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Congratulations! By picking up this book, you have taken the first step toward improving the health of your heart.

As health care professionals, we see people every day who are concerned about heart disease. Perhaps, like some of our patients, you are recovering from a heart attack or have experienced chest pain known as angina. You may be concerned that you are at risk for a heart attack or stroke because you have high blood pressure, diabetes, or high cholesterol. If so, we think this book will provide helpful advice about how you can make changes, starting today, that will improve the health of your heart.

Mind Your Heartbuilds on the authors' more than thirty-five years of research and patient care. Here you will find, for the first time, a step-by-step guide to heart health that combines the latest information about stress management, nutrition, and exercise. This complements advice offered in earlier books by Dr. Herbert Benson, especiallyThe Relaxation ResponseandThe Wellness Book.

The strategies we describe in these pages are the same ones that we offer to patients in our Cardiac Wellness Program at the Mind/Body Medical Institute. The basic Cardiac Wellness Program lasts for thirteen consecutive weeks, during which participants attend weekly three-hour sessions. The Extended Cardiac Wellness Program lasts for twelve months and consists of thir-teen weekly three-hour sessions and eighteen bimonthly three-hour sessions. Many of our patients are referred to the clinic after being diagnosed with heart disease. Slightly more than half of our patients are men. Ages vary, but most people are between fifty-five and sixty years old when they enter our program.

The Cardiac Wellness Program is just one of several clinical programs that we offer at the Mind/Body Medical Institute. We also run programs to help people deal with infertility, insomnia, menopause, chronic pain, and general stress-related symptoms. Founded in 1988 at Beth Israel Deaconess Medical Center, in Boston, the Mind/Body Medical Institute is a nonprofit organization dedicated to advancing scientific research, public education, and professional training in the field of behavioral medicine. This field, also known as mind/body medicine, aims to foster your own natural capacity to heal in a way that enhances more traditional medical approaches such as medication and surgery. At the Mind/

Body Medical Institute, we employ an interdisciplinary team of exercise physiologists, advanced practice nurses, dietitians, psychologists, and physicians who together have developed the techniques you will find in this book.

Of course, we realize that it is not easy to make changes in behavior and lifestyle. We also respect the fact that you are an individual. For both these reasons, we've included quizzes and exercises to help you identify your own particular risks as well as a number of strategies and techniques for behavior change, so that you can choose the ones you feel most comfortable with.

Thousands of people have already completed our mind/body programs and made significant changes in their lives. We hope that this book will provide a useful road map for you as you embark on your own journey of change. Happy reading!

Aggie Casey, M.S., R.N.

Herbert Benson, M.D.

Copyright © 2004 by the President and Fellows of Harvard College

Chapter 1: Mind Your Heart

If you have heart disease, you are not alone. An astounding one in five people in this country has already suffered a heart attack or stroke, or has high blood pressure. One in two men, and one in three women, can expect to develop heart disease after age forty.

Fortunately, heart disease is largely preventable. By changing certain behaviors, you can significantly reduce your risk of developing heart disease or improve your chance of recovery if you've already had a heart attack. The game plan is deceptively simple: stop smoking, eat better, exercise regularly, and reduce stress. By following these steps, you will counter the major factors that put you at risk in the first place. And it's never too late -- or too early -- to start. No matter what your age, adopting healthy habits can significantly improve the health of your heart.

Of course, changing behaviors and habits -- and then maintaining that change -- is notoriously difficult. That is why our goal is to help you become more mindful of situations and behaviors that put you at risk, and then help you develop your own individual strategy for healthy change.

The advice we offer in this book should supplement any advice you receive from your primary care physician and other health care providers. Our intent is not to provide an alternative approach but one that complements traditional medicine. Although we encourage you to use the quizzes and exercises in this book to help you play a more active role in your health care, we also expect that you will continue to see your health care providers on a regular basis for medical care and checkups.

• The Three-Legged Stool

The advice we offer in this book is the same as what we provide to patients in our Cardiac Wellness Program. Like all the programs we offer through the Mind/Body Medical Institute, the Cardiac Wellness Program is based on the philosophy that optimal health care resembles a three-legged stool. One leg of the stool consists of medication. A second represents surgical intervention. The third signifies self-care, the strategies you employ to enhance your own natural capacity to heal. This third leg includes many of the techniques we'll discuss later on: the relaxation response, exercise, nutrition, and cognitive approaches (changing the way you think). Though all three legs of the stool have been validated through scientific research, all too often patients and physicians ignore the self-care leg. Disregarding self-care can result in a health care approach that is as wobbly and off-balance as, well, a two-legged stool.

Our goal in this book is to offer a more balanced approach. Not only will we address the physical aspects of your illness -- in this case, heart disease -- but we also hope to change the types of attitudes and behaviors that may be contributing to your symptoms. In the pages that follow, you will learn more about the various factors that increase your risk for heart disease and how to reduce that risk. Some, such as high blood pressure and cholesterol, will sound familiar. We'll discuss the latest research findings and describe current medical and surgical treatments. But we'll spend most of our time discussing risk factors for heart disease, such as stress, depression, anger, hostility, decreased social support, physical inactivity, and poor nutrition.

We'll provide strategies to help you reduce stress and elicit the healing relaxation response. You will learn how to exercise to improve your heart health and how to prepare more nutritious meals. We also hope to help you discover how to become more mindful of the world around you and to view life in a more positive way.

These strategies are all based on the premise that mind and body are inextricably linked. You probably know about the mind/

body connection instinctively. Have you ever been embarrassed by something and felt your face flush? Have you ever found yourself stuck in traffic and become so angry that your heart beats fast and you breathe in short, quick bursts? Have you ever looked at a big piece of chocolate cake and felt your mouth water? Or felt your mood improve after taking a brisk walk on a sunny day? These are all examples of the mind/body connection at work.

• The Mind/Body Link

Mind/body medicine got its start in the late 1960s when researchers (including one of us, Dr. Herbert Benson) provided the first convincing evidence that it was possible to calm the body simply by quieting the mind. At the time, Dr. Benson was working with colleagues at Harvard Medical School to determine the causes and effects of high blood pressure. The researchers were conducting biofeedback experiments in monkeys to see if various rewards would raise or lower blood pressure and if punishment (which increased stress on the monkeys) would raise it. Several practitioners of transcendental meditation learned of Dr. Benson's work on stress and hypertension and visited him. They claimed that they could lower their own blood pressure by meditating.

The concept intrigued Dr. Benson, but he knew most of his Harvard colleagues would be skeptical. At the time, few believed that a link existed between stress and high blood pressure. But the meditation practitioners persisted, visiting Dr. Benson repeatedly. He finally agreed to take a series of physiological measurements to determine the effects of meditation on the body. As it happened, a separate team in California, led by Drs. Robert Keith Wallace and Archie F. Wilson, were simultaneously conducting related experiments. Both teams of researchers reached similar conclusions based on the physiological readings, and these findings have been confirmed and expanded in subsequent research: Meditation slows heart rate and breathing, reduces metabolism, lowers blood pressure, and even generates the type of brain waves associated with feeling peaceful and calm.

This state of deep relaxation counters the fight-or-flight response. When we are stressed, our heart rate and blood pressure increase dramatically, and adrenaline and other hormones surge through the body. This readies the body to either fight or flee in a situation where our survival depends on one response or the other. Though in the modern world most of us don't face truly life-threatening situations, even minor threats will trigger that same hormonal rush. What's more, even thinking about or recalling a stressful or threatening event can trigger the same chemical cascade. Over time all those chemicals and hormones build up, contributing to what may feel, physically, like a never-ending cycle of stress reactions.

Fortunately, the relaxation response is the physiological antithesis of the fight-or-flight response. This innate response decreases metabolism, heart rate, blood pressure, breathing rate, and muscle tension. You'll learn more about the relaxation response, and how to elicit it, in Chapter 3.

The findings about meditation and the relaxation response were just the first in a series of exciting insights into how the mind affects the body and vice versa. And while the field of mind/body medicine has evolved significantly in the last forty years, its basic premise remains straightforward: Maintaining good health requires that you attend to your mind as well as your body. Negative thoughts and moods can affect you physically, just as pain, stiff joints, and muscles can affect you emotionally. Quiet the mind, and you can calm the body; quiet the body, and you can calm the mind.

According to this philosophy, your health depends on the interplay of a number of factors. Maintaining your heart health means you have to consider blood pressure, cholesterol levels, and family history. But diet, physical activity, stress levels, and social interactions are also important.

• Assess Your Own Mind/Body Health

You will get the most out of this book if you make the information and advice relevant to your own situation. To do that, be sure to take the quizzes and self-assessment exercises we've included throughout.

A great way to get started is to determine where you are now in terms of your own mind/body health. Try doing the following four exercises. We're hoping that they will not only help you to learn something new about yourself, but will also motivate you to change behaviors that are putting your health -- physical, mental, and spiritual -- at risk.

Save your initial exercises, because at the end of the book we'll ask that you do them again. You may be pleasantly surprised at how your responses have changed! (To see how some of our patients changed after completing the Cardiac Wellness Program, see the "before" self-portraits on page 10 and "after" self-portraits on page 260. You may want to return to these exercises occasionally to keep yourself on track while trying to make changes in your life.

• Exercise 1: Draw a Self-Portrait

On a blank piece of paper, draw a picture of yourself. If you have heart disease or some other health condition, depict that in your picture -- as well as any treatments you are receiving. Then explain your drawing in a few sentences. (The object of this exercise is not to see whether you are artistic. You can draw a stick figure. It's the process that is most important.) We've included some sample "before" drawings below based on those made by our patients before starting our Cardiac Wellness Program. (For the corresponding "after" drawings, see page 260 in Chapter 9.)

• Exercise 2: Complete the Balance Exercise

Another tool we use in the Cardiac Wellness Program is based on the "Ten Loves" exercise developed by Dr. Sidney B. Simon, a leader in helping people to identify what they value and whether they need more balance in their lifestyles. In this exercise, list the five things that are most important, valuable, and meaningful to you. They can be personal, professional, or spiritual. Then ask yourself the following questions about each of these things:

• When did I do it last?

• Does my illness (or other demands on my time) interfere with my doing it?

• On a scale of 1 to 5 (with 5 being most important), how important is it to me?

• Exercise 3: Draw Your Time Pie

Now think about a typical day in your life. Draw a circle on a piece of paper and think of it as representing a twenty-four-hour day. Divide it into "pie" slices to represent how you typically spend your day. Label each slice with the activity and the number of hours or minutes you spend on it. We've included a sample time pie as an example. Obviously, your time pie may vary from one day to the next (weekdays may not resemble weekends, for example). Your particular time pie may also look different if you work nontraditional shifts, such as twelve-hour days.

Take a look at your pie. Is this the way you want to be spending a typical day? Are you spending enough time on the things you value and enjoy? Now draw your ideal time pie. How would your day look if you were living a more balanced life?

• Exercise 4: Establish Your Health Contract

Now think about some of the changes you'd like to make so that you can live a more heart-healthy life. In the Cardiac Wellness Program, we ask our patients to sign a health contract. The physical act of writing down specific goals somehow makes them seem more real -- and helps ensure that you will actually attain them. Use the following form to help you determine your own personal goals (and then revisit this form occasionally to see if you are making progress). Feel free to revise and personalize it so that you can focus on goals that are important to you.

GOAL 1: LEARN HOW TO BETTER MANAGE STRESS AND EMOTIONS IN DAILY LIFE.

Read Chapters 3, 4, and 5 to help you with this section.

• Practice a relaxation response technique.

Method: _____________________________________________

Frequency: _________________ Duration: _________________

Find a quiet place where you will not be disturbed.

• Practice three to four minirelaxation exercises every day.

• Try to spend time each day thinking about the small things in life that can bring you pleasure: watching a sunset, taking a warm bath, enjoying a candlelit dinner or a walk with a friend. Identify some of your own: _____________________________

• Focus on the areas in your life that are going well as much as you do on those that are not going well.

GOAL 2: DEVELOP AN EXERCISE PROGRAM THAT IS COMFORTABLE, CHALLENGING, AND ENJOYABLE.

Read Chapter 8 for more information when filling out this section.

Type: _______________________________________________

Include both aerobic and strength-training exercises.

Frequency: _________________ Duration: _________________

Intensity (measured in heart rate or perceived exertion): _____

• Remember to warm up and cool down for five to ten minutes every time you exercise. These are good times to incorporate the yoga stretches we've included.

• Try to accumulate thirty minutes of brisk physical activity on all or most days of the week. (This includes walking to work and walking for enjoyment, as well as housework, yard work, and regular exercise.)

GOAL 3: DEVELOP A HEART-HEALTHY NUTRITION PLAN.

Read Chapters 2, 6, and 7 for more information.

My starting weight is: __________

My short-term weight goal is: __________

My long-term weight goal is: __________

My latest lipid profile is:

Date: ____ TC : ____ LDL: ____ HDL: ____ Trigs : ____

Ideal lipids are TC less than 200, LDL less than 130 (no heart disease) or less than 100 (with heart disease or diabetes), HDL greater than 40, Trigs less than 150.

My fat-gram goal is 25 to 35 percent of calories a day, and I will try to consume more monounsaturated and omega-3 fats, and less saturated and trans fats.

My sodium goal is a maximum of 2,000 mg a day.

To reach these goals I will:

1. Balance my plate.

2. Eat at least five servings of fruits and vegetables a day.

3. ________________________________________________

4. ________________________________________________

5. ________________________________________________

Sample meal plan for the day:

Breakfast

Whole-grain cereal with skim milk and fruit

Coffee or tea

Lunch

Tossed green salad with avocado and several strips of chicken

Oil (unsaturated) and vinegar dressing

Whole wheat roll

Low-calorie beverage

Healthy snack

Cottage by the Cheese (see recipe, page 275)

Dinner

Grilled salmon

Steamed vegetable medley (broccoli, carrots, snow peas, tomatoes)

Brown rice

Low-calorie beverage

• One Step at a Time

Mark Twain once wrote, "Habit is habit, and not to be flung out the window by any man, but coaxed downstairs a step at a time."

Twain had it right. People often talk about "life-changing events," but though certain events may in fact be singular, happening at a particular time and place, change happens over time and takes practice and persistence. Change is also dynamic rather than static. It involves reflecting about your own particular circumstances and beliefs, learning about alternatives, making choices, developing skills, and then making readjustments along the way.

Making changes in behavior is possible no matter what your age, but we're not saying it will be easy. Let's face it, life in the twenty-first century is fast, furious, and frantic. Traffic is stalled, horns blare, E-mail waits, phones ring, deadlines loom. All these external demands and pressures can result in excess stress that worsens symptoms of your heart disease or prevents you from adopting heart-healthy behaviors. That's why we'll suggest real-world strategies that have worked for other people and that may also help you.

The main thing to remember is that change is a process that has to be attended to constantly. The first step, of course, is to identify barriers to change that may be negatively affecting your health, such as a perceived lack of time. The next step, or series of steps, involves setting realistic goals. And the third step is to choose strategies to move toward those goals. As you follow these strategies and adopt new behaviors, you will find the process becomes easier and feels more natural -- much like learning to ride a bike.

There is no "one size fits all" to change. You are unique, and you will have to discover the techniques that work for you. A key to our program is cognitive restructuring. The word cognitive refers to what you perceive and know about the world; cognitive therapy is based on the premise that much of what we find distressing originates in how we perceive or interpret an event, rather than in the event itself. And many times, our perceptions are negative, unrealistic, and distorted. We hope to help you perceive stress in a new, positive, and manageable way.

Copyright © 2004 by the President and Fellows of Harvard College

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Excerpted from Mind Your Heart: A Mind/Body Approach to Stress Management, Exercise, and Nutrition for Heart Health by Herbert Benson, Aggie Casey
All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.