chapter one   Smart at Heart   It's a Monday night, a few weeks before Christmas. Around 5:30, thirteen women file into a conference room at the Massachusetts General Hospital (MGH) Revere Health Center in Revere, Massachusetts. Some grab a clementine from a table of healthy snacks, while others peel off the layers they'd been wearing to protect themselves from the bitter wind coming off the Atlantic Ocean one hundred yards away. Of the thirteen, nine are participants in HAPPY Heart, a two-year-old program that integrates all the facets of a woman's life (including, among other things, physical health, emotional well-being, stress levels, and relationships) to minimize her cardiac-related issues. Three of the women are nurses (or health coaches, in HAPPY-Heart speak) and one is a daughter of a participant. As the group begins to settle into seats around the table, Isabel, one HAPPY Hearter, announces that she's going to gather clothes for the homeless in the next week and pass them out and is looking for donations of any size. Another participant, Jenny, mentions that her daughter is taking finals, and that those tests have the whole house stressed out. A third subject, Kim, has an ankle that's hurting, and Donna Peltier-Saxe, one of the health coaches, promises to take a look at it later.   Donna Slicis, another health coach, sets up her computer, and the first PowerPoint slide shows on a screen. "Family: The Good, The Bad, and The Ugly," it reads, "Holiday survival!" After a few introductory remarks, Slicis, who has a great sense of humor and an even bigger sense of compassion, shows a YouTube video, which is called "Family Survival Kit." The infomercial parody "sells" such helpful items as criticism-canceling headphones and Dr. Phil in a can. ("You can't change what you don't acknowledge," the bald doc preaches from within the aluminum walls.) Laughter and nods of, "So true, so true" fill the room. The mood is light as Slicis focuses on the bulk of her presentation: creating a holiday experience that is low on conflict and bad health habits, and high on self-care.   Self-care is a relatively new topic for the women here tonight. "I've never taken care of my health," says Lucy, echoing the sentiments of many in the group. "I just hoped for the best." Revere is a blue-collar town, and for most of these women's lives, the natural order of basic human needs--food and water, a safe place to live and sleep, a steady income--dictated that their energy and effort be put toward simply surviving as opposed to thriving. One woman is dealing with a foreclosure on her house; another, at age forty-nine, has had to move back in with her mother because she lost her job and can't afford her own place. One was shot by a former boyfriend and still has three bullets in her body, while another woman has a son who is a heroin addict. Understandably, self-care hasn't been a priority for these women; they've been too busy figuring out how to pay the bills, put food on their tables, deal with abusive relationships, and just generally navigate the messy details of life. "My life has never been about me," says Heather, mother of the addicted son. "I've spent it taking care of my mother, my siblings, my children, my husband. I never thought to put myself first."   Those life circumstances, combined with their family health histories, put most of them at risk for cardiovascular disease. To be a participant in the HAPPY Heart study, candidates have to have at least two major risk factors for cardiovascular disease: high blood pressure, abnormal cholesterol levels, diabetes, obesity, cigarette smoking, sedentary lifestyle, and genetic history of cardiac issues in the family. Over 80 percent of the sixty-five women in the program have at least three risk factors; the most common are obesity, low levels of HDL (the good kind of cholesterol), and a sedentary lifestyle.   Unfortunately, the women are in good company. The American Heart Association (AHA) issued new guidelines for the prevention of cardiovascular disease in women in early 2011, and the statistics cited in the introduction are troubling--to say the least. Two in three women over the age of thirty are either overweight or obese. More than twelve million American women have diabetes, a disease that is so tightly linked to cardiovascular disease that doctors often treat the two conditions simultaneously. Many physicians now refer to diabetes and obesity as "diabesity," because of their frequent coexistence. High blood pressure is on the rise, especially among African-American women; an overwhelming 44 percent of that population has high blood pressure.   Although two of the most popular American pastimes--eating fast food and spending extended periods of time in front of a screen--might lead you to think otherwise, the epidemic of cardiovascular disease is not limited to the United States. "Heart disease is the leading cause of death in women in every major developed country and most emerging economies," the 2011 AHA report proclaims.1   Given that heart disease is the number one killer of women--in the United States in 2006, over 430,000 women died from cardiovascular disease while about 270,000 died from various forms of cancer--the public awareness is still disturbingly low.2 In the AHA guidelines, researchers found that only 53 percent of women polled said that the first thing they would do if they suspected they were having a heart attack would be to call 911.3 That lack of awareness, combined with the rise of obesity, is contributing to a trend that shouldn't be happening in the twenty-first century: death rates from cardiovascular disease for women under the age of fifty-four are, amazingly, rising. For the first time in forty years, the number of U.S. women between ages thirty-five and fifty-four who die from heart-related issues is actually increasing.4   As is true for many women across the world, the threat of a cardiac event stares down the HAPPY Heart participants daily. "My father died of arterial sclerosis at sixty-two," says Christie, sixty years old, one of the participants who heard about the program from me when she came to my office with heart palpitations. "And my mother was a diabetic who had a triple bypass and a pacemaker. Seven of her siblings died of heart problems before [heart disease] took her at age eighty. Those thoughts just live in the back of my head."   Daily challenges don't loom so large tonight, though. Tonight, these women--like most of America--are preparing for two weeks of holiday excess: large, rich meals; champagne, eggnog, and plenty of other drinks; intense family time; additional cooking and cleaning; and unspoken, and often huge, expectations. The situation is a recipe for total meltdown for anybody, so Slicis encourages people to forget about perfection. "Be realistic about your expectations," she says. "If the potatoes don't come out perfectly, nobody will notice but you." Then she moves on to talk about more important matters, which include how to protect yourself and your feelings around a group of people who might not always be the most supportive and loving. "You get to be happy even if everybody else around you isn't," she says, adding that it's important to walk away from negative conversations and take a time-out if need be. "The bathroom is a great place to hide," she says with a laugh. After touching on some budget-minded gifts (a family cookbook, certificates for closet organizing), Slicis reminds everyone to go for walks, get enough sleep, and to remember that a holiday is one day. "It's not a holi-week or a holi-month, so celebrate accordingly," she says. The group laughs in agreement.   The holiday survival tips, the hummus and other healthy snacks, and the women who are here tonight are all part of a common goal: building a heart that is strong and healthy in every respect. Although it may seem like cardiovascular disease is best treated by doctors in white coats, medical care is just one piece of the puzzle. Sure, doctors can monitor your cholesterol and your glucose levels, your weight and your blood pressure, but your cardiovascular--and overall--health depends on so much more than simple measurements.   I firmly believe--and science has proven--that getting smart at heart is about evaluating your whole life, from your relationships to your environment to your mental state. "Medications alone aren't enough. Surgical procedures aren't enough. Stents aren't enough," says Kate Traynor, a colleague of mine and the program director at the Cardiovascular Disease Prevention Center at MGH in Boston. "How many times have you heard that somebody needs to go back for another stent? Where the rubber hits the road--and what will keep you and your heart healthy--are lifestyle changes."   In addition to the more obvious factors like diet and exercise, research shows that your cardiac health is influenced, among other things, by how much stress is in your life, and more importantly, how you deal with it; the strength of your friendships and family connections (or the lack of them); the quality of the sleep you do or don't get; your perspective on the world. In other words, defusing toxic relationships is as important to your heart as easing up on the butter in the mashed potatoes. And getting your house in order to receive guests is as key to good health as taking daily walks.   When I care for a patient, I don't treat a number, a heart, or a disease; I treat a person. Similarly, when I put together the premise for HAPPY Heart, I wanted to address individuals and all the aspects of their complicated, challenging lives--not just the ones that usually get discussed in my cardiology office. I can only see a handful of patients daily, though, and the HAPPY Heart ladies are in the greater Boston area; I wanted to share my message with as many people as possible, which is how this book came to be.   A Quick Course in Human Physiology   Before we discuss heart health any further, I want you to have a basic idea of how the heart functions, as well as how the rest of your body reacts to everyday emotions and life. I am a big believer that knowledge is power, and many of the patients I see have not taken ownership of their health, which means they'll never feel empowered enough to believe they can make meaningful, effective changes. "Some women take more time and better care of their fingernails than they do of their heart," says Slicis with a laugh. "They spent ten minutes picking out a polish color and can tell you the whole process of acrylics, but they don't understand what their cholesterol levels mean."   The heart, which is technically a muscle, starts to beat not long after conception and continues working until the very last breath somebody takes; over the course of an average lifetime, it will beat over 2.5 billion times. The heart consists of four chambers: two atria, which receive blood, and two ventricles, which pump blood. Between the chambers are valves, which serve as doors, opening and closing to keep the blood moving forward. Blue blood, or oxygen-depleted blood, flows from the body to the right atrium, through the tricuspid valve, and into the right ventricle. Exiting through the pulmonary artery, it heads to the lungs to lose the carbon dioxide it's carrying and to become oxygenated and red. It returns to the left atrium, through the left ventricle, and on to the aorta, which sends it out into the body. The aorta is the tree trunk of the body; many arteries, arterioles, and capillaries branch off it, getting progressively smaller in size so that blood can be delivered to all the organs and tissues in the body. The blood then returns to the heart via venules that lead into veins.   The pumping of a heart is an incredibly intricate process. By using new detailed imaging techniques, doctors have learned that it doesn't just squeeze with every beat--it also twists and untwists. Those motions, in combination with electrical signals and blood pressure, combine to form a rhythm that cycles blood through your heart seventy times a minute while you're at rest and sends roughly one hundred gallons of blood every hour through your body.   We are born with arteries that are clean and clear, but over time we intentionally and unintentionally expose ourselves to substances that encourage the formation of blockages or plaques within the arteries (or as my grandmother used to call it, "hardening of the arteries"). Plaques are composed of lipids, fat, and scar tissue. A few factors known to initiate and worsen plaque development include high cholesterol, smoking, diabetes, and high blood pressure. In many cases the plaque lining the arteries is filled with a soft fatty core, which makes the plaque highly susceptible to rupturing. When that happens, that inner core attracts blood platelets and blood cells and a clot appears, which results in partial or complete blockage of the artery, which in turn leads to a heart attack. In some people--and in women in particular--the plaque doesn't rupture entirely but instead erodes or is scraped open. In these situations, platelets still accumulate, but the buildup doesn't necessarily obstruct the blood flow through the artery. It does, however, decrease the flow enough to cause some degree of heart muscle damage and symptoms of chest discomfort.   The organ with the four chambers that I just described? That's your physical heart. As you might guess, it's not the only heart I consider when I examine a patient. Harder to quantify but just as integral to good health is what I call the emotional heart. This side of the heart gets brought up regularly in everyday conversations, through common phrases like you have a big heart; let's get to the heart of the matter; she is the heart and soul of this business; that was heart wrenching; he has hardened his heart. Translating that language, it's clear we believe that the heart signifies a place where spirit lives, where purpose is found, where emotion begins and settles. The love, disappointment, contentment, fear, and euphoria we feel deeply within our hearts seems to ricochet through the body; while watching a frightening movie or hearing unbelievably good news, your heart seems to beat so rapidly, it almost echoes in your ears.   While the physical heart is the team captain for the circulatory system, the emotional heart is more of a team player--its health is influenced by other parts of the body, and vice versa. An important teammate to the emotional heart is the brain. Your brain responds to emotions by activating systems in your body that release various compounds and create a change in how your body is functioning.   For instance, when you're watching that scary movie, your body shifts into the fight-or-flight response, a natural reaction that happens when you feel threatened. In fight or flight, the brain signals the adrenal glands to send out adrenaline, noradrenaline, dopamine, and cortisol that cause your heart to beat faster and your blood pressure and blood glucose levels to rise. These phenomena put your body into an aggressive, ultraprepared mode, even though the biggest threat you're really facing is choking on your popcorn. There doesn't have to be a monster haunting your thoughts for your body to react unfavorably to emotions. The trigger can be a parent who is entering a bad spell of health, a boss who requires working on the weekend, or anybody or anything that brings stress into your life.   Fortunately, the brain also controls the release of chemicals that can have positive effects on our health and mood. Neurotransmitters are chemical messengers that allow nerve cells to communicate with one another. Here are four important ones:   •     Serotonin positively influences how we feel, learn, think, and sleep.   •     Dopamine, at lower doses than those released in the fight-or-flight response, provides feelings of enjoyment and is central to motivation and movement.   •     Endorphins are the euphoria-producing neurotransmitters mainly responsible for the so-called runner's high after exercise. (They're also released during orgasm.)   •     Oxytocin, commonly known as the "love hormone," is released during sexual attraction, orgasm, and when people see pictures of those with whom they are in love. It also provides contented, relaxed, and trusting feelings.   That overview just touches on the basics of the two hearts; I'll delve into them more deeply in chapter 2, devoted to physical health, and chapter 3, which covers emotional health. For now, the most important thing to remember is that everything about your health is interrelated; just as I can't fully treat high blood pressure without looking at a person's lifestyle and circumstances, one system in the body also affects the other ones.   Connecting the Physical and Emotional Hearts   One of my patients, Mary, a hard-working paraprofessional in the financial world, was in her early sixties and looking forward to retirement with her husband of over thirty years. Before either of them could cash in a 401(k) though, he had a heart attack while gardening and died within a few hours. Within twelve hours of her beloved passing away, Mary, who was thirty pounds overweight, with borderline diabetes and high blood pressure, was admitted to the hospital with what seemed like a heart attack.   Fortunately, it was not. Instead, a surge of adrenaline, brought on by the trauma of losing her husband, caused the bottom half of her heart muscle to blow up like a balloon and temporarily stop functioning, which then forced the top half of her heart to pick up the slack and work twice as hard. Medically, the condition is called apical ballooning, but it's more commonly known as broken heart syndrome: when your grief is so great, your heart mimics the symptoms of a heart attack.   Affecting a small part of the population--and mostly postmenopausal women--a broken heart is part of our lexicon.5 We say you can die of a broken heart--and, as Mary almost proved, that can be true. Broken heart syndrome is just one example of the strong correlation between the emotional and physical hearts. That said, you don't have to lose a loved one to have a heart that is injured by your emotions. Unemployment, financial uncertainty, an unsupportive spouse, a lack of focus and purpose, unmitigated stress, and a host of other situations can send a heart on an unhealthy path, as recent studies have proven:   •     The ups and downs of the recession have shown a marked influence on the number of cases of heart attacks. Studying the data from the Duke University Databank for Cardiovascular Disease in conjunction with the U.S. stock market performance, researchers in 2010 found a significant increase in heart attack rates during a seven-month period of stock market decrease.6   •     The correlation isn't just an American phenomenon either. Studying the same relationship for two years and publishing results in 2010, Chinese doctors found similar results with the Shanghai Stock Exchange Composite Index. "Both the rising and falling of the Index were associated with more deaths, and the fewest deaths coincided with little or no change of the Index," they concluded, noting that a 100-point change in the Index corresponded to a 5.17 percent increase in coronary heart disease deaths.7   •     Research stemming from the INTERHEART Study, a globally based study that includes over twenty-seven thousand participants in fifty-two countries, is scientifically proving what we long thought to be true: stress and depression, combined with other established risk factors, can increase one's risk of heart attack significantly. One study, based solely on Chinese participants, found that depression and permanent stress put people at risk for a heart attack, while a broader study that reflected international data documented nine modifiable risk factors, which included everything from diabetes to smoking.8 The results were invaluable; for the first time in 2008, stress was included in a very solid, comprehensive study.   •     Looking at eighteen women who had either lost a mother or sister to breast cancer within five years, researchers in 2009 measured the relationship between proteins known to be associated with inflammation (cytokines) released by cells that are associated with infection, disease, low mood and motivation, and brain activation in the areas responsible for emotional processing. They were the first researchers to find a marked relationship between those two components: strong activity in the emotional part of the brain increased the levels of harmful cytokines.9   •     In another study, released in 2011, a team of psychologists recruited forty people who had experienced an unwanted romantic breakup within the previous six months; the break-ups were not initiated by these participants. During one part of the study, they were asked to look at a picture of their ex and think about how they felt by being rejected; during another, they were given a minor irritation on their forearm, akin to holding a hot cup of coffee. The researchers took functional magnetic resonance imaging (MRI) scans of their brains during both tasks and found that both activated the regions of the brain that are involved in physical pain.10 This study illustrates the important link between our emotions, our brain, and our perception of physical pain, and explains why many of us experience physical pain in the setting of significant rejection.   I see these negative emotional-physical heart connections frequently in both my patients and HAPPY Heart participants. For example, my patient Anna had a bullying male boss, which caused her severe anxiety and destroyed her self-confidence. Over the course of a year, she gained thirty pounds, had to take increasingly higher doses of medications to control her blood pressure, and developed severe insomnia. Eventually, on the brink of a breakdown, she filed a complaint and got switched to another department. Within months, she shed all her new pounds, her blood pressure returned to normal, and so did her sleeping habits. Her belligerent boss had caused her body to remain constantly in the fight-or-flight mode, which changed the way it completed basic functions like metabolizing food and sleeping. In other words, she lost her health because of him.   As Anna proves, the information highway between your emotional and physical hearts travels both ways. Your emotions can make you sick, but they can also enhance your well-being. The proof of this has been a hot topic in science lately:   •     Just as scary movies can send your body into fight-or-flight syndrome, comedies--and the accompanying joyous laughter--can relax your cardiovascular system. In 2010, a group of researchers had seventeen adults watch either a comedy or documentary for thirty minutes on separate days. When they were watching the comedy, their heart rates and blood pressure increased, and the blood vessels opened up, increasing blood flow (a good thing; they tightened up during the documentary).   •     Additionally, a different marker of a healthy blood vessel response, the softness of the carotid artery--another good thing--increased after watching the comedy and didn't return to its baseline reading until twenty-four hours after watching--whereas it did not change significantly throughout viewing of the documentary. In other words, to repeat a cliché, laughter is the best kind of medicine. This study demonstrates that not only do our brains feel better in the presence of a good laugh, so do our hearts.11   •     Andrew Steptoe, PhD, a psychology professor at the University of London, is a pioneer in the field of emotion and physical wellness. Through his multiple studies that involve ten thousand middle-aged men and women, he has repeatedly concluded that the happier a person is, the less cortisol (a stress-related hormone; more on that in chapter 4) they produce; the lower their blood pressure and heart rate are; and the fewer the markers of inflammation, which is tied to diseases like cancer, heart disease, asthma, arthritis, and other autoimmune disorders.12 Looking at the risk of death as a single entity, Steptoe and some colleagues performed a review of studies evaluating a sense of positive well-being (which included descriptions like joy, happiness, vigor, energy, hopefulness, sense of humor, and life satisfaction) and risk of death. In both healthy and unhealthy individuals, they found that a sense of optimism is associated with a decreased risk of dying.13   •     In 2010, researchers at Brigham Young University and the University of North Carolina at Chapel Hill conducted a comprehensive analysis of health and relationships. Compiling data from 148 studies that involved more than three hundred thousand people worldwide, the team found that people with weak social connections had on average 50 percent higher odds of death in the study's follow-up period (an average of seven-and-a-half years) than people with more solid connections. That improvement in lifespan is equal to the impact of quitting smoking.14   •     Researchers at Case Western Reserve University pulled together all the studies they could find that looked at altruism, or helping others, and the effect on well-being, health, and longevity. Among other benefits they document, they refer to the "helper's high," a positive physical sensation that occurs as a result of volunteering or aiding others; other emotions that were associated with helping include feeling stronger, more energetic, warm, calmer, and less depressed, greater self-worth, and fewer aches and pains. They also talk about the possibility that positive emotions essentially shove out negative ones. "It is difficult to be angry, resentful, or fearful when one is showing unselfish love toward another person," they write. Although they mention the need for further research, they conclude that "A generous life is a happier and healthier one."15 Excerpted from Smart at Heart: A Holistic 10-Step Approach to Preventing and Healing Heart Disease for Women by Malissa Wood All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.