Keeping it Real

This is not a joke but a man walks into a cardiologist's rooms one day and asks the cardiologist what is his opinion on eating salmon. Fish is high in beneficial proteins and we are all encouraged to eat more of it, especially the oily fish.
The cardiologist asks him what his concerns are about eating salmon. The man replies that he has heard there are PCB's or polychlorinated biphenyls in fish as a result of contaminated water. These are not good things.
"Should I be eating wild or farmed salmon?" the man asks.
The cardiologist looks at him and stays, " Stop smoking!"

In other words choose your fights and fight the big fights first.

There are a myriad of reasons why a person develops cardiovascular disease. And it is to be remembered, if the left one don't get you then the right one will. In other words, you have to die from something. However, standing near the edge of existence, it is quite clarifying to realise when confronted by the prospect of falling off the edge, that a little longer on this planet is a worthwhile personal cause. My wife would agree with this synopsis and so too would my children, I am pretty sure!

I have mentioned Ross Walker, a Sydney based cardiologist,previously. He notes it is rare to see a motivated patient back again after treatment needing further work.. In other words it is quite clear, if you want the doctor to do all the work for you, you are selling yourself and your family short. You need to do something about your health and in this case cardiovascular health yourself. So I did!

If you have followed what I have been writing you will know I decided to eliminate saturated fats from my diet to see what effect that had on my blood profile. Yes, yawn, I went vegan for six or so months. Yep I still have a personality, I don't stop people in the street  and lecture them on the evils of bacon, and I never quite made it to one hundred percent vegan. My free range chooks produce the most wonderful eggs and if someone offers me food, I consider it elitist and rude to turn good food down. However my efforts were robust; almost no meat, very limited dairy, cows milk substituted for soy milk, some eggs.  

As they say, the proof of the pudding is in the eating so what did my blood results indicate after this period of self imposed  exile from meat and dairy?

Total Cholesterol: 

• Unmedicated and the original reading was 12
• 1995 reading after taking cholesterol lowering medication 7.5
• 2012 reading 4.9
• Most recent post six month vegan diet reading 4.5.
• Result: Hey there is a trend and the trend is a good one! Still a little too high but that is genetics for you.

Triglycerides:

• 1995 reading after taking lipid lowering medication 1.5
• 2012 reading 0.6
• Most recent post six month vegan diet reading 0.8
• Result:As long as the figure is below 1.5, this is good.

LDL or Low density lipoproteins...the baddies, the outlaws:

• 1995 reading after taking lipid lowering medication 5.7
• 2012 reading 3.1
• Most recent post six month vegan diet reading 2.9
• Result: The trend thing is happening again and it is good. However a value below 2 is recommended so the trend is good but a target remains.

HDL or High Density Lipoproteins...the goodies or the sheriff and his posse.

• 1995 reading after taking lipid lowering medication 1.1
• 2012 reading 1.6 
• Most recent post six month vegan diet reading 1.25
• Result: Above the recommended level of 1.

Cholesterol to HDL ratio

• 1995 reading after taking lipid lowering medication 7
• 2012 reading 3.1
• Most recent post six month vegan diet reading 3.6
• Result: With a recommendation this ratio should be 3.5 or less, there is some more work to be done.

Blood glucose.

• 1995 reading after taking lipid lowering medication 4.9
• 2012 reading 6
• Most recent post six month vegan diet reading 4.8
• Result: Whilst not a reading for lipid levels, lipid lowering drugs have had an association with the development of diabetes in some individuals. The reading in 2012 was considered pre-diabetic and was of some concern, the latest reading is welcomed.

Conclusion: At this stage it is probably pre-emptive to suggest a miracle cure even if the book royalties alone might make the path to my front door to be paved with gold ingots. However, there is some pleasing news with  definite positive progress. The fingers still wags though and there is the reminder that more needs to be done. A little more exercise would be good, continue with the reduction in saturated fat intake and admit Buddy, the mirror does not lie...lose some more weight. These simple things will help not only increase HDL levels and reduce LDL levels but also provide some clear goals and a positive frame of mind.

With a clear case of irregularities in my lipid profile being largely as a result of genetics, that does not give a reason to sit down and admit defeat. Something can be done and something should be done!

Some back ground to cholesterol readings;

From the Heart Active website, a site from the Heart Foundation of Australia;

Ideal cholesterol levels are less than 5.5mmo/L1. However, people really concerned about their heart health should aim for total cholesterol levels of less than 4mmol/L, as well as LDL cholesterol levels under 2.5mmol/L and HDL cholesterol level above 1.0mmol/L2. For more information about ideal cholesterol levels, visit the Heart Foundation of Australia website (www.heartfoundation.org.au) or speak to your doctor.

The main dietary emphasis for heart health is on lowering lipid levels, namely LDL cholesterol, and raising the HDL or 'good' cholesterol. Saturated fat is the main culprit in the diet for high cholesterol. Cholesterol in food can also raise blood cholesterol levels but to a much lower level than saturated fat1.

Cholesterol in your body comes not only from your diet but is also produced by your liver. So your total cholesterol level also depends on your genetics and some people may have concerns about their cholesterol because of their family history.

Changes and are they worth it?

In his book" If I eat another carrot I will go crazy", Sydney Cardiologist Ross Walker, lists five major risk factors for coronary heart disease. These are;

1. Saturated fat intake
2. Cholesterol
3. Smoking
4. High blood pressure
5. Family History

He also details five minor risk factors for coronary heart disease. These are;

1. Diabetes
2. Obesity
3. Physical inactivity
4. Alcohol
5. Stress.

However, you have to look at the total picture as for example, not all smokers will develop heart disease and not all non smokers will dodge the bullet either.

Tomorrow is another big step in the journey following a health scare and subsequent stenting of one of the main arteries in the heart to ease the blockage which would have killed me. The treatment alone does not save you, it simply buys you time. If you take the issue seriously, you have to buy in to your own treatment or lifestyle adaptation. You cannot expect a health professional to take the issue seriously and provide all the solutions of you don't want to help too.

It is a big step tomorrow as I will be having some blood tests. These are all the standard tests but what makes these ones important is they come at the end of a six month personal experiment. I was aware of the risk factors and have made attempts to modify my lifestyle. The results of the blood tests will let me know if the modifications have had any effect. I certainly hope so.

Everyone can make some change so I tackled the things I thought I could.

1/ Saturated fat intake. Saturated fats are found in red meat in particular, dairy products and a few other things. For six months these things have largely been eliminated from the diet. 

Meat has been replaced by lentils, chickpeas, legumes, tofu, tempeh and more of all the wondrous vegetables that exist. 

Christmas lunch, meat free. "Prawns" are made from vegetable based protein so are mock prawns and the burger pattie is made from lentils.

Milk has been replaced by soy milk, almond milk and rice milk. I have remained 99.99% good but have to settle for cows milk in my tea at work and I still eat the occasional egg as the eggs from our own free ranging chooks are beautiful. The demonisation of eggs by the heart people in the past has now been virtually eliminated anyway. That is another story.

There has been some challenge in cooking and preparation as it was new to me, no meat! Scary for a previously committed omnivore. There was initially some challenge too in the body adapting to the new diet but that soon passed. It has even been exciting to try new foods and new ways of preparing meals. However the proof in the pudding will be if the strict diet has made any difference to my blood profile.

I can clearly say I have not found the change to a majority meat free existence difficult.

2/ Cholesterol. Have remained taking the same dose of statin  to lower blood cholesterol.

3/ Smoking. Finally managed to get this monkey off my back seventeen years ago. so that is not an issue with any life style adaption for me now.I can cheerfully say I am not tempted and will never be tempted again. But it was a huge monkey that took many goes at undoing its firm grip on me.

4/ High blood pressure. Have remained on the medication that effectively reduces this. Have increased exercise and activity levels.

5/ Family history. The biggee that you cannot do anything about which also to a large extent determines risks 2/ and 4/ above! In this western world of making choices for yourself, you cannot choose your family. I have however suggested to the entire family they themselves have some blood tests done to check on levels of cholesterol and its family of markers for heart disease.

The minor risks;

1/ Diabetes.  Not currently diabetic although have been considered pre diabetic in the past. The blood tests will be interesting. Funnily enough, the use of statins to reduce cholesterol is linked with an increased risk for developing diabetes. However I cut out sugar with my tea and coffee, never drink soft drinks, never drink commercial fruit drinks, never eat health bars or breakfast cereals, never eat bought cakes, seldom eat lollies, occasionally eat good quality chocolate and I am tempted by my wife's baking and desserts... occasionally.

2/ Obesity. As weight is something that you have some control over it, I decided to exercise that control. It was obvious to me I was a little overweight, food is beautiful and beautiful food is a thing of joy. Without following any specific diet, without getting all funny about it and punishing myself or doing without, in six months I have lost eight kilos from a starting point of 109 kgs. My body mass index or BMI was 27 and now sits at 25, the top end for a healthy weight. I will go a little further but without effort.

How did I manage this without effort? Portion control, reduced portions and by cutting out meat, cheese and processed foods. Fat which has the highest calorific value in my diet was virtually eliminated. It also pays to read labels and have an idea of how many calories or kilojoules are in foods. It helps in sidelining the under performer in your team who looks all good and showy but is bringing you and the side down.

Portion control. This is breakfast which I eat in the car on the way to work.

If you do lose weight, after a period find something to carry that equates to how much you have lost. It is a real eye opener to carry around, in my case something that weights eight kilos, in my hands. All that weight your heart has to pump blood to. All that weight your joints and spine have to support and all that weight you have to feed to maintain.

3 / Physical inactivity. I wanted to ensure I was doing enough so I  bought a pedometer to measure the number of steps taken in any period and by knowing the length of your stride how far you have covered. I am now conscious of getting enough. 

I have increased my activity accordingly, attack most tasks like mowing the lawn with gusto, and ensure I walk up hills to the point I get slightly puffed. I have not bought running shoes, treadmills, weights, a ski pass or put in an in ground pool.Walking and walking with purpose does it for me and it helps reduce stress.

Walking, smelling the roses and the dogs enjoy it too.

4/ Alcohol. Let's see what the blood tests tell me. I want a happy balanced life and alcohol is part of the party, at this stage.

5/ Stress. This is the most diffuse issue, the one hardest to pin point. If you are a personality type that does think and plan and organise and meet deadlines, it is hard to turn that off. At least a self assessment can help you to recognise when you are stressing and find ways to minimise the cause or assess whether the stress is really worth it. If it is your health that is suffering, it seldom is.

However, stress is something again over which you have some control.  When I walk I often will set myself a problem to thing over. It is remarkable how effective this can be in coming up with a perfect solution. 

If there is a lot on the plate rather than thinking  and worrying about it constantly, I set a time to think about it and mull it over.

I specifically create time now to do some of the things that please me rather than every spare moment being taken up with jobs and performing tasks. The lawn can wait! When I do perform tasks and jobs, I try to focus on the weather, the smells, the heat, the animals around, the birds in the sky, other people, simply life. If you want a life than you have to know what you are wanting to appreciate it.

So tomorrow is a big step in the journey. The results will take about a week to be with my doctor and we can then talk about it and make further adjustments as required. There is more room to move but a sustainable healthy lifestyle is borne about through the ease at which you can achieve it. Once it becomes a huge effort, the seeds are set for failure.

What is good food?

I made a pledge to be a motivated patient. I want this journey called life to be extended. A little surgical intervention has provided me with the bus ticket but the state and condition of the actual bus is now up to me.

Change the things you can change and accept those you cannot.

Dr Ross Walker  has provided a framework to assess my existence to get the bus back in order. I have looked at exercise and am happy with my step programme. It is certainly not arduous as my work provides a good amount of exercise. If and when I retire my exercise regime will need a review but I relish that as the time then will be mine to spend at my will. Exercise I can see then as a joy rather than just something else to be crammed into the day.

I have reviewed my weight, honestly. Okay, there is a reduction required, a burn off,  but that is okay.The energy consumed versus the energy output approach really is simple. You have to expend more energy than you consume to lose weight and keep the energy consumption energy output equation equal to maintain weight. You can either expend more energy you consume by exercising more or simply consume less energy. How straightforward is that?  Weight loss for dummies!

The next subject to consider, over which there is a huge amount of personal control,  is what to eat to obtain the energy needed.  I mentioned a great web site previously. This gives a window into what energy input is required to feed the  metabolic rate that is you just by existing, or your basal metabolic rate(BMR). It will then illustrate the extra energy required to do nothing and in stages right up to performing strenuous exercise.

https://www.walkingwithattitude.com/fitness-tools/basal-metabolic-rate

My personal daily recommended intake is 9,000 kilojoules (or calories, you can find out either measurement on the calculator) just to exist and a further 2,000 kJ if I want to sit on my backside and watch television all day.  I want to exercise moderately so I need to add around 4,000kJ or thereabouts added to the requirement set by my BMR.

1 calorie is equivalent to 4.2 kilojoules

1 gram of fat contains 37kJ of energy
1 gram of alcohol contains 29kJ
1 gram of carbohydrate contains 16kJ
1 gram of protein contains 17kJ

I could consume this energy in many different ways. Presuming I was to exercise moderately as is my norm,  I could consume six Big Macs for the day to consume my 13,000kJ quota. ( Aussie Big Macs contain according to McDonalds, 2060 kJ. A US Big Mac contains 2,300kJ.)  However that would give me 162 grams of fat of which 66 grams would be saturated. It would also shunt  5154 milligrams of sodium into my system.  So what?

The dietary guidelines for Americans advises 20 to 35% of ones energy can come from fats but that no more than 10% should be saturated. Fats are high in energy and saturated fats are heavily linked to heart disease. The current recommended maximum daily allowance for salt or sodium is 2300mg.

Back to the Big Mac. Assuming I am exercising and require around 13000kJs for the day, fat consumption should be in the range of 2600 to 4550 kJ. Saturated fat should be no more than 1300kJ based on the recommended guidelines. Sodium should be no more than 2300mg. The breakdown for the Big Mac is 5994kJ of fat of which 2442kJ is from saturated fat and the amount of sodium is 5154mg. All figures are well over the recommendations.  The point of this analysis is not to slam Maccas but simply to make the point not all food is the same. Energy intake needs further thought than merely how much to consume. There is more that comes with food than just energy and kilojoules.

Here is where it gets difficult. Whilst the energy in versus energy out equation is real basic, the rest of it can and does get complicated. If we let it.

If you read the dietary guidelines as laid out in the publication by the Australian Government, you will be lucky not to fall asleep. You might get some information but you will have to squeeze it out like juice from a wizened old orange that has fallen to the back of the fridge for a few months. I found most guidelines were similar in their complexity. I want something simple that is easy to follow and does not require to cart around with for the day a calculator and a set of scales.

The guidelines are under attack anyway. With regards to the amount of fat we should consume a new review reports that not a single randomized, controlled clinical trial backed the advice when the recommendations were issued in 1977 in the US and in 1983 in the UK. The review believes the dietary fat recommendations should never have been introduced in the first place.

The senior investigator Dr James DiNicolantonio (St Luke's Mid America Heart Institute, Kansas City, MO) says that instead of arbitrarily focusing on limiting one macronutrient perceived to increase the risk of heart disease, individuals should simply eat real food. By reducing the intake of one so called baddie the tendency is to replace it with something else which may in fact be worse for our health. To simply highlight saturated fat as the main dietary villain for cardiovascular disease has distracted from the risks posed by other nutrients such as carbohydrates.
There are other studies to support this and a host of diets and celebrity chef money makers that exploit the dietary insecurity that has been created by "problem" foods. There follows of course special diets and the "miraculous" super foods with claims that can cure all ills. There is also the cookbook, TV show, apron, sunglasses, DVD and yes we do take all major credit cards.
The complexity about what to eat has left so many people bemused. They are then sucked in by simple fix all solutions that leave their wallets panting for a rest.

The recommendation by Dr DiNicolantonio;  "The main message is to eat whole foods and stop taking on a single macronutrient, especially one that comes from a whole food."

A spokesperson for the American Heart Association, Dr Alice Lichtenstein (Tufts University, Boston, MA), says they no longer recommend individuals consume a low-fat diet. Instead, they recommend a moderate amount of fat intake, with approximately 25% to 35% of calories coming from fat. The reason being was that people were substituting simple, refined carbohydrates for fat, which in turn led to dyslipidemia, an increase in triglyceride levels, and a reduction in HDL cholesterol.  All bad.

Dr Rajiv Chowdhury (University of Cambridge, UK), says based on an analysis of a huge range of studies;

"If the saturated fat is lowered by replacing the calories with carbohydrates, you're not going to see a benefit," she said. "If the saturated fat is replaced with polyunsaturated fat, there are numerous studies showing there is a clear advantage in terms of cardiovascular disease risk. . . . There are different biological effects depending what you replace the saturated fat with."

So how do you get the right food and therefore energy to consume?

Just because fat is off the radar when it comes to heart disease now, this does mean it is wise to ignore the consumption of fat. As Dr Lichtenstein points out;

 "People ate more real food, as opposed to processed food, in the 1960s, and we had the highest rates of cardiovascular disease then. We also had high rates of saturated-fat intake. Real food can be butter, cream, and cheese, and very fatty meats."

The recommendations now is to emphasise a dietary pattern rather than focusing on individual foods. The advice is;

• To eat more real food. Processed and packet foods were once called convenience foods but they have become mainstream. Return them to the convenience section in your mind to be used on a limited basis. 
• Beware of fast foods. One store bought pizza supplies half of the energy intake required for a day. When they can sell me a pizza for less that what I can make it for, I am suspicious as to its goodness.
• A healthy food choice is a diet rich in fruits, vegetables, whole grains, fish, legumes.
• Reduce the amount of red meat you eat. 
• In 2011, Australians consumed around 111kg of meat per person. UK-based World Cancer Research Fund  and the American Institute for Cancer Research say you should eat no more than 500 grams of cooked red meat a week, which is equivalent to around 750 grams of raw meat. Thinking of portion sizes, 80 grams of cooked meat is about the size of a deck of cards. That is to reduce your risk of developing bowel cancer.  
• The same applies for coronary heart disease.As reported by the Health Hub from Cleveland clinic in the US researchers have found that when we eat red meat, there is a set of reactions mediated by microbes in our gut. These gut microbe reactions are triggered by carnitine, a nutrient found in red meat. The study found that these reactions, which were previously unrecognized, contribute to the development of heart disease. 

As the celebrated Australian celebrity chef Mathew Evans says, who pushes a diet with no miracle cures,
"A balanced diet, where you have a mixed intake of all food groups (moderation, just like your mother told you), is the key."

Phew, see simple isn't it! Well it is at least clearer to me. I don;t have to do without but I need to reduce the amount of meat I eat and when ever I want a snack, grab a carrot or stick of celery.

Fat, fatter, fattest.

Some times you just have to stand in front of the mirror and be honest with yourself.

" You my lad are overweight!"

There we are, that was not too hard.

A quick way to verify the fact is to use an on line calculator of BMI, or Body Mass Index. For my height and weight my number is 26, when it should be between 20 and 25 to be a "good" weight. By playing with the weight number on the BMI calculator I can see if I lose 10 kgs, I currently sit at 106kgs, then my number drops to 23.5.

If I dropped 15kgs my BMI number would be 22.3 and I can assure you, I would look quite unwell although the number itself would place me in a very respectable zone of the BMI index. BMI is a measure for sure but it is a little crude as we all have different bone structures, shapes and so on. But it at least confirms what I have already told myself. An independent source has confirmed my suspicions that I am overweight and I am a little annoyed as it means my wife was right!

If you Google the question, "What is my ideal weight?" you will be provided with a number of answers. The site  www.calculator.net/ideal-weight-calculator.html  suggests a good range of weight dependent on the original researcher that devised the calculation method. It provides a wide target to aim for if you are thinking of losing weight. It will hopefully keep you in weight loss sanity mode rather than the stressed out, exercised out, starved, objective obsessed nutter space we are all unfortunately familiar with, if not from our own circle of friends family or work colleagues, then at least from the regular parading of these characters in the media.

But yes, I do need to and I do want to lose some weight. It will be a positive thing for both my mind and my body and importantly my heart. I am a committed patient from now on. I have had advice, well to be truthful I discovered advice as previously blogged, and I will act on  it bit by bit. not bite by bite. 

The bit by bit aspect is important when it comes to losing weight as I have  discovered previously. Fads, fasting, flogging and forgoing do not work in the longer term. Weight loss or weight management strategies have to be sustainable and the more normal the process, the more likely is success predictable for the future.

It is unnatural to starve oneself. Quoting from a 1997 publication titled; “Handbook for Treatment of Eating Disorders” by D M Gardner, it states, “One of the most important advancements in the understanding of eating disorders is the recognition that severe and prolonged dietary restriction can lead to serious physical and psychological complications.”

One of the breakthrough pieces of research is a story in itself. One of the problems of looking at eating disorders and diets is the people under observation often have issues and so cannot be considered to be a normal cohort of subjects to observe. However, during the Second World War an experiment was undertaken. A group of thirty six healthy, psychologically normal men underwent a restricted calorie diet for six months.

Initially they were fed normally, for three months, whilst base data was collected. For the next six months, the men were restricted to half of their previous food intake. At the end of six months, the men were slowly brought back to so called normal levels of food intake.

This group of so called normal men had varying responses to the lack of food .The stand out change in the subjects was the huge increase in a preoccupation with food. Men would dream about food, asleep and awake. They would talk about food, collect recipe books or food related items like coffee cups and kitchen utensils. Many would hide food and consume it over long hours away from others. They took on hoarding behaviours even to hoard things that were not related to food. During the rehabilitation phase, these new behaviours did not miraculously disappear. For a number, binge eating continued well after the restrictions to food intake were removed.

There were other changes in their emotional states, personalities, social interaction and how they thought and functioned.

The starvation experiment or the Minnesota experiment, is an interesting study for anyone having difficulty with their attempts to diet.

There is a very simple basic formula for weight loss;

Energy in must be less than energy out.

However simple that fact is, simple is not always straight forward.

To get an idea of what energy you should consume in a day, the website below  is a good start.

https://www.walkingwithattitude.com/fitness-tools/basal-metabolic-rate

It is straightforward and  easy to select metric or imperial measurements and daily activity level. Looking at your sedentary energy requirement is worthwhile for those days where you do struggle to do much and compare the energy needed for those days where you are on the go.

There are plenty of calorie or kilojoule calculators out there to assess how much you might be consuming with your eating pattern at the moment. If you are motivated you will have the motivation to work it out. For your interest though, type ""What does 100 calories look like" into your search engine, the images are interesting.

images courtesy of sparkspeople.com

In short, there are some really simple food choices that can be made to make you feel full or satisfied that have very few calories e.g celery, carrots

But back to weight loss there are some pretty useful things to consider that might help.

You are you and do not try to pretend to be otherwise. There are some foods that maybe you should not eat but really you will feel you are starving yourself if you do without them. There are some food rules that unwittingly you live by.  You have to abide by yourself. Go back to the starvation diet, it ain;'t going to work and you are setting yourself up for failure if you do not take these into account.

Make a list of the foods you love and could not do without, the foods you could do without and the ones you can take or leave. There is likely to be a scale of “Yum” to “Yuk!”

What rules do you live by? “I always have a take away food on Friday nights.” “I like to have a snack when I watch television”. “I must have a cake with my coffee”. There will be a host of things you like and a raft of things you would not like to go without.

When you know what you can’t live without, don’t try to, you are highly likely to cheat, deny  and fail.

Do you love a snack after meal time as you watch television? Make the snack smaller in volume and substitute where you can, healthier alternatives- a piece of fruit, a vegetable stick. But you still want your biscuits too don’t you? Instead of three biscuits, have one and make it a beauty. Boy, does it taste good! Instead of a bar of chocolate why not try one piece but of the most expensive chocolate, lip smackingly good chocolate, the sort you could easily club your partner on the back of the head to get to first.

The answer is to make diet part of a lifestyle option, a positive move that does not see you flogging yourself for being the miserable weak piece of filth that magazines and the media try to push you feel about you. Increase your energy output.again by appreciating the sort of exercise you could see yourself doing and knowing which ones you know you would never do. Don’t bother  buying the full set of Lycra swimwear or cycle wear if you hate swimming or cycling.. Do something you like and start off gradually so you will continue to enjoy it. Exercise does not just mean running, swimming, gym, aerobics, cycling and the like. I feel tired just thinking of those things. What about walking, gardening, dancing to music, shopping. Yes shopping! Maybe park your car a little further away next time. Hate mowing the lawn? Make it one of your exercise options. Mow, one two three, Mow one two three…. 

There will be something that works for you but you need to understand what you really like and what you can forgo, in order to make the necessary changes.

If you want to lose weight, you will do so. If you feel you should, you will not. Make the change because you want to and it will work. The key to dieting is it has got to be easy. Punishment only works in the short term.

Slowly does it. Slowly is like the tortoise and the hare, the slow and steady wins and sustainably as it is more like a lifestyle plan rather than a prison programme. Once you know your own daily energy requirement, if you eat 500 calories less than that requirement, you will lose 500 grams or one pound of weight per week. That is a huge change but one that is manageable. 

It is the HOW not the WHAT.

Reading from the Heart Foundation brochure they gave me whilst I was in hospital, " Coronary angioplasty and stents";

Coronary angioplasty is not a cure.

Okay I get it, it only treats the area of blockage or narrowing and it may happen again and it may occur elsewhere. So it advises you have to reduce or remove your risk factors. Reading again from the brochure;

The most important things that you can do are to:

• take your medicines as prescribed
• be smoke free
• enjoy healthy eating
• be physically active
• control your blood pressure and cholesterol
• achieve and maintain a healthy body weight
• maintain your psychological and social health.

Gosh, that makes it so easy, NOT! I could enjoy eating by wacking down three cheeseburgers and a double order of fries, all done with a healthy appetite! Going to get the cheeseburgers is exercise. Thinking about the cheeseburgers and then getting them is good for my psychological health. It does not tell me how only what to do.

It took me until now to read the damn thing, that shows you how easy it is. Mind you, I do consider myself at least somewhat informed. I did have a mother who was diagnosed with heart issues at 45 years old which means I have been living with at least a passing knowledge since I was about  eighteen.

Mind you you can imagine what a young person did with all the knowledge bestowed from on high, nothing! Partied hard!  Smoke, drank, stayed up late, ate shit, standard stuff and all so predictable. If my heart disease is at least in part genetic, is it not a shame some of the wisdom is not inherited too. Why is it us humans have to relearn all the stuff it takes a lifetime to learn that our grandparents and parents kept telling us about?

Funny how things sometimes happen at the right time or the time when you need them to happen. I stumbled on a book in a second hand shop, local author, a prominent cardiologist called Dr Ross Walker.

"If I eat another carrot I'll go Crazy-The Five Point Plan to a Healthy Heart."

His recommended five point plan is not so didactic and is expansive. It certainly makes me think a little more outside the realms of living a  monastic life of abstinence and punishment.

His plan is as follows as quoted from his book;

1. Physical: How you eat, how you exercise.
2. Mental: Acquisition of knowledge; how stimulating do you find your job?
3. Emotional: Do you value your relationships with those close to you? Do you feel happy, how often do you laugh?
4. Sensual: Is your life very mechanical and concrete or do you look for the beauty in life and nature?
5. Spiritual: Do you have a sense of inner peace? Do you have a belief system that allows you to strive towards higher goals?

"It is the combination of all of thee factors that leads to health" he says. But his next statement is the one that makes me take notice and take heart, no pun intended.

" In my practice, I have witnessed two separate types of patients, the motivated and the unmotivated. I can barely remember one truly motivated patient who required repeat coronary bypass grafting. On the other hand I can remember numerous unmotivated patients whose grafts blocked within a few years"

The motivation he reflects is the motivation to change your lifestyle. "A global approach involving how we eat, how we exercise and how we manage our day to day stresses."

Whilst that appears to be more difficult it provides a meaningful path forward. The framework permits variance to suit the individual and in so doing allows effort in the areas that personally a person feels most confronted by. Finally it is a positive message which gives impetus to action. There is hope with action. What is now provided is a how, not just the what needs to be done. The how relates to your whole being not just one aspect of it. Time for a few more questions on oneself...

Stepping my way to cardiovascular happiness.

The heart specialist recommended exercise as the one single thing that could make a difference to my long term survival. Having been an active person the questions become what sort of exercise and how much to make a valuable difference? 

A doctor to doctor joke goes like this;

 " When you ask a patient how much he/she smokes, double the figure they give you. When you ask a patient how much they drink, triple the figure they give you. When you ask a patient how often they have sex, divide that number by four!"

The point in relation to exercise is you don't want to be delusional about how much exercise you do or don't do. There is no need to kid anyone especially yourself. Furthermore, if you can add facts and figures to any representation you are making to a health professional involved in your care it does two things;
1/ He or she is not making mental calculations as to the validity of what you are saying.
2/ If you are interested in your own health, it makes them feel better about helping you.

Meet the Sports Science SD-PRO 3D pedometer, a beast of a machine when you want to take  measurements and qualify the amount and quality of your exercise. I use it to count the number of steps I take and as I know my stride length, this gives me a good idea of the distance travelled. It will when I get the hang of it also measure the speed at which I walk. 

Two points of digression;
1/ I don't do jogging.I have tried many a time to but it just doesn't fit as an exercise for me. As Winston Churchill once described golf as a great way to ruin a good walk, I think the same about jogging. So I walk and when I do I try to do it with purpose, with vim and vigour, to get the most out of it. When I come to a hill I try to increase my determination and  push myself all the while thinking my thoughts, solving the problems of the world, smelling the breeze, enjoying the wildlife, having a good all round exercise session without it feeling like one.

2/There are two studies I will tell you about shortly but one, the Copenhagen Heart Study defines the states of jogging;

"Light jogging- a slow or average pace, 8km per hour or 5 miles per hour,  three or fewer times per week, less than 2.5 hours total per week. 
Moderate jogging- a slow or average pace, three or fewer times per week, but for 2.5 hours or more per week. 
Strenuous jogging - running at a fast pace, more than 11kph or 7 mph, more than 3 times per week, and 4 hours total per week."

As a good paced walker, I am a moderate jogger by this definition, although generally I walk every day either as part of my exercise or as part of my profession. Even with long legs I could never be strenuous enough to attain 11 kph whilst walking, I will be honest. So if you are not a jogger as I am not, walking is a perfectly valid alternative.

The pedometer is another check on your exercise to ensure you are not fooling yourself and you are getting enough to make a difference to your overall well being and to reduce the chances that you might one day fall down with an "unexpected" heart attack as a result of cardiovascular disease. It always makes me laugh to see or here that. As if people "expect" a heart attack. " Hang on a minute, it's 3 o'clock, I am expecting a heart attack!"

Whilst the slogan of 10,000 steps began as a jingle to sell pedometers, it is recognised by the Surgeon General and the American Heart Organisation as a target for people to get to in order to remain healthy. 10,000 steps equates to approximately 30 minutes of walking per day but when you have a pedometer, you can measure what it means for you.

There does not seem to be a breakdown into how you take your 10,000 steps but I do not count slipper shuffling around the house or the ones required to put the garbage out. The steps that I count are the ones I define as the full monty in order that my stride length and therefore the distance I have travelled is meaningful. Over a four week  period work demanded between 11,000 and 18,000 steps per day. If I added the walking the dogs routine, this added a further 5,000. I was happy I was easily meeting the requirements to perform enough exercise to assist with cardiovascular health.

So why does all this matter?
1/ The heart specialist said it did.
2/ Studies show exercise makes a huge difference to a person's life.
3/Well 1/ and 2/ were so good I don't need a 3/. Thanks you Rik Mayall for that gag.

The conclusions of the Copenhagen Heart Study and also backed up by  a much larger American study looking at over 50,000 exercisers makes interesting reading.

• Joggers who ran 1 to 2.4 hours per week had the lowest risk of mortality, with a significant 71% lower risk of death than sedentary non joggers, the couch potatoes.
• The optimal dose of jogging was two to three times per week. These joggers had a significantly 68% lower risk of death compared with the healthy sedentary group. Even those who ran once per week had a significantly lower risk of death compared with non joggers 
• Slow-paced joggers had a significantly 49% lower risk of death compared with sedentary non joggers. The fastest runners had the same mortality risk as sedentary non joggers.
• More exercise isn't necessarily better in terms of health and longevity. The American study  showed the benefits of running are best accumulated in shorter distances, specifically at less than 20 miles per week. In a later addition to this work it was shown just 5 to 10 minutes of daily running, performed even at very slow speeds, significantly lowered an individual's risk of all-cause and cardiovascular mortality.

I will stick to my walking as it is easy to achieve. I am satisfied I am doing enough to take some responsibility for my own health. I am happy I do not need to become a gym junkie and in fact to become one, may be counter productive. Remember too, walking happens to be  the best exercise to suit me. Exercise comes in many forms, it is the overall duration and intensity that counts. Gardening, vacuuming, cleaning the car, bowling, dancing,swimming and so on are all valid forms of exercise. Just do it but remember to take your pedometer to prove it.

Just a quick note on pedometers. 

1/ The cheap ones are in accurate The model I purchased uses 3D motion sensor technology which really just means it is accurate and does not count bumps and shuffles as steps. It also means that where and how you place it on your body to count your steps does not matter.I did my own accuracy tests when I first tried it out.

2/ I found the reviews on the internet quite confusing and contradictory. I bowed to the knowledge of a helpful shop assistant in the end.

3/ I did not receive any financial incentive to promote the pedometer I mention here. I wish I did so I could get another to replace the one I lost. The next one I buy and I will buy the same one again, I will add my own safety chain. I obviously bumped against something and it was gone. An expensive lesson that is shared with you.

The follow up to my procedure is upon me. I sit and wonder what this visit will bring to my life. My previous appointment saved my life! However I am also cognisant of the fact,  the issue with my heart, a significant narrowing in one of the main arteries feeding the muscles in my heart, was discovered on a whim. The whim was to have some imaging tests on my heart, " as there was nothing to lose," given my family history, as the testing I had been subjected to indicated I was otherwise a fine physical specimen!

So here I am.

Before I get to see the specialist, I have to have more testing so he has all the information as to how I am doing post op. They are a repeat of the ones I had during my initial examination so they are familiar to me but no less daunting.

Daunting is probably a little melodramatic but unless you have had a stress test, bear with me. A stress test is not how a person copes with life. Hey there are prison cells, drink cabinets, divorce courts, methadone treatment clinics, truancy rate data and the like that can show you that one. A stress test is simply being wired up whilst you exercise. The exercise is walking on a treadmill at a designated rate which increases incrementally in both pace and incline over time. The wires inform the person sitting at a computer screen how your heart is performing.

Sounds easy!  If you are used to doing some exercise and watching TV from dawn to dusk is not listed as one of your main interests in life it should be...but it isn't. Maybe it is just me but walking on a treadmill is not natural. You have to hang on for a start which means you can't move your arms, your stance is not right, there is no air moving past you, the noise is irritating, and someone is not only watching you the whole time but talking to you. You are trying to do your best but these distractions do not make it easy.

The wiring up is intimidating and a trifle embarrassing. A very young attractive woman who seems to be about half my height and a third of my age clips things all over my near naked body. Yes fifty shades of  wanting to say " I was once young too you know and I looked great back then not like this weathered drooping soggy old biscuit. Once I could have once written a book adding several new chapters. "Sixty shades of Grey" not fifty,but I digress.

The worst part of this wiring up is when she has to place a wire around my waist and her arms can hardly reach around the circumference with her nose pressed very nearly in my navel. I am glad they are not taking photos as it would be hard to explain this to my wife.

The test starts and it is straight forward enough.

"Okay we are going to increase the speed and increase the incline okay?"

"Fine" and it is but the breathing rate increases. Later the question is again asked,  and  again... and again. I wish I had never started to share my experiences with them about life in the country. I make a note that next time I will ask the questions and listen to their replies.Walking and talking at a leisurely pace is fine but not under exertion. After about eleven minutes we stop. I am breathing a little, sweating a lot and thinking if I could just walk outside on a track say, it would be a walk in the park. Eleven minutes walking to me is just not an issue under normal circumstances but  this is their test under their conditions and it is harder than you think.

Stress ECG-eleven minutes. My pedometer tells me that equates to 1100 steps. My morning walk with the dog is around 5000 steps.

Now I am instructed to lie on my side whilst I continue to sweat and heave. A probe is passed over my chest to look at how my heart is working; an ultrasound.

By the time I am sitting across from the heart specialist I have regained my composure, almost. He checks the results and tells me good news.

"Your heart is performing well. There is no indication of any clots and closing of the stent that we  placed, it all looks good."

"So how long before the other arteries might need some work and what is the rate of restenosis of my stent?"

" We get you in every year to re do what we have done today and that will give us a pretty good idea of how your heart is going. I reckon we have probably bought you another 10 to 15 years before we have to worry."

I want to say that I felt fine before my procedure, I still feel fine, my tests we all good before and now but I still had an underlying problem that was only shown by imaging. I let it pass. Nothing worse than a precious patient.

He continues, " The other narrowings could close quickly or it could take years. There is nothing mathematical in how this all works but if we keep an eye on you regularly..."

"What about my blood results what more could I do to improve these? I have pretty much eliminated salt from my diet, I don't eat processed foods generally, I average around 16,000 steps a day at work, I have reduced my intake of saturated fat, I don't smoke..."

"Exercise is good"

"Can I over exercise?"

He ruminates for a time and says "Not generally and overall more is better."

I ask, " I have been on cholesterol lowering drugs and blood pressure reducing medication for two decades now. Have I just been wasting my money?"

His reply is measured, "If you hadn't been on the drugs this might have happened in your early fifties.
There are many unknowns. We know a lot and we know some things with great certainty but there are many factors and each person is different"

Any doctor who doesn't pretend to know everything has got my vote. I put other questions back in the box and decide to do more investigation of my own. Next time my questions will be more researched and specific.

Living with uncertainty. Isn't that what life is all about?

So I will do my own investigations;

• into exercise, what is good and how much is good.
• into diet.
• into salt intake
• into what else matters
• into what else does not matter

I will learn to cope with uncertainty.