"Hello, Susan. Come in and sit down. I've been expecting you." Dr. Robbins came from behind his desk, motioning to a leather arm chair.
"Good afternoon, Dr. Robbins," Susan responded."Yes, mother's heart attack got my attention." She perched on the edge of the chair, tightly clutching her purse.
"I suspect it did," he mused aloud, leaning against the edge of his desk. "But we already had a conversation about her condition at the hospital, so I suspect that this visit isn't about her."
"No, it's not." Susan looked up at him. "It's about me. What are my chances of having the same thing? You know that my father died of congestive heart failure just two years ago. He was only seventy."
"Yes, I remember."
"He wasn't that old. Seventy isn't that old," she hurried on, "and mother is only sixty-eight. What's wrong with us?"
Not responding to her anxiety, Dr. Robbins paused and decided to grasp the teachable moment. "What do you know about heart disease, Susan?"
"Mostly what I see on television, you know, those commercials during the news. I don't read the articles in the women's magazines. They scare me." When Dr. Robbins wrinkled his forehead into a frown, she quickly added, "I know that it happens to older people and that it runs in families."
"Okay, that's good for a start." Dr. Robbins nodded approvingly. "Actually the heart researchers at the Framingham Institute use age and family history in their six test questions to see if people are at risk for heart disease. You are only fifty-one, so that's a mark in your favor, but having both parents with heart disease suggests that genetics is not on your side. We can't change your genetics or your age, but we can address the other risk factors."
He stood up and moved behind his desk, reaching for her medical chart. "In my examination two months ago, you had a blood pressure-135/75," he said as he sat down while scanning the pages. "Pre-hypertension we call it. Not too bad, except that we only got it down there with medication." He looked up. "Those are the next two questions used to assess heart disease risk: Do you have high systolic blood pressure and do you take medications for it? Yes to both for you."
"I don't like to take medications," Susan said, frowning. "They have side effects."
"Yes, they do," he agreed. "We probably use medicine way to much. But it's only because people won't make the lifestyle changes that we recommend, lifestyle changes that are probably more effective than any medicine." He smiled quickly and looked at the chart again. "Which brings us to the last two factors: your total cholesterol was 272 mg/dL, and your HDL cholesterol, the good cholesterol, was 52 mg/dL." He looked up at her again. "I would have expected a woman of your age to have a higher HDL cholesterol, at least 65 or more. A high HDL cholesterol level is one of the most helpful ways to prevent heart disease. It offsets a multitude of other bad markers, including your very high total cholesterol."
"Okay," Susan said, rising to the challenge, "how do I raise my HDL?"
"That's good, Susan," he immediately commented, "Take charge of what you can do." Looking at the chart, he remarked, "I see that your weight is 185 pounds and your body mass index is 33.8. That puts you in the obese category."
"It's been a stressful two years, first Daddy and now Mother," she murmured.
"And your weight has suffered as a result, and your cholesterol, too, no doubt," he deduced. "Some doctors are suggesting that the body mass index is just as good a measure of heart risk as cholesterol, and I think they are right. A new marker that we didn't check on you is C-reactive protein, a protein in the blood that indicates a high degree of inflammation. But given your inflammatory bowel disease and your arthritis, I would guess that you probably have a high inflammatory state in your body." He closed the chart. "So what can we do about this? It's actually easier than you think, if you're willing to make some changes."
"I am," she said, nodding vigorously.
"Okay," he said, reaching for his prescription pad. "I'm going to make an appointment with a dietician to talk about foods that increase inflammation, like transfats and high glycemic index foods." When she looked puzzled, he asked, "Do you read labels on the foods you buy? No? You will learn."
"But I'm a vegetarian," she replied.
"That's good. Meats can be highly inflammatory. But vegetarians frequently make poor choices in substituting for animal products." He quickly scribbled several more lines on his pad and tore it off. "And now a prescription for an exercise program," he said, writing again.