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Healthy Lifestyles for Heart&Vascular Health (Dr Blackburn PhD&Julia Zumpano RD LD 11 18 13)

Monday, November 18, 2013 - Noon


A heart healthy diet can help control cholesterol, blood pressure, blood sugars and weight. Like all muscles in your body, the heart is also a muscle and needs exercise to remain in good shape. Gordon Blackburn, PhD and Julia Zumpano, RD, LD answers your questions about heart healthy foods and exercises.

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tkmdak: I am a 55 year old male with an Aortic Aneurysm of the Aortic Root/Ascending Aorta. AO is 4.6 cm as measured by my latest Echo. My question is - What limitations (if any) would you put on my exercise program? I currently ride bikes, do spin classes, some running, and weight training. Using a heart monitor, I try to keep my heart rate under 140. When I do go above 140 I try to slow down. Am I at risk?

Gordon_Blackburn,_PhD_: It certainly sounds as though you have an active lifestyle. With an aneurysm of 4.6 cm in general we would recommend no vigorous exercise or heavy weight lifting; not activity that requires straining or valsalva maneuver and no exercise that includes risk of body trauma or collision. As for specific heart rate, a common medication to control blood pressure for people with aneurysms is a beta blocker; which has a significant blunting of heart rate response to exercise and rest. To pick a specific target heart rate for exercise, we recommend you discuss having a graded exercise test on medication with your physician to determine your functional capacity and heart rate response to activity. With an aortic aneurysm it is recommended that you discuss participation in regular activity with your cardiologist since there are other contributing factors that should be considered.

MaryJo-O: If my mom has an aneurysm in her abdomen, are aerobic exercises are advised (treadmill, exercise bike) will they affect the aneurysm in any way? How much exercise can she safely do without causing harm to the aneurysm?

Gordon_Blackburn,_PhD_: The risk associated with an abdominal aneurysm is related to the size of the aneurysm and the stability of the aneurysm. If she has been cleared by her cardiologist to begin an exercise program, treadmill and cycle are excellent options. The intensity of the exercise should be moderate and her blood pressure response to activity is also a concern. Guidelines for target heart rate during exercise; exercise settings (speed and grade of treadmill) and blood pressure can be determined based on the results of an exercise test and prescribed by her cardiologist or exercise physiologist in her local cardiac rehab program.

Heart Failure

cpk2001: I am a person with heart failure due to heart attack. There seems to be mixed opinions about diet, type of exercise, supplements, etc. One concern I have is the best source of protein. Since I am almost a vegetarian due to heart issues, how can I get enough protein? Also, does the ejection fraction ever improve from exercise, diet or supplements?

Julia_Zumpano,_RD,_LD: Beans, dried beans or legumes, nuts, tofu, soy products such as veggie burgers or dogs, and if you eat animal product at all such as diary or eggs, I would suggest egg whites; low fat cottage cheese and yogurt; and there are also grain based sources of protein such as quinoa, barley, oats, brown rice.

Gordon_Blackburn,_PhD_: The recommended type of exercise for individuals with heart failure is moderate intensity aerobic exercise. As to the question of improvement in EF, in the case when heart failure is secondary to damage to the heart muscle due to heart attack, there may be an initial recovery time shortly after the heart attack - but this is not related to exercise or diet. Appropriate medications may provide a benefit in resting the heart and lead to an improvement in EF. Overly aggressive exercise can challenge the heart in an individual with heart failure and can lead to greater risk.

SandyG: I have heart failure. My EF is 20 percent and my ability to do activity is limited by shortness of breath. I read that exercise is good for heart failure but how do you start with this. Can I exercise if I get short of breath with activity - does it get better with time? I am very discouraged with my decrease in activity and inability to do activities.

Gordon_Blackburn,_PhD_: I can certainly understand your frustration with your declining exercise capacity and increasing symptoms. The first place to start is with your managing cardiologist to obtain their approval to exercise. I strongly recommend a cardio-pulmonary exercise test to assess your current functional capacity and cardiovascular response to activity. This can be used to tailor an individual exercise program to your current ability. Regular exercise at the appropriate intensity has demonstrated improvement in symptoms; quality of life; as well as functional capacity. There is strong evidence that regular aerobic exercise also impacts positively on reducing mortality.

Coronary Artery Disease and Heart Attack

clara: My husband had a massive heart attack several years ago - LAD- 99 percent blockage. His injection fraction is 35. What sort of exercise do you suggest? He seems to be getting fatigued more. The recent cath was done in Sept.

Gordon_Blackburn,_PhD_: You describe a situation with significant blockage in the coronaries. The first strategy would be to look at interventional or surgical options - if those are not appropriate, then looking at medical management would be the next step. As a part of this, a tailored activity program and dietary intervention is appropriate. For individuals with CAD who withdraw from activity, they will experience deconditioning and greater fatigue over time, especially with weight gain over that time period. Shortness of breath can be due to deconditioning, or weight gain or your heart condition - so regular follow up is necessary.

BaigK: My LDL cholesterol is 101mg/dl, HDL is 34mg/dl serum, triglycerides 142mg/dl total cholesterol is 185mg/dl , I am male 51 years of age. Last month, I had an angina attack. My doctor advised me for ETT, in which my Duke treadmill score was (-8), doctor advised me for angiography, and prescribed statin & aspirin, I had heard a lot about statins side effect so I am not taking statin just taking aspirin 75mg daily. Can I reduce my LDL by just adapting Good Life Style? kindly give me your expertise in this regard.

Gordon_Blackburn,_PhD_: If your physician has recommended angiography based on symptoms and risk factor profile that would be the most prudent action at this time. The recommendation regarding starting a statin will be impacted by the results of the catheterization. Regardless of the presence or absence of CAD, lifestyle is always an integral part of lipid lowering.

Diet and Heart Health

thenzlik: I am a dietitian in Cardiac Rehab @ our hospital. I am advising low saturated fat to my patients. Is this still correct? I stress low sugar, no trans, healthy mono unsaturated fats like nuts, avocado. I am hearing that saturated fat is actually ok? What do I advise regarding saturated fat intake? What resource do you recommend for newest heart healthy eating recommendations. I need to stay current with my knowledge. Thanks.

Julia_Zumpano,_RD,_LD: You can have saturated fats - 7 % of daily calories. We recommend the Mediterranean diet for our patients. I am a 51 yr. old woman. For the last year I have I jogged 4 miles a day, lift weights 3xs a week, eat high fat, very low carb diet. My carbs are from veggies. Juice twice a week with raw spinach, blueberries, eggs, other veggies. No processed or sugar free foods, no colas or alcohol. Do not smoke. I have so much energy and have no joint problems that I previously have had. I looked forward to seeing my results back from blood work at my annual checkup. I was shocked to hear my doctor wanted to put me on Statins as my cholesterol was 284. My triglycerides are 59! My HDL is 83, LDL is 189. My A1C and all other 4 pages of results were super great. Only cholesterol was flagged. I do not want to take a statin drug. I do not take any medications currently and do not want to start. What else can I change to lower the number so not to have my gyn concerned?

Julia_Zumpano,_RD,_LD: Reduce egg yolks and red meat. No more than 4 yolks a week and red meat no more than once a week which includes beef, lamb, pork or veal; and I would suggest you limit your cheese to 1 - 1.5 oz (a serving) per day or less. You are making excellent lifestyle changes but in addition to the changes you have made, I would suggest you work with your cardiologist or primary care physician to look at your 10 year atherosclerotic cardiovascular risk. This factors in additional risk factors. If the risk is very low - ongoing attention to lifestyle issues is appropriate. If the risk is high (greater than or equal to 7.5%) additional discussion with your physician regarding the benefit of statin therapy would be appropriate.

BrianM: I believe I once read that coconuts were bad for cholesterol. However I now read that coconut oil helps HDL, is also good for your brain and combats memory loss side effects of simvastatin. Is it true that coconut oil is NOT bad for cholesterol?

Julia_Zumpano,_RD,_LD: Coconut oil provides a significant source of saturated fat but still can be included in a heart healthy diet as long as total saturated fat is less than 10% of total calories on an 1800 calorie diet not to exceed 18 grams of saturated fat.

ColleteK: Ms. Zumpano, My cholesterol LDL is 100 but I want to get it to less. My doctor wants me on a statin but I really want to try diet first. Can you tell me what diet to follow? Should I be vegetarian? What are the goals if you are trying for a lower LDL cholesterol value?

Julia_Zumpano,_RD,_LD: Reducing your intake of animal fats and plant based sources of saturated fat will have the greatest impact on LDL reduction. If you are considering a vegetarian diet, I would begin with eliminating red meat and significantly reducing cheese intake and choosing fat free dairy or a dairy alternative such as soy, almond or rice milk. The next step would be to eliminate dark meat, skin, and fat in poultry or eliminating it all together. Be sure to replace meat with lean vegetarian sources of protein such as beans or legumes, tofu or soy based products and nuts in moderation (1 oz per day).

LitaMO76: What is better - butter or margarine? Or should I switch to an olive oil brand of spread? I also saw a yogurt spread? Every day it is changing. What do you tell your patients?

Julia_Zumpano,_RD,_LD: There is really no specific answer to this question. Let the label and the ingredient list be your guide. Completely avoid products that contain hydrogenated or partially hydrogenated oils. Choose a product that has the least amount of saturated fat. Good options are light butter or margarine spreads blended with olive oil. A yogurt spread could be a good possibility given that saturated fat is low (less than 2g per serving).

veggiegirl: Can you talk about the role cholesterol plays with heart disease. There is so much recent information that speaks more to the influence that sugar and inflammation plays. Are there other alternatives to statins or other ways to eliminate inflammation?

Julia_Zumpano,_RD,_LD: Your LDL or bad cholesterol is a plaque forming cholesterol which can lead to greater amounts of plaque in the arteries which increases your risk of developing coronary artery disease (CAD). Sugar intake can increase triglycerides which are also blood fats called lipids therefore they also increase your risk of developing CAD. Inflammation in general has been shown to be a risk factor for heart disease. An anti-inflammatory diet consists of whole grains, fruits, vegetables, very minimally processed foods and ingredients, very low or no red meat and an abundance of fish specifically omega 3 fatty fish such as salmon, tuna, herring, mackerel and plant based sources of omega 3 such as flax seeds, chia seeds, soy and walnuts.

thenzlik: I am a registered dietitian in cardiac rehab. I conduct diet consults on every Phase 2 patient. I would like to stay current on Heart healthy eating nutrition guidelines. What resource do you recommend? What are the current recommendations for saturated fat intake for heart patients? What is your opinion on using coconut oil/coconut milk?

Julia_Zumpano,_RD,_LD: The recommendation continues to be no greater than 7% of daily total calories for saturated fat. Given the high amount of saturated fat in coconut oil, this limits its ability to be included in abundance in a heart healthy diet. Coconut products can be included given that you maintain your restriction of saturated fat for the day. I suggest coconut oil and milk more commonly for vegans and vegetarians given that their saturated fat levels tend to be lower than those who eat meat.

djl04: What recommendations for heart healthy eating do you have to help the patient recovering from recent MI?

Julia_Zumpano,_RD,_LD: Reduction in sodium (salt) intake to 1500 - 2000 mg of sodium per day (less than 3/4 of a teaspoon of salt). Limit processed foods specifically meats and cheeses. I encourage whole grains, fruits, vegetables, very lean meat, low fat and fat free dairy products.

CG21: What is your opinion of the moderate protein diet? I am a 32 year old female with occasional heart palpitations. Is this heart healthy or would you recommend another diet?

Julia_Zumpano,_RD,_LD: My understanding of a moderate protein diet is that it encourages lean sources of proteins while reducing carbohydrate intake. This can be considered a heart healthy diet as long as red meat, cheese, and added saturated fats are kept to a minimum and sources of protein are from fish, very lean meat, egg whites, beans and legumes, and low fat and fat free dairy.

cpk2001: So lean meat such as pork is OK now and then for someone with moderate heart failure?

Julia_Zumpano,_RD,_LD: Fresh pork is acceptable in moderation, about once or twice a week at a 3oz portion. Keep in mind pork can commonly provide a very high source of sodium. Read labels and choose lean sources of pork with less than 140 mg of sodium per serving.

ruehawk: Julia: What is your recommendation for eggs. I know one yoke would have the daily recommended amount of cholesterol. I had MI in May 2013 (100% blockage of RCA treated with Stent). I have narrowing in the LAD. I have been avoiding foods with any cholesterol.

Julia_Zumpano,_RD,_LD: No greater than 4 yolks per week is what I recommend.

Getchell: What is the recommended daily cholesterol and sodium intake for someone with hypertension and hypercholesterolemia. I am constantly reading labels and if something is low in fat or cholesterol it is high in NA. For example is it better to go with low NA peanut butter and have the 16 gm of fat or go with lower fat and have high NA.

Julia_Zumpano,_RD,_LD: Cholesterol should be less than 200 mg per day. Sodium should be less than 2000 mg ideally as low as 1500 per day. Peanut butter contains healthy sources of fats and all natural peanut butter without added oils, salt and sugar is the best option, keeping the portion controlled to no greater than 2 tablespoons per day.

Pacemakers and Implantable Defibrillator

nutzy: I am female 67 years old, my mitral valve was replaced with mechanical one, I have permanent atrial fib.(low) and a pacemaker implant for sss. My doctor insist to exercise almost everyday, but it's not easy to do that after 10 minutes I’m already tired. I would appreciate very much any advice!!

Gordon_Blackburn,_PhD_: Mitral valve replacement we will assume has improved the mitral valve function and should not be a restriction for activity, however chronic afib and the impact of the pacemaker (depending on your condition) may play a role in limiting activity. However, I do agree with your cardiologist that regular daily activity should be beneficial when tailored to your individual needs. If you are fatigued after 10 minutes it may be an issue that your intensity should be decreased or duration should be divided in multiple shorter segments, looking to build toward a total of 30 minutes ideally 60 minutes of activity per day. To personalize the program, to your individual needs we strongly suggest you investigate participation in a cardiac rehab program which you should qualify for based on the mv replacement surgery you had. Patients who participate in cardiac rehab programs have a reduction in mortality of about 30- 50% as compared to patients who do not participate and there is a significant ghost response benefit - the more you participate the better your outcome.

hembra: Hi there, my father has a defibrillator, should he be experiencing shortness of breath? He had a Heart Attack in 2011 thank you.

Gordon_Blackburn,_PhD_: Typically cardiac defibrillators or ICDs are implanted for issues of arrhythmia and or heart failure. If your father has known heart failure, this may limit his functional capacity and may be contributing to his shortness of breath. If the shortness of breath is occurring with activities of daily living or is worsening over time, I would recommend follow-up with his cardiologist.

Hypertrophic Cardiomyopathy

larryfromkansas: I'm a 55-year old HOCM patient. I had a septal myectomy and had a ICD implanted three years ago. The ICD is paced to 60 bpm and my ejection fraction is near normal, though I do have a bit of a-fib. The ICD did go off once nearly two years ago, which has left me a bit skittish about getting really physical in my activity. My cardiologist is in a "do what you feel you can" mode, but I'd like to lose some additional weight and look better, too. Any ideas about exercise tolerance and target heart rates for someone like me?

Gordon_Blackburn,_PhD_: To get more specific, I would need to know more about how the pacemaker is programmed and the threshold of the ICD. An exercise test if approved by your cardiologist could be used to give specific exercise settings and appropriate target heart rate ranges to allow for improvement of functional capacity with minimal risk. Routinely at Cleveland Clinic, we will perform regular or cardiopulmonary exercise tests based on the patient's needs to assess functional capacity and coordinate that with the patient's interests to set up an optimal activity program with a focus on safety and benefit.

In addition to the intensity of exercise, for weight loss, we want to focus on the volume of exercise or calories burned per session or week and couple that with a dietary program to optimize caloric intake. For moderate weight loss a deficit of between 300-600 calories per day would be a realistic target but rarely do we exceed a deficit of 800-1000 calories per day.

Peripheral Artery Disease

Trevor: Hi. I want to know about PAD as I underwent a surgery but the artery is blocked again.

Gordon_Blackburn,_PhD_: One of the most effective treatments in managing symptoms of PAD is a regular walking program. Walking has demonstrated an improvement of 200 - 400% in maximal walking distance as well as improvement in maximal distance walked in relation to the onset of symptoms. Smoking cessation, weight management and regular exercise and when appropriate - medications - are part of the treatment strategies for PAD. If necessary surgical intervention or interventional procedures can treat the blockage directly.

Heart Surgery

ladyL25: My dad is having heart surgery next week. I am trying to prepare for when he comes to stay with me after surgery. I read that you need extra calories to heal but want him to have the best diet for his heart. What do you suggest? Also - what can I expect activity wise for him?

Julia_Zumpano,_RD,_LD: Healing after surgery requires extra protein on a heart healthy diet. Choose the leanest sources of protein possible such as chicken or turkey breast, egg whites, beans or legumes, fat free dairy, and nuts. Otherwise, a balanced diet including whole grains, fruits and vegetables should meet his needs. Calories in general do not need to be increased but specifically protein, vitamins and minerals will help with healing.

Gordon_Blackburn,_PhD_: Immediately after surgery, the focus is on frequent short bouts of activity such as walking. The intensity should be something that he can easily tolerate - we do not focus on speed or target heart rate in early recovery period. If he experiences shortness of breath, progressive fatigue or non-incisional chest discomfort, you should contact his physician or surgeon. Until the incision is well healed and stable, approximately 6 - 8 weeks post op, we do not recommend weight lifting in any formal fashion.

Exercise General

djl04: Regarding Cardiac Rehab programs, do you have any suggestions on how to encourage the patients to continue with exercising once their sessions are done?

Gordon_Blackburn,_PhD_: Unfortunately a large percentage of patients - approx 50% - discontinue regular exercise one year after finishing with cardiac rehabilitation. While patients are in cardiac rehab, we work to identify specific activities and scheduling to reduce barriers and promote long term compliance. Patients who are most successful with maintaining activity are those who embrace the intrinsic benefits of lifestyle changes. This can be issues of feeling better; having more stamina; seeing a grandchild graduate from high school - it is the issue that is important to the patient and not just because we recommend the exercise as a way to reduce mortality.

cpk2001: I have lost 35 pounds and am probably underweight. This includes losing a lot of muscle mass. What is the best way to put back some muscle pounds? I used to work out a lot, but am limited now.

Gordon_Blackburn,_PhD_: The most important question in relation to your information is how fast you lost your weight. A recommended weight loss of 1 - 3 pounds per week is best to focus on fat loss. Weight loss at a higher rate can include a loss of lean body mass/muscle. If there is significant loss of muscle mass, you may feel fatigued and weak as the weight comes off. We recommend a gradual sustained weight loss rather than rapid and dramatic weight loss. Weight loss is best achieved by moderate changes in the diet to restrict calorie intake while insuring a nutritionally balanced program as well as a regular activity program. To maintain muscle mass, consider adding resistance exercises - weight training. In general for adults, weights that can be lifted 10 - 15 repetitions to the point of local fatigue, one - three sets of each exercise per session - at least twice per week. Focus on the large muscles of both the upper and lower extremities as well as the core. If you have not been involved in a regular activity program, we recommend discussing with your family physician before starting if you are over the age of 35 or have known cardiovascular conditions.

JamesKansas: Dr. Blackburn - what do you think of new articles that talk about shorter more intense workouts are better for you?

Gordon_Blackburn,_PhD_: The high intensity interval training strategy has demonstrated greater improvement in functional capacity as compared to steady state moderate intensity exercise. There has been no demonstrated increase in risk however the studies have been conducted in very controlled environments and there is no evidence to this point that there is an increased decline in mortality with this type of exercise. We will use the HIIT format for select patients in our cardiac rehab program and have had no problem. But - this is not for all patients.

JoanyLA: Dr. Blackburn - have you heard of the vibration platform machines? Do they work? My mom has heart problems and cannot exercise for long periods of time. I was thinking of purchasing one of these for her. Would it help?

Gordon_Blackburn,_PhD_: They help the company that you buy it from and that is about it. We recommend aerobic activity such as stationary cycling, walking, water walking, water aerobics. If the duration of activity is limited by fatigue, it may be necessary to reduce the exercise intensity and perhaps consider shorter bouts of exercise summed up over the day to achieve a longer overall duration. Because she has heart problems, she may qualify for participation in a cardiac rehabilitation program which can provide an individually tailored program. If she does not qualify for cardiac rehab, she should discuss details of activity with her cardiologist.

Young People and Heart Health

MrsGregory: I work at the East Cleveland Public Library and I would like to collaborate with you and your department on designing some workshops that will educate and cultivate the community on having a Healthy Heart. Also what are some suggestions that you may have to introducing Healthy Heart lifestyles to the younger community.

Gordon_Blackburn,_PhD_: We have an active community outreach program at Cleveland Clinic and I would recommend you contact them directly. Unfortunately I do not have that number - but it is listed on our website. Cleveland Clinic does offer several programs focused on activity and diet for youth. In the community we offer Fit-Youth programs at several of our family health centers and at main campus we do conduct pediatric preventive cardiology counseling for families.

Reviewed: 11/2013

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

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