drinking, too.

Is "moderation" the same for older people?

The definition of moderate changes as you get older. Most experts think that after 65, moderation means half a drink a day for a woman, one drink for a man. If you’re over 65, you probably can’t hold your alcohol as well as you used to. That’s because your body doesn’t process alcohol as well, so you end up with a higher BAC than a younger person would. And you feel the effects more from a given BAC. Alcohol is doubly risky for hip fractures, too: not only does excessive drinking decrease bone density, it also increases the risk of falls in older people. Alcohol can interfere with many medications older people take, as well as increase age-related driving risks.

What about breast cancer?

The American Cancer Society lists alcohol as a risk factor for breast cancer, but most of the evidence concerns heavy drinking. Studies have yielded conflicting results about light to moderate drinking. Should a woman have a drink a day to ward off heart disease and forget about the possible breast cancer risk? Nobody should start drinking to protect the heart. But if you already have a drink a day, there’s no health reason to quit, unless you know you are at high risk for breast cancer. Even then, the evidence is far from clear.

Why does the American Cancer Society recommend
restricting alcohol or abstaining?

Because even a moderate intake may increase the risk of cancers of the mouth, esophagus, liver, bladder, pancreas, and colon—besides the concern about breast cancer.

Wouldn’t it be okay for a pregnant or nursing woman to drink just a small amount?

If you are pregnant, trying to conceive, or nursing, you should abstain. Alcohol harms the fetus and the nursing infant, and is a leading cause of birth defects and mental retardation. No one has been able to determine if any level of intake—even one drink now and then—is safe.

Who, besides pregnant women, should steer clear of alcohol?

• Anyone who is unable to drink moderately. This includes recovering alcoholics and possibly those with a strong family history of alcoholism.

• Anyone taking sedatives, sleeping pills, antidepressants, or anticonvulsants should get medical advice about whether these drugs can be safely combined with alcohol. Alcohol can interact with many other medications, too, including over-the-counter pain relievers. When you get a new prescription, ask whether it’s okay to drink. With nonprescription medication, read the label carefully and abstain if necessary.

• Don’t drink if you are planning to drive or operate machinery within the next few hours. If you have had a drink, don’t get behind the wheel.

• Don’t drink if you have uncontrolled hypertension, high blood levels of triglycerides, abnormal heart rhythms, peptic ulcers, or sleep apnea. If diagnosed with any disorder, talk to your doctor about the advisability of drinking.

What are other risks of heavy drinking?

Heavy drinking increases the risk of liver disease, damage to the brain and pancreas, and hemorrhagic stroke. It can damage heart muscle. It increases the risk of falls, injuries, car crashes (often involving pedestrians who have been drinking), workplace injuries, firearms injuries, homicides, and suicides. It contributes to domestic violence and child abuse.

Should anybody start drinking for heart benefits?

Few doctors think so, particularly since much is left to learn and alcohol is so risky. If you don’t drink, for whatever reason, don’t feel pressured to start. There are better ways to prevent heart disease: following a heart-healthy diet, exercising regularly and vigorously, not smoking, keeping your blood pressure under control, and losing weight if need be. On medical advice, you may also want to take low-dose aspirin and, if necessary, a cholesterol-lowering drug. If you already drink moderately, you are probably getting some additional benefit. But do consider your age, sex, and family history. Remember that "moderation" for a woman means no more than one drink a day, on average, two drinks for a man. And that if you are past 65, you should probably cut that amount in half.

New Advice for a Healthy Heart

New Advice for a Healthy Heart

We reported in February on the growing popularity of cholesterol-lowering "statin" drugs, which many healthy people take to prevent heart disease. Among the most widely prescribed drugs in the world, statins will surely be even more popular now that an important government-sponsored panel of heart disease experts has announced aggressive new recommendations for treating high blood cholesterol. If everyone followed the guidelines, it's estimated that 65 million Americans would change their diet and make other life-style changes, up from 50 million under the old guidelines, and as many as 36 million would take cholesterol-lowering drugs, compared to the current 13 million. Recent studies show that such preventive treatment could substantially cut the number of deaths from heart disease, the No.1 killer in this country.

Under the new guidelines, many more Americans are considered to be at high risk for a heart attack than before, and are thus candidates for cholesterol-lowering life-style changes and possibly drug therapy. Now more than ever, you really need to work with your doctor to evaluate your level of risk. Even if you have previously had your blood cholesterol measured and discussed your heart health with your doctor, the new guidelines mean that you'll need re-evaluation.

Here are some of the main changes in testing and treatment that may affect you:

• First, everyone age 20 or older should have a complete blood cholesterol test, called a "lipid panel" or "lipoprotein profile," which, unlike the simpler screening test, requires a 12-hour fast. This measures total cholesterol, as well as LDL ("bad") and HDL ("good") cholesterol and triglycerides (fats in the blood). You also need to know your blood pressure.

• While the guidelines for total cholesterol haven't changed (below 200 is "desirable," 240 and above is "high"), those for LDL and HDL have. Desirable LDL levels (now called "optimal" or "near optimal") are still less than 130, unless you're at high risk for a heart attack (see below), in which case the new goal is a very low 100. In the past only those who already had heart disease needed to aim for this stringent target. For most people, this requires medication. The minimum for HDL has been raised to 40, up from 35. HDL below 40 is considered a coronary risk factor.

• The risk factors for heart disease are mostly the same, notably age, smoking, high total and/or LDL cholesterol, low HDL, high blood pressure, family history of premature heart disease, and obesity. These factors are even more important now in determining how aggressively your elevated cholesterol will be treated.

• Diabetes is now singled out as so potent a risk factor for heart disease that by itself it puts you in the highest-risk category, along with people who already have heart disease. So everyone aged 45 and over should be tested for diabetes. And people with diabetes now need to get their LDL below 100, which usually requires drug therapy.

• One new risk factor is called "metabolic syndrome," which is largely related to obesity and inactivity. You qualify if you have three or more of the following: abdominal obesity (a waist more than 40 inches for a man, 35 for a woman); low HDL (below 40 for a man, 50 for a woman); fasting triglycerides of 150 or more; elevated blood pressure; and fasting glucose of 110 or more.

The risk calculator

The guidelines include a "risk calculator," based on research from the famous Framingham Heart Study. It uses your age, cholesterol levels, smoking status, and blood pressure to come up with your risk for having a heart attack during the next decade. The calculator does not, by itself, provide the whole picture, however, and the results can be confusing. You should do this risk assessment test with your doctor. The results, along with your LDL level and other risk factors, will help your doctor determine how much you need to lower your LDL through life-style changes and perhaps cholesterol-lowering drugs.

Still, if you want to try this formula yourself, it's easiest to use the government's website, which also provides lots of helpful information about coronary artery disease. You can also get a free copy by writing to the NHLBI Information Center, P.O. Box 30105, Bethesda MD 20824-0105, or call 301-592-8573; ask for "High Blood Cholesterol—What You Need to Know."

Living the good life

The guidelines also stress the importance of life-style changes, even for those taking medication. These steps include exercising, losing weight (via calorie reduction), stopping smoking, and especially adopting a cholesterol-lowering diet. For people with elevated blood cholesterol and risk factors, the dietary goals are stringent: lower saturated fat (less than 7% of total calories, instead of 10% on the usual heart-healthy diet) and lower dietary cholesterol (less than 200 milligrams a day, down from 300). But they do allow for more monounsaturated fat (up to 20% of total calories, instead of 10 to 15%, especially for those with diabetes or the "metabolic syndrome" described above). There's also new emphasis on consuming lots of cholesterol-lowering soluble fiber, like that found in oats and beans, along with plant compounds called stanols or sterols, found in some specialty margarines, such as Benecol.

Most people, and many doctors, are going to focus on the drug advice in the new guidelines, rather than the life-style advice. That would be a mistake. Statin drugs are expensive—$1,000 to $1,800 a year—and presumably you'll have to take medication for life. While they seem to be safe and work well (and may have other benefits, too), statins can cause minor side effects, such as gastrointestinal upset, sleep problems, and rashes. More rarely, statins can cause severe muscle and liver damage, so you need periodic blood tests for liver function. In addition, no one knows how safe they are when taken for many years or decades.

Last words

The new recommendations make it all the more important that you talk to your doctor about heart disease. They also make it more likely that doctors will quickly put more patients on statins (or other cholesterol-lowering drugs). That will save lives, but having tens of millions of Americans on cholesterol-lowering drugs is a far-from-perfect solution. Most people don't give life-style changes a real chance, and their doctors don't help them enough in their efforts. Take medication if you need it, but make sure you really need it first. Losing weight, becoming more active, improving your diet (especially by eating more fruits, vegetables, and whole grains), and stopping smoking will help keep you healthy in many ways besides lowering your cholesterol. These steps, for instance, will also help prevent diabetes and "metabolic syndrome," two of the big risk factors for heart disease.

Maintaining Mental Health in Time of Crisis

Maintaining Mental Health in Time of Crisis

The attacks on New York City and the Pentagon in September, among many other results, have played havoc with our mental and emotional life. No one knows how many people sought crisis counseling in the aftermath—or needed it and did not seek it. The list of traumatized people was very long: rescue workers, those who had lost friends, colleagues, spouses, parents and other family members, and eyewitnesses to the disasters, in reality or on TV.

As the war against terrorism goes on, anxiety about economic repercussions and bioterrorism also take their toll. Mental-health experts, testifying before the Senate in mid-September, said that an unprecedented number of Americans were at risk for depression and other disorders. Part of the federal aid package for New York City was a grant for mental-health services. Research from the aftermath of the Oklahoma City bombing in 1995 suggests that it may take a while before people work through the shock and denial phases of their reaction and come in for professional help.

Unfortunately, many people deny the need for help. To admit that a problem exists is often the first step in solving it. No form of therapy is a guaranteed cure. But the very act of seeking help may be a form of therapy in itself.

Maybe all you need is some sympathetic advice—or just somebody to listen to you and reassure you—and short-term therapy is growing in availability. Short-term counseling can help the bereaved or those with family problems. These times may also put a stress on relationships. Couples counseling is one good example of short-term therapy. One of the strongest trends of recent years has been toward a varied menu of therapies—a person may try everything from years of psychoanalysis to single sessions or self-help groups. It is important to find out how various therapists work and how you feel about the process.

Start by asking your primary-care physician for advice and a referral. Or a friend may be able to recommend a therapist. Shop around before making a commitment. Talk with several therapists, if you wish, and compare approaches. Most people will want to be sure that the therapist is comfortable with them, too—that he/she can treat a variety of problems without prejudice. Most therapists will charge for trial visits. Some may be willing to discuss their methods over the phone without charging.

Some people may opt for psychoanalysis, requiring frequent sessions and usually years of delving into the past. (Not all long-term psychotherapy is psychoanalysis, however.) Those trying to deal with grief or other crises may do just as well with other trained and qualified therapists. If you or a family member suffers from severe psychosis (such as schizophrenia or manic depression) you'll need an M.D., because hospitalization and psychotherapeutic drugs may be necessary.

Evaluating the care you get

The therapist's credentials and reputation are important, but so are your own feelings. You should ask yourself if you feel comfortable with the therapist, and if you believe this person can help you. According to guidelines issued by the National Institute of Mental Health, you should be able to express your concerns openly with your therapist, and if you don't "click" with one therapist you should consider finding another.
Be sure that both you and your therapist understand your goals—even if your goal is as vague as simply feeling less miserable. If you have doubts about the therapy or the therapist, express them to your therapist.

Paying for it

Self-help groups are free. But self-help may not answer your needs. Psychoanalysis, on the other hand, costs thousands of dollars annually. Drugs, if you require them, may be expensive and may not be covered by insurance. Short-term care is obviously less costly and may be available through employee-assistance programs. Many therapists are willing to accept what their patients can afford. But think twice before counting on your health insurance policy. Most insurance policies pay only in part for outpatient mental-health care. Some policies exclude psychiatric treatment altogether. Moreover, if you apply for reimbursement for mental-health care, this will become part of your permanent medical records, and may be a factor if you apply later for life insurance or individual health insurance.

The good news: Medicare covers up to half the cst for mental health services, and most supplemental (Medigap) policies pick up the rest—provided the therapist is willing to settle for what they allow. A bill is currently before Congress mandating higher Medicare coverage (Medicare Mental Health Modernization Act of 2001, sponsored by Senator Paul Wellstone of Minnesota and Representative Pete Stark of California).

Medicine for the mind

Antidepressants and anti-anxiety drugs have come into wide use as adjuncts to talk therapy—or replacements for it. Drugs usually work faster and cost less than therapy, so HMOs favor them, and sometimes doctors and patients do, too. Prescriptions for these drugs were the third largest category of all drug sales by 1998, written not only by psychiatrists, but also primary-care physicians.

Antidepressants: Those prescribed today are usually the SSRIs (selective serotonin reuptake inhibitors). This mouthful means that the medication helps keep the brain chemical serotonin at desirable levels—so that instead of feeling depressed, for example, you may have a sense of well-being. Prozac is the most famous of these; it is now also available as a generic (fluoxetine). Other SSRIs include Paxil (paroxetine), Celexa (citalopram), Zoloft (sertraline), and Luvox (fluvoxamine). All have been shown to be helpful for mild to moderate depression. Other antidepressants that work on different brain chemicals may also help.

Choosing the right drug and the right dose usually takes experimentation—under a physician's supervision. It takes about two to six weeks before SSRIs are fully effective. All of these drugs have side effects.

Anti-anxiety drugs: Benzodiazepines, the most commonly prescribed tranquilizers, are used for anxiety rather than depression. Examples include Xanax (alprazolam), Valium (diazepam), Ativan (lorazepam), and Librium (chlordiazepoxide). They can cause drowsiness—indeed, sometimes they are prescribed as sleeping pills or sedatives. But they should not be used long term, because they are habituating—that is, they lose their effectiveness over time. They can also cause disorientation and other side effects.

Antidepressants and anti-anxiety drugs should not be used with alcohol.

Dealing with traumatic stress

Post-traumatic stress disorder (PTSD) is a relatively new term for what used to be called "shell shock," the disabling anxiety disorder first noticed among soldiers who had been through battlefield horrors. (Every war produces its share of such cases.) But PTSD can affect civilians, too—people who've lived through bombardment, imprisonment, or torture; earthquake and hurricane survivors; children who witness terrible events or are subjected to abuse; and victims of rape or other forms of violence. Some survivors of the September terrorist attacks may suffer from it, particularly rescue workers and the bereaved, as well as those who witnessed events up close.

Symptoms can include intense feelings of helplessness, anger, denial coupled with numbness, grief, and possibly hatred and mistrust of everyone. Insomnia is common, along with bad dreams and nightmares. Survivor guilt ("why didn't I get killed, too?") may torment people. Many relive their experiences in flashbacks and dreams. A few think of suicide.

Still, the great majority of people recover and go on. PTSD is usually diagnosed when the symptoms continue for more than a month. Nobody can explain why some people recover from trauma and others don't. But the very young and the very old, those in frail physical or mental health to begin with, and survivors of past trauma may be more vulnerable than others.

If you or someone you care about needs help with PTSD, look for a therapist with training in treating it. Psychotherapy and medication are the two main approaches. If your symptoms are milder, you may do all right without medications. But if therapy doesn't help, medication can get you past a crisis. A therapist can teach you skills to manage your anxiety and help you challenge irrational beliefs.

A glossary of therapies and therapists

Talk therapy takes place in many settings and in many forms. It may consist of long-term therapy or short-term counseling. Individual therapy may be combined with group therapy or self-help groups. There's little to indicate that one kind of therapy is superior to another.


• One-on-one therapy: May deal with immediate or long-term problems; often tries to uncover underlying causes in the past.

• Couples and/or family therapy: Discussions with a psychiatrist, psychologist, marriage and family therapist, or other trained and licensed mental-health professional. Focuses on psychological dynamics between spouses, partners, lovers, and friends, and among family members and even co-workers.

• Self-help groups: Informal groups that discuss shared problems, such as a mental or physical illness, addictions, and personal crises and life changes. Alcoholics Anonymous is the oldest and best known.

• Psychologists: Clinical psychologists usually treat single patients; may work as counselors in businesses, schools, mental-health centers, and hospitals. Usually have a doctorate plus postdoctoral training.

• Psychiatrists: M.D.s with several years of postgraduate training. Can prescribe medicines and hospitalize patients. May treat a range of problems, from severe psychoses to milder emotional disorders; may specialize in child, adolescent, or geriatric psychiatry.

• Psychoanalysts: Usually M.D.s with additional psycho-analytic training. Only those who are M.D.s can prescribe drugs and hospitalize patients. Members of the American Psychoanalytic Association have received rigorous training in institutes approved by the Association. However, other schools also train analysts, and almost anybody can legally call himself a "psychoanalyst."

• Psychiatric social workers: May direct clinics or have private practices, and are often active in community programs, such as drug-abuse treatment. Must be licensed.

• Psychotherapist, psychiatric counselor: If you choose someone who practices under such a catchall title, ask about his/her training and background. In particular, marriage and family therapists and clinical social workers often call themselves psychotherapists. But people can set themselves up as "psychotherapists" without being trained or licensed.

Resources

Your primary-care physician, teaching hospitals, university departments of psychology and social work, and local self-help groups are potential sources of referrals. Many employee-assistance programs also offer confidential counseling and referrals. Your local library, and even the Yellow Pages, are other good places to start. Here's a partial listing:

• The Knowledge Exchange Network (KEN) of the Center for Mental Health Services can direct you to organizations and offers many publications.
KEN, P.O. Box 42490
Washington, DC 20015
800-789-2647


• The National Mental Health Association (NMHA) provides brochures and referrals.
NMHA, 1021 Prince Street
Alexandria, VA 22314
800-969-NMHA (6642) or 703-684-7722


• The National Mental Health Consumers Self-Help Clearinghouse can help you connect with self-help groups.
1211 Chestnut Street, Suite 1207
Philadelphia PA 19107
800-553-4539 or 215-751-1810


• The American Psychiatric Association offers free pamphlets on mental disorders, substance abuse, and choosing a psychiatrist.
APA Division of Public Affairs
1400 K Street NW, Washington, DC 20005
888-357-7924


• The American Psychological Association publishes pamphlets on mental health problems, as well as lists of psychological associations in your area.
750 First Street NE
Washington, D.C. 20002-4242
800-964-2000


• The National Association of Social Workers (NASW) provides lists of credentialed members.
750 First Street NE, Suite 700
Washington DC 20002-4241
800-638-8799 or 202-408-8600


• The American Association for Marriage and Family Therapy provides tapes, brochures, and lists of licensed counselors.
1133 15th Street NW, Suite 300,
Washington DC 20005-2710
202-452-0109