Interactive Learning : HealthCast Transcripts
Episode 34: Prevention, Prevention, Prevention
Release Date: January 29, 2010
Dr. Meyerson: Hi. I'm Dr. David Meyerson, Cardiologist at Johns Hopkins and your host for this edition of Vascular Disease Foundation's Health Cast.
We're very excited to be able to bring excellent, easy to understand science to you on all topics relating to heart and blood vessel diseases as a public service.
Prior episodes in this series have dealt with clinical predictors of disease, the symptoms and the identification of all forms of vascular disease including peripheral arterial disease, diseases of the aorta, coronary artery disease, carotid artery disease, etcetera.
Starting from the legs and going up, we'd like to be able to prevent things like claudication and amputation, complications from aortic aneurysms, heart attacks, strokes and the like, but it turns out that risk factor modification no matter whether you use surgical approaches or medicines, it is – prevention is still the bedrock of all of the therapy of vascular disease.
Controlling blood pressure, diabetes, high blood cholesterol, remaining active and smoking cessation, those are the critical bedrock pieces of prevention and whether you have -- I'll give you an example, if you have had a bypass operation, a coronary artery bypass operation, your work first begins because for example, when you take the veins from the legs and when you take an artery inside the chest wall called a left internal mammary artery and you plug it into blocked arteries in the heart muscle to give new blood supply, you are still dependent upon the smaller arteries in the heart to take that new blood supply into the heart muscle. You are then also dependent upon the health of those grafts as long as they can stay healthy. If you want those grafts to go down in a week or a month or a year, continue smoking, don't watch your blood pressure, don't control your diabetes, don't exercise. Don't do any of these things.
So prevention, whether you have had a surgical procedures, whether you're trying to avoid a surgical procedure, prevention is the name of the game.
With me in studio is my host, my co-host from the very beginning with these health cast series, Dr. Kerry Stewart. He is Professor of Medicine here at Johns Hopkins along with me in the Division of Cardiology. He is an expert on exercise physiology and Kerry, thank you for coming back today.
We're going to look at prevention once again.
Dr. Stewart: All right. I think you hit it right on the head. It's probably the critical factor for so many people to prevent and then – secondary prevention to help manage the disease if they, if they have it.
Dr. Meyerson: We know that there are certain disease that are absolutely preventable. History does not have to repeat itself. If your grandfather had a heart attack when he was fifty, if your father had a heart attack when he was fifty-three, you can bet that the, the probability is there that you are at risk for a heart attack. You should not be -- you know my favorite topic is, is smoking cessation, right?
Dr. Stewart: I heard that before.
Dr. Meyerson: But it's, it remains true. I don't have a medicine or an operation that will add more years onto your life than stopping smoking. Smoking causes spasm for example, of the arteries that nourish the heart muscle and all of the arteries throughout the body. It makes the platelets, the little cells that inappropriately in some cases cause blood clots where they don't belong, whether they be stroke or heart attack or, or peripheral vascular disease and critical limb ischemia. It accelerates the hardening of the artery process all over the body.
Smoking cessation is key. Wouldn't you agree?
Dr. Stewart: Absolutely. That, that is one of the -- that is the number one risk factor.
Dr. Meyerson: And you, you treat a lot of people with peripheral vascular disease, peripheral arterial disease and you do exercise studies on them and what have you found in the exercise capacity of a smoker compared to a non-smoker?
Dr. Stewart: Well clearly smokers have a much diminished exercise capacity. They get on a treadmill or a bicycle, we put them through a defined protocol and they're the first ones to stop compared to non-smokers.
Dr. Meyerson: And they stop for more than one, a couple of reasons. The peripheral arterial people stop because they can't go any further.
Dr. Stewart: They stop because they, they most likely are getting leg claudication, intermittent claudication which is the pain the leg that is a common symptom of peripheral arterial disease or they will get short of breath or they'll get chest pain and have ECG changes during the exercise test.
Dr. Meyerson: So again, I can't emphasize enough if you are a smoker, I want you to go to your mirror, I want you to look in your mirror and I want you to say to yourself, I, I -- say it out loud. It's worth it. Who am I kidding? If you, if you are smoking and saving for retirement, who am I kidding. If you want to see your kids graduate from college, go to graduate school, have babies of their own and, and watch those, those grand kids grow up and you're smoking, who am I kidding? I want you to go to your mirror and I want you to look at yourself once and for all and don't look at all, don't look at the other doctors to say, oh I'm going to give you this tranquilizer, I'm going to give you this smoking cessation tool. You know what, we understand that this is an addiction. We understand it's very hard, but at some point, somebody's got to wake up and smell the coffee and once you wake up and smell the coffee, my, my own brother -- Kerry, my own brother was smoking for years and it took us four or five different times to get him to quit. It's been a decade now. He is so grateful that he stopped. It was very hard when he did it, but now he is, he will not go anyplace where he smells the smell of smoke because he is "reformed." But that is absolutely critical and I couldn't say it enough. I don't have a medicine or an operation that will add more years to your life than smoking cessation.
Kerry, what do you want to talk about now? What's it, what's the next topic that you'd like to deal with in this prevention episode?
Dr. Stewart: Let's talk about exercise since I --
Dr. Meyerson: Very good.
Dr. Stewart: -- know a little bit about that.
Dr. Meyerson: Well, you know the interesting thing is that your field of exercise physiology is critical to control of weight and blood pressure and central obesity and good pulmonary function and good cardiac function and if you want to stay active when you're seventy and eighty and ninety, then you have to be active when you're forty and fifty and sixty. Isn't that right?
Dr. Stewart: Yeah and if you haven't been active at forty or fifty or sixty, you can always start. There's absolutely no reason why you can't start at any age and studies, multiple studies now have clearly shown that age is not a limiting factor in getting some benefit from exercise.
Dr. Meyerson: So if you feel like you want to start something and you don't want to go through a big medical work up in order to go to a gym and pump iron or something like that, if somebody is comfortable walking, is walking good for them?
Dr. Stewart: Absolutely and actually according to the American College of Sports Medicine which is a leading organization that writes guidelines on this whole topic, most people don't need medical clearance to start a walking program unless they -- certainly if they've had a history of heart problems or if they get symptoms while doing activity then it's necessary to go to a doctor --
Dr. Meyerson: And this is --
Dr. Stewart: -- and get evaluated.
Dr. Meyerson: We're not talking about competitive athletics here.
Dr. Stewart: No, we're not talking about --
Dr. Meyerson: We're not talking about going to the gym and trying to bench press three hundred pounds.
Dr. Stewart: No.
Dr. Meyerson: Or something like that, but --
Dr. Stewart: Like just getting out and walking --
Dr. Meyerson: A walking program.
Dr. Stewart: Anybody could start if, with the precaution that if you do get symptoms, then, then see your doctor. More people probably get are at a disadvantage because they wait to get a medical evaluation which they never get and that's a reason why they don't start walking. There would be more benefit of just starting walking. The risk of walking without a medical evaluation for most people is extremely low.
Dr. Meyerson: So here, so here's what we then recommend. I, I recommend sometimes something called the talk test and for example, if I am on a -- this example, if I'm on a treadmill in a health club and we're on adjacent treadmills and you and I are just walking at a brisk clip on a treadmill or even a little bit of a run, but if we can have a conversation; if I can get out full sentences, I'm not having chest pain, I'm not feeling dizzy and you and I can finish most of a conversation in full sentences, then that, that's quite reasonable, isn't it?
Dr. Stewart: That is one of the guidelines we use when we talk to people about doing a home based program.
Now we also know that supervised programs tend to be better for most people mainly because the people doing the supervision make sure that people are getting a sufficient amount of exercise to get the most benefit.
Many people when they take it up on their own actually often do too little, so we recommend that at least a couple of sessions under supervision, but if not, what you just said about getting started is certainly appropriate.
Dr. Meyerson: And you know, walking, a walking program is wonderful for weight control too because I understand if you walk for example, an extra twenty-five or thirty minutes a day and you end up burning maybe three hundred or three hundred and fifty calories a day, at the end of a week, you have burned an additional, almost twenty-four hundred calories.
Dr. Stewart: Yeah.
Dr. Meyerson: Which is --
Dr. Stewart: One mile is about a hundred calories so that, that, that is what can be used to gauge how many calories you burn from exercise.
Dr. Meyerson: So if you, if you burn an additional twenty-four hundred calories in a week, that's the equivalent of starving yourself for a day and a half for many people and it's much healthier because you can, you can tell me more about this, but I understand that large muscles that have been active burn more calories not only when they're active, but they continue to burn more calories even when they're sitting doing nothing.
Dr. Stewart: That's true and particularly if you also supplement the walking with some weight lifting or what we call resistence training because that actually focuses on increasing muscle mass or lean tissue which is the metabolic engine of the body, so this is what contributes to burning more calories.
Dr. Meyerson: When you talk about, when you talk about --
Dr. Stewart: But let give you, let met give you --
Dr. Meyerson: -- weight lifting, are you talking about a two year old or a three year old or --
Dr. Stewart: No. We're talking about doing a moderate level of, of resistence training, so what do we mean by moderate? So in the laboratory for example, we'll test somebody on a particular exercise and let's say they can lift one time a hundred pounds. That would be their maximum, but during the work outs that they do two or three times a week, we actually recommend that they work out at half that level. That's a moderate level and a weight that you can lift twelve to fifteen times before saying I have to stop is a weight that would be considered moderate.
Dr. Meyerson: Now before again, weight, for weight lifting programs, a doctor supervision or a doctor's permission might be a smart thing?
Dr. Stewart: No actually the guidelines are similar for weight lifting as it is for walking. The stress on the --
Dr. Meyerson: But what if, what if we have some of my patients --
Dr. Stewart: -- that's actually been --
Dr. Meyerson: -- who have had coronary disease?
Dr. Stewart: Well, in fact we have -- we at Hopkins have been kind of at the forefront of this in many ways. We, we were among the first to do studies of using weight lifting in people who have had heart attacks and, and I think what you said was the standard of care maybe fifty years ago when patients were told don't lift more than five or ten pounds. As it turns out, this moderate level of weight lifting actually puts less stress on the heart than walking fast or jogging, so there are a lot of benefits with very little risk.
Dr. Meyerson: And, but you do -- we have several people who have had active chest pains syndromes, with active shortness of breath --
Dr. Stewart: Well if you have active chest pain, then that's a whole different story.
Dr. Meyerson: -- that kind of stuff. And I just, it's those people I want to get to.
Dr. Stewart: But even those people actually who come to our cardiac rehab program, most of them are involved in some type of resistence training program.
Dr. Meyerson: So walking is a wonderful exercise, burning extra calories gets you leaner. If -- you remember we've talked about central obesity before and, and how important it is to get the central fat --
Dr. Stewart: Yes.
Dr. Meyerson: -- out of your body and, and the activity of burning calories by physical activity and moderately reducing your caloric intake is far better than starving yourself, isn't it?
Dr. Stewart: Absolutely. But let me just also give some precaution about walking in terms of, or at least make the listeners aware of the fact that walking while it will burn calories, needs to be complimented with a weight loss diet because the number of calories burned walking is actually relatively small to some of the kinds of foods that people might eat, so we had a patient recently who was doing exercise religiously. She was coming three times a week, doing everything we told her, yet she was gaining weight and what was happening was, she would leave our gym, stop at the donut shop and have two donuts.
Dr. Meyerson: She was so proud of herself that she would reward herself with the donuts.
Dr. Stewart: And so she thought she earned this reward and though she was burning about three hundred and fifty to four hundred calories during the hour with us --
Dr. Meyerson: It doesn't take much to inhale those calories right back, does it?
Dr. Stewart: -- two, two donuts and a cup of coffee with three packs of sugar was probably five hundred calories or more so she was actually putting on more calories that day than she was burning off.
Dr. Meyerson: Yeah. So again, modest activity, modest calorie restriction, pick some smart foods. Try to, try to make good choices, but this is real -- and smoking cessation.
Now, let's go to blood pressure because blood pressure goes hand in hand, people who are at, with high blood pressure, have a higher risk of stroke of heart failure, of heart attack, of peripheral arterial disease, of abdominal aortic aneurysms; the whole shooting match is at greater risk if you, if you have high blood pressure.
And again to normalize your weight the best you can, there's a new push by the American Heart Association which is one of the sister organizations of the Vascular Disease Foundation. There is a wonderful website, if you want to go to www.heart.org, O-R-G and if you want to get even more specific, you could do \hbp and they have a wonderful --
Dr. Stewart: Hbp stands for high blood pressure.
Dr. Meyerson: For high blood pressure. Exactly. And, and they have a wonderful website where you can look, you can look at your own risk, you can design a program where you can get your salt down, you can watch your blood pressure and, and activity and salt restriction and, and weight modification are enormously beneficial for people who have high blood pressure and the loss of even eight or nine or ten pounds, in many people have been shown to lessen to some extent, the, the need for medications, so --
Dr. Stewart: Absolutely.
Dr. Meyerson: -- in your studies Kerry, you've seen blood pressure improvements in exercise.
Dr. Stewart: Well we did a study several years ago where we, everybody was in an exercise program and then we divided the group up into three separate arms of the study and one group took a dummy pill, one group took one type of blood pressure medicine and the other group took another type of blood pressure medicine and at the end of ten weeks, all three of those groups lowered their blood pressure, the higher number, the systolic blood pressure by about ten points and their lower number, their diastolic blood pressure by ten points which suggested that if you just exercise, you will get as just, almost just as much benefit -- well actually in that case, we got the same benefit as exercising plus taking medicine. The medicine really didn't add much to being physical active.
Dr. Meyerson: Well there of course, some people who's blood pressures are much higher --
Dr. Stewart: Yeah. Obviously.
Dr. Meyerson: -- and those risks are, are very high and --
Dr. Stewart: But I think our study is just an example of the possibilities.
Dr. Meyerson: Absolutely.
Dr. Stewart: And obviously each person has to talk to their physician and figure out what the best regime is, but for almost every patient, exercise should be part of that regime even if you take some pills.
Dr. Meyerson: Did you just call, you call them dummy pills?
Dr. Stewart: Dummy pills.
Dr. Meyerson: I wonder if they work?
Dr. Stewart: Actually dummy pills or placebo actually sometimes works better than the real medicine and there's often a psychological advantage of, or some psychology going on that causes physiological changes. When people think they are getting treated, even if they're not because they're taking a false, dummy pill, they actually get better.
Dr. Meyerson: But the salt in the diet, there is salt --
Dr. Stewart: That is critical.
Dr. Meyerson: Salt is ubiquitous in the American diet and many other places and you will find absolutely --
Dr. Stewart: How do you spell ubiquitous?
Dr. Meyerson: You'll find, you'll find it in, in, in very high quantities in canned soups, --
Dr. Stewart: Yeah.
Dr. Meyerson: -- in prepared meats, in those Ramen noodles that sometimes we like to do in the microwave.
Dr. Stewart: Yeah.
Dr. Meyerson: Popcorn, the snack foods. It is absolutely incredible the amount -- they even put salt – you know, we think Cheerios are a nice food to give to a toddler.
Dr. Stewart: Yeah.
Dr. Meyerson: They put salt in Cheerios. We're not saying cut out the salt entirely because it -- you know what -- a patient once explained to me, that they, they tried to eat a salt free diet and Kerry, have you ever had a cup of coffee from a Styrofoam cup?
Dr. Stewart: I know what you're getting at.
Dr. Meyerson: And if you spill out the coffee and eat the Styrofoam cup, that's what a no salt diet tastes like. I, we understand that.
Dr. Stewart: Sure.
Dr. Meyerson: But you really can be very smart. When you're -- if you're going out to eat, you can ask the wait staff what do you have that, that people are saying it's not, it's not too salty? You know, make wise decisions. We don't want you to be miserable, but you know, if you make good wise decisions over long period of time, so many of these diseases that Kerry and I have spoken to you about, are truly preventable and, and if you've had one event, it is still possible to prevent the next.
Dr. Stewart: And given the amount of salt that's in foods that are either pre-prepared or from a restaurant, then you go to the restaurant or you see people picking up the salt shaker without even tasting the food first and just dumping on I don't know how many grams of salt, but an awful lot.
Dr. Meyerson: Right. And, and that is something that is a, that's a personality issue for some.
Dr. Stewart: For some it is.
Dr. Meyerson: And some people wouldn't, wouldn't ever pick up a salt shaker without first tasting and I, you know, if you're one of those people who just has grown up with salt and your momma cooked with salt and you love it, it doesn't love you and this is the time to really start to cut back.
There are some other seasonings and spices and things --
Dr. Stewart: Use the pepper.
Dr. Meyerson: Yeah, exactly and are very palatable, they make -- they're very interesting, but you, you -- small changes over long period of time and you can make some major benefits.
Kerry, what about cholesterol and exercise?
Dr. Stewart: Well actually cholesterol and exercise is an interesting area. Most of the research shows that the biggest benefit is, is on triglyceride levels and if you exercise at a higher and harder level, you can increase the HDL or good cholesterol, but exercise generally doesn't have a big impact on the overall cholesterol patterns, except to the extent that it might help you lose weight and it's probably the weight loss that has the biggest impact on cholesterol levels except perhaps for triglycerides; that's where we see most of the benefit.
Dr. Meyerson: Well and one of the things that I like to tell my patients is go to the public library or go to a book store and get the two CD abridged version of the South Beach Diet. It is something that has been written by a cardiologist. It has some reasonable insights as to how the body sees different foods, how the triglycerides are elevated, what you can restrict to avoid that triglyceride and the combination of an exercise program, a moderate diet with, with calorie restriction and, and smoking cessation; all of the things we've spoken about today. These are the bedrock of the prevention of vascular disease all over the body; not only heart disease, but cerebral vascular disease, cardiovascular disease, peripheral vascular disease, the whole shooting match and, and again this is doable.
This is preventable disease and whether you've had a heart attack or you're trying to prevent one, whether you have had a stroke and you are trying to prevent or you've never had one or you're trying to prevent the second one. If you have claudication, you're trying to prevent that from getting worse or if you've never had these diseases and everybody in your past family history has, and you do not want history to repeat itself, these are the right things to do. These are the absolute right things to do, so weight modification, salt restriction, watch and know your blood pressure, watch and know your cholesterol and for heaven's sake, if you're a smoker -- you know what I say when people say they're cutting down? I say cutting down tobacco smoking is like saying I'm only going to drive a hundred and thirty five miles an hour two days a week. Are you going to run off the road on a Tuesday or a Saturday, but cutting down is, is of value, but take it the rest of the way.
For the Vascular Disease Foundation, for my friend and colleague in studio, Dr. Kerry Stewart, I'm Dr. David Meyerson, yours in good health.
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