February 2013 Issue

Prevent Heart Disease — How to Dispel the Five Common Heart-Health Myths With Clients and Set the Record Straight
By Juliann Schaeffer
Today’s Dietitian
Vol. 15 No. 2 P. 20

Heart disease is the leading cause of death in Americans. In fact, it’s responsible for roughly 25% of deaths in the United States, according to the Centers for Disease Control and Prevention. For a condition that RDs know can be largely prevented, treated, and reversed through lifestyle modifications, this number is far too high.

Your clients already may know that high blood pressure, smoking, and eating fast food twice per week increase their risk of heart disease, especially if it runs in their family. Any knowledge they receive that can persuade them to engage in more healthful behaviors is considered a boon. The problem lies in the multitude of misinformation that often is found on the Internet when clients search for practical heart-health tips. Much of the information is inaccurate and misleading, causing them to make the wrong choices.

“Fortunately, the lay public is getting more interested in nutrition and health,” says Farzeen Sukheswalla, MS, RD, LD, CNSC, the clinical nutrition and dietetic internship manager at Texas Health Presbyterian Hospital Dallas. “Many people are taking charge of their health and are interested in getting more knowledgeable. Unfortunately, quick browsing on the Internet may not produce the most reliable information we want our patients to follow.

“I struggle as a professional to keep up with the latest studies, so I know some of our clients have a really hard time with this,” Sukheswalla adds. “As nutrition experts, it’s our role to help demystify some of these misconceptions and help our clients obtain a better understanding.”

To help you set the record straight, Today’s Dietitian asked nutrition professionals and other heart-health experts to address the five most common misconceptions about heart disease they hear often from clients and the public at large and how to relay the correct information to them.

Myth #1: Everyone Experiences the Same Heart Attack Symptoms
Fact: It’s true that chest pain (a crushing sensation in the chest with pain radiating down the arm) is the most common symptom of heart attack. But it’s important to note this is more common in men than in women, who have been known to experience more subtle warning signs.

“Both women and men can experience the intense pain in the chest, but women often experience subtler signs, such as jaw achiness, nausea or vomiting, breathlessness, or intense low energy, which sometimes can be dismissed,” says Cheryl Kuhta-Sutter, RD, LDN, of Presbyterian Novant Heart & Wellness.

“Seventy percent of women reported unusual fatigue as the primary symptom before their myocardial infarction [MI],” notes Janet Bond Brill, PhD, RD, LDN, CSSD, a cardiovascular nutritionist and author of two books on heart health, and a study published in Circulation in 2003.

Because these lesser-known signs aren’t as commonly associated with heart attack, it can make the condition inherently harder to treat for two reasons: It can be more difficult for physicians to diagnose, and women experiencing these symptoms may be more likely to delay treatment, not realizing the gravity of the situation.

“Vague symptoms often aren’t treated aggressively, and women often delay seeking medical attention, which leads to poorer outcomes,” Brill says. “This situation most probably contributes to the sad statistic that 38% of women who have heart attacks die within a year compared to 25% of men.”

However, while noting that women can experience less typical symptoms, such as breathlessness and abdominal pain, before a heart attack, that’s still no reason for a woman to brush off chest pain, says Daniel Edmundowicz, MS, MD, FACC, a GNC Medical Advisory Board member. “Women also can experience crushing chest pain just like men do as symptoms of a heart attack,” he says, adding that even more important is the distinction that in one-quarter of cases, patients experience no warning sign at all, “With the first sign/symptom of coronary artery disease [being] sudden death.”

According to Malissa J. Wood, MD, codirector of Massachusetts General Hospital’s Heart Center Corrigan Women’s Heart Health Program and a national physician spokesperson for the American Heart Association’s Go Red For Women movement, women aren’t the only ones who should be on the lookout for atypical heart attack symptoms. “While men in general are more likely to have typical symptoms of heart disease, some groups of men, including patients with diabetes, may not experience the classic symptom of an elephant on the chest,” she explains, stressing that any new or unusual symptom in any patient should be evaluated carefully, “Particularly when it occurs in [someone] with risk factors for heart disease.”

Myth #2: Chocolate of Any Kind Is Good for Your Heart
Fact: For clients who might have caught a smidgen of a TV news segment and walked away with the assumption that adding a regular dose of chocolate to their diet can help stave off heart disease, there are some specifics that are worth extrapolating, specifically that not all chocolate provides the same benefits—and the benefits are limited.

“There’s evidence that dark chocolate may provide benefits to the blood vessels,” Wood says, such as one 2009 Swedish study that found dark chocolate helped patients improve blood pressure control. “But this is only in small quantities.”
Brill stresses that the studies linking chocolate’s flavonoid benefits refer to only dark chocolate, so while an afternoon snack of milk chocolate M&Ms may not bring about a heart event on its own, it certainly won’t keep one from occurring. “Only dark chocolate with a high percentage of flavonoids has heart and vascular benefits,” Brill says, denouncing the ever-popular milk chocolate as well as white chocolate and Dutch processed varieties for their lack of heart-health benefits.

Even with the studies touting dark chocolate’s possible heart-health benefits, it’s important to note that patients can easily eat too much, according to Edmundowicz. “While there are antioxidants in dark chocolate, the amount of saturated fats consumed easily can outweigh any potential benefits,” he says.

Overall, Kuhta-Sutter recommends clients enjoy their sweet treats on occasion but look for antioxidant benefits elsewhere—in healthful whole foods and whole grains. “Heart-healthy eating means eating a variety of healthful food throughout the day and balancing the nutrients in your meals,” she says. “There are no superfoods. Chocolate is high in a plant chemical called flavones that have antioxidant properties. Remember, fruits, vegetables, and whole grains have antioxidants also but aren’t so high in calories like chocolate. If you like chocolate, enjoy it in moderation. It should be a treat, not an indulgence.”

Myth #3: Eggs Can Be Eaten With Abandon
Fact: The message of eggs’ healthfulness (or lack thereof) has been anything but consistent over the years: One day they’re in (a healthful diet), the next day they’re out. But the consensus among the experts interviewed here is that while egg whites are healthful, the same isn’t necessarily true of egg yolks.

“Though eggs are packed with protein and nutrients, egg yolks also are packed with cholesterol,” says Jay Kenney, PhD, RD, a nutrition research specialist at Pritikin Longevity Center + Spa in Miami. “Consistently, research has found that the more dietary cholesterol we eat, the higher our blood cholesterol levels rise and the greater our risk of heart disease. That’s why it’s so important to keep a lid on the amount of cholesterol we eat.”

To back up his case, Kenney points to research as far back as a Lancet study performed in 1984, in which Harvard researchers concluded that including one jumbo egg daily increased participants’ dietary cholesterol intake an average of 97 to 418 mg/day. “After three weeks, blood cholesterol levels among the men and women also had increased. Levels of LDL cholesterol rose on average 12%,” Kenney says.

In a 2006 study in the Journal of Nutrition, researchers at the University of Sao Paulo in Brazil sought to distinguish the effects of egg whites vs. egg yolks, feeding one group three egg whites per day while giving another three whole eggs—the remainder of their diets was the same, “fairly low in fat and high in a variety of whole foods such as fruits, green vegetables, beans, chicken, and fish,” Kenney says.

The results? “Among the men in the group eating three egg whites daily, total intake of dietary cholesterol averaged only 174 mg/day. Among the men eating three whole eggs a day—egg whites plus egg yolks—daily dietary cholesterol intake averaged a whopping 804 mg,” he says. “Along with increased dietary cholesterol, the egg yolk eaters ended up with increased blood cholesterol. Their LDL bad cholesterol, after 15 days of eating whole eggs, was 30% higher compared to the egg white eaters.”

Kenney also refers to a study published recently by scientists at the Stroke Prevention & Atherosclerosis Research Centre in Ontario, Canada, in which researchers found that participants who ate the most eggs had the most plaque-ridden arteries.

While he doesn’t demonize eggs as a whole, Kenney says at Pritikin, guests are advised to enjoy egg whites while steering clear of the yolks, at least most of the time, opting for a diet that “substantially limits saturated and trans fats as well as dietary cholesterol and promotes an eating plan full of whole, fiber-rich foods plus daily exercise.”

Brill agrees, pointing out that the American Heart Association recommends Americans who wish to lower their LDL cholesterol or overall heart disease risk limit their daily cholesterol intake to 200 mg—just one egg yolk contains more than this amount.

“Furthermore, many Americans consume dietary cholesterol in foods other than egg yolks throughout the day, such as organ meats and baked goods made with eggs,” she says. “Hence, egg yolks should not be eaten with abandon, and their cholesterol count should be considered in a person’s daily cholesterol intake.”

Kuhta-Sutter doesn’t debate the research concerning egg yolks, though she does note that recent analysis has shown the amount of cholesterol in eggs has decreased in the past decade. Still, she agrees that moderation is the key. “Recommended is one egg yolk and unlimited egg whites daily,” she says. “Eggs are a healthful food in a diet that includes a variety of other foods.”

Myth #4: Only a Regular, Strenuous Exercise Program Will Improve Heart Health
Fact: It’s true that the more clients include regular exercise into their daily lives, the more benefits they’ll see, but that’s not a reason to decline going for a 20-minute walk when they have the time.

“Even a 15-minute walk is better than sitting on your butt,” Mary Finckenor, RD, CDE, BC-ADM, CSSD, of Morristown Medical Center in New Jersey, tells patients. “Even if your exercise needs to be cut down, it’s still worth doing. You’ll still get some health benefits, and it keeps you in the routine of regular exercise.”

When Kuhta-Sutter meets with patients who have heart disease, first she clearly explains how much exercise can benefit their condition. “Research strongly supports the role of regular physical activity in managing and reducing the risk of heart disease,” she says. “Consistent exercise isn’t only important for heart health, but research has shown that it enhances your mental and physical well-being and overall quality of life.”

But she’s also clear that while regular exercise is best, any activity is still beneficial—and some types of activity help heart disease patients more than others. “All exercise is extremely important in patients with heart disease and has a positive influence on the risk factors for heart disease, such as high blood pressure, high cholesterol, diabetes, and obesity,” she adds. “The type and frequency of exercise is important in order to maximize the benefits of exercise on the heart. Cardiovascular exercises that increase the heart rate, such as walking, jogging, biking, and swimming, are the most important types of exercise for patients with heart disease because these exercises help strengthen the heart and lower the amount of work the heart has to do.”

For clients who can, recommend they go walking to start. Kuhta-Sutter also suggests biking for lower functioning individuals. “Resistance and core training, along with flexibility, also are important for patients with heart disease in order to increase strength and functionality. Patients with heart disease should get in at least three to four days of cardiovascular exercise each week to begin with and increase to four to six days each week as they progress.”

That might sound daunting to a patient unaccustomed to walking any farther than to his or her mailbox, but patients should take heart: every step helps. “In fact, only 150 minutes of exercise a week can lead to a significant reduction in death due to heart disease,” Wood says. “And this can be achieved by breaking exercise up into increments of 10 to 15 minutes at a time.”

Myth #5: Heart Disease Is in My Genes, so I Can’t Prevent It
Fact: Yes, a family history of heart disease will boost patients’ risk of having to deal with the disease sometime in their future. But instead of letting this knowledge defeat them at the starting line, experts say clients should let it empower them to do what’s necessary to prevent the disease, as it’s far from an inevitability. When talking with patients, be sure to stress that whether someone gets heart disease is, largely, in their own hands (and their own choices).

“Heart attack and stroke are, for the most part, completely preventable,” Edmundowicz says, “but only if we focus on risk factor levels early in life, not later in life when symptoms usually develop. The disease of cholesterol buildup in the heart or brain arteries—for that matter, any artery in the body—is one that has an asymptomatic incubation period that can be years long in some people, giving them plenty of time to make the changes necessary to avoid clinical manifestations of that disease.”

The hardest part of preventing heart disease, according to Edmundowicz, is convincing clients they’re at risk even before any symptoms present. “The challenge is convincing individuals they may be vulnerable to the process. This requires education about the risk factors, perhaps identification of asymptomatic disease already present, and compliance with lifestyle and dietary changes and perhaps medication therapies to impact progression of the process and risk of clinical disease,” he says.

When comparing family history to lifestyle choices, Brill says, “Lifestyle trumps genes any day of the week. Research has proven that even in those individuals with genetic cholesterol disorders predisposing them to heart disease, controlling the modifiable risk factors and getting their LDL down can and will prevent an MI.”

For patients presenting with risk factors for heart disease, Kuhta-Sutter highlights a list of lifestyle modifications with which they’re likely to see the most benefit, including maintaining a healthful weight, eating a healthful diet, limiting salt and alcohol intake, avoiding tobacco, getting consistent exercise, and controlling stress. Addressing only one or two of these at a time might help patients who feel overwhelmed making too many changes all at once.

When it comes down to it, Brill says whether or not clients have a family history of heart disease (as she does), everyone is at risk to some extent. Yet this also means everyone is in a position to decrease their risk daily with smart choices and healthful decisions. “All Americans are at risk for heart disease, our nation’s leading cause of death in both men and women,” she says. “Clients need to understand this disease is preventable through heart-healthy living.”

Brill breaks down the basics of what she views “heart healthy” to mean: “Heart-healthy living translates into knowing our numbers: modifiable risk factors that can be changed via diet, exercise, and drugs, if necessary. Heart-healthy eating also means subtracting or minimizing intake of those foods known to raise LDL cholesterol and promote atherosclerotic disease: saturated fat, trans fat, and dietary cholesterol. Heart-healthy eating also means adding into your day the foods that promote heart and artery health, such as extra-virgin olive oil, dark leafy greens, deeply hued vegetables and fruit, legumes, fish, and all the other foods comprising the time-tested optimal heart diet: the Mediterranean diet.”

— Juliann Schaeffer is a freelance editor and writer based in Allentown, Pennsylvania, and a frequent contributor to Today’s Dietitian.


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