Austin, Texas: Is wine good for your health, and how much per day is healthy?
Dr. Thomas H. Lee: No one should start drinking alcohol to improve his health, but there's also no reason to stop for people who drink a moderate amount of wine or other forms of alcohol. "Moderate" means one to two drinks per day for men, and one drink per day for women. (The lower recommended amount for women reflects their smaller body size, not male gender among the authors of the guidelines.)
People who drink moderately have lower rates of heart disease than teetotalers, presumably because alcohol raises levels of high-density-lipoprotein (HDL) cholesterol—the so-called good cholesterol. Some researchers have speculated that the benefit might be greatest with wine, particularly red wine, which is rich in flavonoids and other "antioxidant" chemicals that might help protect artery walls. However, a major epidemiological study published in 2003 in The New England Journal of Medicine found that all types of alcohol offered about the same amount of benefit.
If some is good, isn't more better? Not in the case of alcohol. Higher amounts increase risk of heart disease and stroke by raising blood pressure and directly weakening the heart muscle. And alcohol has a lot of calories, so people who drink heavily tend to gain weight, which raises their risk of diabetes.
Durango, Colo.: Are there any promising treatments on the horizon for removing calcified plaques from the arteries?
You don't have to wait for promising treatments to lower your risk for a heart attack if you have calcified plaques in your coronary arteries. There are medications that can help you right now, and you may already be taking them.
First, though, you should focus on the real goal. You don't need to make these atherosclerotic plaques disappear; you just want to prevent them from breaking open. If they do rupture, the injury to the artery wall can cause the formation of a blood clot that chokes off blood flow. The result can be the death of the heart muscle supplied by that artery.
Plaques break because they have gooey cores filled with cholesterol, and you can reduce the risk of having a plaque rupture by lowering your "bad" cholesterol (LDL) with statins and drugs that block cholesterol absorption from the gut. Another approach is to raise HDL, which helps transfer cholesterol out of the body, but a promising HDL-raising drug developed by Pfizer failed spectacularly in late testing last December. Older drugs like niacin can raise HDL, but have high rates of side effects. So until researchers come up with better medications, the best way to raise HDL may be exercise.
The other key medication for you is aspirin, which slows your body's blood-clotting system. If an atherosclerotic plaque does rupture, aspirin will reduce the risk that a blood clot will form and block off the artery.
Columbia, Md.: What tests should I have to see whether I have some level of heart disease? A nuclear stress test was normal. With Lipitor, my HDL, LDL and total cholesterol are within the acceptable range; C-reactive protein is normal; triglycerides are low; blood pressure is normal; HbA1c is normal. But I am 60 years old, female, postmenopausal and overweight (with a body-mass index of 28). I have a strong family history of cardiac disease; my father had a heart attack at 53, and both parents suffered from congestive heart failure. Should I ask for more studies—for example, to evaluate the status of my small blood vessels?
I don't think you need more tests—you already know what to do. You should make exercise a regular part of your life, and you should lose enough weight so that your BMI gets under 25 (into the normal range). With your family history of early heart disease, your concern is quite understandable, but it sounds as if your risk factors for atherosclerosis are under control. (I am assuming that you are not a cigarette smoker. If you are, giving up cigarettes is the most important thing you can do.)
Are you wondering about the need for further testing because you are having chest pain that remains undiagnosed? It is true that some people with chest-pain symptoms have negative exercise tests, but later, doctors find abnormal function of very small coronary arteries. And a study published last year showed that women who had persistent chest pain despite normal-appearing coronary arteries had double the risk of developing cardiovascular problems.
Nevertheless, the risk of problems was pretty low (2 to 3 percent per year), and what you should do to reduce that risk wouldn't be affected by any further testing. You should do your best to make sure your blood pressure, cholesterol and other risk factors are at their targets, try to drop that weight and exercise to keep your arteries limber.
Monticello, Miss.: If you don't have high blood pressure or high cholesterol, what are the chances of developing heart disease if several members of your immediate family do have it?
Having normal blood pressure and cholesterol levels is terrific, but that doesn't mean you are home free—especially if your family's genes have already sent the message "watch out." There are other important risk factors mentioned in the responses to several of the other queries on this page (e.g., smoking and diabetes), and there are newer tests that can help refine estimates of your risk for heart problems, most notably C-reactive protein—a test of inflammation in your blood that can reflect the formation of atherosclerosis.
Dr. Paul Ridker and his colleagues recently published a new "prediction tool" for women that you can access at www.reynoldsriskscore.org. You just need to enter your age, smoking status, blood pressure, total and HDL cholesterol levels, C-reactive protein and whether either parent had a heart attack before the age of 60. The Web page will calculate your risk of a heart attack, stroke or other cardiovascular problem in the next 10 years.
We'd all like to hear that our risk is zero, but you are not going to get that kind of reassurance from any honest physician or risk-prediction tool. Given your family history, you should do your best to get your blood pressure and cholesterol to optimal levels, even if your current levels are normal. That means using diet and exercise to get your blood pressure under 120/80 and your LDL cholesterol under 100.
Albuquerque, N.M.: My 18-year-old son's blood pressure has been running 140/90. He is thin, walks a lot and doesn't smoke. Since childhood he has taken daily decongestants (Rynatan or Sudafed) for allergies. Could that be the cause? If he stops the Sudafed, how long will it take for his blood pressure to come down?
That is high blood pressure for a teenager, and the decongestants you describe could indeed be the problem. They include a medication called pseudoephedrine, which helps runny noses by causing blood vessels to clamp down and allow less fluid to leak into the lining of nose, throat and sinuses.
The problem with pseudoephedrine is that this constricting of blood vessels can also cause blood pressure to rise. He should stop those medications, and use just antihistamines (like over-the-counter Loratadine) to control his allergy symptoms.
If his blood pressure is still high after a few days, then his doctor should examine him to look for other causes of high blood pressure, such as kidney disease, narrowing of the aorta or arteries supplying the kidneys, or hyperthyroidism.
Oakville, Canada: Does extra-virgin coconut oil increase the risk of heart disease?
It's a mixed story at best. Coconut oil is a saturated fat, like the kind of fat found in milk, butter and red meat. This kind of fat raises LDL cholesterol, which increases your risk for heart disease. Saturated fats also raise the "good" cholesterol, HDL, but the consensus is that saturated fats cannot be considered a heart-healthy food.
Why, then, are their ads in magazines and on the Internet claiming that extra-virgin coconut oil might reduce one's risk for heart disease? The fatty acids that are the main components of coconut oil are shorter than those found in saturated fats in animal products, so they might not have the same adverse effects as, say, a cheeseburger. Still, no one has proved that this type of saturated fat is good for your heart. If anything, we think it's "guilty until proved innocent."
So my colleagues believe that modest amounts of coconut oil in your diet are reasonable. Unsaturated fats like olive and corn oil are probably better ... and less expensive!
Until 2003, most people would not have thought twice about a blood pressure in your range, but that year guidelines from the National Institutes of Health introduced the term "prehypertension" for blood pressures of 120-139/80-89. People with prehypertension have about three times the risk of a heart attack compared with those with blood pressures lower than 120/80.
Despite this increased risk, most experts do not recommend medications for people with blood pressures like yours. Drugs have not been shown to be beneficial for patients with blood pressures in this range, and medications do carry some risks of side effects.
Instead, I would go all out with lifestyle steps to drop your blood pressure under that 120/80 target. It's great that you exercise three times per week, but the more the better. You should try to exercise most days for at least 30 minutes, and there is nothing wrong with working out every day, and for longer periods.
If you are heavy, losing weight will help. So will eating plenty of fruits and vegetables, and controlling the amount of salt in your diet. You shouldn't have more than two alcoholic drinks per day if you are a man; one if you are a woman. Finally, if you are sore from all the exercise, be careful with pain relievers like ibuprofen and naprosyn. They can make you retain water and cause your blood pressure to go up!
People with gum problems like gingivitis and periodontitis have higher rates of heart disease, but they also have higher rates of cigarette smoking. Some researchers have speculated that periodontal disease might cause atherosclerosis if inflammation in the gums caused chemicals that injured blood vessels to circulate in the blood stream. However, epidemiological studies have found no relationship between gum problems and heart disease after statistical adjustment for smoking and other risk factors for atherosclerosis.
If you have gum disease, you should brush, floss and do all you can to control it simply to preserve your teeth. And you should do all you can to control your risk factors for heart disease whether or not you have gum problems. But there is no evidence that improving your oral health directly leads to any benefit for your heart.
That is a high blood pressure for a teenager, and the decongestants you describe could indeed by the problem. They include a medication called pseudophedrine, which helps runny noses by causing blood vessels to clamp down and allow less fluid to leak into the lining of nose, throat and sinuses. The problem with pseudophedrine is that this constricting of blood vessels can also cause blood pressure to rise.
He should stop those medications, and use just antihistamines (like over the counter loratadine) to control his allergy symptoms. If his blood pressure is still high after a few days, then his doctor should examine him to look for other causes of high blood pressure, such as kidney disease, narrowings of the aorta or arteries supplying the kidneys, or hyperthyroidism.
You probably can be a big help to him, and you can start by assuring him that he is not alone. Many other Americans are carrying this much extra weight and more, and are feeling depressed—and hungry! I am a bit nervous about his blaming his medications, because I doubt they are the cause of his hunger, and he might use this notion as an excuse to stop taking them. That could cause his blood pressure to go out of control, leading to a stroke or other complications.
You should consider going to a nutritionist together. His hunger even after meals suggests that he is probably eating foods rich in carbohydrates that release a lot of sugar quickly. The sugar load causes his pancreas to secrete a lot of insulin, which drives his sugar levels down, making him even hungrier. Foods that take longer to digest and release their energy will make him feel full longer.
The reason you should go along is that he is more likely to change his diet if you do, too. I presume that you eat together, and you have the ability to help him stay on a healthier regimen. You can help him start and stay on an exercise regimen by making it part of your relationship. A daily walk of 30 minutes or more would be part of my prescription.