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Title: When Normal Isn't Healthy.
Author: Michael Tennesen
Source: PREVENTION; Aug2000, Vol. 52 Issue 8, p134, 10p, 10c
Database: MasterFILE Elite
WHEN NORMAL ISN'T HEALTHY
by Michael Tennesen
Your medical test results may come back normal, but some studies suggest
that for optimal health, normal isn't good enough
I got back the results from my physical the other day. Only one item,
cholesterol, was in the "out of range" column and only by four points.
In general, things looked pretty good. I was healthy. Time for a
celebration. Pizza and spumoni all around.
But then I got this assignment from Prevention. The editors explained
that in recent years, researchers were thinking that certain normal or
borderline test results for blood pressure, cholesterol, triglycerides,
glucose, and weight that previously raised no eyebrows might actually be
unhealthy-possibly even early warning signs for heart disease. And you
might not ever know because the word hasn't filtered down to the
laboratories or doctors' offices. They wanted me to look into it.
I put down the phone and looked at my scores. My goose was cooked. Not
only did I have to cut back on the pizza, but the spumoni was out.
The Dangers of Being Average
Medicine used to set healthy standards by finding what was average for
the population and calling that the norm, says cardiologist Bernadine
Healy, MD, president and CEO of the American Red Cross. "What we're
saying now is, 'Wait a minute. It may be average, but it's not
necessarily healthy.'"
According to cardiologist John LaRosa, MD, president of the State
University of New York Science Center at Brooklyn, "Normal should be the
point where cardiac problems either don't exist, or they're so low that
they don't provide a major health risk."
How low is that? In many cases, lower than what's considered normal. On
the following pages, you'll see numbers that many experts consider your
"optimal" healthy scores on five tests measuring heart health. If you've
been going merrily along thinking that you're healthy, don't panic. Most
likely you are pretty healthy. You're at that point where, as Dr. LaRosa
notes, you're not at major risk. But if you'd like to be at the point
where heart problems are virtually unheard of, talk to your doctor about
what you can do to hit those optimal numbers.
Blood Pressure
Your blood pressure readings gauge the force that your heart and
arteries exert to pump blood through your body. Systolic blood pressure,
the top number in a blood pressure reading, indicates the pressure as
the heart contracts. The diastolic reading indicates the blood pressure
between contractions. When you have high blood pressure (hypertension),
your heart and arteries are exerting excessive force to pump your blood.
The harder they work, the more likely that your heart will become
enlarged and your arteries scarred and less elastic, which leaves you
prone to heart attacks and strokes.
What's Normal: Your blood pressure is considered normal if it's less
than 130/85.
What's Optimal: The American Heart Association (AHA) has recently
established 120/80 and lower as optimal.
"What we've found with blood pressure is that as long as it's allowing
you to function with plenty of energy and not faint when you stand up,
your blood pressure almost can't be too low," says Dr. Healy.
The Framingham Heart Study, the longest research project for assessing
heart risks, found that half of all heart attacks occurred between 120
and 140 systolic and 80 to 90 diastolic-numbers considered normal to
borderline.
What about the rise in blood pressure most people experience when they
get older? Some heart experts, such as Dr. Healy, think that higher
pressures-as much as 160/80-in those 60 and older may reflect a normal
"stiffening of the pipes" that comes with age. About half of all
Americans over 60 have high blood pressure. But other experts point out
that older people in non-Western cultures have lower blood pressures as
they age, so what's considered normal here may not be normal at all.
Further Testing: Dr. Healy and other experts recommend using home blood
pressure monitors to keep track of your pressure on a monthly basis.
It's also helpful to self-monitor if you think you may have white-coat
hypertension, a term used for the higher blood pressure readings some
patients experience when they're in the presence of a doctor. Take and
record your blood pressure three times a day, 3 days a week for 2 weeks,
and review the numbers with your doctor.
But if you do have white-coat hypertension, don't celebrate. Pressure
that's elevated only in the doctor's office is not normal, and you may
need to make some lifestyle changes-such as losing weight, exercising
regularly, and eating more vegetables and fruits-to prevent your
pressure from being elevated all the time.
Cholesterol
Cholesterol is measured by a blood test called the lipid (fat) profile,
which screens for the following: the two main cholesterol subfractions
(bad LDL and good HDL), total blood cholesterol (LDL + HDL), total
cholesterol/HDL ratio, and triglycerides, another blood fat. LDL
cholesterol is the artery clogger; high readings are cause for worry.
HDL is the good guy; it actually helps you get rid of the LDL, and high
readings here can offset high LDL readings. When you have too much LDL
cholesterol in your blood, the excess builds up on artery walls, narrows
the arteries, and slows down bloodflow, possibly leading to chest pain
(angina), heart attack, and death.
What's Normal: The AHA sets its standard for total cholesterol at less
than 200 mg/dl and HDL at 35 mg/dl or higher.
What's Optimal: Not all doctors agree on what number is best, but it
looks like lower is better. "If you go from 200 to 150, there is more
coronary disease at 200 than there is at 150," points out Dr. LaRosa.
But in the Framingham study, about 35% of all heart attacks occurred in
people whose cholesterol levels were in that normal healthy range.
"Every time we set the cholesterol levels, we look at population studies
and find that people below that do better than people above. We reset it
lower, and we find the same thing," says Ann Bolger, MD, a cardiologist
and associate professor of medicine at the University of California, San
Francisco, School of Medicine.
For example, a study of 6,500 people in rural mainland China who
consumed half as much fat and 1/10 as much meat as Americans found that
the Chinese had a mean cholesterol level of 127 mg/dl compared to our
203 mg/dl. As a result, their death rates for heart disease were almost
17 times less for men and 6 times less for women.
So what should you do? Most experts agree that the total cholesterol
number isn't necessarily the most important one. After all, you can have
a high total cholesterol because you have buckets of good HDLs. The
Framingham Cardiovascular Institute (FCI) now urges its patients to
think more about the levels of bad LDLs and the ratio of total
cholesterol to HDL, which may be a more accurate gauge of your heart
health. The FCI recommends that you shoot for an LDL below 110 and a
total cholesterol/HDL ratio below 4.
Further Testing: A recent joint Harvard and Brigham and Women's Hospital
study also found that adding a screen for a substance called C-reactive
protein (an indication of inflamed arteries) to the usual lipid
screening may be an even better predictor of cardiovascular risk than
cholesterol. Another new study suggests that tests for apolipoprotein
(apo) B and apo AI (proteins found in LDL cholesterol) also may be
superior to standard cholesterol tests for persons with average total
cholesterol and LDL levels, but below-average HDL levels. Ask your
doctor about ordering these tests for you.
Triglycerides
Triglycerides are the chemical form in which most fat exists in the
body. High triglycerides are often associated with abdominal fat.
What's Normal: The AHA defines normal triglycerides as less than 200
mg/dL.
What's Optimal: As with cholesterol and blood pressure, the lower the
better. Evidence now suggests that normal may be twice as high as it
should be.
A study of 350 people with coronary disease done at the University of
Maryland School of Medicine in Baltimore found that those with
triglyceride levels above 100 mg/dl-at levels traditionally thought
safe-were more likely to have a heart attack or die from heart disease
than those with lower levels.
The FCI recommends staying below 120 if you haven't had heart problems,
and below 90 if you have.
And watch your waist. According to Jean-Pierre Despres, Ph.D., professor
of medicine and director of research at the Quebec Heart Institute,
Laval University, St. Foy, moderate elevations of triglycerides (175 or
higher) combined with stomach fat are high-risk indicators for heart
disease.
Further Testing: Dr. Despres recommends measuring your waist monthly.
Cause for concern: if you're under 40 years old, anything over 35 inches
for women, over 40 for men; if you're between 40 and 65 years old, your
waist should be under 35 inches. (Study is pending for those persons 65
and older.)
High triglyceride levels, low HDLs, and too much abdominal fat can be
symptoms of Syndrome X (actually a collection of symptoms, including
high blood pressure and high blood sugar), which accounts for almost
one-third of the heart attacks in the Framingham study. Syndrome X may
be the precursor to both heart disease and diabetes, yet people who have
it may have normal total cholesterol-less than 200 mg/dl.
Glucose
The fasting plasma glucose test is the preferred way to diagnose
diabetes. After fasting overnight (at least 8 hours), you'll have a
sample of your blood drawn. Fasting plasma levels of 126 mg/dl on two or
more tests on different days indicates diabetes. Scores between 110 and
125 indicate impaired fasting glucose, sometimes a precursor to
diabetes.
Adults with diabetes have heart disease death rates about two to four
times higher than those adults without. Diabetes can cause blindness,
kidney disease, and nerve damage and can result in amputations of the
limbs. Type 1, which usually occurs in lean people under 30, can be
controlled with insulin; type 2, once known as adult-onset and linked to
obesity, can be reversed with diet, exercise, and sometimes insulin.
Type 2 accounts for 90 to 95% of all diagnosed cases of diabetes.
What's Normal: Scores of 110 mg/dl or lower were previously considered
good.
What's Optimal: The FCI now recommends keeping your fasting plasma
glucose score at 100 mg/dl or below. "By choosing 110 mg/dl as the
cutoff point, we may be missing people who are at high risk for
developing diabetes or may even be in the early stages of it," says Dr.
Bolger.
Further Testing: If your glucose is high, your physician may require a
hemoglobin A1c test. A fasting plasma glucose score may tell you what
your glucose is at the moment of the test, but the hemoglobin A1c test
tells you what it's been over the past 3 months. If your previous
healthy scores on the fasting plasma glucose test have been about 110
mg/dl, you may want to have yourself tested again.
Weight
Things have come a long way since we used to evaluate our bodies by
insurance tables. Today, physicians gauge body composition, and
specifically the amount of body fat, using the Body Mass Index (BMI).
(To find yours, multiply your height in inches by itself, divide your
weight in pounds by that number, and multiply that figure by 705.) To
ward off future problems, measure your waist (at the navel) and figure
your Waist/Hip Ratio (WHR) as well. (To find your WHR, measure your
waist at your navel, and your hips at their widest point, and divide
your waist measurement by your hip measurement.)
Experts now consider obesity a disease risk factor almost as significant
as cigarette smoking. "A high Body Mass Index, waist circumference, or
Waist/Hip Ratio triples the risk of heart disease in both men and
women," says JoAnn Manson, MD, professor of medicine at Harvard Medical
School and chief of Preventive Medicine at Brigham and Women's Hospital
in Boston.
Recently, the AHA listed obesity in and of itself as a risk factor for
heart disease. It also predisposes you to diabetes, stroke, and certain
cancers.
What's Normal: A BMI below 25 is considered normal. The AHA and the
World Health Organization consider a BMI of between 25 and 29 as
overweight, and anything more than 30 as obese. A WHR less than 0.80 is
considered normal for women, less than 0.95 for men.
What's Optimal: For optimal health, shoot for a BMI of 21 to 23. Waist
measurements of more than 35 inches for women or 40 inches for men are
serious cause for concern, according to guidelines from the National
Institutes of Health in Bethesda, MD.
In a study of stroke risk factors in 28,643 men ages 40 to 75, doctors
at the Harvard School of Public Health found that men who had a WHR
greater than 0.98 also had the highest stroke risk. Study authors think
that those statistics hold true for women as well.
Testing Frequency: If weight is a concern, measure BMI, waist
circumference, and WHR once monthly. Keep a journal, and note your
progress.
Further Testing: There are some people who can have a high BMI and still
be healthy. If you work out so much that you're very muscular, your
too-high BMI could actually be just right. But don't just tell yourself
that your high numbers are caused by muscle. Get a body-fat test at your
gym to make sure.
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IMPROVING YOUR SCORES
The truth is that most heart test readings are interrelated. "Almost all
of these risk factors will improve with healthy lifestyle practices,"
says JoAnn Manson, MD, professor of medicine at Harvard Medical School
and chief of Preventive Medicine at Brigham and Women's Hospital in
Boston.
A heart-healthy diet and exercise, accompanied by a reduced Body Mass
Index (see p. 142), will lower LDLs, triglycerides, glucose, and blood
pressure and raise protective HDLs. Here's your "Better Than Normal"
plan.
Diet and exercise: "Between diet and exercise," says Michael Miller, MD,
associate professor of medicine and director of preventive cardiology at
the University of Maryland School of Medicine in Baltimore, "the average
drop in cholesterol is 20 to 30%, but up to a 50% reduction is not
unheard of." Losing just 5 to 10 pounds can normalize blood pressure.
Weight loss can also reverse diabetes.
Diet: Trim saturated fat from the diet, and start eating more fruits and
vegetables. Prevention's Millennium Diet (Jan 2000, p. 122) calls for
eating nine servings of fruits and vegetables every day. Studies link
diets highest in fruits and vegetables with less heart disease,
diabetes, and even osteoporosis. It can also help you lose weight.
Other diet tips:
* Limit daily salt intake to 2,400 mg of sodium (equal to about 1
teaspoon of salt).
* Load up on fiber, which can improve your lipid profile as well
as lower blood sugar.
* Get more omega-3s from fatty fish such as salmon, sardines, and
mackerel, or in fish oil capsules, to help reduce triglycerides.
* Eat a moderate carbohydrate diet (where you replace some of the
starches in a high-carb diet with monounsaturated fats such as olive oil
and other good fats (nuts, peanut butter, canola oil, and flaxseed) to
help lower triglycerides.
* Ask your doctor about supplements made from red yeast, which
contains the same ingredient in the cholesterol-busting statin drugs, or
about using niacin (see Prevention, May 2000, p. 132), which can lower
both cholesterol and trigylcerides. Don't take either supplement without
a doctor's supervision.
* Take 100 to 400 IU of vitamin E, which may help prevent
abdominal weight gain by protecting against insulin resistance.
* Avoid excessive alcohol (more than one drink a day for women,
two for men). It raises your blood pressure and promotes a fatty middle.
Exercise: The positive benefits of exercise start the very next day,
says Ann Bolger, MD, a cardiologist and associate professor of medicine
at the University of California, San Francisco, School of Medicine.
"Take a 3-mile walk today, and tomorrow you will be better in so many
physiological parameters including glucose, blood pressure, cholesterol,
and triglycerides," she recommends.
Exercise is a good way to raise your HDLs, regulate your blood sugar,
and lower your triglycerides. It can also help reduce stress, which may
play a role in the accumulation of fat around your waist.
Prevention urges you to do 30 minutes of moderate-intensity activity
(such as walking, jogging, or biking) at least 5 days a week. Strength
training for 20 to 30 minutes 2 or 3 days a week is another good bet.
By Michael Tennesen
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