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Tag: Heart Disease

  • Op-Ed | How we’re fighting a leading cause of death for New Yorkers | amNewYork

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    As the head of our state’s leading public health agency, I track a seemingly endless list of threats to the health, safety and wellbeing of New Yorkers. Some come from out of nowhere – disease outbreaks or distant wildfires that threaten our air quality – but some are stubbornly persistent. Every February we renew our focus on one of those areas as we mark American Heart Month.

    This year, that comes as our State happens to be celebrating a major milestone: February 19th is the 125th anniversary of the creation of the New York State Department of Health. By creating one of the nation’s first state health departments, lawmakers and elected officials in 1901 were taking a leadership role in public health that continues to this day.

    Take the issue of heart health: Just last month, Governor Hochul unveiled a budget proposal that makes major investments in our fight against cardiovascular disease. Healthy hearts start with healthy diets, which is why Governor Hochul included over $100 million for nutrition programs, food banks and food pantries in the Executive Budget.

    We also want to be ready when the worst happens. That’s why the Governor’s budget includes proposals to strengthen cardiac emergency readiness across New York State – like $3.2 million to establish regional training hubs and ensure communities know how to use Automated External Defibrillators (AEDs) and support new, scalable approaches to cardiopulmonary resuscitation (CPR) education; and New York’s first statewide AED registry with the precise location of every AED across the state, enabling emergency dispatchers to direct individuals to the nearest device, saving critical time during cardiac events.

    To be sure, over the last 125 years we have made major progress. While the percentage of adults who report having a stroke, heart attack or coronary heart disease has remained relatively unchanged over the past decade, investments in public health means cardiovascular disease is no longer a death sentence.

    Moreover, we know the risk of developing cardiovascular disease can be reduced with certain lifestyle changes – like never starting to smoke or quitting smoking, not drinking or reducing alcohol intake, increasing physical activity and eating well. It’s also important to manage blood pressure and cholesterol levels and maintain routine visits with a primary care provider. Successful public health campaigns have tackled all of these issues.

    But our work is not done.

    Cardiovascular disease remains a leading cause of death around the world and here at home in New York. Our research shows that over 1.25 million adults in New York State report that they have cardiovascular disease, meaning they have experienced a heart attack, angina, coronary heart disease or stroke, and an estimated 4.2 million adult New Yorkers report being told by a health professional they have high blood pressure, a leading cause of cardiovascular disease.

    Social drivers of health such as lack of access to healthy food, lack of safe places for physical activity, lack of access to affordable medical care, and lack of housing stability contribute to disparities in the burden of high blood pressure and cardiovascular risk. High blood pressure is more prevalent among American Indian/Alaska Native and Black, non-Hispanic adults.

    Data shows we are on the right track – rates of high blood pressure control among adults in New York are higher compared to the national average. Ensuring those suffering from these conditions continue to have access to treatment will be vital to continue this progress.

    With the support of Governor Hochul, we are working with our health care partners across the state to ensure every New Yorker has the ability to protect themselves and their family from cardiovascular disease.

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    By State Health Commissioner Dr. James McDonald

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  • How Low Can LDL Cholesterol Go on PCSK9 Inhibitors? | NutritionFacts.org

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    People with genetic mutations that leave them with an LDL cholesterol of 30 mg/dL live exceptionally long lives. Can we duplicate that effect with drugs?

    Data extrapolated from large cholesterol-lowering trials using statin drugs suggest that the incidence of cardiovascular events like heart attacks would approach zero if LDL cholesterol could be forced down below 60 mg/dL for first-time prevention and around 30 mg/dL for those trying to prevent another one. But is lower actually better? And is it even safe to have LDL cholesterol levels that low?

    We didn’t know until PCSK9 inhibitors were invented. Are PCSK9 Inhibitors for LDL Cholesterol Safe and Effective? I explore that issue in my video of the same name. PCSK9 is a gene that mutated to give people such low LDL cholesterol, and that’s how Big Pharma thought of trying to cripple PCSK9 with drugs. After a heart attack, intensive lowering of an individual’s LDL cholesterol beyond a target of 70 mg/dL does seem to work better than more moderate lowering. There were fewer cardiovascular deaths, heart attacks, or strokes at an LDL less than 30 mg/dL compared with 70 mg/dL or higher, and even compared to less than 70 mg/dL. There is a consistent risk reduction even when starting as low as an average of 63 mg/dL, and pushing LDL down to 21 mg/dL, remarkably, showed “no observed offsetting” of adverse side effects.

    Maybe that shouldn’t be so surprising, since that’s about the level at which we start life. And there’s another type of genetic mutation that leaves people with LDL levels of about 30 mg/dL their whole lives, and they are known to have an exceptionally long life expectancy. So, where did we get this idea that cholesterol could fall too low?

    The common claim that lowering cholesterol can be dangerous due to depletion of cell cholesterol is unsupported by evidence and does not consider the exquisite balancing mechanisms our body uses. After all, that’s how we evolved. Until recently, most of us used to have LDL levels around 50 mg/dL, so that’s pretty normal for the human species. The absence of evidence that low or lowered cholesterol levels are somehow bad for us contrasts with the overwhelming evidence that cholesterol reduction decreases risk for coronary artery disease, our number one killer.

    What about hormone production, though? Since the body needs cholesterol for the synthesis of steroid hormones—like adrenal hormones and sex hormones—there’s a concern that there wouldn’t be enough. You don’t know, though, until you put it to the test. For decades, we’ve known that women on cholesterol-lowering drugs don’t have a problem with estrogen production and that lowering cholesterol doesn’t affect adrenal gland function. As well, it doesn’t impair testicular function in terms of causing testosterone levels to fall below normal. If anything, statin drugs can improve erectile function in men, which is what you’d expect from lowering cholesterol. But you’ll notice these studies only looked at lowering LDL to 70 mg/dL or below. What about really low LDL?

    On PCSK9 inhibitors, you can get most people under an LDL of 40 mg/dL and some under 15 mg/dL! And there is no evidence that adrenal, ovarian, or testicular hormone production is impaired, even in patients with LDL levels below 15 mg/dL. The risk of heart attacks falls in a straight line as LDL gets lower and lower, even below 10 mg/dL, for example, without apparent safety concerns, but that’s over the duration of exposure to these drugs. The longest follow-up to date of those whose LDL, by way of using multiple medications, was kept less than 30 mg/dL is six years.

    Now, we can take comfort in the fact that those with extreme PCSK9 mutations, leading to a lifelong reduction in levels of LDL to under 20 mg/dL their whole lives, remain healthy and have healthy kids. Cholesterol-affecting mutations are what cause the so-called “longevity syndromes,” but that doesn’t necessarily mean the drugs are safe. The bottom line is we should try to get our LDL cholesterol down as low as we can, but much longer follow-up data are necessary anytime a new class of drugs is introduced. So far, so good, but we’ve only been following the data for about 10 years. For example, we didn’t know statins increased diabetes risk until decades after they were approved and millions had been exposed. Also worth noting: PCSK9 inhibitors cost about $14,000 a year.

    Doctor’s Note

    How can we decrease cholesterol with diet? See Trans Fat, Saturated Fat, and Cholesterol: Tolerable Upper Intake of Zero.

    For more on statin drugs, see the related posts below. 

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    Michael Greger M.D. FACLM

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  • How to Beat Heart Disease Before It Starts | NutritionFacts.org

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    Why might healthy lifestyle choices wipe out 90% of our risk for having a heart attack, while drugs may only reduce risk by 20% to 30%?

    On the standard American diet, atherosclerosis—hardening of the arteries, the number one killer of men and women—has been found to start in our teens. Investigators collected about 3,000 sets of coronary arteries and aortas (the aorta is the main artery in the body) from victims of accidents, homicides, and suicides who were 15 to 34 years old and found that the fatty streaks in arteries can begin forming in our teens, which turn into atherosclerotic plaques in our 20s that get worse in our 30s and can then become deadly. In the heart, atherosclerosis can cause a heart attack. In the brain, it can cause a stroke. See the progression below and at 0:35 in my video Can Cholesterol Get Too Low?.

    How common is this? All of the teens they looked at—100% of them—already had fatty streaks building up inside their arteries. By their early 30s, most already had those streaks blossoming into atherosclerotic plaques that bulged into their arteries. From ages 15 through 19, their aortas had fatty streaks building up throughout them, but no plaques yet, on average, as seen below and at 1:15 in my video.

    The plaques started appearing in their abdominal aorta in their early 20s and worsened by their late 20s, by which time fatty streaks had infiltrated throughout. By their early 30s, their arteries were in bad shape, as seen below and at 1:25 in my video.

    But that’s just the abdominal aorta, the main artery running through the torso that splits off into our legs. What about the coronary arteries that feed the heart?

    Researchers found the same pattern: fatty streaks in teens, early signs of plaque in early 20s that progress with age, and by the early 30s, most people already had plaques in their coronary arteries, as seen below and at 1:47 in my video.

    Atherosclerosis starts as early as adolescence.

    That’s why we shouldn’t wait until heart disease becomes symptomatic to treat it. If it starts in our youth, we should start treating it when we’re youths. If you knew you had a cancerous tumor, you wouldn’t want to wait until it grew to a certain size to treat it. If you had diabetes, you wouldn’t want to wait until you started going blind before you did something about it. So, how do you treat atherosclerosis? You lower LDL cholesterol through a diet low in saturated fat and cholesterol—a diet that’s low in eggs, meat, dairy, and junk.

    If we want to stop this epidemic, we have to “alter our lifestyle accordingly, beginning in infancy or early childhood. Is such a radical proposal totally impractical?” (Eating more healthfully? Radical?!) It would take serious dedication to change our behavior, but atherosclerosis is our number one cause of death. In the case of cigarettes, we did pretty well, slashing smoking rates and dropping lung cancer rates. And, yes, healthy eating is safe. According to the Academy of Nutrition and Dietetics, the largest and oldest association of nutrition professionals in the world, even strictly plant-based diets are appropriate for all stages of life, starting from pregnancy. (NutritionFacts.org is among the websites recommended by the Academy for more information.)

    The title of an important study published in the Journal of the American College of Cardiology declares: “Curing Atherosclerosis Should Be the Next Major Cardiovascular Prevention Goal.” What evidence do we have that a lifelong suppression of LDL will do it? There is a genetic mutation of a gene called PCSK9 that about 1 in 50 African Americans are lucky to be born with because it gives them about a 40% lower LDL cholesterol level their whole lives. Indeed, they were found to have dramatically lower rates of coronary heart disease—an 88% drop in risk compared to those without the genetic mutation, despite otherwise terrible cardiovascular risk factors on average. Most had high blood pressure and were overweight, almost a third smoked, and nearly 20% had diabetes, but that highlights how a lifelong history of low LDL cholesterol levels can substantially reduce the risk of coronary heart disease, even when there are multiple risk factors.

    This near-90% drop in events like heart attacks or sudden death occurred at an average LDL level of 100 mg/dL, compared to 138 mg/dL in those without the genetic mutation. This means LDL can drop below even 100 mg/dL. Why does a drop in LDL cholesterol by about 40 mg/dL from a lucky genetic mutation lower the risk of coronary heart disease by nearly 90%, while the same reduction with statin drugs lowers it by only about 20%? The most probable explanation? Duration. When it comes to lowering LDL cholesterol, it’s not only about how low it is, but how long it’s been low.

    That’s why healthy lifestyle choices may wipe out about 90% of our risk for having a heart attack, while drugs may reduce it by only 20% to 30%. If you’re getting treated with drugs later in life, you may have to get your LDL under 70 mg/dL to halt the progression of coronary atherosclerosis. But if we start making healthier choices earlier, it may be enough to lower LDL cholesterol just to 100 mg/dL, which should be achievable for most of us. That’s consistent with country-by-country data that suggested death from heart disease would bottom out at a population average of about 100 mg/dL, as seen below and at 5:21 in my video.

    But that’s only if you can keep your LDL cholesterol down your whole life.

    If you’re relying on medication later in life to halt disease progression, you may need to get your LDL below 70 mg/dL, and if you’re trying to use drugs to reverse a lifetime of bad food choices, you may not get to zero coronary heart disease events until your LDL drops to about 55 mg/dL. If your heart disease is so bad that you’ve already had a heart attack but you’re trying not to die from another one, ideally, you might want to push your LDL down to about 30 mg/dL. Once you get that low, not only would you likely prevent any new atherosclerotic plaques, but you’d also help stabilize the plaques you already have so they’re less likely to burst open and kill you.

    Is it even safe to have cholesterol levels that low, though? In other words, can LDL cholesterol ever be too low? We’ll find out next.

    Doctor’s Note

    Didn’t know atherosclerosis could start at such a young age? See Heart Disease Starts in Childhood.

    For more on drugs versus lifestyle, check out my video The Actual Benefit of Diet vs. Drugs.

    Want to learn more about so-called primordial prevention? See When Low Risk Means High Risk.

    Does Cholesterol Size Matter? Watch the video to find out.

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    Michael Greger M.D. FACLM

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  • Strong relationships provide the willpower needed to sustain a healthy lifestyle

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    Skepticism reigns supreme in America, and it’s been my experience that men over 50 reside on the more skeptical end of the continuum.

    It takes strong and substantial evidence to convince men to adopt new ideas, particularly when the subject is not one readily embraced — like a healthy lifestyle. That’s why I continue to highlight any new science that reinforces the relationship between health and happiness, the centerpiece of my advocacy for men’s health.

    The good news is that the studies just keep coming, with the latest documenting the impact that relationships can have on our health. In this case, the impact has an especially strong connection to men.

    The study, published Dec. 15 in the Canadian Journal of Cardiology, indicates that “social relationships, particularly the quality of intimate partnerships, play a significant role in cardiovascular outcomes and recovery.” The findings are based on researchers’ review of 12 randomized controlled trials involving 1,444 patients with heart disease and their partners. The study focuses on spouse or intimate partner relationships and shows that such relationships are especially important in predicting cardiac health, but the report also acknowledges that “all sources of positive social relationships may protect from CVD (cardiovascular disease).”

    The analysis recounts a robust body of science that supports the findings. One of the 16 studies the researchers examined determined that unmarried people — whether never married, divorced or widowed — are 40% more likely to suffer from cardiovascular disease and die from heart attacks than married people. 

    The researchers also stress the importance of “relationship quality” which they define as the “degree of warmth, affection, support and closeness.” Researchers emphasize that “it is not just the presence of such a relationship that counts, but its quality.” Going deeper, researchers describe how positive couple relationships are associated with well-controlled diabetes, lower weight or obesity, improved diet, and better blood pressure, all factors behind the development and progression of heart disease.

    Special meaning for men

    If the growing body of evidence showing the health benefits of social relationships is not enough, the Canadian study’s focus on heart disease should really strike a chord for men. 

    Why? Heart disease remains the leading cause of death in the United States, influenced by a rise in risk factors like obesity, diabetes, hypertension and physical inactivity. 

    As men age, the risk of developing heart disease rises dramatically. When men hit 50, the decline of testosterone, poor lifestyle choices, undetected disease symptoms (due to lack of check-ups) and co-morbidities like type 2 diabetes, obesity and sleep apnea can contribute to the increased risk.

    Building intimate partner relationships

    No matter your age, if you’re a guy looking to build a more intimate partner relationship, improve your health and reduce the risk of heart disease, there are plenty of ways to do so. 

    Life Coach Wayne Parker, who authored the book “Power Dads: The Ten Basic Principles Successful Fathers Use to Raise Responsible and Happy Children,” and psychiatrist Carly Snyder recommend several strategies, including creating a safe space to share feelings without fear of judgment, and engaging in meaningful and stimulating conversations that build bonds. 

    They also recommend all forms of physical touch — from hugs and cuddles to holding hands — and maintaining a healthy balance between yourself and your partner, with each partner engaging in some good self-care. Building a “Fun List” is a great way to spend time doing things that you both enjoy, too.

    Relationship therapist Jessica Lorraine suggests developing a growth mindset in which couples see difficulties as temporary and manageable, build relationship resiliency by establishing emotional and physical boundaries, practice gratitude to boost their moods and celebrate small wins to foster a sense of shared accomplishment.

    Motivation to live healthy

    The Canadian study reports that couples are more likely to engage in physical activity, adhere to their medications, quit smoking and stay smoke-free and eat less saturated fats and salt than single people.

    The analysis shows that strong and sustained intimacy provides motivation and increased willpower to carry out a healthy lifestyle. This creates the purpose that translates into the drive to develop the habits, routines and rituals to exercise, eat right, and see your doctor on a regular basis. 

    What does that lifestyle look like in real-time?

    Sticking with the theme of cardiovascular health, the American Heart Association promotes eight essential components for ideal heart and brain health, a combination of behaviors and key metrics that you’ll want to track. Here’s the breakdown:

    • Eat better with a diet that includes whole foods, lots of fruits and vegetables, lean protein, nuts, seeds, and cooking in non-tropical oils such as olive and canola.
    • Be more active by getting 2 1/2 hours of moderate physical activity or 75 minutes of vigorous physical activity per week.
    • Quit tobacco. Cigarettes are the leading cause of preventable death in the United States.
    • Get a healthy amount of sleep, about 7-9 hours each night.
    • Manage your weight. Optimal body mass index is less than 25 (there are many online calculators available). 
    • Control your cholesterol. High levels of non-HDL, or “bad,” cholesterol can lead to heart disease (your doctor can help).
    • Manage your blood sugar. High levels of blood sugar can damage your heart, kidneys, eyes and nerves (another reason to see your doctor regularly).
    • Manage your blood pressure. Keeping your blood pressure within acceptable ranges can keep you healthier longer and yet another factor your doctor will measure.

    The power of relationships

    Beyond the science, my lived experience has shown me the tremendous power of relationships. As the Canadian study points out, loving, intimate relationships can have a profound impact on your ability to live healthy. Other research suggests that relationships, like that of father-son and even grandfather-grandson, can provide a man with the meaning and purpose to stick with his diet and exercise regimen and maintain routine medical practices.

    Regardless of your emotional source (optimally multiple sources), the established value of relationships and this new Canadian study should help even the most skeptical man stop and take note. Strengthening bonds with the most important people in your life is good for the mind, body and soul. It’s a life-changing and life-saving proposition. Give it a try.

    Louis Bezich, senior vice president and chief administrative officer at Cooper University Health Care, is author of “Crack The Code: 10 Proven Secrets that Motivate Healthy Behavior and Inspire Fulfillment in Men Over 50” and “Saving Men From Themselves: 20 Proven Tactics with a New Approach to Healthy Living for Men Over 50.” Read more from Louis on his website.

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    Louis Bezich

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  • Can Vegan Fecal Transplants Lower TMAO Levels? | NutritionFacts.org

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    If the microbiome of those eating plant-based diets protects against the toxic effects of TMAO, what about swapping gut flora?

    “Almost 2,500 years ago, Hippocrates stated that ‘All disease begins in the gut.’” When we feed our gut bacteria right with whole plant foods, they feed us right back with beneficial compounds like butyrate, which our gut bugs make from fiber. On the other hand, if we feed them wrong, they can produce detrimental compounds like TMAO, which they make from cheese, eggs, seafood, and other meat.

    We used to think that TMAO only contributed to cardiovascular diseases, like heart disease and stroke, but, more recently, it has been linked to psoriatic arthritis, associated with polycystic ovary syndrome, and everything in between. I’m most concerned about our leading killers, though. Of the top ten causes of death in the United States, we’ve known about its association with increased risk of heart disease and stroke, killers number one and five, but recently, an association has also been found between blood levels of TMAO and the risks of various cancers, which are our killer number two. The link between TMAO and cancer could be attributed to the inflammation caused by TMAO, but it could also be oxidative stress (free radicals), DNA damage, or a disruption in protein folding.

    What about our fourth leading killer, chronic obstructive pulmonary disease (COPD), like emphysema? TMAO is associated with premature death in patients with exacerbated COPD, though it’s suspected that it’s due to them dying from more cardiovascular disease.

    The link to stroke is a no-brainer—no pun intended. It is due to the higher blood pressure associated with higher TMAO levels, as well as the greater likelihood of clots forming in those with atrial fibrillation. Those with higher TMAO levels also appear to have worse strokes and four times the odds of death.

    Killer number six is Alzheimer’s disease. Can TMAO even get up into our brains? Yes, TMAO is present in human cerebrospinal fluid, which bathes the brain, and TMAO levels are higher in those with mild cognitive dysfunction and those with Alzheimer’s disease dementia. “In the brain, TMAO has been shown to induce neuronal senescence [meaning, deterioration with age], increase oxidative stress, impair mitochondrial function, and inhibit mTOR signaling, all of which contribute to brain aging and cognitive impairment.”

    Killer number seven is diabetes, and people with higher TMAO levels are about 50% more likely to have diabetes. Killer number eight is pneumonia, and TMAO predicts fatal outcomes in pneumonia patients even without evident heart disease. Kidney disease is killer number nine, and TMAO is strongly related to kidney function and predicts fatal outcomes there as well. Over a period of five years, more than half of chronic kidney disease patients who started out with average or higher TMAO levels were dead, whereas among those in the lowest third of levels, nearly 90% remained alive.

    How can we lower the TMAO levels in our blood? Because TMAO originates from dietary sources, we could limit our intake of choline- and carnitine-rich foods. They’re so widespread in foods,” though we’re talking about meat, eggs, and dairy. “Therefore, restriction of foods rich in TMA-containing nutrients may not be practical.” Can we just get a vegan fecal transplant? “Vegan donors provided the investigators with a fresh morning fecal sample…”

    If you remember, if you give a vegan a steak, despite all that carnitine, they make almost no TMAO compared to a meat-eater, presumably because the vegan hasn’t been fostering steak-eating bugs in their gut. See below and at 3:40 in my video Can Vegan Fecal Transplants Lower TMAO Levels?.

    Remarkably, even if you give plant-based eaters the equivalent of a 20-ounce steak every day for two months, only about half start ramping up production of TMAO, showing just how far their gut flora has to change. The capacity of veggie feces to churn out TMAO is almost nonexistent. Instead of eating healthier, what about getting some vegan poop?

    In a double-blind, randomized, controlled trial, research subjects either got vegan poop or their own poop back through a hose snaked down their nose, and it didn’t work.

    First of all, the vegans recruited for the study started out making TMAO themselves, in contrast to the other study, where they didn’t make any at all. This may be because the earlier study required the vegans to have been vegan for at least a year, and this study didn’t. So, there wasn’t much of a change in TMAO running through their bodies two weeks after getting the vegan poop, but the vegan poop they got seemed to start out with some capacity to produce TMAO in the first place.

    So, the failure to improve after the vegan fecal transplant “could be related to limited baseline microbiome differences and continuation of an omnivorous diet” after the vegan-donor transplant. What’s the point of trying to reset your microbiome if you’re just going to eat meat? Well, the researchers didn’t want to switch people to a plant-based diet since they knew that alone can change our microbiome, and they didn’t want to introduce any extra factors. The bottom line is that it seems there may not be any shortcuts. We may just have to eat a healthier diet.

    Doctor’s Note

    Want to become a donor? Find out How to Become a Fecal Transplant Super Donor.

    For more on TMAO, check out related posts below. 

    See the microbiome topic page for even more.

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    Michael Greger M.D. FACLM

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  • 4 Healthy Cat Diet Tips to Prevent Obesity | Animal Wellness Magazine

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    These four key healthy cat diet tips will help you understand how to use food to keep your feline friend lean and full of energy!

    Obesity is a common health issue in cats. In fact, it’s estimated that over 60% of cats are overweight or obese. Luckily, it’s easy to prevent, and there are plenty of reasons you should take steps to do so. Excess weight can shorten their lifespan, reduce their quality of life, and cause health conditions like diabetes, joint problems, and heart and liver disease. Regular play and exercise are essential components for a healthy lifestyle, but the real key to preventing obesity in cats lies in their food bowl. Here are four healthy cat diet tips that will help you keep your kitty lean, happy, and healthy!

    1. Practice Portion Control

    Overfeeding is one of the biggest contributors to cat obesity. The easiest way to combat it is by feeding your cat twice daily instead of allowing them to free feed, which can easily lead to constant snacking, overeating, and weight gain. And be sure to measure the proper amount of food for your cat based on the feeding guidelines provided by your vet or the food manufacturer.

    2. Adjust Calories Based on Life Stage and Activity Level

    Cats have different caloric needs depending on their age and how active they are. Kittens need more calories and nutrients to support growth, while adults and seniors typically require fewer calories. Spayed or neutered cats also have slower metabolisms and may gain weight more easily. Similarly, indoor cats who aren’t as active as outdoor cats may need a weight-maintenance formula. Regular checkups with your veterinarian will help you stay on track with a healthy cat diet.

    3. Prioritize Nutrient-Rich Cat Foods

    While it is important to pay attention to the number of calories your cat consumes, it’s just as important to make sure they’re getting the right nutrients. Cats are obligate carnivores, and they thrive on meat-rich diets. Look for foods with real animal protein as the first ingredient, minimal carbohydrates, and no artificial additives. High-quality foods ensure your cat gets the vitamins, minerals, and nutrients they need while also helping them feel satisfied with smaller portions.

    4. Keep Treats and Human Food to a Minimum

    Treats are okay, as long as they’re just that—treats. They shouldn’t make up more than 10% of your cat’s daily calories. And that includes human food. Even though some human foods are safe for cats (like lean meats, salmon, tuna, and even some vegetables), you must be careful not to overfeed. When you do feed treats, prioritize nutrient-dense ones. Here are some things to look for:

    • Single- or minimal-ingredient treats
    • Meat as the first ingredient
    • No added salt or sugar
    • Real-food ingredients

    A Healthy Cat Diet Starts with NutriSource Recipes!

    NutriSource has been nourishing cats for over 60 years with nutrient-dense foods, prioritizing high-quality ingredients and meat-rich recipes that supply cats with the calories and nutrients they need to maintain energy and a healthy body condition. They have a variety of options for cats of all ages in their NutriSource, Element, and PureVita lines, including grain-inclusive options, grain-free recipes, and weight management formulations, all of which feature animal protein as the first ingredient.

    Visit NutriSource to learn more and find the purrfect healthy cat diet for your feline friend!

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    Animal Wellness is North America’s top natural health and lifestyle magazine for dogs and cats, with a readership of over one million every year. AW features articles by some of the most renowned experts in the pet industry, with topics ranging from diet and health related issues, to articles on training, fitness and emotional well being.

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    Animal Wellness

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  • Polly the dog to be crowned a “CPR Hero” for helping save her owner’s life during a cardiac arrest

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    A golden retriever is being lauded as “the first responder” who helped saved her owner’s life when he suffered a cardiac arrest in the middle of the night.

    Hannah Cooke, from County Fermanagh in Northern Ireland, was woken up one night last year by a bark from Polly, she and her husband’s four-year-old dog, who the couple said normally sleeps quietly through the night.

    When she turned to her husband sleeping next to her, Hannah found him breathing irregularly, and then he stopped breathing entirely, according to the British Heart Foundation, which told the couple’s story ahead of a ceremony on Tuesday that will see both Hannah and Polly crowned “CPR Heroes” for their actions.

    Golden retriever Polly from Fermanagh helped save her owner Adam’s life when he had a cardiac arrest asleep in bed in 2024.

    British Heart Foundation


    “When I heard the noise Adam was making I sat bolt upright in bed, as I previously worked as a carer and it hit me that it was the same noise I’ve heard when people are taking their final breaths,” said Hannah, 33.

    She immediately sprang into action, calling an ambulance and performing CPR on her husband until paramedics arrived to whisk him to the hospital. On the way, they shocked Adam seven times with a defibrillator before his heart rate normalized.

    Adam woke up at the hospital six days later and learned that he had been diagnosed with a heart disease called dilated cardiomyopathy, which prevents the heart from pumping blood around the body effectively.

    After weeks of recovery and a procedure to have a Implantable Cardioverter Defibrillator put in his chest, Adam was finally allowed to go home — where he was reunited with Polly.

    polly-cooke.jpg

    Polly’s barking woke Adam’s wife Hannah who performed life-saving CPR and contacted the emergency services

    British Heart Foundation


    “When I got out of hospital, I’ll never forget seeing Polly again and knowing how she had intervened that night. I just cuddled her and cried for 20 minutes,” Adam said.

    The couple credit Polly with having saved Adam’s life by being “in tune” with him, and they believe she even knew what was happening.

    “Polly alerted me, possibly within seconds of Adam’s cardiac arrest, she was the first responder,” Hannah told the BHF, a charity that raises awareness of cardiovascular disease and money to fund research into treatments and cures. “Because of her, I was able to start CPR almost immediately.”

    Hannah and Polly were set to receive their honors as “CPR Heroes” at the BHF’s Heart Hero Awards ceremony in London on Tuesday evening.

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  • Plant-Based Hospital Menus | NutritionFacts.org

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    The American Medical Association passed a resolution encouraging hospitals to offer healthy plant-based food options.

    “Globally, 11 million deaths annually are attributable to dietary factors, placing poor diet ahead of any other risk factor for death in the world.” Given that diet is our leading killer, you’d think that nutrition education would be emphasized during medical school and training, but there is a deficiency. A systematic review found that, “despite the centrality of nutrition to a healthy lifestyle, graduating medical students are not supported through their education to provide high-quality, effective nutrition care to patients…”

    It could start in undergrad. What’s more important? Learning about humanity’s leading killer or organic chemistry?

    In medical school, students may average only 19 hours of nutrition out of thousands of hours of instruction, and they aren’t even being taught what’s most useful. How many cases of scurvy and beriberi, diseases of dietary deficiency, will they encounter in clinical practice? In contrast, how many of their future patients will be suffering from dietary excesses—obesity, diabetes, hypertension, and heart disease? Those are probably a little more common than scurvy or beriberi. “Nevertheless, fully 95% of cardiologists [surveyed] believe that their role includes personally providing patients with at least basic nutrition information,” yet not even one in ten feels they have an “expert” grasp on the subject.

    If you look at the clinical guidelines for what we should do for our patients with regard to our number one killer, atherosclerotic cardiovascular disease, all treatment begins with a healthy lifestyle, as shown below and at 1:50 in my video Hospitals with 100-Percent Plant-Based Menus.

    “Yet, how can clinicians put these guidelines into practice without adequate training in nutrition?”

    Less than half of medical schools report teaching any nutrition in clinical practice. In fact, they may be effectively teaching anti-nutrition, as “students typically begin medical school with a greater appreciation for the role of nutrition in health than when they leave.” Below and at 2:36 in my video is a figure entitled “Percentage of Medical Students Indicating that Nutrition is Important to Their Careers.” Upon entry to different medical schools, about three-quarters on average felt that nutrition is important to their careers. Smart bunch. Then, after two years of instruction, they were asked the same question, and the numbers plummeted. In fact, at most schools, it fell to 0%. Instead of being educated, they got de-educated. They had the notion that nutrition is important washed right out of their brains. “Thus, preclinical teaching”— the first two years of medical school—“engenders a loss of a sense of the relevance of the applied discipline of nutrition.”

    Following medical school, during residency, nutrition education is “minimal or, more typically, absent.” “Major updates” were released in 2018 for residency and fellowship training requirements, and there were zero requirements for nutrition. “So you could have an internal medicine graduate who comes out of a terrific program and has learned nothing—literally nothing—about nutrition.”

    “Why is diet not routinely addressed in both medical education and practice already, and what should be done about that?” One of the “reasons for the medical silence in nutrition” is that, “sadly…nutrition takes a back seat…because there are few financial incentives to support it.” What can we do about that? The Food Law and Policy Clinic at Harvard Law School identified a dozen different policy levers at all stages of medical education and the kinds of policy recommendations there could be for the decision-makers, as you can see here and at 3:48 in my video.

    For instance, the government could require doctors working for Veterans Affairs (VA) to get at least some courses in nutrition, or we could put questions about nutrition on the board exams so schools would be pressured to teach it. As we are now, even patients who have just had a heart attack aren’t changing their diet. Doctors may not be telling them to do so, and hospitals may be actively undermining their future with the food they serve.

    The good news is that the American Medical Association (AMA) has passed a resolution encouraging hospitals to offer healthy food options. What a concept! “Our AMA hereby calls on [U.S.] Health Care Facilities to improve the health of patients, staff, and visitors by: (a) providing a variety of healthy food, including plant-based meals, and meals that are low in saturated and trans fat, sodium, and added sugars; (b) eliminating processed meats from menus; and (c) providing and promoting healthy beverages.” Nice!

    “Similarly, in 2018, the State of California mandated the availability of plant-based meals for hospital patients,” and there are hospitals in Gainesville (FL), the Bronx, Manhattan, Denver, and Tampa (FL) that “all provide 100% plant-based meals to their patients on a separate menu and provide educational materials to inpatients to improve education on the role of diet, especially plant-based diets, in chronic illness.”

    Let’s check out some of their menu offerings: How about some lentil Bolognese? Or a cauliflower scramble with baked hash browns for breakfast, mushroom ragu for lunch, and, for supper, white bean stew, salad, and fruit for dessert. (This is the first time a hospital menu has ever made me hungry!)

    The key to these transformations was “having a physician advocate and increasing education of staff and patients on the benefits of eating more plant-based foods.” A single clinician can spark change in a whole system, because science is on their side. “Doctors have a unique position in society” to influence policy at all levels; it’s about time we used it.

    For more on the ingrained ignorance of basic clinical nutrition in medicine, see the related posts below.

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    Michael Greger M.D. FACLM

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  • Fetterman says he’s back home after a fall put the Pennsylvania senator in the hospital

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    WASHINGTON — WASHINGTON (AP) — Sen. John Fetterman says he has returned home to his family in Pennsylvania after being hospitalized due to what his office said was a ventricular fibrillation flare-up that caused him to feel light-headed and fall during an early morning walk Thursday.

    Fetterman, D-Pa., posted a picture Saturday on X that showed the aftereffects to his nose and forehead, saying “20 stitches later and a full recovery, I’m back home” with his wife, Gisele, and their children.

    The smiling Fetterman also said he was grateful for the medical team in Pittsburgh that “put me back together.”

    “See you back in DC,” he concluded.

    Ventricular fibrillation is the most serious form of abnormal heartbeat and can lead to cardiac arrest — when the heart suddenly stops beating — and sudden cardiac death, according to the American Heart Association.

    Ventricular fibrillation occurs in the heart’s lower chambers, and the heart association says its causes include cardiomyopathy, which Fetterman was diagnosed with in 2022. Cardiomyopathy can impede blood flow and potentially cause heartbeats so irregular they can be fatal.

    Fetterman, 56, disclosed that he was diagnosed with cardiomyopathy and another type of abnormal heartbeat, atrial fibrillation, after he had a stroke during his 2022 campaign.

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  • Pennsylvania Sen. John Fetterman Hospitalized After Fall, His Office Says

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    HARRISBURG, Pa. (AP) — U.S. Sen. John Fetterman had what his office says was a “ventricular fibrillation flare-up” that caused him to feel light-headed and fall during an early morning walk Thursday.

    Fetterman was doing well and hospitalized in Pittsburgh, his office said. He sustained minor injuries to his face and was under “routine observation” at the hospital while doctors fine-tune his medication regimen, his office said.

    Cardiomyopathy can impede blood flow and potentially cause heartbeats so irregular they can be fatal. Atrial fibrillation can cause blood to pool inside a pocket of the heart, allowing clots to form. Clots then can break off, get stuck and cut off blood, causing a stroke.

    Fetterman has said the stroke was atrial fibrillation. Fetterman, 55, underwent surgery after the stroke to implant a pacemaker with a defibrillator to manage the condition.

    The lingering effects of his stroke include diminished auditory processing speed, called auditory processing disorder, which makes it harder to speak fluidly and quickly process spoken conversation into meaning.

    Weeks after joining the Senate in 2023, Fetterman checked himself into the hospital for clinical depression. He was released six weeks later and has since urged people who are depressed to get professional help.

    Post-stroke depression is common and treatable through medication and talk therapy, doctors say.

    Copyright 2025 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

    Photos You Should See – Oct. 2025

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  • Rates of high blood pressure in children have nearly doubled in 20 years

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    (CNN) — Global rates of hypertension, or high blood pressure, in childhood and adolescence have nearly doubled since 2000, putting more kids at risk for poor health later in life.

    “In 2000, about 3.4% of boys and 3% of girls had hypertension. By 2020, those numbers had risen to 6.5% and 5.8% respectively,” said Dr. Peige Song, a researcher from the School of Public Health at Zhejiang University School of Medicine in China. Song is one of the authors of a study describing the findings that published Wednesday in the journal The Lancet Child and Adolescent Health.

    Children who have hypertension could be at greater risk later on of developing heart disease –– the No. 1 cause of death in the United States, said Dr. Mingyu Zhang, assistant professor of medicine at Harvard Medical School and Beth Israel Deaconess Medical Center. He was not involved in the research.

    “The good news is that this is a modifiable risk,” Song said in an email. “With better screening, earlier detection, and a stronger focus on prevention, especially around healthy weight and nutrition, we can intervene before complications arise.”

    High blood pressure in kids can be addressed

    The rise in hypertension in children is likely due to many factors.

    Childhood obesity is a significant risk factor, because it is associated with factors like insulin resistance, inflammation and vascular function, Song said.

    Dietary factors such as consuming high levels of sodium and ultraprocessed food can also contribute to hypertension risk, as well as poor sleep quality, stress and genetic predisposition, she said.

    Many children also get less movement than past generations and spend more time on sedentary activities, like screen use, which may be affecting risk, she said.

    “We are also starting to know that other factors, including environmental pollutants, can contribute,” Zhang added.

    Zhang served as senior author on a previous study that showed a connection between prebirth exposure to chemicals called PFAS — a class of about 15,000 human-made compounds linked to cancers, endocrine-related conditions and developmental issues in children — and childhood hypertension. Short for perfluoroalkyl and polyfluoroalkyl substances, PFAS are sometimes called “forever chemicals” because they don’t fully break down in the environment.

    The biggest takeaway of this research for families is not to assume high blood pressure is only a problem for adults, Song said.

    If you are worried about your child’s risk for obesity or hypertension, pressure, shame and restriction are not the best approaches.

    Instead, focus on increasing healthy behaviors in a happy way, said Jill Castle, a pediatric dietitian in Massachusetts, in a previous CNN article.

    “The goal of the food pillar is really to embrace flexibility with food and to emphasize foods that are highly nutritious and … to allow foods also that might be minimally nutritious within the diet in ways that can be fully enjoyed and flexible,” Castle said.

    Try to prioritize sitting down as a family for meals and avoid labeling foods as “good” or “bad,” said Castle, author of “Kids Thrive at Every Size.”

    “The clean plate club or rewarding with sweets — they might work in the moment, but they don’t do a good job of establishing the self-trust and an intuitive, good relationship with food as kids grow up,” Castle said.

    Masked hypertension in children

    The study didn’t just track rates in the United States. Instead, researchers analyzed data from 96 studies across 21 countries.

    Another important consideration the study team made is how blood pressure differs in and outside the doctor’s office. Some children might have normal blood pressure at home, but a higher reading in the office, while others might have a lower blood pressure in the office than they normally would.

    By including data from both office visits and at-home blood pressure readings, the researchers were able to include hypertension rates that are “masked,” or wouldn’t be caught in a doctor’s visit, Zhang said. Masked hypertension was found to be the most common kind, according to the data.

    “This is important because it means that many children with true hypertension could go undetected if we rely only on office blood pressure readings,” he said.

    The result show that one reading may not be enough, and there may be a need for more scalable solutions for better monitoring and care of hypertension around the world, Song added.

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    Madeline Holcombe and CNN

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  • A study questions melatonin use and heart health but don’t lose sleep over it

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    WASHINGTON (AP) — Don’t lose sleep over headlines linking melatonin to heart failure.

    That’s the message after some scary-sounding reports about a preliminary study involving the sleep-related supplement. It raised questions about the safety of long term use of melatonin for insomnia.

    Doctors have long known that too little or interrupted sleep raises the risk of heart disease. But heart experts say this kind of so-called observational study can’t prove that melatonin use plays any role — instead of the insomnia patients were trying to treat.

    “We should not raise the alarm and tell patients to stop taking all their melatonin,” said Dr. Pratik Sandesara, an interventional cardiologist at Emory Healthcare who wasn’t involved with the research.

    Our bodies naturally produce melatonin, a hormone that regulates our sleep cycles. Levels normally increase as it gets darker in the evening, triggering drowsiness.

    People may take lab-produced melatonin to help them fall asleep or to adjust for jet lag or time changes.

    The new study used international electronic health records, tracking adults diagnosed with insomnia who had a melatonin prescription that suggested they used the supplement for at least a year.

    Over five years, 4.6% of the chronic melatonin users developed heart failure compared to 2.7% of insomnia patients whose charts showed no melatonin use, the researchers found. The study is being presented at an American Heart Association meeting but hasn’t undergone peer review.

    This article is part of AP’s Be Well coverage, focusing on wellness, fitness, diet and mental health. Read more Be Well.

    But only certain countries require a melatonin prescription. It’s over-the-counter in the U.S., meaning Americans in the study might have used the supplements without it being recorded, said Northwestern University cardiology chief Dr. Clyde Yancy, who wasn’t involved in the study. The study also did not show dosages.

    Also, U.S. supplements don’t require government approval, meaning brands can vary in their ingredients. The researchers, from SUNY Downstate Health Sciences University, characterized the findings as a call for more research.

    Meanwhile, patients wondering about melatonin should talk it over with their doctors, said Emory’s Sandesara. Generally doctors recommend it for short-term use, like for jet lag.

    Yancy noted that while the study doesn’t prove there’s a danger from long term melatonin use, there’s also no evidence that people should use melatonin indefinitely.

    And one key to better shut-eye is to practice better sleep hygiene, like making sure your room is dark.

    “When we expose ourselves to blue light in particular at night, we are diminishing our melatonin levels. That’s science,” he said. Sleep problems aren’t about “just being sleepy and tired — they’re putting yourself at risk.”

    ___

    This story has been corrected to show that the Northwestern University cardiology chief is Dr. Clyde Yancy, not Yancey.

    ___

    The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.

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  • A study questions melatonin use and heart health but don’t lose sleep over it

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    WASHINGTON — Don’t lose sleep over headlines linking melatonin to heart failure.

    That’s the message after some scary-sounding reports about a preliminary study involving the sleep-related supplement. It raised questions about the safety of long term use of melatonin for insomnia.

    Doctors have long known that too little or interrupted sleep raises the risk of heart disease. But heart experts say this kind of so-called observational study can’t prove that melatonin use plays any role — instead of the insomnia patients were trying to treat.

    “We should not raise the alarm and tell patients to stop taking all their melatonin,” said Dr. Pratik Sandesara, an interventional cardiologist at Emory Healthcare who wasn’t involved with the research.

    Our bodies naturally produce melatonin, a hormone that regulates our sleep cycles. Levels normally increase as it gets darker in the evening, triggering drowsiness.

    People may take lab-produced melatonin to help them fall asleep or to adjust for jet lag or time changes.

    The new study used international electronic health records, tracking adults diagnosed with insomnia who had a melatonin prescription that suggested they used the supplement for at least a year.

    Over five years, 4.6% of the chronic melatonin users developed heart failure compared to 2.7% of insomnia patients whose charts showed no melatonin use, the researchers found. The study is being presented at an American Heart Association meeting but hasn’t undergone peer review.

    But only certain countries require a melatonin prescription. It’s over-the-counter in the U.S., meaning Americans in the study might have used the supplements without it being recorded, said Northwestern University cardiology chief Dr. Clyde Yancy, who wasn’t involved in the study. The study also did not show dosages.

    Also, U.S. supplements don’t require government approval, meaning brands can vary in their ingredients. The researchers, from SUNY Downstate Health Sciences University, characterized the findings as a call for more research.

    Meanwhile, patients wondering about melatonin should talk it over with their doctors, said Emory’s Sandesara. Generally doctors recommend it for short-term use, like for jet lag.

    Yancy noted that while the study doesn’t prove there’s a danger from long term melatonin use, there’s also no evidence that people should use melatonin indefinitely.

    And one key to better shut-eye is to practice better sleep hygiene, like making sure your room is dark.

    “When we expose ourselves to blue light in particular at night, we are diminishing our melatonin levels. That’s science,” he said. Sleep problems aren’t about “just being sleepy and tired — they’re putting yourself at risk.”

    ___

    This story has been corrected to show that the Northwestern University cardiology chief is Dr. Clyde Yancy, not Yancey.

    ___

    The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.

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  • Treat the Cause | NutritionFacts.org

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    Treat the underlying cause of chronic lifestyle diseases.

    It’s been said that more than 2,000 years ago, Hippocrates declared, “Let food be thy medicine and medicine be thy food.” In actuality, it appears that he never actually said those words, but there’s “no doubt about the relevance of food…and its role in health and disease states” in his writings. Regardless, 2,000 years ago, disease was thought to arise from a bad sense of “humors,” as you can see here and at 0:32 in my video Lifestyle and Disease Prevention: Your DNA Is Not Your Destiny.

    Now, we have science, and there is “an overwhelming body of clinical and epidemiological evidence illustrating the dramatic impact of a healthy lifestyle on reducing all-cause mortality”—meaning death from all causes put together—“and preventing chronic diseases such as coronary heart disease, stroke, diabetes, and cancer.” But don’t those diseases just run in our family? What if we just have bad genes?

    According to the esteemed former chair of nutrition at Harvard, for most of the diseases that have contributed “importantly” to mortality in Western peoples, we’ve long known that non-genetic factors often account for at least 80% to 90% of risk. We know this because rates of the leading killers, like major cancers and cardiovascular diseases, vary up to 100-fold around the world, and, “when groups migrate from low- to high-risk countries, their disease rates almost always change to those of the new environment.” Modifiable behavioral factors have been identified, “including specific aspects of diet, overweight, inactivity, and smoking that account for over 70% of stroke and colon cancer, over 80% of coronary heart disease, and over 90% of adult-onset [type 2] diabetes”—diseases that can largely be prevented by our own actions.

    If most of the power is in our own hands, why do we allocate massively more resources to treatment than prevention? And speaking of prevention, “even preventive strategies are heavily biased towards pharmacology rather than supporting improvements in diet and lifestyle that could be more cost-effective. For example, treatment of [high] serum cholesterol with statins alone could cost approximately 30 billion dollars per year in the United States and would have only a modest impact on coronary heart disease incidence. The inherent problem is that most pharmacologic strategies don’t address the underlying causes of ill health in Western countries, which are not drug deficiencies.”

    Ironically, the chronic diseases that are most amenable to lifestyle treatment are the same ones most profitably treated by drugs. Why? If you don’t change your diet, you have to pop the pills every day for the rest of your life. So, the cash-cow drugs are the very drugs we need the least. “Even though the most widely accepted, well-established chronic disease practice guidelines uniformly call for lifestyle change as the first line of therapy, physicians often do not follow these recommendations.” “By ignoring the root causes of disease and neglecting to prioritize lifestyle measures for prevention, the medical community is placing people at harm.”

    “Traditional medical care relies primarily on the application of pharmacologic and surgical interventions after the development of illness,” whereas lifestyle medicine relies primarily on “the use of optimal nutrition (a whole foods, plant-based diet) and exercise in the prevention, arrest, and reversal of chronic conditions leading to premature disability and death. It looks in a holistic way at the underlying causes of illness.”

    Dr. Adriane Fugh-Berman, director of PharmedOut, a wonderful organization I’m proud to support, wrote a great editorial entitled “Doctors Must Not Be Lapdogs to Drug Firms.” “The illusion that the relationship between medicine and the drug industry is collegial, professional, and personal is carefully maintained by the drug industry, which actually views all transactions with physicians in finely calculated financial terms…The drug industry is happy to play the generous and genial uncle until physicians want to discuss subjects that are off limits, such as the benefits of diet or exercise, or the relationship between medicine and pharmaceutical companies…Let us not be a lapdog to Big Pharma. Rather than sitting contentedly in our master’s lap, let us turn around and bite something tender.”

    Doctor’s Note

    The organization I mentioned, PharmedOut, is a project of Georgetown University Medical Center.

    For more on Lifestyle Medicine, see related videos below.

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    Michael Greger M.D. FACLM

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  • Ideal vs. Normal Cholesterol Levels  | NutritionFacts.org

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    Having a “normal” cholesterol level in a society where it’s normal to die from a heart attack isn’t necessarily a good thing.

    “Consistent evidence” from a variety of sources “unequivocally establishes” that so-called bad LDL cholesterol causes atherosclerotic cardiovascular disease—strokes and heart attacks, our leading cause of death. This evidence base includes hundreds of studies involving millions of people. “Cholesterol is the cause of atherosclerosis,” the hardening of the arteries, and “the message is loud and clear.” “It’s the Cholesterol, Stupid!” noted the editor of the American Journal of Cardiology, William Clifford Roberts, whose CV is more than 100 pages long as he has published about 1,700 articles in peer-reviewed medical literature. Yes, there are at least ten traditional risk factors for atherosclerosis, as seen below and at 1:11 in my video How Low Should You Go for Ideal LDL Cholesterol?, but, as Dr. Roberts noted, only one is required for the progression of the disease: elevated cholesterol.

    Your doctor may have just told you that your cholesterol is normal, so you’re relieved. Thank goodness! But, having a “normal” cholesterol level in a society where it’s normal to have a fatal heart attack isn’t necessarily good. With heart disease, the number one killer of men and women, we definitely don’t want to have normal cholesterol levels; we want to have optimal levels—and not optimal by current laboratory standards, but optimal for human health.

    Normal LDL cholesterol levels are associated with the hidden buildup of atherosclerotic plaques in our arteries, even in those who have so-called “optimal risk factors by current standards”: blood pressure under 120/80, normal blood sugars, and total cholesterol under 200 mg/dL. If you went to your doctor with those kinds of numbers, you’d likely get a gold star and a lollipop. But, if your doctor used ultrasound and CT scans to actually peek inside your body, atherosclerotic plaques would be detected in about 38% of individuals with those kinds of “optimal” numbers.

    Maybe we should define an LDL cholesterol level as optimal only when it no longer causes disease. What a concept! When more than a thousand men and women in their 40s were scanned, having an LDL level under 130 mg/dL left them with atherosclerosis throughout their body, and that’s a cholesterol level at which most lab tests would consider normal.

    In fact, atherosclerotic plaques were not found with LDL levels down around 50 or 60, which just so happens to be the levels most people had “before the introduction of western lifestyles.” Indeed, before we started eating a typical American diet, “the majority of the adult population of the world had LDLs of around 50 mg per deciliter (mg/dL)”—so that’s the true normal. “Present average values…should not be regarded as ‘normal.’” We don’t want to have a normal cholesterol based on a sick society; we want a cholesterol that is normal for the human species, which may be down around 30 to 70 mg/dL or 0.8 to 1.8 mmol/L.

    “Although an LDL level of 50 to 70 mg/dl seems excessively low by modern American standards, it is precisely the normal range for individuals living the lifestyle and eating the diet for which we are genetically adapted.” Over millions of years, “through the evolution of the ancestors of man,” we’ve consumed a diet centered around whole plant foods. No wonder we have a killer epidemic of atherosclerosis, given the LDL level “we were ‘genetically designed for’ is less than half of what is presently considered ‘normal.’”

    In medicine, “there is an inappropriate tendency to accept small changes in reversible risk factors,” but “the goal is not to decrease risk but to prevent atherosclerotic plaques!” So, how low should you go? “In light of the latest evidence from trials exploring the benefits and risks of profound LDLc lowering, the answer to the question ‘How low do you go?’ is, arguably, a straightforward ‘As low as you can!’” “‘Lower’ may indeed be better,” but if you’re going to do it with drugs, then you have to balance that with the risk of the drug’s side effects.

    Why don’t we just drug everyone with statins, by putting them in the water supply, for instance? Although it would be great if everyone’s cholesterol were lower, there are the countervailing risks of the drugs. So, doctors aim to use statin drugs at the highest dose possible, achieving the largest LDL cholesterol reduction possible without increasing risk of the muscle damage the drugs may cause. But when you’re using lifestyle changes to bring down your cholesterol, all you get are the benefits.

    Can we get our LDL low enough with diet alone? Ask some of the country’s top cholesterol experts what they shoot for, “and the odds are good that many will say 70 or so.” So, yes, we should try to avoid the saturated fats and trans fats found in junk foods and meat, and the dietary cholesterol found mostly in eggs, but “it is unlikely anyone can achieve an LDL cholesterol level of 70 mg/dL with a low-fat, low-cholesterol diet alone.” Really? Many doctors have this mistaken impression. An LDL of 70 isn’t only possible on a healthy enough diet, but it may be normal. Those eating strictly plant-based diets can average an LDL that low, as you can see here and at 5:28 in my video.

    No wonder plant-based diets are the only dietary patterns ever proven to reverse coronary heart disease in a majority of patients. And their side effects? You get to feel better, too! Several randomized clinical trials have demonstrated that more plant-based dietary patterns significantly improve psychological well-being and quality of life, with improvements in depression, anxiety, emotional well-being, physical well-being, and general health.

    For more on cholesterol, see the related posts below.

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    Michael Greger M.D. FACLM

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  • A Longer Life on Statins?  | NutritionFacts.org

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    What are the pros and cons of relative risk, absolute risk, number needed to treat, and average postponement of death when taking cholesterol-lowering statin drugs?

    In response to the charge that describing the benefits of statin drugs only in terms of relative risk reduction is a “statistical deception” created to give the appearance that statins are more effective than they really are, it was pointed out that describing things in terms of absolute risk reduction or number needed to treat can depend on the duration of the study.

    For example, let’s say a disease has a 2% chance of killing you every year, but some drug cuts that risk by 50%. That sounds amazing, until you realize that, at the end of a year, your risk will only have fallen from 2% to 1%, so the absolute reduction of risk is only 1%. If a hundred people were treated with the drug, instead of two people dying, one person would die, so a hundred people would have to be treated to save one life, as shown below and at 1:01 in my video How Much Longer Do You Live on Statins?.

    But there’s about a 99% chance that taking the drug all year would have no effect either way. So, to say the drug cuts the risk of dying by 50% seems like an overstatement. But think about it: Benefits accrue over time. If there’s a 2% chance of dying every year, year after year, after a few decades, the majority of those who refused the drug would be dead, whereas the majority who took the drug would be alive. So, yes, perhaps during the first year on the drug, there was only about a 1% chance it would be life-saving, but, eventually, you could end up with a decent chance the drug would save your life after all.

    “This is actually the very reason why the usage of relative risk makes sense…” Absolute risk changes depending on the time frame being discussed, but with relative risk, you know that whatever risk you have, you can cut it in half by taking the drug. On average, statins only cut the risk of a cardiovascular “event” by 25%, but since cardiovascular disease is the number one killer of men and women, if you’re unwilling to change your diet, that’s a powerful argument in favor of taking these kinds of drugs. You can see the same kind of dependency on trial duration, looking at the “postponement of death” by taking a statin. How much longer might you live if you take statins?

    The average postponement of death has some advantages over other statistics because it may offer “a better intuitive understanding among lay persons,” whereas a stat like a number needed to treat has more of a win-or-lose “lottery-like” quality. So, when a statin drug prevents, say, one heart attack out of a hundred people treated over five years, it’s not as though the other 99 completely lost out. Their cholesterol also dropped, and their heart disease progression presumably slowed down, too, just not enough to catch a heart attack within that narrow time frame.

    So, what’s the effect of statins on average survival? According to an early estimate, if you put all the randomized trials together, the average postponement of death was calculated at maybe three or four days. Three or four days? Who would take a drug every day for years just to live a few more days? Well, let’s try to put that into context. Three or four days is comparable to the gains in life expectancy from other medical interventions. For example, it’s nearly identical to what you’d get from “highly effective childhood vaccines.” Because vaccines have been so effective in wiping out infectious diseases, these days, they only add an average of three extra days to a child’s life. But, of course, “those whose deaths are averted gain virtually their whole lifetimes.” That’s why we vaccinate. It just seems like such a small average benefit because it gets distributed over the many millions of kids who get the vaccine. Is that the same with statins?

    An updated estimate was published in 2019, which explained that the prior estimate of three or four days was plagued by “important weaknesses,” and the actual average postponement of death was actually ten days. Headline writers went giddy from these data, but what they didn’t understand was that this was only for the duration of the trial. So, if your life expectancy is only five years, then, yes, statins may increase your lifespan by only ten days, but statins are meant to be taken a lot longer than five years. What you want to know is how much longer you might get to live if you stick with the drugs your whole life.

    In that case, it isn’t an extra ten days, but living up to ten extra years. Taking statins can enable you to live years longer. That’s because, for every millimole per liter you lower your bad LDL cholesterol, you may live three years longer and maybe even six more years, depending on which study you’re reading. A millimole in U.S. units is 39 points. Drop your LDL cholesterol by about 39 points, and you could live years longer. Exercise your whole life, and you may only increase your lifespan by six months, and stopping smoking may net you nine months. But if you drop your LDL cholesterol by about 39 points, you could live years longer. You can accomplish that by taking drugs, or you can achieve that within just two weeks of eating a diet packed with fruits, vegetables, and nuts, as seen here and at 5:30 in my video. 

    Want to know what’s better than drugs? “Something important and fundamental has been lost in the controversy around this broad expansion of statin therapy.…It is imperative that physicians (and drug labels) inform patients that not only their lipid [cholesterol] levels but also their cardiovascular risk can be reduced substantially by adoption of a plant-based dietary pattern, and without drugs. Dietary modifications for cardiovascular risk reduction, including plant-based diets, have been shown to improve not only lipid status, but also obesity, hypertension, systemic inflammation, insulin sensitivity, oxidative stress, endothelial function, thrombosis, and cardiovascular event risk…The importance of this [plant-based] approach is magnified when one considers that, in contrast to statins, the ‘side effects’ of plant-based diets—weight loss, more energy, and improved quality of life—are beneficial.” 

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    Michael Greger M.D. FACLM

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  • The Real Benefits of Statins and Their Side Effects  | NutritionFacts.org

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    A Mayo Clinic visualization tool can help you decide if cholesterol-lowering statin drugs are right for you.

    “Physicians have a duty to inform their patients about the risks and benefits of the interventions available to them. However, physicians rarely communicate with methods that convey absolute information, such as numbers needed to treat, numbers needed to harm, or prolongation of life, despite patients wanting this information.” That is, for example, how many people are actually helped by a particular drug, how many are actually hurt by it, or how much longer the drug will enable you to live, respectively.

    If doctors inform patients only about the relative risk reduction—for example, telling them a pill will cut their risk of heart attacks by 34 percent—nine out of ten agree to take it. However, give them the same information framed as absolute risk reduction—“1.4% fewer patients had heart attacks”—then those agreeing to take the drug drops to only four out of ten. And, if they use the number needed to treat, only three in ten patients would agree to take the pill. So, if you’re a doctor and you really want your patient to take the drug, which statistic are you going to use?

    The use of relative risk stats to inflate the benefits and absolute risk stats to downplay any side effects has been referred to as “statistical deception.” To see how one might spin a study to accomplish this, let’s look at an example. As you can see below and at 1:49 in my video, The True Benefits vs. Side Effects of Statins, there is a significantly lower risk of the incidence of heart attack over five years in study participants randomized to a placebo compared to those getting the drug. If you wanted statins to sound good, you’d use the relative risk reduction (24 percent lower risk). If you wanted statins to sound bad, you’d use the absolute risk reduction (3 percent fewer heart attacks).

    Then you could flip it for side effects. For example, the researchers found that 0.3 percent (1 out of 290 women in the placebo group) got breast cancer over five years, compared to 4.1 percent (12 out of 286) in the statin group. So, a pro-statin spin might be a 24 percent drop in heart attack risk and only 3.8 percent more breast cancers, whereas an anti-statin spin might be only 3 percent fewer heart attacks compared to a 1,267 percent higher risk of breast cancer. Both portrayals are technically true, but you can see how easily you could manipulate people if you picked and chose how you were presenting the risks and benefits. So, ideally, you’d use both the relative risk reduction stat and the absolute risk reduction stat.

    In terms of benefits, when you compile many statin trials, it looks like the relative risk reduction is 25 percent. So, if your ten-year risk of a heart attack or stroke is 5 percent, then taking a statin could lower that from 5 percent to 3.75 percent, for an absolute risk reduction of 1.25 percent, or a number needed to treat of 80, meaning there’s about a 1 in 80 chance that you’d avoid a heart attack or stroke by taking the drug for the next ten years. As you can see, as your baseline risk gets higher and higher, even though you have that same 25 percent risk reduction, your absolute risk reduction gets bigger and bigger. And, with a 20 percent baseline risk, that means you have a 1 in 20 chance of avoiding a heart attack or stroke over the subsequent decade if you take the drug, as seen below and at 3:31 in my video.

    So, those are the benefits. In terms of risk, that breast cancer finding appears to be a fluke. Put together all the studies, and “there was no association between use of statins and the risk of cancer.” In terms of muscle problems, estimates of risk range from approximately 1 in 1,000 to closer to 1 in 50.

    If all those numbers just blur together, the Mayo Clinic developed a great visualization tool, seen below and at 4:39 in my video.

    For those at average risk, 10 people out of 100 who do not take a statin may have a heart attack over the next ten years. If, however, all 100 people took a statin every day for those ten years, 8 would still have a heart attack, but 2 would be spared, so there’s about a 1 in 50 chance that taking the drug would help avert a heart attack over the next decade. What are the downsides? The cost and inconvenience of taking a pill every day, which can cause some gastrointestinal side effects, muscle aching, and stiffness in about 5 percent, reversible liver inflammation in 2 percent, and more serious damage in perhaps 1 in 20,000 patients.

    Note that the two happy faces in the bottom left row of the YES STATIN chart represent heart attacks averted, not lives saved. The chance that a few years of statins will actually save your life if you have no known heart disease is about 1 in 250.

    If you want a more personalized approach, the Mayo Clinic has an interactive tool that lets you calculate your ten-year risk. You can get there directly by going to bit.ly/statindecision.

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    Michael Greger M.D. FACLM

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  • Are We Being Misled About the Benefits and Risks of Statins?  | NutritionFacts.org

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    What is the dirty little secret of drugs for lifestyle diseases?

    Drug companies go out of their way—in direct-to-consumer ads, for example—to “present pharmaceutical drugs as a preferred solution to cholesterol management while downplaying lifestyle change.” You see this echoed in the medical literature, as in this editorial in the Journal of the American Medical Association: “Despite decades of exhortation for improvement, the high prevalence of poor lifestyle behaviors leading to elevated cardiovascular disease risk factors persists, with myocardial infarction [heart attack] and stroke remaining the leading causes of death in the United States. Clearly, many more adults could benefit from…statins for primary prevention.” Do we really need to put more people on drugs? A reply was published in the British Medical Journal: “Once again, doctors are implored to ‘get real’—stop hoping that efforts to help their patients and communities adopt healthy lifestyle habits will succeed, and start prescribing more statins. This is a self-fulfilling prophecy. Note that the author of these comments [the pro-statin editorial] disclosed receipt of funding from 11 drug companies, at least four of which produce or are developing new classes of cholesterol-lowering agents,” which make billions of dollars a year in annual sales.

    Every time the cholesterol guidelines expand the number of people eligible for statins, they’re decried as a “big kiss to big pharma.” This is understandable, since the majority of guideline panel members “had industry ties,” financial conflicts of interest. But these days, all the major statins are off-patent, so there are inexpensive generic versions. For example, the safest, most effective statin is generic Lipitor, sold as atorvastatin for as little as a few dollars a month. So, nowadays, the cholesterol guidelines are not necessarily “part of an industry plot.”

    “The US way of life is the problem, not the guidelines…” The reason so many people are candidates for cholesterol- and blood-pressure-lowering medications is that so many people are taking such terrible care of themselves. The bottom line is that “individuals must take more responsibility for their own health behaviors.” What if you are unwilling or unable to improve your diet and make lifestyle changes to bring down that risk? If your ten-year risk of having a heart attack is 7.5 percent or more and going to stay that way, then the benefits of taking a statin drug likely outweigh the risk. That’s really for you to decide, though. It’s your body, your choice.

    “Whether or not the overall benefit-harm balance justifies the use of a medication for an individual patient cannot be determined by a guidelines committee, a health care system, or even the attending physician. Instead, it is the individual patient who has a fundamental right to decide whether or not taking a drug is worthwhile.” This was recognized by some of medicine’s “historical luminaries such as Hippocrates,” but “only in recent decades has the medical profession begun to shift from a paternalistic ‘doctor knows best’ stance towards one explicitly endorsing patient-centered, evidence-based, shared decision-making.” One of the problems with communicating statin evidence to support this shared decision-making is that most doctors “have a poor understanding of concepts of risk and probability and…increasing exposure to statistics in undergraduate and postgraduate education hasn’t made much difference.” But that understanding is critical for preventive medicine. When doctors offer a cholesterol-lowering drug, “they’re doing something quite different from treating a patient who has sought help because she is sick. They’re not so much doctors as life insurance salespeople, peddling deferred benefits in exchange for a small (but certainly not negligible) ongoing inconvenience and cost. In this new kind of medicine, not understanding risk is the equivalent of not knowing about the circulation of the blood or basic anatomy. So, let’s dive in and see exactly what’s at stake.

    Below and at 3:55 in my video Are Doctors Misleading Patients About Statin Risks and Benefits? is an ad for Lipitor. When drug companies say a statin reduces the risk of a heart attack by 36 percent, that’s the relative risk.

    If you follow the asterisk I’ve circled after the “36%” in the ad, you can see how they came up with that. I’ve included it here and at 3:56 in my video. In a large clinical study, 3 percent of patients not taking the statin had a heart attack within a certain amount of time, compared to 2 percent of patients who did take the drug. So, the drug dropped heart attack risk from 3 percent to 2 percent; that’s about a one-third drop, hence the 36 percent reduced relative risk statistic. But another way to look at going from 3 percent to 2 percent is that the absolute risk only dropped by 1 percent. So, in effect, “your chance to avoid a nonfatal heart attack during the next 2 years is about 97% without treatment, but you can increase it to about 98% by taking a Crestor [a statin] every day.” Another way to say that is that you’d have to treat 100 people with the drug to prevent a single heart attack. That statistic may shock a lot of people.

    If you ask patients what they’ve been led to believe, they don’t think the chance of avoiding a heart attack within a few years on statins is 1 in 100, but 1 in 2. “On average, it was believed that most patients (53.1%) using statins would avoid a heart attack after statin treatment for 5 years.” Most patients, not just 1 percent of patients. And this “disparity between actual and expected effect could be viewed as a dilemma. On the one hand, it is not ethically acceptable for caregivers to deliberately support and maintain illusive treatment expectations by patients.” We cannot mislead people into thinking a drug works better than it really does, but on the other hand, how else are we going to get people to take their pills?

    When asked, people want an absolute risk reduction of at least about 30 percent to take a cholesterol-lowering drug every day, whereas the actual absolute risk reduction is only about 1 percent. So, the dirty little secret is that, if patients knew the truth about how little these drugs actually worked, almost no one would agree to take them. Doctors are either not educating their patients or actively misinforming them. Given that the majority of patients expect a much larger benefit from statins than they’d get, “there is a tension between the patient’s right to know about benefiting from a preventive drug and the likely reduction in uptake [willingness to take the drugs] if they are so informed,” and learn the truth. This sounds terribly paternalistic, but hundreds of thousands of lives may be at stake.

    If patients were fully informed, people would die. About 20 million Americans are on statins. Even if the drugs saved 1 in 100, that could mean hundreds of thousands of lives lost if everyone stopped taking their statins. “It is ironic that informing patients about statins would increase the very outcomes they were designed to prevent.”

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    Michael Greger M.D. FACLM

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  • Should You Take Statins?  | NutritionFacts.org

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    How can you calculate your own personal heart disease risk to help you determine if you should start on a cholesterol-lowering statin drug?

    The muscle-related side effects from cholesterol-lowering statins “are often severe enough for patients to stop taking the drug. Of course, these side effects could be coincidental or psychosomatic and have nothing to do with the drug,” given that many clinical trials show such side effects are rare. “It is also possible that previous clinical trials”—funded by the drug companies themselves—“under-recorded the side effects of statins.” The bottom line is that there’s an urgent need to establish the true incidence of statin side effects.

    “What proportion of symptomatic side effects in patients taking statins are genuinely caused by the drug?” That’s the title of a journal article that reports that, even in trials funded by Big Pharma, “only a small minority of symptoms reported on statins are genuinely due to the statins,” and those taking statins are significantly more likely to develop type 2 diabetes than those randomized to placebo sugar pills. Why? We’re still not exactly sure, but statins may have the double-whammy effect of impairing insulin secretion from the pancreas while also diminishing insulin’s effectiveness by increasing insulin resistance.

    Even short-term use of statins may “approximately double the odds of developing diabetes and diabetic complications.” As shown below and at 1:49 in my video Who Should Take Statins?, fewer people develop diabetes and diabetic complications off statins over a period of about five years than those who do develop diabetes while on statins. “Of more concern, this increased risk persisted for at least 5 years after statin use stopped.”

    “In view of the overwhelming benefit of statins in the reduction of cardiovascular events,” the number one killer of men and women, any increase in risk of diabetes, our seventh leading cause of death, would be outweighed by any cardiovascular benefits, right? That’s a false dichotomy. We don’t have to choose between heart disease and diabetes. We can treat the cause of both with the same diet and lifestyle changes. The diet that can not only stop heart disease, but also reverse it, is the same one that can reverse type 2 diabetes. But what if, for whatever reason, you refuse to change your diet and lifestyle? In that case, what are the risks and benefits of starting statins? Don’t expect to get the full scoop from your doctor, as most seemed clueless about statins’ causal link with diabetes, so only a small fraction even bring it up with their patients.

    “Overall, in patients for whom statin treatment is recommended by current guidelines, the benefits greatly outweigh the risks.” But that’s for you to decide. Before we quantify exactly what the risks and benefits are, what exactly are the recommendations of current guidelines?

    How should you decide if a statin is right for you? “If you have a history of heart disease or stroke, taking a statin medication is recommended, without considering your cholesterol levels.” Period. Full stop. No discussion needed. “If you do not yet have any known cardiovascular disease,” then the decision should be based on calculating your own personal risk. If you know your cholesterol and blood pressure numbers, it’s easy to do that online with the American College of Cardiology risk estimator or the Framingham risk profiler.

    My favorite is the American College of Cardiology’s estimator because it gives you your current ten-year risk and also your lifetime risk. So, for a person with a 5.8 percent risk of having a heart attack or stroke within the next decade, if they don’t clean up their act, that lifetime risk jumps to 46 percent, nearly a flip of the coin. If they improved their cholesterol and blood pressure, though, they could reduce that risk by more than tenfold, down to 3.9 percent, as shown below and at 4:11 in my video.

    Since the statin decision is based on your ten-year risk, what do you do with that number? As you can see here and at 4:48 in my video, under the current guidelines, if your ten-year risk is under 5 percent, then, unless there are extenuating circumstances, you should just stick to diet, exercise, and smoking cessation to bring down your numbers. In contrast, if your ten-year risk hits 20 percent, then the recommendation is to add a statin drug on top of making lifestyle modifications. Unless there are risk-enhancing factors, the tendency is to stick with lifestyle changes if risk is less than 7.5 percent and to move towards adding drugs if above 7.5 percent.

    Risk-enhancing factors that your doctor should take into account when helping you make the decision include a bad family history, really high LDL cholesterol, metabolic syndrome, chronic kidney or inflammatory conditions, or persistently high triglycerides, C-reactive protein, or LP(a). You can see the whole list here and at 4:54 in my video.

    If you’re still uncertain, guidelines suggest you consider getting a coronary artery calcium (CAC) score, but even though the radiation exposure from that test is relatively low these days, the U.S. Preventive Services Task Force has explicitly concluded that the current evidence is insufficient to conclude that the benefits outweigh the harms.

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    Michael Greger M.D. FACLM

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  • Women who experienced stalking or obtained restraining orders have higher risk of heart disease, study finds

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    Dr. Ramneek Dosanjh got married young. But before long, she says her marriage dissolved into a cycle of control and domestic violence. 

    “Within a week of meeting and dating, tells you they love you and they will marry you, you know, it all seems dreamy,” Dosanjh told CBS News. 

    It got worse, she says, when she tried to leave.

    “You just don’t know if you can sustain living that way,” said Dosanjh, who then chose to get an order of protection against her then-husband.

    The toll on her health started to show.
     
    “I had abnormal stress tests,” Dosanjh said. “I had to have a cardiac catheterization.”

    And she’s not alone according to a study released last month by the Harvard T.H. Chan School of Public Health.

    “We saw this association, which frankly also blew me away,” said Dr. Karestan Koenen, who led a team of Harvard researchers who analyzed data for about 66,270 American nurses, ages 36 to 56, who were surveyed about their own health for 20 years between 2001 and 2021.

    Of those in the survey, 11.7% reported experience with stalking, and 5.6% reported experience with obtaining a restraining order.

    The study, published in the scientific journal Circulation, found that the risk for cardiovascular disease was 41% higher in women who had experienced stalking — and 70% higher for women who had obtained a restraining order — compared to those who had not.

    “We have all the information on their diet and exercise,” Koenen said. “And we find that it’s really the stalking that increases the risk, not all these other factors, because we can adjust for them.”

    “Experiences of stalking and obtaining a restraining order are both associated with an increased risk of developing CVD (cardiovascular disease) in women,” the study concluded. “Common experiences of violence among women may affect cardiovascular health and warrant consideration alongside more traditional risk factors.”

    Many of the women that CBS News talked to were afraid to disclose their identities. One of them says she and her children were abused by their father.

    “I had three recurring episodes of deep vein thrombosis, which means another three blood clots in a short amount of time,” the woman told CBS News.

    According to a 2016-2017 survey from the U.S. Centers for Disease Control and Prevention, nearly one in three women have experienced stalking at some point in their lives.

    Researchers say the results of the study could spur doctors to add questions about stalking and restraining orders when screening for heart health risk factors in the future.

    Said Koenen, “The ultimate goal is to improve women’s health.”

    For anonymous, confidential help, people can call the National Domestic Violence Hotline at 1-800-799-7233 or 1-800-787-3224. People can text START to 88788 or chat on TheHotline.org.

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