Heart Disease Prevention: Expert Q&A

February is American Heart Month, a great time for all people to focus on their cardiovascular health. Despite significant progress in research and treatment options, heart disease continues to be the leading cause of death in the United States, claiming the lives of more than 650,000 people each year. Primary care physician Dr. Maria Ferrera and cardiologist Dr. Alan Jackson will discuss heart disease risk factors and prevention methods, plus they'll take your questions. That's coming up right now on At the Forefront Live.

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And we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. Let's start off with having each one of you introduce yourselves. Tell us a little bit about what you do here at UChicago Medicine.

And you're both new to the program. I've never had either one of you on. So thank you both for being here today. We really appreciate it. And, Dr. Jackson, we're going to start with you, since you're up here at the table. You drew the short straw. You have to be up here.

Well, I'm a cardiologist here at University of Chicago. I'm a native Chicagoan, and happy to be here. Fantastic. And Dr. Ferrera?

Hi, my name is Maria Ferrera. I'm one of the primary care physicians at our River East location. I control and manage chronic medical conditions such as high blood pressure, diabetes. And I'm very grateful to be here today. Thank you for having me.

And I want to give a shout-out to our River East facility, because it's one of our newer facilities. And it's an absolutely beautiful, beautiful place to get care. I do it myself there. So really wonderful to have both of you on the program today.

So do you want to remind viewers that we will be taking questions from you. So if you want to type them in the comment section, we'll try to get to as many as possible over the next half hour. And we're going to start off with some basics.

We heard a little bit in the intro to the program that heart disease is, unfortunately, still pretty common in the United States, even though we know more about it. Can you tell us a little bit about that and explain what's going on there. Why is it still so common? I would imagine I have some idea.

Well, we look at the risk factors for heart disease. They include high blood pressure, diabetes, tobacco, and cholesterol, for example. And we're not controlling those like we should. People aren't really making decisions with diet that are good for them. Some people continue to smoke. And so these things contribute to the prevalence of heart disease.

Exactly. So, Dr. Ferrera, can you talk to us a little bit about heart disease and how it affects women and people of color. I think oftentimes we think of men having heart attacks, but heart disease is a real killer of women, as well, and something that people need to be quite aware of.

Absolutely. Heart disease is the leading cause of death in the United States. And it's the leading cause of death-- is the number one killer in women above the age of 25, regardless of their race or ethnicity. So it's definitely very common. In African-Americans, too, also, the risk increases, mainly because we find in them that they have higher risk factors that leads to heart disease, for example, high blood pressure, diabetes, and obesity.

And yeah, there's just a higher prevalence in communities of color. And I know that's an area that folks here at UChicago Medicine have been doing some work to try to improve those numbers, but it's been a challenge so far. I don't know if you care to talk about that at all, or what do you tell your patients when you talk to them about, maybe, how they can help with lifestyle choices, that sort of thing?

Well, when a patient comes into our office, we really try to do a global risk assessment of trying to identify what risk factors they have that might increase the risk of having heart disease. So we go into various questions because, like I said, it's very comprehensive. We dig into past medical history. The patient themselves might have any-- already diagnosed-- a diagnosis of high blood pressure or diabetes.

We also look into their past family history, which plays a big part. And then also we look into their activities. For example, are they exercising the way that they should? Are they eating healthy? Are they sleeping well? And so by identifying these risk factors we can already note if somebody is in a different group and has a higher risk of having heart disease.

Sleep is one of the things that you just mentioned and I think is very interesting. And we-- I want to spend a little bit more time on that later in the program, because it's amazing as we talk to various physicians, how important sleep is just in overall health. And I just-- I think that's fascinating. So, Dr. Jackson, if you can talk to us-- diabetes is something that we hear a lot about on the program, and we talk about this and its impact on other diseases. Could you talk to us a little bit about diabetes and how that triggers heart disease, and what do you do with your patients that specifically--

So--

--suffer from that?

--diabetes is perhaps the most important factor in developing heart disease. So we try and make sure, working with our primary care physicians, that we keep it under control. One of the things I emphasize is a vegetarian or vegan diet, because that can help control that kind of thing. Diabetes also has an impact on cholesterol and lipid metabolism. So it's kind of a lead-in to a lot of different issues with heart disease. It helps accelerate the coronary artery disease development.

And we talk about Americans' diets, and I know I'm guilty here as well. And it's very easy, I think, to fall in that trap of fast food, or even if it's not fast food from a fast food restaurant but fast food from the grocery store. You buy something in a box, and not necessarily the way to go. And I've heard people describe shopping the exterior of the grocery store. I don't know if you can talk to us a little bit about diet and just some of the things that people need to be aware of. And both of you can participate in this one, if you will.

So fried chicken and ribs is not the answer, OK? So more healthy salads, without having-- many times I say to a patient, have a salad. And then they want to add turkey, cheese, and all that, and a big creamy dressing.

[WRONG ANSWER BUZZER NOISE]

So you really have to have a nice all colored salad with balsamic or Italian dressing. So that's kind of where we start with. And a lot of times, there's some pushback. But eventually some people like it.

One of the things I've started advocating is meatless Monday. And I tell people, look, I'm not vegan. But if I had diabetes, hypertension, was on 13 pills, I might eat like a rabbit, because there's no side effects. So we go through this with them. And there's always-- what's interesting is I say, well, you need to become a vegetarian. And they say, well, I gave up steak. Well, yes.

[LAUGHTER]

But that includes eggs, fish, whatever, right? Invariably, that's what they say.

Well, Dr. Ferrera, I'm a big fan of hamburgers. I'm a big fan of steaks. I love red meat. Again, I'm probably like 90% of the people watching this. I like all of the things that are bad for me.

But one of the things that my physician, who also practices there at River East, has told me is to try to cut back on those things. Eat more fish. Eat more leafy greens, that sort of thing. It's a bit of a challenge. But once you start falling in the habit, it gets a little easier.

Absolutely. There are diets that have been shown that reduce the risk of having cardiovascular disease. Among them are the Mediterranean diet, also the DASH diet. But the overall emphasis of having a heart healthy diet is really trying to incorporate more fruits and vegetables into your diet. Preferring whole grains is definitely something that's recommended as well, and trying to obtain protein from a healthy source, for example, trying to eat more legumes or nuts, fish and seafood, and if you're going to have dairy products, trying to have low fat dairy products.

Also trying to avoid processed foods, such as red meat, is encouraged, no added salt, no added sugars, and trying to avoid tropical oils. Tropical oils include palm oil or coconut oil. The oils that I actually recommend is olive oil.

Interesting. So, Dr. Jackson, when you talk to your patients, is there a certain age range that you really start looking at people, as far as the potential for having heart disease-- their 50s, their 40s, or is that a misnomer?

20s, 30s.

Really?

Honestly, because we're seeing that these kids are more obese than when I grew up, because they supersize everything. So I would say a healthy diet should be all your life. I don't think there's a particular cutoff for that. So I think probably you would agree, Dr. Ferrera, that the younger the better.

Absolutely. I think being healthy, eating healthy, and exercising is a way of life, really. And I think that the earlier that you start doing these changes, it definitely lowers your risk tremendously to develop heart disease. I am internal medicine, so I typically only see patients above the age of 18. But once they start coming into my office, I start screening them. And I recommend them to have yearly physicals. Some people might be a little bit reluctant. And they're like, no, I don't think I have to come every year, especially if I'm healthy.

But the way that I see it is that a lot can change in a year. I think that, if anything that the past couple of years have taught us is that the way that we live can change, and it can change significantly. And so I've had patients where they've had transition to more stressful jobs, and because of that, they've had changes in their diet and poor diet and poor sleep. And their numbers from one year to the next have increased significantly. So I'm a very big advocate of getting yearly examinations.

Let's talk about the stress aspect of things, particularly when it comes to diet, because I think that's a pretty valid comment, particularly with COVID. I think there are a lot of folks that have experienced stressors in their lives that they probably haven't experienced before. And for a lot of folks, coping mechanism might be eating or eating poorly. Have you seen a lot of that, and if so, how do you work with your patients to deal with that?

With stress-- yeah, unfortunately, like I said, over the last couple of years the level of stress has increased. I think that a big component is sleep. I-- one of the first questions that I ask my patients, amongst the questions that I ask my patients when they come is, are they sleeping OK at night. And the question would be, are you sleeping OK?

But the reason behind it is that it's not only how much you sleep, but it's also the quality of sleep that you get. And so that plays a tremendous role in not only your cardiovascular health, but also your emotional health. And so trying to tease out these questions and basically trying to give tips into better ways to how to cope with stress, but also doing simple things that we might not see, like sleeping well is a big one.

So we do have some viewer questions coming in. Wanted to get to as-- always as many as possible during the program. This question is, what should people with a family history but whom otherwise typically feel healthy, what should they look out for? And either one of you can take that one.

Make sure to check your lipid level. Make sure to get your blood pressure checked. Don't smoke. Come see your primary care or cardiologist. You may be a candidate for a CT scan of the chest or for an echocardiogram.

So when you talk about lipid levels, what should people look for, and what does that mean?

So what we're looking for-- there's really three components we look for-- the total cholesterol, the LDL, which is the low density lipids, and then the HDL. The higher your HDL, the better your survival. The lower the LDL, the better your survival. So if you are a diabetic or have a family history or have had previous heart disease, we'd like you below 100, if not closer to 70. And that can be done through medication, diet, or some combination.

And blood pressure, I imagine, varies greatly with age.

It can, but it still should be treated aggressively, no matter how old you are. And we try and get you now into the 110s. That's called optimal, and so we're shooting for that now. And so some patients may wind up on five pills.

And then if they have sleep issues like sleep apnea, that can drive the blood pressure up, too. So we treat the sleep apnea. We give them their pills. They exercise. They change their diet. And their outcomes are usually pretty optimistic.

That's great. Dr. Ferrera, let's talk a little bit more about sleep, because that's been brought up a couple of times and the importance of sleep. And you mentioned the quality of sleep is so important. How do you know if you have good quality sleep? I mean, you go to bed and you wake up in the morning. How do if it's been a good eight hours or not?

Well, ideally, you should feel rested the next morning. I think that's an important point. One of the questions that we ask our patients who we suspect a sleep disorder, whichever-- especially sleep apnea is, do you feel rested in the morning? So if you slept-- it is recommended for us to get at least seven hours of sleep, an average from seven to nine. And if the person is getting that adequate amount of sleep but they don't feel rested in the morning, then that's definitely a red flag.

Are there ways you can track your sleep? I know with my watch, it supposedly tracks my sleep and can kind of tell me if I've had a good night's rest or not. I don't know how accurate that is, though. I don't know if I believe it or not.

There's definitely applications, like the smartwatches. The smartwatch will actually tell you how many hours you've been in REM sleep and the stages. And so I think it's definitely a good tool to use.

So if you do think that you're not getting a good night's sleep, I know there are experts that you can see, even, of course, here at UChicago Medicine that can do sleep studies and things like that. What happens-- I know that's not your area of expertise. But if you can kind of generally tell us, what does that mean? What happens if somebody has something like that?

Well, if the patient comes to our office and we suspect that they're having, again, any sleep disorder, because there is others, not necessarily only sleep apnea, although sleep apnea is a big one that we screen for. Then typically we refer to the sleep medicine clinic. They're very useful. We work very closely with them.

And what they do is, they go into a consultation, and they'll also ask questions. And then they'll determine whether they're a good candidate for a sleep study or other tests to kind of tease out if there are any other sleep abnormalities.

So we talked a little bit about screening tests. Let's talk about physical activity, because that's obviously an important thing that I think, particularly in this day and age, a lot of us probably don't get much-- enough physical activity. How much should a person have each day or each week? And what are some good things to do if you're not a big athlete?

So I think walking, to start with walking. Now, the three best exercises are swimming, biking, and walking, swimming because it's easy on the joints, bicycling same thing, and then walking. Running would be next. So the longest lived people often aren't high performance athletes, but when you look at them, they walk a lot. Just simple walking is a good place to start.

Not everyone has to train for the US judo team, right? So a lot of patients want to go back to their high school workout in football, which was, as we now know, inappropriate anyway. So I like to just start slowly, recommend yoga, Tai Chi for some of our older folks, so that you get both resistance and flexibility. And then a simple walking program, water aerobic for those who have knee problems.

I try and say anywhere from three to five days a week, anywhere from 15 to 30 minutes should be enough. For some people, they want to max it out. That's fine, but the curve of how much that benefit starts flattening at some point. If you go to Europe, you'll see all these ladies who walk places, can't even spell gym, never been in one. But they're 95, 100 years old.

Yeah, the benefits of walking, I think, are oftentimes underrated with a lot of folks. And to your point, I think a lot of us feel like you have to go and really spend some time in the gym doing a heavy workout, and that's not necessarily what you need to do.

Correct.

Which is good news.

Yeah, so if you're already working hard, that's OK. But for 55, 60-year-olds, your cardiac workout is probably the most important. You need resistance training, and you need flexibility just to prevent falls. But for your heart, again, reaches a level that at some point sort of maxes out.

Interesting. So let's talk a little bit about-- we talked about what are good things to eat. But how do you get folks started on-- to ramp up that heart healthy eating plan? And, Dr. Ferrera, if you could kind of guide us through that and maybe how we could help ourselves on that?

Absolutely. I think this is a great conversation to have, initial conversation to have, with your primary care physician. And I'm a very big advocate of baby steps. It's very hard. It's very hard to change the way that you've been eating for a long time or the way that you've been doing anything for a long time. So you have to make a habit of it.

And just as in regards to exercise, you-- I tell my patients, please don't go tomorrow, run like you're going to train for a marathon, because the next day you're not going to want to get up, because you're going to be sore. Well, it's the same thing regarding eating-- just making healthier choices. Start small. If you're somebody that's having-- drinking five sodas per week, try to cut down to three. So I think that choosing attainable goals that you can sustain over a long period of time, I think that is a great initial point.

Here's a question from Cynthia. It's regarding exercise. She says, I use my steps at home, about 15 steps up and down for three rounds as exercise. Does that help or count?

Yes, it's excellent. Very happy with that. Don't shovel snow.

Talk to us a little bit about shoveling snow, because we always hear about that, people having heart attacks. Is there something specific to that--

Yeah, have seen at least five men come in with that, with V-tach through--

Really?

Yeah, so there's something about the heaviness of the snow, the cold weather, and sort of being out of shape and trying to live as a teenager again, that's-- we find them in the snow holding the shovel in their hand, or they come in with the chest pain. So that's what teenagers are for.

[LAUGHTER]

God created them to help you with-- I mean, that's what I used for my dad, right?

Yeah, well, I can call my teenagers and see if we can get them-- well, they're not teenagers anymore. But that's funny, because I was wondering-- it's not funny. But it's interesting. I was wondering if that is-- because we hear that all the time, every winter. And I wondered how--

I had a guy who came in-- what-- three days ago. He'd been shoveling and had chest pain. What should I do? So I sent him to the ER.

Wow.

That's what you should do.

So speaking of chest pains, because I think this is an interesting point, as well, what constitutes significant chest pains to come and see a doctor or go to the ER? If-- because we've all been there, where maybe you've been shoveling snow and you think maybe you just pulled a muscle or something like that. And you don't want to be a big baby and go to the hospital and then things go south from there.

Well, it's kind of an interesting question. There is no right answer. And in women, it can be an atypical presentation. It's not the classic-- the elephant sitting on my chest. So what I tell people-- they say, oh, I didn't have chest pain. So now I've started to use the term discomfort, because for them, pain means somebody filleted them open and tortured them.

Is that because women have a higher tolerance than men?

Well, it's interesting. There was a recent study on that, and that may be part of it. But I think that we don't listen to women, quite frankly. So that may be part of it, too. That also includes, tragically, sometimes women physicians, too, not just the men, which is sad because that means we've been acculturated the same way. But yeah, so I just tell people, is it that feeling that you just don't feel great? So it's easier to go to the ER, get an EKG, versus getting the call that the funeral home would like you to sign the death certificate.

Yeah. Yeah. Another question from a viewer-- can diet and exercise alone eliminate the need for statins in patients with high cholesterol or high HDL?

So there is a study using, again, there's-- I'm not a vegan, but the data is beginning to even sway me. So there is data that, if you can use a real plant-based diet-- there's a guy out of Cleveland Clinic named Caldwell Esselstyn who has a book on this, Reversing Heart Disease. There's-- Dean Ornish has written something on this. And hey, they have shown reversal. I don't think that's true in all cases, but it is compelling that at least you can postpone it for a long time.

So if you can adhere to this and your LDL and HDL are what we need them to be, some people come off of it. However, you must stay on that vegan, vegetarian diet forever. Otherwise, your numbers will go right back up. So I don't advise people to stop statins if they're on them. But if you want to really max it out, become a vegan.

Now, those pretend meats that they serve-- Beyond Burger, beyond this and that. When you look at the back of the package-- there was a historian who said, if you want to hide something from people, put it in print.

[LAUGHTER]

So if you read the back of it, you'll see that the saturated fat level, because of coconut oil-- you were talking about the tropical oils--

Interesting.

And the sodium content are as much as a whopper.

Wow.

If you look at turkey bacon, for example, turkeys don't have bacon.

[LAUGHTER]

So it's made in a lab, right? So it's-- so really read labels, don't just blow them off. And canned anything in the United States is loaded with salt or loaded with sugar. So you have to be sort of the concerned reader.

You know, Dr. Ferrera, I was eating a-- it was cold, and I was in a hurry. And I grabbed a can of soup the other day out of the cupboard, and I did look at the back on it. And I was stunned with the level of sodium, because it had more than what my whole US-- or my whole daily allowance of sodium was supposed to be, just in that one can of soup. So it's an excellent point.

I do-- I want to throw this out to both of you because it's kind of a fun question coming in from a viewer. As a non-vegan, what's your favorite vegetarian recipe? And I don't know if you can come up with something right off your head. Dr. Ferrera, I'm going to put you on the spot first.

[LAUGHTER]

I have family members that are vegetarians. I am not a vegetarian myself. So I, unfortunately, out off the top of my head, I don't have any preferred vegetarian recipe.

Let me throw this out to you-- beans and rice, lentils. So I just ate at the Nile Restaurant. I had lentil soup. I had falafel. I had hummus and baba ganoush, which are spreads. Now, just a little exotic, I know.

I thought you weren't a vegetarian, though.

I'm not a vegan, but I will eat mainly that stuff.

I see.

But I think that-- so spaghetti with marinara, a salad with all colors fruits and vegetables, oatmeal with almond milk-- there's a variety of things that even we omnivores/carnivores can tolerate.

Excellent. Another question from a viewer-- this is from Jill. Can someone in their 80s have a successful open heart valve replacement surgery? When are you not a good candidate? That's an interesting one.

So the answer is yes. We have these new techniques where we can actually go-- we don't have to open you up. It's called a TAVR, so basically it's a catheter procedure to replace the valve. Now of course, it depends on which valve. But the success rate, especially here at University of Chicago, are as good or better than anyone in the country.

So yes, you can have it. We can do it using catheters without necessarily using open heart surgery in selected cases. In some cases, we do wind up having to open you up.

Yeah, it is interesting. That's something that's been just fascinating to me here at UChicago Medicine, is the ability to do some of these surgeries without cracking open the chest. I remember my father, and this was years ago, had a heart attack, and he had multiple bypasses. And they had to open him up.

And I talked to him about some of the things that were done by-- robotically here. And he said, boy, if that would have been available in his time, he sure would have loved to have had that. I think it makes a big difference in the quality of life for patients.

So we are about out of time. Dr. Ferrera, I want to get kind of some closing thoughts from you. And then, Dr. Jackson, we'll let you-- we've got-- let me-- hang on. I've got one more question from a viewer. So let's do this real quickly. Dr. Ferrera, what can be done-- this is from Mary-- what can be done for a high heart rate, and when should something be done? This is a person who's 68 years old.

Well, typically the resting heart rate of somebody who's not an athlete should be between 60 to 100. And people that exercise more often, they'll have lower heart rates. Typically they can go into the 40s. If it's something-- and the good thing about having Apple Watches now is can actually monitor your heart rate, too, whether you're at resting. And I have a lot of my patients tell me, I was doing laundry yesterday or watching TV, and my heart rate shot up to 140s or 130s.

So if you see that your heart rate is consistently elevated and then you have those spikes, and then on top of that, you're having symptoms, whether you have palpitations with-- typically the patients will describe it as, oh, I felt like my heart skipped a beat. Then it's definitely a good time to go see your primary care physician.

Yeah, I love that question because you mentioned people-- and I do that myself. I watch my heart rate occasionally on my watch. And if you do see those spikes, sometimes it can alarm you a little bit. It doesn't necessarily mean you're having an issue. But if it's regular, you're saying, you probably should talk to somebody.

Absolutely, yeah.

Great. All right. So now I'm going to let you have your final word, if you will, Dr. Ferrera.

Yes, heart disease definitely is very common. And again, it's the leading cause of death in the United States. We have a lot of resources out there, talking about-- we talked about physical activity. We talked about diet. We talked about-- there are other factors also that influence having heart disease, higher risk for heart disease, like smoking or obesity.

The American Heart Association has a website, and they have absolutely excellent resources there, where you can get tips for healthy eating, tips to quit smoking, and tips to how to incorporate more exercise in your daily routine. So I would definitely recommend that. If you're interested in trying to live a healthier lifestyle, then that's probably a good resource to look up.

Fantastic. Dr. Jackson, any parting shots?

Yes, eat to live. Don't live to eat. And walk. Walk. Stop smoking. Enjoy life. Have a prayerful, meditative life. Enjoy your family. And come see your primary care physician.

Those are-- you both have fantastic advice. And that was really, really good stuff and good questions, too. We are out of time, though. Special thanks to our guests for being with us today. And a big thank you to those of you who watched and participated in the program.

Please remember to check out our Facebook page for our schedule of programs coming up in the future. To make an appointment, go online to uchicagomedicine.org or give us a call at 888 824-0200. Thanks again for being with us today, and I hope everyone has a great weekend. 

Despite significant progress in research and treatment options, heart disease continues to be the leading cause of death in the United States, claiming the lives of more than 650,000 people each year. During this live Q&A show, primary care physician Dr. Maria Ferrera and cardiologist Dr. Alan Jackson will discuss heart disease risk factors and prevention methods.
Alan Jackson

Alan L. Jackson, MD

Alan L. Jackson, MD, is an expert cardiologist who specializes in identifying and treating a wide range of cardiac conditions, including everything from common heart problems like hypertension and hyperlipidemia to complex cardiac diseases, such as valve disease, chronic heart failure and coronary heart disease.

Learn more about Dr. Jackson
Maria Ferrera

Maria Ferrera, MD

Maria J. Ferrera, MD, is a board-certified physician specializing in internal medicine. In addition to providing comprehensive preventive medicine, she also offers ongoing medical management of complex chronic illnesses, such as hypertension, diabetes, cholesterol disorders (hyperlipidemia) heart disease and more.

Learn more about Dr. Ferrera
Dr. Polonsky and patient

Heart Disease Prevention

UChicago Medicine cardiologists understand the risks and causes of heart disease, including hereditary factors that could play a part in your heart health, and we are dedicated to having you be a part of creating the strategies to avoid heart disease. 

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