Low T

We have all seen the advertisement. An ex-ballplayer, a Hall of Famer, is approached by a couple of pretty women in the gym. They comment on how muscular the player is, that he hasn’t changed a bit since his playing days. They inquire, “How do you do it?” The player then launches into his pitch. His supplement keeps him fit and virile due to its “man-boosting” properties. What are these “man- boosting” properties? Can it help boost the heart muscle as well?

The “man-booster” is the male sex hormone testosterone (T).  T is responsible for normal sperm production, maturation of the male sex organs, growth of the beard and pubic hair and deepening of the voice. In addition, T increases muscle mass and strength and helps with bone density.  Low T is a syndrome where T is not secreted in sufficient amounts. Low T may be caused by radiation, trauma, mumps and medications (such as opioids and steroids like prednisone).  In addition, levels of T decline as men get older. About 25% of men over 65 will have Low T while 54% of hospitalized patients and 50% of diabetics have Low T.  The condition is diagnosed by checking levels of T in the blood. Levels are drawn on two separate mornings before 10 AM (T levels drop after 10 to 11 AM).  Total T and free T are measured, with free T the more accurate test. Symptoms of Low T include hot flashes, decreased libido, depression, fatigue, erectile dysfunction and reduced muscle mass. In addition, there is a relationship between Low T and blockages in the heart arteries as well as heart attacks and cardiac deaths.  Many studies have shown lower levels of T in men with significant blockage in the heart arteries, especially when those blockages occur at younger ages (45 years old or younger). However it is unclear whether Low T causes the blockages or whether the Low T is just a marker of poor overall health. 

There are several different ways to replace T in patients with Low T. A patch containing T can be applied to the skin. This isn’t used much as the patch is very irritating and can cause a rash. A gel with T can be applied to the skin. T may also be injected into the muscles.  Oral T replacement (a pill or tablet) is not recommended as it can cause liver toxicity (injection and skin application bypass the liver and are safer).  Regardless of the formulation used, the goal of T replacement is to restore T levels in the blood to normal and reverse the symptoms of Low T.  T replacement has been shown to improve libido but it is less effective at improving mood and depression. Fatigue and vigor improve with T replacement. In addition, there is a decrease in fat, and an increase muscle mass and strength.  Lastly, T replacement reduces blood sugar and triglycerides with no significant improvement in cholesterol and blood pressure.  There are serious side effects with T replacement.  The prostate increases in size under the stimulation of T, which can lead to difficulty urinating.  T replacement can trigger prostate cancer to grow. Before being placed on T, screening for prostate cancer should be performed either with an examination of the prostate or a blood test (PSA).  T replacement may make sleep apnea worse. Lastly, T replacement may cause blood clots in the legs. 

Since most studies have shown that Low T is associated with heart disease, what is the role for T replacement in the cardiac patient?  Unfortunately, the answer is not clear. Many studies have shown an increased rate of cardiovascular events in those taking T replacement.  However, there are an equal number of studies showing the opposite; that T replacement can decrease the risk for a heart attack. There are no high quality studies looking at T replacement and cardiac outcomes as the primary endpoint. Therefore, at the present time, the issue of cardiovascular safety in T replacement is controversial. One area where T replacement may be beneficial is congestive heart failure.  Although the heart’s pumping ability (ejection fraction) was not improved on T replacement, patients on T replacement could exercise more, have less shortness of breath and did not have an increase in heart attack or death. 

Due to aggressive advertising, marketing and celebrity pitches, there seems to be an epidemic of Low T, but who should be treated? The bottom line is that young men with low levels of T in the blood and with symptoms of Low T should be offered T replacement.  Symptoms should be significant; just having fatigue is not enough to warrant T replacement. While on therapy, these patients need careful surveillance to make sure they don’t develop prostate cancer or any of the other side effects of T replacement. The use of T replacement in older men and those with heart disease is still controversial and those patients should be counseled about the potential cardiac side effects. Those with recent heart attack, heart stent, or stroke likely should avoid T replacement, given the uncertainty of the risk.

If you are interested in participating in a study examining Low T and heart disease, please call the Medicor Cardiology research department at 908-243-5009 to see if you qualify.

The Mediterranean Diet Melodrama

The Mediterranean diet has long been the standard for heart healthy eating.  It is a diet that emphasizes olive oil, fresh vegetables, nuts, whole grains over refined grains, fish and plant-based protein over red meat, herbs and spices to flavor food over salt, and fresh fruit for dessert instead of refined sweets. The US News and World Report even named the Mediterranean diet its number one diet for 2018. In addition to diet, the Mediterranean lifestyle incorporates moderate alcohol consumption, exercise and socialization with meals.  There has been a lot of data to support the claim that this diet and lifestyle is good for heart patients. However recent revelations may have knocked the Mediterranean diet off its pedestal.

The most important and influential trial of the Mediterranean diet, the PREDIMED study, was published in 2013.  The trial looked at 7,400 people who were at high risk for heart disease. They were randomized to either the Mediterranean diet or a reduced fat diet.  After five years the trial was stopped early and in dramatic fashion. The Mediterranean diet was declared the winner because it lowered the risk for heart attack, stroke and cardiac death by a substantial 30% compared to the reduced fat diet. Reductions of this magnitude are rarely seen with medications much less with dietary therapy. Since this trial was published, cardiologists have prescribed the Mediterranean diet to their patients. PREDIMED was felt to be an excellent study providing rock solid evidence in a field (nutritional science) that is filled with flawed studies. However in a shocking and rare move in June 2018, the New England Journal of Medicine printed a retraction of the PREDIMED trial, questioning the outcomes. It turns out that about 1,500 patients (about 20%) were not properly assigned to the various diet groups. The researchers recalculated the data, without the 1,500 people, and found that the results were much the same, but the evidence was now much weaker.

Does the PREDIMED retraction nullify the Mediterranean diet? Does this mean that the diet is not beneficial for heart disease? Likely not.  The Mediterranean diet remains the standard for heart healthy eating. Each of the components of the Mediterranean diet has been shown to be beneficial and make common sense for the heart patient. In separate and independent studies, fish, fresh fruit, vegetables, nuts, olive oil and plant based protein have all been shown to lower the risk for heart disease. In addition, the Mediterranean diet is nutritious and sustainable (people can follow it rather easily for years).

Another component of the Mediterranean diet, a glass of wine per day, has also recently come into question. A recent study looking at 600,000 current alcohol drinkers showed that imbibing seven or more glasses of wine per week was associated with an increased risk of death from all causes.  The more alcohol consumed per week, the higher the risk of death.  They estimated an upper safe limit of alcohol was five standard glasses of wine per week for both men and women. Drinking above that limit was associated with shorter life expectancy.

These new data and retractions point out that nutritional studies are notoriously difficult to perform. In general, there are several different problems with these studies. It is hard for people to eat the proper foods consistently without straying (ask anyone who has been on a diet).  There is a huge influence of culture and society on what a person eats and the amount of alcohol consumed.  There is a complex interplay between diet, alcohol and other behaviors (for example exercise and smoking).  In addition, heart disease takes a long time to develop, so diet studies must be carried on for years to see a possible effect.  Lastly, nutritional studies are often funded by industry and thus subject to bias. For example, a study sponsored by the National Institutes of Health looking at alcohol and heart disease was halted in June 2018 when it was discovered that it was partially funded by the alcoholic beverage industry. 

Why is this important? It underscores the fact that even professional researchers, who are trying to conduct a scientifically sound study, have a hard time. Keep this in mind while reading the next sensational newspaper story touting the effects of the latest diet or watching television and hearing about the benefits of alcohol. Please evaluate these types of stories with some healthy skepticism.

Get a Haircut, Lower Blood Pressure

“My blood pressure is all over the place”. This is a common refrain from patients. What is a “good” blood pressure? Where is the best place to measure the blood pressure? How does getting a hair cut affect the blood pressure?

The blood pressure is never a single solitary number. It will fluctuate over the course of the day and is affected by many things, such as activity or drinking a cup of coffee. Think of the blood pressure as a wave on the ocean, it will have highs and it will have lows.  It is best to avoid tsunamis with wild swings between the peak and the trough. Large fluctuations in blood pressure are associated with an increased risk for heart disease. A controlled blood pressure will have gentle swings from high to low and be centered around an ideal number. That ideal number, or target blood pressure reading, has been a source of controversy. In late 2017 the American College of Cardiology published new guidelines declaring that patients with blood pressure greater than 130 systolic now have hypertension, supplanting the previous recommendation of 140. This reclassification means that there are 31 million people who now have hypertension and about 45% of Americans are considered to have hypertension, up from about 32% using the previous level. However, according to the new guideline, not all of the people with blood pressure > 130 should be treated with medication. Blood pressure lowering medications are recommended for patients with systolic pressure > 130 and who already have established heart disease or those whose estimated ten year cardiac risk is greater than 10% (based on the risk calculator cvriskcalculator.com).  Those with lower cardiac risk should continue with life style modification (exercise, weight loss, smoking cessation).  For patients with systolic blood pressure > 140, medication is recommended.

Where is the best place to measure the blood pressure? The doctor’s office is not the ideal location for blood pressure checks. Patients are often stressed about getting to the office on time and are often nervous. They are rushed into the exam room, not given time to relax, and a blood pressure cuff is slapped on their arm. None of this reflects a true reading of the pressure.  More and more these days doctors are relying on patients taking their blood pressure at home, where they are relaxed and comfortable. Another reliable method is an ambulatory blood pressure monitor, a blood pressure cuff worn for 24 hours, which gives an average blood pressure reading during the day and at night.  Both methods, home blood pressure readings and an ambulatory blood pressure monitor, can confirm hypertension in patients who have high readings in the office. Both can show if the patient has white coat hypertension (high readings in the office but normal at home) to avoid over diagnosis and over treatment.  Most importantly, ambulatory blood pressure monitoring is a stronger predictor of cardiac disease and mortality than office blood pressure values.  Given this data, the guidelines recommend the following for blood pressure targets: 140/90 in the office, 135/85 for home measurements and 130/80 for ambulatory monitors.  Lastly, the systolic blood pressure is a better predictor of mortality than the diastolic pressure. 

What does having a haircut have to do with blood pressure? Black men have more hypertension, more hypertension resistant to treatment and a higher risk for cardiac death due to blood pressure than white men or black women. Until now, this population has been very difficult to treat.  A trial involving 15 black owned barbershops in Texas was able to reduce blood pressure by 27 points and was very successful at reaching blood pressure goals. How was this done? Blood pressure checks were done with the men in a relaxed environment while getting their haircut. A pharmacist was present in each barbershop and medication was prescribed and increased based on blood pressure readings each time the men came in.  These checks occurred every two to four weeks and the results were as dramatic as had ever been seen.

In general, the blood pressure should be lower than 140 systolic while avoiding wild swings. Ideally the blood pressure should be measured at rest and when comfortable, either at home or in your favorite hair salon.

Getting to the Heart of Vitamins

By any measure, the vitamin supplement industry is booming.  Estimates put vitamin sales around $12 billion annually.  According to a 2013 Gallop poll, more than half of Americans take vitamin supplements.  Vitamin use is even higher in older Americans, with 68% of those over 65 years old regularly taking a vitamin supplement. More women (54%) take vitamins than men (46%). A 2017 study found that 54% of adults older than 60 took at least one vitamin supplement, while 29% took four or more supplements. With more than 90,000 vitamin products available to choose from, is there evidence to recommend vitamin supplementation? Does taking a vitamin lower the risk for heart disease?  Let’s look at the data for some specific vitamins.

First there are the B vitamins, whose story is closely tied to homocysteine. In the late 1960’s and early 1970’s it was observed that patients with high levels of homocysteine in the blood tended to develop blockage in their heart arteries at an early age.  This began the homocysteine theory of atherosclerosis. Homocysteine is an amino acid (one of the building blocks of protein) and is metabolized using folic acid (a B vitamin) and vitamin B12. Patients with high levels of homocsyteine in the blood can have a genetic defect, but two thirds are due to deficiency of folic acid, vitamin B6 and vitamin B12.  Giving folic acid supplementation decreases the level of homocysteine.  It seemed plausible that giving vitamin supplementation with folic acid would reduce homocysteine levels and decrease heart artery blockages.  However well done studies showed that giving folic acid did reduce homocysteine levels but this did not translate into lower risk for heart attack, stroke and cardiac death.  It is now felt that homocysteine rises as a consequence of a vascular event, rather than as a cause of the event and that vitamin B supplementation doesn’t reduce cardiovascular risk. 

Next up are the antioxidant vitamins, C and E.  Foods rich in antioxidants, such as fruits and vegetables, are known to protect against heart disease.  Does supplementation with the antioxidant vitamins, C and E, provide the same heart protection?  To test this theory, the British Heart Protection study gave vitamin C and vitamin E to patients at high risk for cardiac death.  They found that there was no benefit of vitamin C or E in reducing heart attack, heart death or cancer. The Women’s Health Study followed nearly 40,000 healthy women for 10 years to see if supplementation with vitamin E would reduce cardiac events. Vitamin E did not decrease the risk for heart attack, stroke or death.  Lastly, vitamin E was given to patients with known heart artery disease to see if it reduced cardiac events.  Once again there was no difference in heart attack, stroke or death. In fact, congestive heart failure occurred more often in patients taking vitamin E, showing that excess vitamin E may be harmful. Because of this, cardiologists have stopped prescribing vitamin E.

Next at bat is vitamin D. Vitamin D has been most extensively studied in bone disease, especially osteoporosis, but there is a strong association between vitamin D deficiency and cardiovascular disease.  Studies of hundreds of thousands of patients, followed for more than 20 years, have shown an association between vitamin D deficiency and hypertension, diabetes, high cholesterol and heart disease. Unfortunately, supplementation with vitamin D is not effective in lowering blood pressure, is not useful as a treatment for diabetes and doesn’t significantly change the cholesterol blood panel. It is possible that vitamin D deficiency is a result of cardiovascular disease, rather than a cause of it. The jury is out on vitamin D treatment in heart disease, as some studies show a small reduction in heart deaths, while others show no benefit. The reason for the discrepancy is that most studies looked at vitamin D’s effect on the bones, the heart events were secondary. In addition, these studies tended to involve older patients and patients who already had established heart disease. Studies specifically looking at vitamin D supplementation and heart disease are ongoing, with results due in the coming years. Despite this, it is well established that patients with chronic kidney disease benefit from vitamin D therapy. In this population vitamin D reduces blood pressure and heart deaths. 

It seems that supplementation with B vitamins, vitamin C and vitamin E have struck out with heart disease while vitamin D is still in play. The US Preventive Services Task Force, a group of independent physicians, agrees. They reviewed all of the data on vitamin supplements and could not recommend them for heart protection.  This appears to be a common phenomenon with supplements in general. Whenever humans try to capture the good ingredients found in food and produce a pill, the pill comes up short in terms of benefit. In the case of vitamins, there may be a couple of reasons for this.  Perhaps it is not the vitamin that is beneficial, but some other substance.  For example, fruits and vegetables are high in fiber, vitamin supplements are not. In addition, the body carefully regulates its use of vitamins. The body uses what it needs and any excess is excreted in the urine.  The typical American diet, for all of its faults, provides plenty of essential vitamins and minerals. Many of our foods are fortified, for example, milk with vitamin D, and flour with B vitamins. Any excess supplementation just isn’t being used.

Appropriate vitamin intake is essential for overall health.  In addition, there are many clinical situations where vitamin supplementation is indicated and useful (such as nutritional deficiencies). However, for heart protection eat fresh and natural foods, especially fruits, vegetables, whole grains, and seafood. Don’t expect vitamin supplements or a daily multivitamin to reduce the risk for heart disease.

Is There Something Fishy About Heart Disease?

In the never-ending quest to prevent heart attacks, many populations with low rates of heart disease have been studied.  What are the unique properties of these people that protect them from heart disease? One factor that seems to protect against heart disease is the regular consumption of fish, especially fish high in omega 3 fatty acids.

Omega 3 fatty acids are polyunsaturated fatty acids that can be found in plants (alpha linolenic acid) and fish (eicosapentaenoic acid or EPA and docosahexaenoic acid or DHA).  The omega 3 fatty acids from fish are felt to be especially cardio protective. The oily (dark meat) fish that contain omega 3 fatty acids include halibut, herring, mackerel, oysters, salmon, sardines, trout, tuna, cod, char and mussels. Fish oil containing omega 3 fatty acids has several properties that may be beneficial for heart heath.  It lowers triglycerides and may lower blood pressure while improving the health of arteries.  Omega 3 fatty acids stabilize heart membranes and reduce the risk of heart arrhythmias. Fish oil may also be a blood thinner and it may have anti-inflammatory effects as well.  Do the benefits of fish oil translate into a lower risk for heart disease?

In studies of populations who consume large amounts of fish rich in omega 3 fatty acids, it was found that there was a very low risk for death from heart artery disease.  For example, one of those populations, the Eskimos in Alaska, eat on average about 20 times the amount of omega 3 fatty acids as compared to people in the continental United States. In studies of patients without previous heart artery disease, those with higher intake of omega 3 fatty acids had a lower risk of dying from a heart attack. The death rate is 15% lower for weekly consumption of fish and 23% lower if fish is eaten two to four times per week. In patients with a prior heart attack, fish consumption was also associated with lower rates of cardiac death.  The effect of fish oil seems to be in the reduction of sudden cardiac (arrhythmia related) deaths rather than nonfatal heart attacks (where there is no real benefit). Fish oil may not stabilize heart artery plaque (which would lower the overall rate of heart attacks). Because of these studies, the American Heart Association recommends that patients who have heart artery disease eat oily fish two times per week.  In addition, the heart healthy Mediterranean Diet advocates for two or more servings of fish per week.

If consuming fish is good for the heart, is the same true for fish oil supplements containing omega 3 fatty acids?  Fish oil supplements also lower triglycerides and LDL cholesterol but it is more controversial whether they reduce the risk for heart disease.  In general, these supplements are safe although they can increase the risk for bleeding. Early studies showed a benefit for fish oil supplements but more recent data don’t show the same benefit.  A recent study of 77,000 patients given supplements with omega 3 fatty acids for 4 years showed no reduction in heart attacks, stroke, cancer or death. There may be several reasons for the difference. More recent studies include higher consumption of fish; people have gotten the message and have increased their fish intake on their own.  Adding fish oil supplements to a diet that includes fatty fish wouldn’t reduce risk further. In addition, more recent studies include patients receiving maximal therapy for heart disease.  Adding fish oil supplements won’t reduce risk further. The American Heart Association reviewed all of the available data on fish oil supplements and recommended the following. For patients without heart disease there is not enough data to recommend fish oil supplements. For patients with heart artery disease, already on optimal medical treatment, the role of supplements is not settled. Given the fact that fish oil supplements are relatively safe, their addition may be reasonable.

The best way to prevent heart artery disease is to exercise regularly and follow a prudent diet, including a good amount of fish. Fish oil (omega 3) supplements can be used for patients with established heart artery disease, but only after other medications, especially statins, are maximized and with the realization that the benefit of the supplement may only be minor.

Broken Heart Syndrome

Can a heart truly be broken? Unfortunately many people have suffered the emotional aspects of a broken heart, but can the heart be physically broken as well? Consider the following scenario. A sixty-seven year old woman presents to the emergency room (ER) with chest pain.  She lives alone and earlier in the day she learned that her faithful companion, her dog, passed away.  In the ER, she is found to have a very abnormal electrocardiogram (EKG) and her blood enzymes are suspicious for a heart attack.  She is admitted to the hospital and undergoes a heart catherization the next day. Her cath reveals normal heart arteries, without evidence for blockage, but her heart is severely damaged. What is happening?

She is suffering from a condition known by various colorful names including broken heart syndrome, apical ballooning syndrome, and stress-induced cardiomyopathy (cardiomyopathy is a weakened or damaged heart muscle).  This condition was first described in Japan in 1991. The Japanese coined the condition Takotsubo cardiomyopathy because the heart muscle resembles a Japanese octopus trap with a narrow neck and a wide base.  Stress-induced cardiomyopathy occurs primarily in women (90%), the majority of whom are post-menopausal. It is often associated with a chronic psychiatric disorder such as anxiety or depression.  It is commonly triggered by an emotional event. Stressors include learning of the death of a loved one, public speaking, a surprise birthday party, a lightning strike, or an earthquake. Physical triggers, such as pain or anxiety over a medical procedure can provoke an event as well.  In women, an emotional trigger is more likely, while a physical stressor is more common in men. The vast majority of patients present with chest pain and EKG changes; their presentation often looks like an acute heart attack. In addition, there are high levels of cardiac enzymes in the blood. These enzymes are typically released when the heart is damaged, as occurs with a heart attack. Heart catherization often shows no blockage in the heart arteries but the heart muscle is severely damaged and not contracting. The most common area of damage is the apex or the tip of the heart. Due to this damage, the heart’s pumping capacity, the ejection fraction, is significantly reduced.  Patients are treated with beta-blockers to reduce the effect of adrenaline (catecholamine) on the heart and ACE inhibitors to prevent congestive heart failure from the low ejection fraction. While death and stroke can occur with stress-induced cardiomyopathy, the vast majority recover.  Fortunately, the heart function also usually recovers and returns to normal after several days to several weeks. The prognosis is usually good, although about 10% of patients have a recurrent event, despite treatment.

The exact cause of stress-induced cardiomyopathy is not known. There are many possible explanations but the prevailing theory is that a trigger provokes a “fight or flight response” resulting in a rush of stress hormones (adrenaline, catecholamines) and an exaggerated stimulation of the nervous system. It is well known that adrenaline and nervous system stimulation can cause severe damage to the heart.  The brain is the common factor. Adrenaline is released on command from a part of the brain (the pituitary gland) and the nervous system is activated in the brain. Stress-induced cardiomyopathy is felt to be part of a number of syndromes with a brain-heart connection. For example, patients with an acute stroke or a bleed in the brain often have EKG changes similar to those seen with stress-induced cardiomyopathy. Activation of the “fight or flight” response can also cause irritability of the heart leading to arrhythmias and potentially sudden cardiac death. In fact, the brain-heart axis may contribute to deaths associated with primarily neurologic conditions such as stroke, seizure disorders and head trauma.

For this upcoming Valentine’s Day, let’s keep both the heart and the brain healthy and hope that there are no broken hearts out there.

Get Off the Couch. Walk the Dog. Live Longer.

“Sitting is the new smoking”. This is the new mantra in cardiology and global population health. Sitting, or a sedentary lifestyle, has long been known as a risk factor for the development of heart disease. Excessive sitting is also associated with a higher mortality rate. Is sitting really as bad as smoking for your health? Why is sitting so detrimental? What strategies can combat a sedentary life?

A sedentary lifestyle is a global health hazard.  In a recent study looking at adults in 54 countries (representing 25% of the world’s population), more than 61% of people sat for more than 3 hours per day. It was found that sitting for > 3 hours per day could account for 433,000 deaths per year globally.  Why is sitting so bad? Sitting reduces glucose uptake and leads to diabetes. When sitting, triglycerides are not used or broken down. This increases the level of triglycerides in the blood, which subsequently lowers the good cholesterol (HDL). The combination of high triglycerides, low HDL and diabetes all lead to heart disease.  Sitting also results in obesity and fat deposition in the heart.  In addition, recent research showed that patients who sat for more than 10 hours per day had above average levels of troponin in their blood. Troponin is an enzyme that is released when the heart muscle is injured. High levels of troponin are released during a heart attack.  It was found that sedentary individuals have chronically high levels of troponin (although at much lower levels than heart attack patients). Chronically high troponins indicate that the heart muscle has ongoing damage occurring.

To combat this ongoing damage, a change from a sedentary lifestyle to even a mildly active lifestyle can yield great benefits. Any physical activity is better than no physical activity. For instance, replacing sitting with standing for 2 hours per day is associated with a 10% lower chance of death. There appears to be a benefit even if the recommended amount of exercise (150 minutes of moderate exercise per week or 75 minutes of vigorous exercise per week) is not met. In those who only exercised to about two thirds of the weekly recommended volume, there was a lower mortality rate than those who were sedentary.  Increasing the amount of exercise results in further reductions in cardiac disease and mortality. 

Walking is a great way to get the recommended exercise. It doesn’t require any training or equipment; it’s cheap and easy to do. Since walking alone can be boring, many people join a walking group or walk with a friend. However, what if the friend is ill and can’t walk? What if they are away or have other engagements?  Wouldn’t it be great to have a walking partner available at all times? A partner that has walking in its DNA? A partner that would never refuse to go out for a walk, no matter the weather? Look no further than the family dog. It has been shown that dog owners who walk their dogs are more likely to achieve recommended exercise goals, have lower cholesterol levels, lower blood pressure and less obesity. In addition, dogs offer social support by providing companionship and acting as a vehicle for increased interaction with other people while out walking.  Can owning a dog prolong life?  In a recent study of 3.4 million Swedes, researchers compared hospital records with dog ownership registers. They showed that owning a dog reduced the risk of death by 33% and reduced the risk of a heart attack by 10%.  Perhaps this effect may be because more active people choose to own dogs or perhaps dogs alter the balance of the household and force people to be active at least a couple of times per day.

The most troubling aspect of the research on sedentary lifestyles is that sitting for prolonged periods (more than 7 hours per day) can still increase the risk for death even if the recommended amount of exercise is met. This means that going to the gym after work won’t offset the potential damage done by sitting for hours in an office all day. Therefore it is important to consider physical activity across the entire spectrum, by incorporating a weekly exercise regimen and to use light intensity physical activity to replace sitting during the daily routine.

So, to live a longer and healthier life, first get off of the couch. Next, in addition to starting a weekly exercise program, start altering your daily habits to incorporate more exercise and less sitting. Take the stairs at work. Park at the end of the parking lot and walk further to the office. Instead of sitting at your desk, try a standup desk, or a desk that has a treadmill underneath it. With more activity and less sitting, you might find yourself more productive. Hold meetings in rooms without chairs. By standing and talking meetings may be quicker and more productive. Buy a smart watch that gives you an alert when you have been sitting too long. And, of course, take your furry friend out for a nice long walk when she scratches at the door.