Heart Health Starts Early! Lifestyle Matters

With COVID-19 on our minds so much these days, it is easy to forget that people are still dying of cardiovascular disease (CVD). The new heart disease and stroke statistics are out for 2022, and there is some good news and bad news (Tsao et al., Circulation, 2022). Let’s get the bad news out of the way first: CVD is still the leading cause of death in the United States, accounting for ~30% of all deaths regardless of sex and ethnicity. While deaths from CVD began dropping in the 1970s, the bad news is that since 2010 the rates have begun to rise again. Based on the latest data available from 2017-18, the average total cost of CVD in the United States is $378 billion per year.

Now for the good news

Although CVD is still a major cause of death in the U.S., we have so many tools to lower one’s risk for CVD and the burden on the U.S. economy. The initiating event in CVD is endothelial dysfunction, where the arteries are damaged due to any number of factors, including physical inactivity, poor diet, hypertension, diabetes, obesity, stress and smoking, just to name a few. We also know this process can begin early in life, so that by the time a child is 18 years old, they can already have the beginnings of endothelial damage (Juonala et al., Pediatrics, 2020). So, what can we do to lower our risk of CVD and the risk of our children and family members?

We now have so much data that clearly indicates that a healthy lifestyle will lower our risk of CVD, even if we have a family history of heart disease. To simplify the message, the American Heart Association (AHA) has developed “Life’s Simple 7” (Tsao et al., Circulation, 2022). Using these approaches, you, your family and your clients can lower the risk of CVD, regardless of genetic factors. These seven evidence-based approaches — four health behaviors and three health factors — are listed below (Tsao et al., Circulation, 2022):

1. Be active: Aim for 150 minutes of aerobic physical activity per week, and add two days of strength training per week. The Physical Activity Guidelines for Americans can provide more guidance. Remember, every little bit helps. Individuals ≥ 60 years who are physically active have a 25-40% lower risk for CVD.
2. Keep a healthy weight: If you are overweight, even a 5-10% reduction in weight can improve blood lipids, glucose and blood pressure (BP).
3. Eat a heart-healthy diet: Eat more whole grains, fruits, vegetables, nuts, legumes and unsaturated oils. Decrease saturated fats, refined grains and added sugars. Use low-fat dairy and lean proteins. Eat less red meat. Add fish, especially fatty fish, to the diet. Drink in moderation. Select low-sodium options. Learn to plan and cook meals at home. Eating just five servings of fruits and vegetables each day can lower your risk of CVD by 12%. See more guidance below, under “Healthy dietary patterns.”
4. Do not smoke or use smokeless tobacco: Stop smoking. Don’t start.
5. Know your blood cholesterol level: Know your low-density lipoprotein cholesterol (LDL-C) level. Keep LDL-C levels below 100 mg/dL.
6. Keep your BP healthy: AAim for a healthy BP pf ≤ 120/80 mmHg, where hypertension or high BP is defined as 140/90 mmHg or higher. Keeping BP low can get harder to do as one ages, so monitor your BP frequently and notice when changes begin to occur. Being physically active, maintaining a healthy weight and lowering sodium intake can help BP management. See more on sodium intake below.
7. Learn about blood glucose (e.g. blood sugar) and risk of diabetes: The American Diabetes Association recommends keeping your A1c levels < 7%. A1c gives you a picture of your average blood sugar level over the past two to three months. This is especially important to track if you have a family history of diabetes.

The goal is that we all learn to live a heart-healthy lifestyle across the lifespan. This means that adults need to help children learn heart-healthy habits and need to set an example in their own lives. Even making small changes in some of these factors will lower your lifetime risk of CVD.

Healthy Dietary Pattern – at every stage of life

Regardless of your age, food preferences and cultural traditions, it is possible to eat a diet that can improve health and lower your risk for CVD. The Dietary Guidelines for Americans (DGA) outlines the core elements needed for building a healthy dietary pattern for you and your family.

1. Vegetables of all types: Eat vegetables of all colors, especially dark greens, red and orange; beans, peas and lentils; and other starchy vegetables. Start your day with a plan for how you can add veggies to your meals and snacks.
2. Fruits: Eat whole fruits whenever possible. They taste great and make you feel full, thus helping to manage appetite. Learn to pack easy-to-carry fruits with you for a snack.
3. Grains: Choose whole grains whenever possible, with at least half your grains being whole grains. Swap brown rice, whole wheat bread and pasta for white, and explore adding new whole grains in your diet like quinoa, oatmeal or whole-grain cereals.
4. Dairy: Use low-fat and fat-free milk, yogurt and cheese, and/or lactose-free versions or fortified soy beverages and yogurt as alternatives.
5. Protein foods: Use lean meats, poultry and eggs; seafood, beans, peas and lentils; and nuts, seeds and soy products. Try adding meatless meals to your week.
6. Oils: Use vegetable oils and oils in foods over saturated fat alternatives.

Foods to limit in the diet

With better food labeling and learning to cook at home, you can begin to limit foods or food ingredients that might increase your risk of CVD. Once you have added the health foods listed above, your diet won’t have much extra room for additional calories. Thus, monitoring your intake of the following foods or ingredients will help to lower your risk of CVD:

1. Added sugars: New labeling allows for easier monitoring of added sugars in the foods we buy. The goal is that < 10% of our daily calories come from added sugar starting at the age of 2. For most of us, this means eliminating sweetened beverages and consuming fewer desserts and other high-sugar foods.
2. Saturated fat: Again, the goal is to keep saturated fat intake to < 10% of daily calories starting at age 2. This means less animal-based foods and baked/fried goods that are typically higher in saturated fat. If you consume 2,000 calories daily, this means < 22 g/day of saturated fat. To put this number in perspective, a large serving of fries (~3.5 g saturated fat) with a 3 oz hamburger patty (5 grams) topped with 1 oz of cheddar cheese (6 grams) will be more than half your saturated fat intake for a day (total = 14.5 g).
3. Sodium intake: Keeping sodium intake < 2,300 mg per day; this means paying attention to processed and prepared foods with added salt and using the salt shaker sparingly at home. Americans consume ~3,400 mg of sodium per day, with most of our sodium coming from the salt added during commercial food processing or prepared foods in restaurants.
4. Alcohol intake: Choose not to drink or drink in moderation (< 2 drinks/day for men and < 1 drink/day for women). Drinking less is better for health and helps with weight management. Some individuals, such as pregnant women, should not drink.

Adapting a heart-healthy lifestyle

Making change isn’t easy, but selecting to follow a few of the recommendations above will help move you toward a heart-healthy lifestyle. It is never too late to start: just open the door and take a walk, plan some healthier food options into your day and learn the joy of cooking. We all have to start somewhere — you can start today!

References:

• Tsao CW, Aday AW, Almarzooq ZI et al. Heart disease and stroke statistics – 2022 Update: A report from the American Heart Association. Circulation, 2022;145 (in press, on-line).
• Juonala M, Wu F, Sinaiko A, et al. Non-HDL Cholesterol levels in childhood and carotid intima-media thickness in adulthood. Pediatrics 2020, 145(4);1-9.

Related links: Handout | Women and Heart Disease
Video | How to Perform a Blood Pressure Assessment
ACSM Position Stand | Exercise and Acute Cardiovascular Events: Placing the Risks into Perspective


Melinda M. Manore, Ph.D., RD, FACSM, is a Professor Emeritus in Nutrition at Oregon State University (OSU) where her research focuses on the interaction of nutrition and exercise for obesity and chronic disease prevention, health and performance. She has especially focused on active women over her research career. Although retired, she continues to do research, write textbooks and keeping in touch with colleagues and former students.  

Resistance exercise is a fundamental aspect of athletes’ training programs, especially in sports where force- and power-production capabilities are keys for elite performance. In traditional strength-training programs, equal absolute load is applied during both the concentric and eccentric phases of muscle contraction. Skeletal muscle is capable of 30%, or more, force production during maximum eccentric compared to concentric contractions. Thus, the relative load is reduced during the eccentric phase when training with an equal absolute load. Recent research has provided evidence that eccentric-only training with greater external loads than the relative concentric training intensity is a potent stimulus for strength and size changes of skeletal muscle.

Furthermore, one bout of exhaustive exercise with damaging eccentric muscle contractions has been shown to cause an enhanced response of satellite cells (the stem cells of skeletal muscle). Satellite cells are thought to play a crucial role in muscular adaptation to training, in muscle fiber maintenance and repair. However, the investigated high repetition number of ~200-300 high-force eccentric contractions is not part of regular strength-training regimes. Furthermore, the transfer of eccentric-only training to specific tasks in sport seems to be limited, especially because of a limited involvement of the stretch-shortening cycle.

In contrast, eccentric-overload resistance exercise requires coupled eccentric and concentric actions with minimal disturbance of the natural mechanics. This form of exercise can be integrated in regular strength-training programs. We and others have provided evidence that several weeks of eccentric-overload strength training might be superior to traditional strength training with regard to the development of muscle hypertrophy and a fast-muscle phenotype. Accentuated eccentric loading can be implemented on an isokinetic training device. The load is controlled by velocity. For example, during leg-extension exercise, an angular velocity of 60°·s^-1 might be chosen for the concentric and 180°·s^-1 for the eccentric phase. During leg-press training, the leg-press plate might move away from the subject with 100 mm·s^-1 during the concentric phase and toward the subject during the eccentric phase with 400 mm·s^-1. Subjects are instructed to develop maximal force in both the concentric and eccentric phase, which usually results in a higher eccentric load of approximately 30%.

Our randomized controlled study, published in the March 2022 issue of Medicine & Science in Sports & Exercise_®, provided novel aspects on the effects of accentuated eccentric loading during strength training. After one bout of exhaustive eccentric-overload leg-extension exercise, we observed a significant satellite cell response in biopsies obtained from the vastus lateralis muscles of recreational athletes. Satellite cell content, the number of satellite cells related to type II myofibers and the proportion of activated satellite cells were significantly increased one week after the resistance exercise. This suggests there is ongoing muscle repair. No such increases were found after one bout of comparable traditional leg-extension exercise and in a non-exercising control group. Interestingly, the significant increase in satellite cell number related to type II myofibers suggests enhanced recruitment of type II myofibers during eccentric-overload resistance exercise. There is a need for further studies on the mechanisms related to why accentuated eccentric loading might be a superior method to enhance strength and power performance, including research on the satellite cell response.

Birgit Friedmann-Bette, M.D., is the temporary medical director of the Department of Sports Medicine (Internal Medicine VII) in the Center of Internal Medicine of the Heidelberg University Hospital in Heidelberg, Germany. She is also involved in the medical attendance of elite athletes at the Olympic training center in Heidelberg. She was trained in general medicine with a focus on internal medicine and, as a former track and field athlete — the first IAAF world champion in the women’s 3,000 m run (1980) — took a major interest in exercise physiology. After studying the effects of altitude training, the focus of her research activities is now on muscular adaptation to strength training. 

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent ACSM positions or policies. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.

In the U.S., the death rate for African Americans with heart disease is declining. However, more than 100,000 African Americans continue to die each year from cardiovascular disease and retain a significantly higher death rate than any other racial group. A January 2022 report from the Office of Minority Health noted that approximately 57% of African Americans have hypertension, with 60% of African American women more likely to be diagnosed with the disease. It is interesting to note that cardiovascular disease risk factors tend to appear earlier in life for African Americans, resulting in a much earlier onset of cardiovascular disease. In a study of coronary artery disease risk in young adults, 96% (n = 26) of the cases of heart failure were in African Americans under the age of 50. A 2014 study published in the American Journal of the Medical Sciences found that on average, a 45-year-old African American man living in the U.S. Southeast has the same risk of having a stroke as a 55-year-old Caucasian man living in the same region or a 65-year-old Caucasian man living in the Midwest. While there are apparent disparities among the prevalence of heart disease in African Americans and other racial groups, physical activity (PA) appears to be a powerful weapon against the onset of high blood pressure.

The Jackson Heart Study tracked PA for more than 1,300 African Americans to examine the relationship between PA and the onset of hypertension. At baseline, 61% of the study participants were physically active, with 24% meeting the current PA recommendations. Researchers found that physically active participants had a 16% lower risk of developing hypertension compared to inactive adults, and those who met the PA recommendations had a 24% lower risk of developing hypertension. In addition, researchers found that the type of PA mattered, and study participants engaged in sport/exercise-related activities had a lower risk of developing hypertension. With only about 20% of African Americans currently meeting the guidelines pre-COVID-19, how can health professionals encourage young African Americans to adopt preventive lifestyles? They can begin by understanding the historical, sociocultural and individual factors that influence African Americans in their care. Specific tasks can include:

• Actively listening to clients in order to build relationships;
• Recognizing and understanding personal biases and how clients may perceive them;
• Educating oneself about the local community and African American culture within that community;
• Asking the client relevant questions to learn more; and
• Providing feedback, data, and resources that the client can identify with instead of utilizing generalized and Eurocentric resources. 

A 2021 study by Lemacks et al. explores a practical example of the aforementioned tasks. The researchers explored the perceptions of weight management among young to middle-aged African American adults. Among their findings was that when participants did not engage in the program because of perceived lack of time, researchers discovered it was more due to physical or mental fatigue. Acknowledging physical or mental fatigue is an important finding because it allows the client to feel heard and the professional to provide resources to address fatigue versus time barriers. The more the client feels heard, the more likely they trust their health professional and implement lifestyle interventions that promote improved health.

It is important to note that individual behavior changes in young and middle-aged African Americans will not dramatically change the national statistics. There needs to be an intentional and concerted effort to provide a public health solution. The American Heart Association News suggests those changes can begin to address the inequities that link structural racism and hypertension to the health of African Americans. “Asking people to improve their diet when they don’t have access to healthy foods, to exercise when they don’t have access to safe or affordable spaces, to take blood pressure medications when they can’t afford them — while also failing to ensure access to quality universal health care — will never succeed in eliminating health inequities,” reports the author. Now is our chance to help young African Americans reduce or eliminate their risk for hypertension by encouraging them to be proactive in seeking care from providers who understand them and adopt preventive lifestyle behaviors.

Related links: 
Blog | Exercise, Type 2 Diabetes and Communities of Color
Handout | Women and Heart Disease
Blog | Mythbusting: Genetics and Heart Disease

Alicia T. Bryan, Ph.D., FACSM, serves as the chair of the Strategic Health Initiative: Women, Sport & Physical Activity of the American College of Sports Medicine. She is a tenured associate professor and interim associate provost of faculty affairs and academic innovation at Columbus State University. She also is an ACE Certified Medical Exercise Specialist and serves as the CEO of Evolutions, Inc. in Phenix City, AL.

The long-term effects of sport-related head trauma have gained notable attention from the scientific community, sport governing bodies, and the mainstream media in the past two decades. Concussions and repetitive head impacts that do not result in clear clinical signs and symptoms have been investigated as risk factors for worse health-related outcomes in later life. However, longitudinal studies describing head trauma as a risk factor for health-related and functional declines throughout the aging process are lacking. In lieu of longitudinal data linking sport-related head trauma to health outcomes many years later, researchers have relied on alternate measures of head trauma exposure. These included self-reported concussion history and various repetitive head impact metrics obtained retrospectively. Therefore, observed associations between retrospectively recalled head trauma and later-life health outcomes in former athletes — neurodegenerative disease progression, for example — do not permit causality to be fully understood. Still, those findings can and should be used to inform future studies that are targeted toward understanding and treating the long-term effects of sport-related head trauma.

In our recent survey study published in Medicine & Science in Sports & Exercise_®, we described the prevalence of self-reported medical diagnoses of mild cognitive impairment (MCI) and dementia in a sample of 922 former National Football League players aged 50 years and older. We also investigated the associations of MCI and dementia prevalence with self-reported concussion history, years of football played and other potential predictors observed in studies with the general population. We hoped to detect possible intervention targets for reducing the risk of MCI and dementia. The strongest predictors of MCI and dementia were lifetime diagnosis of depression and anxiety. Self-reported concussion history was a significant predictor of MCI and dementia, but only for those reporting 10 or more lifetime concussions compared to those reporting no concussions. Total years of football participation, a rough estimate for football-related repetitive head impact exposure, was not significantly associated with either MCI or dementia. Other significant predictors were greater pain severity (MCI and dementia), a diagnosis of sleep apnea (MCI), racial/ethnic identity other than white/non-Hispanic (dementia) and older age (dementia).

Our findings suggest that many factors are associated with later-life health and function in former football players beyond exposure to sport-related head trauma. Further, many factors that we did not measure could also have contributed to MCI and dementia diagnoses. Some possible factors are adverse childhood experiences, access to and utilization of health care resources, childhood socioeconomic status, and participation in health-promoting behaviors (e.g., physical activity). In a recent related study with an overlapping sample, we observed self-reported lifetime concussions were significantly associated with worse self-reported cognitive and mood-related functioning. At the same time, more frequent participation in physical activity, better diet quality, and obtaining adequate sleep were associated with better cognitive and mood-related function scores.

It is important that clinicians, researchers and former athletes understand that some factors associated with health and function in later life are non-modifiable (e.g., sport-related concussion history). However, there are also many modifiable factors (e.g., pain, depressive symptoms, exercise participation, etc.) that could improve the health and well-being of former athletes.


Samuel R. Walton, Ph.D., ATC, is a postdoctoral researcher at UNC-Chapel Hill and an ACSM member. He is a certified athletic trainer who has accrued more than a decade of clinical experience with collegiate and secondary-school athletes, along with eight years of clinically oriented research. His research interests are in the clinical assessment of sports-related concussion, as well as in both short- and long-term effects of concussions on biopsychosocial outcomes in current and former athletes.



Zachary Yukio Kerr, Ph.D., MPH, is an assistant professor in the Department of Exercise and Sport Science UNC-Chapel Hill and serves as core faculty with the Center for the Study of Retired Athletes, the Matthew Gfeller Center and the UNC Injury Prevention Research Center. His research focuses on the development and evaluation of injury prevention strategies in sport settings across the lifespan. Dr. Kerr was a previous recipient of the ACSM New Investigator Award and is a current ACSM member.


Disclosures:
Drs. Walton and Kerr work on research projects that were funded by the National Collegiate Athletic Association and the National Football League. These entities provide no oversight of the work performed by either individual, including this work. Dr. Walton has previously received funding from the Mid-Atlantic Athletic Trainers’ Association. Dr. Kerr additionally has received funding from the National Institutes of Health, the Centers for Disease Control and Prevention, the National Athletic Trainers’ Association Research and Education Foundation, and the National Operating Committee on Standards for Athletic Equipment.

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent ACSM positions or policies. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.