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Factors that increase the risk for cardiovascular disease fall into two categories: those that can be controlled and those that cannot. As you read about each factor, ask yourself whether it applies to you, and note the steps you can take to reduce its influence.
Stop Smoking
As early as 1984, the Surgeon General of the United States asserted that smoking was the greatest risk factor for heart disease. Generally, the more a person smokes, the greater the risk for heart attack or stroke. The risk for cardiovascular disease is 70 percent greater for smokers than for nonsmokers. Smokers who have a heart attack are more likely to die suddenly (within one hour) than are nonsmokers. Available evidence also indicates that chronic exposure to environmental tobacco smoke (ETS or passive smoking) increases the risk of heart disease by as much as 30 percent.
Although we do not fully understand how cigarette smoking damages the heart, there are two plausible explanations. One theory states that nicotine increases heart rate, heart output, blood pressure, and oxygen use by heart muscles. Because the carbon monoxide in cigarette smoke displaces oxygen in heart tissue, the heart is forced to work harder to obtain sufficient oxygen. The other theory, states that chemicals in smoke damage the lining of the coronary arteries, allowing cholesterol and plaque to accumulate more easily. This additional buildup constricts the vessels, increasing blood pressure and causing the heart to work harder.
When people stop smoking, regardless of how long or how much they’ve smoked, their risk of heart disease declines rapidly. Three years after quitting, the risk of death from heart disease and stroke for people who smoked a pack a day or less is almost the same as for people who never smoked. Quitting today will also raise your HDL levels, reducing your risks even further.
Cut Down on Fats and Cholesterol
Researchers now realize that high-fat diets are even more dangerous than previously thought. Fatty diets not only raise cholesterol levels slowly over time, but also can send the body’s blood-clotting system into high gear and make the blood sludgy in just a few hours, increasing the risk for heart attack. Studies indicate that fatty foods apparently trigger production of factor VII, a blood-clotting substance. Switching to a low-fat diet promptly eliminates the risk of clotting.
A fatty diet also increases the amount of cholesterol in the blood, contributing to atherosclerosis. In past years, cholesterol levels of between 200 and 250 milligrams per 100 milliliters of blood (mg/dl) were considered normal. Recent research indicates that levels between 180 and 200 mg/dl are more desirable for reducing the risk for CVD. Cholesterol comes in two varieties: low-density lipoproteins (LDLs) and high-density lipoproteins (HDLs). Scientists used to think that the critical question was whether a person had more of the “good” HDLs than the “bad” LDLs. But now, according to scientists, what may really count is the HDL component Lp(a). The more of this protective protein a person has, it seems, the lower the risk for heart disease.


The T person toxifies himself with his constant need to explain himself and justify his behavior to others. These explanations and justifications bog him down and hamper his freedom to act decisively. Explanationitis ranges from meek defensiveness to belligerent defiance. The victim torments himself by seeking to justify or excuse his every action. The hook in this self-torture game is the importance the person places on other people’s understanding and accepting the “whys” of his attitudes and actions. Since one rarely finishes explaining himself, this T pattern becomes an endless barrier to free-flowing self-expression and spontaneity of action.
This is a dialogue between an explainer and her inquisitor:
JOHN: I want to make love to you.
MARY: I like you, but I don’t feel I know you yet. I’d like to take more time for us to get acquainted.
J: Why can’t we get more acquainted by making love?
M: (Somewhat flustered) I just don’t feel ready for it yet. Sex is too important to me to take lightly.
J: How long do you have tp know me before you’ll be ready?
M: I don’t know.
J: I thought you liked me.
M: I do like you as a person, but I don’t feel ready to go to bed with you.
J: If there’s something that bothers you about me, I wish you’d tell me what it is.
M: It’s nothing like that—I can’t make you understand. …
J: Well, I don’t feel you’ve given me any reasonable explanation. M: I’ve tried to tell you how I feel about it. J: Are you always this slow in making up your mind about going to bed with a guy? M: I’m not trying to be difficult; I just need a little more time. … I wish you would understand that.
J: I still don’t feel you’ve given me any satisfactory explanation.
M: I’m feeling more and more pressured by you. I feel like you’re putting me on the spot.
J: Okay. I’ll have to reach my own conclusion—you just don’t like me. M: Please don’t feel that way. That’s not true. J: I don’t know what else to think. Maybe we shouldn’t see each other for a while. M: I guess I spoiled things. I’m sorry. J: Well, you can make it right if you really want to. M: I don’t know what to say—I don’t want you to think I’m a prude. … I guess I don’t have any really good reason not to go to bed with you.
Justifying or explaining why one feels as one does is a self-poisoning pattern when it involves personal choices about how one wants to relate to another person.


As a physician, I’m trained to cast critical eye on all types of statistics and supposed success rates that don’t have solid research behind them. Whenever a beauty company quotes a level of improvement with their latest product after a certain number of weeks, it doesn’t quite paint the full picture. In other words, the public is never told just how many participants were in the study, or even what the condition of the skin was to begin with.
That said, it doesn’t necessarily mean that every quoted percentage of improvement is full of dead air. The bottom line is: don’t believe everything you hear just because it’s in a lively commercial with a gorgeous twenty-year-old model.
What is it about creams with astronomical price tags that make perfectly sane women, and a handful of men, too, run to the stores to stock up on them? Judging from my patients’ testimonials, a lot of this brouhaha is wildly undeserved. But let’s face it – there’s something very exciting about buying a luxurious cream with the price tag to match, but any informed consumer will see past the glamour appeal.
To be fair, it is sometimes necessary to place a higher price tag on certain creams simply because better ingredients are more expensive.
Some of the chain store own-label brands, for example, can’t make use of certain raw ingredients because it would simply cost too much, an expense that they would have to share with their customers.


With aging, all women reach an end to their fertility. First, there is a gradual decline in female reproductive capacity from age thirty on, reflecting both a drop in fertility and a higher rate of miscarriages. In addition, abnormalities of the menstrual cycle become more frequent over thirty-five as the aging ovaries respond less efficiently to LH and FSH from the pituitary gland. After age forty, the frequency of ovulation generally begins to decrease, and around age forty-eight to fifty-two, menstrual flow stops entirely in a process called the menopause.* However, since deciding when the menopause has occurred can only be done retrospectively — by convention, after one year without further menstrual flow — women who are sexually active at this stage of their lives should continue to practice birth control until it is certain they cannot become pregnant.
The timing of the menopause and the symptoms that accompany it vary greatly from one woman to another. Although the ovaries stop producing all but a minute amount of estrogen, and ovarian progesterone production ceases entirely, small amounts of these hormones are still present because of continued activity of the adrenal glands. LH and FSH levels typically become elevated after menopause.


The old adage, ‘You are what you eat’, is still true but recently people are becoming aware of the sad fact that, health-wise, we are often better for what we don’t eat. By this I mean that it is sometimes possible to regain your health simply by not eating a particular food. When eating or even touching a particular food causes a ‘reaction’ that is not commonly experienced by the majority of people, one can say that the individual is ‘allergic’ to that food.
I am sure you know someone who breaks out in a rash when eating, say, strawberries or eggs. You may also have a friend who cannot drink milk without becoming congested and having a runny nose or, worse, an asthma attack. You may also know people who have stomach ulcers or suffer from arthritis or feel depressed most of the time, but regain their physical and mental health once they have given up a particular food. I have lost count by now of the number of patients I have seen who suffered the pains of arthritis for years, only to find relief when I placed them on the correct diet, after the appropriate food-allergy testing procedures.
Your GP may insist that your gastritis is not really an allergy, in spite of the fact that whenever you eat a particular food your stomach feels as if a band of gremlins has taken it over for a game of soccer. Many professionals are trying to abandon the term ‘allergy’ and prefer the less precise ‘intolerance’.
The name makes little difference to the sufferer, except perhaps when it comes to finding out exactly what he or she is allergic to. Even when you do find out, the problem remains of just how many and which foods, grasses, pollens, moulds/ fungi and so on in any given group you should avoid, not to mention for how long.
As I have treated literally thousands of patients with all kinds of allergies, I know only too well how confused people can become when trying to make up a suitable meal from the meagre list of permitted foods.


In the 1970s it was discovered that the body had its own natural painkillers which were similar in structure to morphine – a drug used to relieve severe pain in cancer patients. These natural painkillers were called ‘endogenous morphines’, or endorphins for short.
Since their discovery it has been found that endorphins also:
• help control the body’s response to stress
• regulate contractions of the intestine
• lift our mood
• regulate the release of hormones from the pituitary gland
In the mid-1980s it was found that women with PMS have low levels of beta-endorphins in the luteal phase of the menstrual cycle. This led to the suggestion that PMS could be a kind of opiate withdrawal syndrome.
According to this concept, women are dependent on their own endorphins and at times of the menstrual cycle, when endorphin levels are low, they experience irritability and depression – a form of ‘cold turkey’.
Oestrogen is known to increase levels of beta-endorphins so this may be one reason why women feel all right before ovulation when oestrogen levels are high and experience PMS afterwards when oestrogen is on the decline.
There is also some evidence that endorphin levels are affected by prostaglandins. So if there is a shortage of the necessary prostaglandins there may in turn be a shortage of endorphins.


Many people overload themselves by trying to anticipate problems in advance. Their basic aim in doing this is usually to avoid being emotionally hurt or disappointed if plans don’t come out the way they want them to. Sometimes the people who habitually do this have deep fears and insecurity, perhaps arising from early childhood experiences. Being able to anticipate and deal with problems in advance, and thus guarantee the success of some proposed activity, enhances the person’s feelings of power over fate, or the forces of nature, or destiny, or whatever, and reduces feelings of personal vulnerability.
Of course, the difficulty with anticipating problems in advance is that while we can rehearse what we will do if some project goes awry, we can rarely anticipate the reactions of others.
Thus if the problems we anticipate are going to require the cooperation of others in order to solve them, our preparations in advance, on our own, are really a waste of energy. Sometimes we may try to hold other people to promises in advance that they will do exactly what we want when we want it, but this situation usually comes unstuck, because other people don’t like to be tied up in promises to us.
For example:
‘ Now George, I want you to promise me that when the plumber comes out to quote on the repairs, you will insist that he pay for the damage his truck caused to the front lawn. And don’t let him get away with any lame excuses!’
‘I want you to go up to the dress shop, describe the dress I’m making exactly, and buy a twelve inch zip fastener exactly the same colour. And don’t get the colour wrong!’
‘Get whatever meat looks good at the butcher’s, but don’t buy anything we won’t all like!’
‘Remember, when the visitors come, don’t start showing them around the house when it’s such a mess, even if they ask to see how the renovations are coming along!’


Once, women with breast cancer were routinely advised to have a radical mastectomy (removal of the breast and lymph nodes under the arm). But 18 years ago, Dr. Bernard Fisher of the University of Pittsburgh began a pioneering study in many hospitals simultaneously. The research compared two treatments for early cancer. One was radical mastectomy. The other combined radiation with lumpectomy (cutting out small cancers). The results, published in 1985, showed the treatments were equally effective against early-stage cancer. Women now had a choice.
In 1982, Wilma Gauthier, a secretary in San Diego, chose lumpectomy. Her doctors were against it. “They told me that if I didn’t have a mastectomy, I would orphan my children,” she recalls. “I did feel scared that I had made a mistake. My husband supported me. It has been 12 years, and I am cancer-free.”
Still, only 20 percent of women who have early-stage cancer – and so are good candidates for lumpectomy – have that treatment. Surgeons may still be recommending mastectomy.
The issue was raised again this year after it was revealed that a Canadian doctor had committed fraud when he participated in Dr. Fisher’s studies. In a complicated way, he had entered patients into the research who did not meet the qualifying guidelines.
Dr. Fisher did another analysis of the results, leaving out the Canadian data. Fortunately, the outcome remained the same: Lumpectomy with radiation is just as effective as radical mastectomy for early-stage cancer.
But Fisher waited months before revealing the fraud and announcing the new analysis. Cancer scientists and women’s health advocates were infuriated. “It was a terrible thing,” says Dr. Jeffrey S. Abrams, a breast cancer specialist at the NCI.


When a problem is interfering with a given goal, you might ask yourself whether the goal is realistic at that particular time. If you determine that the goal is unrealistic, you may find that you needn’t confront the problem you’ve been struggling with until later, when it may more easily be overcome. Or maybe, if you change your goal, you won’t have to confront a particular problem at all. Do not let impossible expectations lock you into a no-win situation.
If you begin an exercise program and you decide you want to be able to walk three miles by the third day, you are setting an unreasonable goal. If your house is a mess and you are not feeling well and you set a goal of having the house spotless by sunset, you are setting an unreasonable goal. Setting unreasonable goals leads you to set yourself up to be disappointed and discouraged, and discouragement may make you give up on your exercise program or put off yet again getting a start on household chores. On the other hand, if you succeed in meeting an unrealistic goal, you may pay the price tomorrow.
A wiser plan is to divide the goal up into segments of small tasks which can be accomplished in steps. Not only will your goal ultimately be accomplished (perhaps in a week rather than a day, or in four weeks rather than one), but you will also gain confidence in your capability to reach the other goals you set for yourself.
It is often helpful to make a contract with yourself composed of incremental assignments leading to the eventual goal. Success breeds success. Failure to attain an unrealistic expectation may make you resist trying again or afraid to try again. It may lower your confidence and self-esteem. On the other hand, when your self-expectations are in line with your capability, you are more likely to succeed.
A word about exercise plans: If your goal is to improve your strength and endurance, don’t become a weekend athlete. Instead, set daily exercise goals. Taking this approach will make it much more likely that you’ll meet your goal.


As you limit the amount of meat you eat, occasionally substitute other types of high-protein foods such as eggs or legumes (dried beans and peas) for meat. Although an egg contains a significant amount of cholesterol (about 210 milligrams), it is an excellent source of protein and contains only about 80 calories and less than 6 grams of fat. Most of the cholesterol is contained in the egg yolk. Eat no more than three to four egg yolks each week, including those contained in foods that contain a large number of eggs (such as custards, souffles, quiches).
Discard half the egg yolks when you make scrambled eggs, or substitute two egg whites for each whole egg in most baked products. Use commercial egg substitutes, which have no cholesterol, in cooking or for scrambled eggs, omelets, or quiches.
Legumes are another low-fat meat alternative. They have the added advantage of containing no cholesterol, yet they are high in protein. Legumes also contain lots of fiber. Many choices of legumes are available: butter beans, kidney beans, black beans, lima beans, pinto beans, navy beans, “baked” beans, black-eyed peas (cow-peas), chickpeas (garbanzo beans), lentils, and split peas.
Combining legumes with foods from the grain group (for example, bean tacos, meatless chili and corn bread, peanut butter sandwich) provides high-quality protein.