Male Speaker:
You're listening to ReachMD, the channel for medical professionals. Welcome to Heart Matters, where leading cardiology experts explore the latest trends, technologies, and clinical developments in cardiology practice. Heart Matters is produced in cooperation with the American College of Cardiology. Your host is Dr. Janet Wright, Senior Vice President for Science and Quality for the American College of Cardiology.
Dr. Janet Wright:
One of my favorite quotes is, "All things in moderation, including moderation." That one came from Mark Twain. When it comes to changes that influence a person's cardiovascular health, are big changes the way to go, or are we more likely to change health through small, incremental change? Our guest today is Dr. Steve Kopecky, cardiologist at Mayo Clinic's Cardiovascular Health Clinic and professor of medicine at the Mayo Clinic in Rochester. Welcome, Dr. Kopecky.
Dr. Steve Kopecky:
Thank you, Janet.
Dr. Janet Wright:
Delighted to have you here. I think we're all hearing, more and more, that it's less and less about drastic steps to improve cardiovascular health and maybe more advantageous to do small things on a daily basis. Am I on the right track here? What can you tell us about that?
Dr. Steve Kopecky:
Well that's exactly right, Janet. We used to feel that it took such large changes in our lifestyle to make a difference, and with the exception of stopping smoking, which is either an all-or-none phenomenon, the rest of these things are really relatively small changes, especially small changes over time, that can help us the most.
Dr. Janet Wright:
This seems to be such common sense, and yet, what you just said, it so hard to execute.
Dr. Steve Kopecky:
Well, it is very difficult to do, and I think what has held us back somewhat is the lack of science that shows it's beneficial, but I think in the last few years we've had some wonderful studies, such as the ARIC study, the Atherosclerosis Risk In the Communities, that has shown that making four changes in your lifestyle and doing it over decades can reduce your chance of a heart attack, or stroke, or fatal events like that by almost 90 percent, which is really much more than any of us thought.
Dr. Janet Wright:
Oh, that's so powerful.
Dr. Steve Kopecky:
Now, those four things are, of course, not smoking, which is an all-or-none phenomenon, and even I tell patients and their families about not only primary smoke and secondary smoke, which everyone seems to know about, but also third-hand smoke. So if your spouse, say, worked with someone that smoked, and they came home, and you smell it on their hair or on their clothes. If you smell it, you absorb it. If you absorb it, it gets in your blood, and then it causes some of the problems. They've seen changes in endothelial function within the coronary arteries within an hour of being exposed to third-hand smoke, and that's important to get across, like to grandmothers who have grandkids and never smoke with them, but smoke outside.
The other three things that are important are, one, is trying to work towards a body mass index of 25, and you know, I tell patients 25 isn't all that important, but certainly getting below 30 is because that's a big cut point. Obesity, a BMI of 30, puts you at risk for heart disease significantly so. The other two, one is eating five fruits or vegetables a day, which, really, you would think would be pretty easy, but only one in four American adults eats five fruits or vegetables a day. Now, what's the serving? About the size of a tennis ball, and unfortunately, we just don't do that as well as we should.
And then lastly is exercising at least 150 minutes a week. We recommend here at Mayo 200 minutes a week. It should be vigorous. You can ask a patient, "How often do you exercise? Did you actually sweat or perspire?" And that should be three or four times a week, of course unless you live in a real hot climate or something, but just that single idea of doing these four events was actually put into a prospective study, and the reason it was put into a prospective study is only three percent of American adults do these four things.
When we do them, however, as was done in the prospective part of the ARIC study, it showed that we could reduce our chance of heart attack, stroke, or fatal cardiovascular events in four years, just four years, by 40 percent, which is much better than a lot of the much more expensive and aggressive interventional treatments that we have currently available.
Dr. Janet Wright:
As we said earlier, not only do these make sense, these are not rocket science. Most people, given a test, would pick these answers as components of a healthy lifestyle. In the past, as you mentioned, the limitation was that we didn't have, perhaps, as firm a foundation in science as we now have. How can we begin to help folks implement this in a daily way into their lifestyle?
Dr. Steve Kopecky:
Well, that's a real good question, and I think that we're up against some very clever marketing that's being done on the Internet and other places, and the patients are deluged with information and sales pitches. You know, take this pill, or take that pill, or eat this certain fruit smoothie and you'll live longer. I think we, first off, need to tell patients that, here's good scientific data and make it easily available to them. So, here at Mayo, we actually print out these four things on one sheet of paper and give it to them, and instead of them worrying about what type of food to eat or something, we say, "Just eat five fruits or vegetables a day." The fresher, the better. The less cooked, the better. The more the skin's on, the better, and we know that will help you.
Try to exercise vigorously at least four or five times a week, and we'll actually give them an exercise prescription and say, "This is what we want you to do." You know, get on an elliptical machine. If your backs hurts you or _____ (5:21), don't walk on a treadmill because that can make your back or knee pain worse, and try to be real specific, because I think patients just get so confused with all the information out there.
Dr. Janet Wright:
And there are so many cues in our environment now to eat more. That it is either economically advantageous to order the larger size, or the conveniences that we have in life discourage any sort of physical activity. Am I right there?
Dr. Steve Kopecky:
Oh, boy. We're in a farming community up here, and what we do with animals like young hogs, young cattle, we try to put them in a small little pen, and don't let them exercise much, and feed them because we know they eat more...
Dr. Janet Wright:
It sounds like a computer cubicle.
Dr. Steve Kopecky:
But does that remind you of a human in a cubicle?
Dr. Janet Wright:
Exactly.
Dr. Steve Kopecky:
With a computer in front of them.
Dr. Janet Wright:
And no time to eat lunch, and so, the order in comes. The snack food is available on the desk as well. So we're sort of growing this problem ourselves.
Dr. Steve Kopecky:
Exactly right, and if you look at these trends that, compared 20 years ago to now, we actually are worse with these four things than we were 20 years ago. Meaning we're more obese. We're eating less fruits and vegetables. We're smoking more and exercising less.
Dr. Janet Wright:
Now, I see that missing from the four is something about stress, how to manage stress. Can you speak to how you address that at Mayo or what you've observed in your practice?
Dr. Steve Kopecky:
You know, we tell patients that some stress is actually good. The sports field stress. You're with your friends. You're playing a game. You win. You lose. Nobody really cares. It's just that you got out there and had fun. The bad stress is the one where you have no control. Say your economy is bad and your particular position in your company is having trouble. Your business is having trouble, or you're going through some horrible family event like the death of a loved one or a divorce where you have no control over things. That's the bad kind of stress, and when they have that kind of stress, we really try to ask patients to get some help with it. It may just be reading a book. We recommend some very good stress books here that are very readable, and easy to understand, and kind of a self-help thing, and if it doesn't prove to be enough, then the next step is to seek professional help.
Dr. Janet Wright:
If you're just joining us, you're listening to Heart Matters on ReachMD. It's a channel for medical professionals. I'm your host, Dr. Janet Wright, and our guest is Dr. Steve Kopecky, cardiologist at Mayo Clinic's Cardiovascular Health Clinic and professor of medicine at the Mayo Clinic in Rochester. We're discussing the benefits of moderate lifestyle changes for cardiovascular health. Steve, you were addressing the issue of stress and how to help patients manage it. You know, I'm struck...as you were describing, asking them to get help, to take their minds off their stress perhaps with a book, reaching out to a friend I'm sure, but the other thing I look at that is giving them those four things to form the foundation for managing their stress. In other words, if they have the foundation of the regular exercise and the healthy diet, if you can give them those solid things to fall back on, the likelihood is they're going to get through that stressful period and be healthier at the end of it.
Dr. Steve Kopecky:
Very true.
Dr. Janet Wright:
What other prevention strategies have you recommended?
Dr. Steve Kopecky:
Well, I think that our lifestyle now is so hectic, as you alluded to earlier, we don't have much time to do anything. So we'll talk to patients, and many physicians we see as patients and they'll say, "I can't exercise. I don't have time. You don't understand." We say, "You don't understand that you either find time for exercise or find time for disease, because you're going to get one or the other, and at least the exercise is on your schedule."
So we encourage them to do more interval training, and by that I mean that you start exercising, and instead of just getting your heat rate up to a certain level for 20, 30 minutes, you can actually go real hard for a about one or two minutes, and then back off to get your breath back, and then go hard again, and go hard enough that you say, wow, I can't do this for more than a couple minutes or I'm going to give out. The advantage to that is that you use about a third more calories than just the continuous heart rate.
And so, if you're real pressed for time, just go out and do some of that for 10 or 15 minutes, whatever you can. It raises your good cholesterol, your HCL, more. It burns more calories. You actually have more vasodilatation, and it gets you in better shape. So there's a lot of real plusses to that.
Dr. Janet Wright:
Well, and the sense of accomplishment I think is even greater when people see themselves kind of stressing the system, finding out that they can do it. They get into sort of a game theory with themselves.
Dr. Steve Kopecky:
Oh, yeah. You're right. Just getting something done, and I've had patients that, if you ask them, you'll find probably two thirds of Americans have a treadmill, or elliptical, or something in their basement, and you just ask them, how many layers of clothes are on it? And usually, it's a whole lot.
Dr. Janet Wright:
Well, in fact, I had a patient who decorated his treadmill according to the seasons. There was the Christmas decorations hanging, and then Easter, and throughout the year.
Dr. Steve Kopecky:
At least he's using it.
Dr. Janet Wright:
That's right. Have you observed any racial or ethnic differences or challenges by gender in becoming more fit?
Dr. Steve Kopecky:
Well, certainly, the single biggest challenge I think is for a single parent with two jobs and two kids at home. It's almost impossible for them to eat right because they're into this fast food world. It's almost impossible for them to exercise because they don't have time with the children, and the jobs, and such. So those are the ones we really try to just be very specific and say, "We'd like you just to do something for 10 minutes. Exercise for 10 minutes. Just try to increase your fruits and vegetables by one or two a day." Just something they can achieve, and then grow on that.
Now, with the exercise, you know, we have no fountain of youth in our world, but exercise is probably the closest thing we have to it, and what we'll encourage patients to do is a little behavior modification, which is what, basically, this is, is to say two things when you exercise. One is, when you exercise, do something you like, because we found...and Harris has actually polled Americans and found that 40 percent of Americans, they don't say they dislike exercise. They say they hate it.
We all like to go out and play _____ (11:09) with our kids, or walk in the woods with our spouse, or something, but to get on a machine and sweat, we don't like to do. So we say do something you like during the exercise. Read a book you like. Listen to music you like. Watch a show you like. Something that your brain will at least interpret as fun.
And secondly, after you exercise, give yourself a reward. So if you like ice cream, you'll go to the ice cream shop. Don't get a big milkshake because that's a thousand calories, but get, say, a fudgesicle on a stick, which is maybe 40 or 60 calories. It's been shown if you can reward yourself, after about a month of doing this regularly, your brain will say hey, you know, I really hate this exercise, but I like that thing I'm doing during it, and I like that reward I get later, and I'll keep doing it.
Dr. Janet Wright:
I realize that the advice you're giving us today applies whether you're a cardiologist, primary care doctor, or nurse, any healthcare professional taking care of a patient, and all of our interaction begins with taking a good history. So I wonder if you could walk the audience through, again, your approach to your first visit with someone, finding out what their pattern is and then helping direct them toward a healthier pattern.
Dr. Steve Kopecky:
I think it's always important, in talking with the patient, to understand where they're coming from, what their life is like, where they work, what the stresses are there, what their home life is like, what their pattern of living is. When do they get up? What do they eat? Do they eat a breakfast? You know, so many patients now that are people in our country don't eat a breakfast, and it's been shown that patients that do eat breakfast actually weigh less than those that don't. Just kind of get a feel, and it may take 60 or 120 seconds just to get a feel for their lifestyle.
And then secondly, there are a few, I think, key questions. One is I'll ask a patient, "How many times per week do you exercise that you perspire?" And if a patient says, "Doc, I don't exercise, but I'm busy all the time. I'm always doing something," I basically know that if I put that patient on the treadmill, they're going to be pretty well deconditioned or out of shape. So they've got to go out and do something that's kind of vigorous.
Certainly the questions about the smoking are important, but also their eating. Say, "Where do you eat lunch? Where do you eat supper? What about weekends?" Because most people you'll find eat the same breakfast, the same lunch every day, the ones that work on the weekdays. It's suppers during the week, and then on the weekends, they get most of us into trouble. You go out, and you have a big barbecue with friends or a picnic or a party at somebody's house. Have too much alcohol, too much fatty foods, etcetera, and that's where we can just make little changes.
And so, what we'll ask them to do in an instance like that would be just don't eat so fast. Don't eat so much at first, because patients seem to be one of a few types of eaters. We either eat too much at our first helping or we eat our second helping right on top of our first helping, and for instance, in the latter, say, do you ever walk away from a table and feel that, "Gee, I'm so full. I didn't think I ate so much," and just about everybody will say, sure I did. Say, then what you need to do is realize is that there's a about a 15-minute lag between when your stomach gets full and your brain knows it.
So eat your first helping, and then go over, and set the timer on the microwave, and set 15 minutes, and don't eat your second helping for 15 minutes. Talk to your spouse. Have a glass of low-fat, low-calorie drink. Eat a piece of fruit. Talk to your family, and then when the beeper goes off, you can have your second helping, but you'll be much fuller. You'll feel fuller. You won't eat as much.
Dr. Janet Wright:
We've been talking with Dr. Steven Kopecky about the benefits of moderate lifestyle changes for cardiovascular health. Dr. Kopecky, thank you so much for being our guest today.
Dr. Steve Kopecky:
Thank you, Janet.
Male Speaker:
You've been listening to Heart Matters on ReachMD, the channel for medical professionals. Heart Matters is produced in cooperation with the American College of Cardiology. For more information on this week's show or to download a podcast of this segment, please visit us at ReachMD.com. Thank you for listening.
