A Guide to Help You Live and Thrive with Cardiovascular Disease

Transcription

1 A Guide to Help You Live and Thrive with Cardiovascular Disease Cardiovascular Prevention & Rehabilitation Program September 2016

2 Cardiovascular Prevention & Rehabilitation Program Authors Kerseri Scane, R. Kin, MSc, BPHE Nicole Sandison, R. Kin, MSc, HBSc HK Sylvia Maksymiu, BPHE Fatim Ajwani, RD, BSc Regan Leader, MSW, RSW Jaan Reitav, PhD, C. Psych, CBSM Maria Ricupero, RD, CDE, MHSc Diane Nixon, RN Contributions Kelly Angevaare, R. Kin, MSc Avi Biswas, PhD(c) Margaret Brum, RD, CDE, BA Sc Tracey Colella, RN, ACNP, PhD Daryl Dooks, BSc Evelyn Foster, R. Kin, BPHE Joan Kitchen, R. Kin, BSc Kin Renee Konidis, R. Kin, BA Phyllis Mancini, MA Gabriela Melo Ghisi, PhD Dr. Paul Oh, MD, MSc, FRCPC, FACP Dr. Michael Sarin, MD, MEd, FRCPC, CDE Farrah Schwartz, MA Health Advocacy Ellen Silaj, BSc PT Valerie Skeffington, R. Kin, BPHE Plain Language (2016) Tina Papadakos, MA(Ed) Crystal Aultman, R.Kin, MSc Editing & Formatting (2016) Lauren Morrison, BSc Patients and Family We would like to thank all of our patients and families who contributed their time and effort towards the development and evaluation of this workbook. A special thank you goes to Jennifer Carling for her dedication and significant contributions to this workbook. Our program and our patients appreciate the numerous hours she spent doing clear design and editing. Graphics Kristen Foster Adam Latuns

3 Welcome Congratulations on joining Toronto Rehab s Cardiovascular Prevention & Rehabilitation Program! You are in good hands. Our team of rehabilitation specialists is a leader in delivering cardiac rehabilitation and secondary prevention programs. We offer one of the largest, most comprehensive out-patient cardiovascular prevention & rehabilitation programs in North America. Over the next several months, we will work with you to develop your own personal program of exercise and education to help improve your cardiovascular fitness and muscular strength. This will reduce your chance of having another heart event. Once you start your exercise and education program, your progress will be followed by your Cardiac Rehab team, who will help you to achieve your individual goals. This guide has been designed to support you through the various stages of the Cardiovascular Prevention & Rehabilitation program. We will help you work through the different sections of the guide as your own personal program of exercise and education progresses. We look forward to working with you and helping you reach your goals for living a heart healthy lifestyle! UHN CV Prevention & Rehabilitation Program Page I

4 Table of Contents Section #1 - Build a Foundation for a Safe Heart Chapter 1 Orientation to Your Cardiac Rehab Program... 1 Chapter 2 Safe Exercise... 6 Chapter 3 Your Aerobic Exercise Prescription Chapter 4 Angina Chapter 5 Irregular Heartbeats Chapter 6 Exercising & Cold Weather Chapter 7 Exercising & Hot Weather Chapter 8 Your Heart & Heart Disease Chapter 9 Cardiac Medicines Section #2 - Develop Skills to Take Care of Your Heart Chapter #10 Controlling Your Risk Factors Chapter #11 Goal Setting and Action Planning Chapter #12 Resistance Training Chapter #13 Nutrition Fats, Cholesterol and Your Diet Chapter #14 Nutrition Benefits of Fibre and Plant Food Chapter #15 Nutrition Reading Food Labels Chapter #16 Nutrition Sodium and Blood Pressure Chapter #17 Stress & Your Heart Chapter #18 Sexual Intimacy UHN CV Prevention & Rehabilitation Program Page II

5 Section #3 - Prepare for Life After Rehab Chapter #19 How Much Physical Activity is Good for You? Chapter #20 Progressing Your Exercise Program Chapter #21 Relapse Planning Chapter #22 Graduation Section #4 Tool Box Exercise Tools Nutrition Tools Risk Factor Tools Goal Setting and Action Planning Tools Medicine Tool UHN CV Prevention & Rehabilitation Program Page III

6 Section #1 Build a Foundation for a Safe Heart Chapter Topic Page # 1 Orientation to Your Cardiac Rehab Program 1 2 Safe Exercise 6 3 Aerobic Exercise 17 4 Angina 23 5 Irregular Heartbeats 28 6 Exercise & Cold Weather 33 7 Exercise & Hot Weather 41 8 Your Heart & Heart Disease 50 9 Cardiac Medicines 63

7 Chapter # 1 Orientation to your Rehab Program Know how your rehab program will help you You Will Learn: 1) The benefits of participating in a cardiac rehab program 2) The components of a cardiac rehab program 3) Who is on your team 4) What is expected of you Chapter 1 Orientation to Your Program pg. 1

8 How will the Cardiovascular Prevention & Rehabilitation Program (Cardiac Rehab program) help me? Sometimes, despite your best efforts, you develop heart disease. The disease may be caused by things you cannot control (such as your family history or age). The purpose of the Cardiac Rehab program is to help you identify the things you can change that are within your control (such as healthy eating and exercise). What the Research Says: If you join a Cardiac Rehab program you will: Improve how your body functions Improve your quality of life Decrease your risk of dying early Feel better in mind and body What Does my Program Include? There are three main parts in your Cardiac Rehab Program: 1) Stress test 2) Exercises 3) Education You will complete 3 stress tests while you are in the program: 1) At the start of the program 2) Half-way through your program 3) Near the end of the program You will do two types of exercise: 1) Aerobic training 2) Weight training You will learn about your heart problem and how to live a heart healthy lifestyle Chapter 1 Orientation to Your Program pg. 2

9 Your Team There are many members on your Cardiac Rehab team to help you through all three parts of your program. You are a key member of that team. Referring Doctor Your family doctor, heart doctor (cardiologist), surgeon or other specialist who referred you to the program. Cardiopulmonary Assessment Team You will work with your cardiopulmonary assessment team (CPA) for your exercise stress test. The CPA team includes: Doctors Cardiac Technologists Exercise Technicians Program Doctor The program doctors are available if necessary. The program doctors do not replace your own doctor. Cardiac Rehabilitation Supervisor A cardiac rehabilitation supervisor (CRS) will be your main contact person throughout your program. Your CRS will: Design your rehabilitation program Progress your exercise program Make sure your exercise is safe Connect you with resources and tools An exercise leader (EL) will work with your cardiac rehabilitation supervisor (CRS) to: Exercise Leader Help you exercise safely on the exercise track at our Centre Check your exercise heart rate Chapter 1 Orientation to Your Program pg. 3

10 Dietitians Registered dietitians offer advice on healthy eating. Speak to your cardiac rehabilitation supervisor (CRS) if you would like to meet with a dietitian. Psychologist Psychologists are available to offer advice about how to improve your mental and social health as well as your mood. Speak to your cardiac rehabilitation supervisor (CRS) if you would like to meet with a psychologist. Social Worker Social workers are available to offer advice about how to improve your mental and social health. You can also talk to a social worker about money, housing and travel issues. Speak to your cardiac rehabilitation supervisor (CRS) if you want to meet with a social worker. Your Peers Other people living with cardiovascular disease are also part of your exercise class. Talk to them to share your journey and learn from each other. Volunteers Volunteers have finished the program and can relate to what you are going through. They are involved with the exercise classes e.g., greeting and checking patients in when they arrive, walk with you on the exercise track Researchers The Toronto Rehabilitation Institute is a research hospital that works to make rehabilitation better. A member of the research team may ask you to join a study. It is your choice if you want to join. You can withdraw from a study at any time and it will not affect your care. Chapter 1 Orientation to Your Program pg. 4

11 What is my Role in the Program? You have an important role on your Cardiac Rehab team. Your role in the program is to: 1) Complete Exercise Stress Tests (also called a cardiopulmonary assessments, CPA) Your program begins with an initial appointment to assess your health. After this appointment you will be asked to come back for an exercise stress test A stress test is one of many factors used to assess your fitness and create your personal exercise prescription During a stress test you will exercise on a treadmill or a bike. Your safety will be checked while you exercise Be sure to take your medicines, wear loose fitting clothing and running shoes for your stress test You will complete a stress test again when you are half-way through your program and at the end of your program Your Cardiac Rehab team will use the results of your stress test to update your exercise prescription 2) Do Your Exercise Prescription and Track Your Activity Once you complete your stress test, you will receive your personal exercise prescription. Your exercise prescription will answer these questions: o What type of exercise should I do? o What pace should I walk or cycle? o How long should I exercise for? o How often do I exercise? You will also receive a resistance training program (for example, using dumbbells or exercise bands). Resistance training will increase the strength of your muscles. Fill out your exercise diary each week and hand it in to your CRS. On your exercise diary you can write down details about the aerobic and resistance exercise you do, as well as medical visits and medicine changes. 3) Attend the education sessions and workshops available at our Program Chapter 1 Orientation to Your Program pg. 5

12 Chapter # 2 Safe Exercise Know how to exercise safely You Will Learn: 1) How to manage symptoms during exercise 2) 10 tips to stay safe while exercising 3) How to track your exercise and symptoms using an exercise diary Chapter 2 Safe Exercise pg. 6

13 What Do I Do If I Feel Symptoms While I Exercise? You should not feel symptoms while you exercise. You may be working too hard if you develop any of the symptoms below. If you have any of these symptoms, slow down your exercise right away. Angina A warning signal that your heart is under stress When there is not enough blood and oxygen getting to your heart muscle, you may feel pain or discomfort in one or more of these areas (jaw, throat, chest, upper back, arms, nausea, shortness of breath or fatigue) The way you feel angina may be different from other people. It is important that you know your symptoms of angina. If you have angina follow the steps in the next section to manage your angina during exercise. For more detailed information on angina see Chapter 4 Angina Irregular Heartbeats Your heart may be skipping beats. Your heart could also be beating faster or slower than what is normal for you. See Chapter 5 Irregular Heart Beats to learn more Feeling Dizzy You may feel as though you are going to faint. You may also feel like things around you are moving Shortness of Breath You may feel like it is hard to get enough air Shortness of breath can be a symptom of angina. If shortness of breath is a symptom of angina for you, follow the steps in the next section to manage angina Muscle or Joint Pain You may feel more pain in your muscles and joints than what is normal for you Chapter 2 Safe Exercise pg. 7

14 If You Feel Angina During Exercise Slow your exercise pace for 1 minute If angina does not go away If angina goes away Stop exercising, sit down and wait 1 minute If angina does not go away Continue exercising at that slower pace for 5 minutes Continue on if you have no angina Sit down and take your Nitroglycerine as prescribed by your doctor. Rest for 5 minutes If angina does not go away Take a second Nitroglycerine and rest for 5 minutes If angina does not go away Safety Alert! If angina goes away after taking 1 spray of your Nitroglycerine, talk to your doctor and Cardiac Rehab team to see if it is safe for you to return to your exercise the same day. Even if your angina goes away after taking 2 sprays of your Nitroglycerine, do not return to exercise the same day. Call your doctor if these symptoms are new or different for you. Take a third Nitroglycerine and rest for 5 minutes If your angina does not go away after your third Nitroglycerine, Call 911 for help Chapter 2 Safe Exercise pg. 8

15 How Do I Avoid Symptoms During Exercise? Here are 10 ways to avoid symptoms and stay safe while you exercise 1) Follow your Exercise Prescription You will receive an exercise prescription that is tailored for you by your Cardiac Rehab team. It is important that you follow your exercise prescription to avoid symptoms. Avoid going faster or longer than what you are prescribed Your Cardiac Rehab team will progress your exercise prescription and keep you safe from heart symptoms and muscle injury 2) Warm up The first part of your exercise prescription is your warm up. The purpose of the warm up is to slowly get your heart, lungs, blood vessels and muscles ready for exercise. A warm up gets your blood vessels to relax and open up. This gets more blood flowing to your working muscles and heart. How Do I Warm Up? Your warm up can be the same type of exercise you are doing for your exercise program If you walk for your exercise, then your warm up can be walking If you bike for your exercise, then you can warm up on the bike Warm up for 5-10 minutes at a slower speed (2 minutes/mile slower) than your prescribed exercise E.g.,: If you walk for your exercise, then walk at a slower pace for 5-10 minutes before you start exercising E.g.,: If you bike for your exercise, then bike at a slower speed, on an easy gear for 5-10 minutes before you start exercising 3) Cool-down The final part of your exercise prescription is your cool down. The purpose of cooling down is to lower your chances of having angina, having irregular heartbeats or feeling dizzy. If you stop Chapter 2 Safe Exercise pg. 9

16 exercising too quickly this causes pooling of blood in your legs and less blood flow to the heart and head which can increase your chances of having symptoms. How Do I Cool Down? Your cool down can be the same type of exercise you are doing for your exercise program. Cool down for 5-10 minutes at a slower speed (2 minutes/mile slower) than your prescribed exercise 4) Take Your Medicine(s) If you do not take the medicines that your doctor prescribed, you may get symptoms while you exercise. Take your medicine(s) at the same time every day, as prescribed by your doctor 5) Avoid Exercising When You Are Ill Do not exercise if you are ill with an infection (like the flu or a cold). Your body needs to rest during this time. If you exercise when you are ill, it is harder for your body to fight the infection. When you are ready to return to exercise: Restart your exercise gently (slower pace) Take the amount of time you took off from your exercise to get back to your regular exercise routine. For example, if you were ill for a week, take a week to get back to the same level of exercise you were at before your illness 6) Avoid Smoking (including medical marijuana) and Caffeine Before Exercise Caffeine and the nicotine in cigarettes may increase your heart rate and can cause irregular heartbeats or angina. Caffeine may cause your body to lose water (dehydration). Be sure to drink water during exercise. Do not smoke or have caffeine right before you exercise There is no smoking on Hospital property 7) Eat on Time & Stay Hydrated The purpose of eating on time is to allow for your food to digest before you exercise. After you eat, much of your blood is being used to help digest food. This means your muscles have to Chapter 2 Safe Exercise pg. 10

17 compete for the blood and oxygen that is in your stomach digesting your food. Your exercise will feel harder and you may feel tired, short of breath and may even get angina. If you eat a meal, wait at least 2 hours before you exercise Make sure you drink enough water unless your doctor has told you otherwise. Drink 6 to 8 ounces of water for every 20 minutes of exercise 8) Dress Right for Exercise Wearing the right clothes during exercise will help you keep your body at the right temperature. Getting too hot or too cold makes your heart work harder which could lead to symptoms of angina, or being dizzy or short of breath. See Chapter 6 Exercise in Cold Weather and Chapter 7 Exercise in Hot Weather to learn more about how to be safe in cold and hot weather. Wearing Running Shoes It is important to wear proper running shoes when you exercise. This type of shoe will support and cushion your feet. Ask someone who is trained in selling shoes to assess how you walk. Running shoes typically last for 6 to 12 months or 500 miles. 9) Stretch Your Muscles The purpose of stretching is to: improve flexibility, and lower the risk of injury while you exercise. Flexibility training (stretching your muscles) is a key part to fitness. How Do I Stretch? Stretch after your cool down, when your muscles are already warm. If you are not doing aerobic training that day, warm up for at least 5 minutes before you stretch Stretch to a point where you feel tightness without causing pain or discomfort in the muscle Hold the stretch for seconds and keep breathing while you stretch Do not bounce See the Exercise Tools of this guide for a list of stretches Chapter 2 Safe Exercise pg. 11

18 10) Listen to Your Body Track Your Pulse and Effort Another way to keep your heart safe is to track your pulse, effort and exercise on your exercise diaries. Your Cardiac Rehab team will review your exercise diary at each visit. Tracking your pulse, effort and exercise on your exercise diary allows you and your Cardiac Rehab team to: About Your Pulse Track your home exercise Know when it is safe to progress your exercise prescription The first thing you need to track while you exercise is your pulse. Tracking your pulse is one way to make sure that you feel well during exercise. Facts about Your Pulse Your pulse rate is the same as your heart rate Your pulse count should go up during exercise because your heart beats faster and harder Your pulse rate may not be the same as someone else s Some medicines can impact your heart rate Taking Your Pulse WHY? WHERE? Track your body s response to exercise Know if your pulse is within your target range On your wrist (radial artery pulse). Place two or three fingers on your right or left wrist below the base of your thumb. you can get lightheaded. Chapter 2 Safe Exercise On your neck (carotid artery pulse). Place two or three fingers on the right or left side of your neck in the hollow area beside your Adam s apple. Be careful you do not press too hard; there is a risk pg. 12

19 WHEN? Before you warm up (resting heart rate) At the end of exercise before you cool down HOW? Count the number of beats you feel in 10 seconds About Your Effort To track your effort, you will use a scale to help you describe how you are feeling. It is called the Borg Rating of Perceived Exertion (RPE) Scale. Borg Rating of Perceived Exertion (RPE) Scale The Borg Rating of Perceived Exertion (RPE) scale will help you know how hard you are working during exercise. The scale goes from Some of the numbers have a verbal rating to help you describe how you are feeling. Use the RPE scale to find the example that matches your effort and then find the number rating that matches the example What is the Best Level for My RPE? During aerobic exercise, the best level for your RPE is between 11 and 14 If you rated your RPE at 15 or higher, then you should slow down your exercise. This is too high for a person with a heart problem Chapter 2 Safe Exercise pg. 13

20 About Your Exercise Use the exercise diary found in the Exercise Tools section of this guide to track your aerobic and resistance training exercises. Tracking your pulse, effort and exercise will help keep you safe and maintain gains in your health. Your Cardiac Rehab team will look at your exercise diary each week to see how you are feeling and track your progress. Below are instructions on how to fill in each part of the diary as well as a sample of the diary. How to fill in Your Exercise Diary It is important for you to complete and submit a weekly Exercise Diary. Name: Print first and last name Exercise prescription: Record your exercise prescription (example walk 1 mile in 20 min) Date: Record the day you exercised Type of Exercise: Record type of exercise e.g., walk, bike, elliptical, used treadmill etc. Distance: Record in miles, the distance that you completed Duration: Record the time in minutes and seconds it takes you to complete your exercise Pulse Pre-Exercise: Take your 10 second pulse count BEFORE you do your warm-up exercises Post-Exercise Pulse: Take your 10 second pulse count as soon as you finish your prescription as quickly as possible (within 10 seconds) before cooling down Symptoms: Record any body strains or pains (e.g. chest discomfort, leg discomfort etc) Remarks: Record any reasons or comments regarding condition: windy/snowing/humid etc R.P.E.: Record your RPE (Rating of Perceived Exertion) using the scale provided on the diary Your Action Plan This is an area for you to record your weekly action planning activities Your Medical Visits If you have any medical visits or medicine changes during the week, please record the details Chapter 2 Safe Exercise pg. 14

21 Date (mm/dd) Type of Exercise Aerobic Training Diary Distance (miles) Duration (min/sec) Name: Nicole Doe Exercise Prescription: 1 mile in 22 minutes 10 sec pulse Pre Post Ex. Ex. RPE Symptoms/ Remarks/Other Activities Sep 5 walk 1 22 min/15 sec Felt good. No problems. Sep 6 walk 1 22 min/5 sec Felt good. No problems. Sep 8 walk 1 22 min/33 sec Felt good. No problems. Sep 9 walk 1 22 min/1 sec A bit short of breath My Action Plan: What do I want to do? What will I realistically be able to do this week? My plan will include: What I am going to do When I am going to do it Where I am going to do it How Much I am going to do it How Often I am going to do it This week I will Eat extra vegetables (what) At lunch (when) At work (where) an extra ½ cup fresh vegetables (how much) 3 days this week (how often) My confidence rating that I can do this plan is: not confident at all totally confident Rating of Perceived Exertion (RPE) 6 7 Very, Very Light 8 9 Very Light Fairly Light Somewhat Hard Hard Very Hard Very, Very Hard 20 Chapter 2 Safe Exercise pg. 15

22 Resistance Exercises 1. Dumbbell Row 2. Half Squat 3. Bicep Curl 4. Leg Curl 5. Ext.Rot/ Lat. Raise 6. Heel Raises 7. Supine Fly/Wall Push up 8. Abdominal Exercise 9. Tricep Extension 10. Bird Dog Other Exercise Date: Sep 7 Weight 10 pounds 0 8 Red band Yellow band Reps & #Sets 12 reps RPE Date: Weight Reps & #Sets RPE Date: Weight Reps & #Sets RPE Medical Visits & Medicine Changes: List any changes in medicine and hospital/emergency/lab/doctor s visits Visits & Reason Date Name of Service/Test/Procedure Heart doctor Sep 10 Check up Medicine(s) Date of Change Dose/Frequency Metoprolol Sep 10 Lower dose Chapter 2 Safe Exercise pg. 16

23 Chapter # 3 Aerobic Exercise Know how your aerobic exercise program works You Will Learn: 1) What aerobic exercise is and why it is important 2) The components of your aerobic exercise program 3) Why it is important to follow your exercise program Chapter 3 Aerobic Exercise pg. 17

24 What is Aerobic Exercise and Why is it Important? Aerobic exercise is an activity that you sustain for a longer length of time. You can use the large muscle groups in your body to do aerobic exercise. E.g.: walking, biking, jogging Aerobic exercise starts slowly to allow your heart rate to increase slowly. Once your heart reaches a target level, you keep that pace (of walking, biking, jogging or swimming) constant for a prescribed length of time. In your Cardiac Rehab program, your aerobic exercise is tailored to you so that it is safe and right for you. You will have your own target level for your heart rate. Doing aerobic exercise will help you achieve a healthy body. Aerobic exercise can: Make your heart and lungs stronger and work better (improve your cardiovascular fitness) Decrease your blood sugar levels (if you have diabetes) Reduce your risk for heart disease Help you live longer The Components of your Aerobic Exercise Program How Was My Aerobic Exercise Program Made? Your aerobic exercise program was tailored for you by your Cardiac Rehab team. To make your aerobic exercise program, your Cardiac Rehab team looked at your: 1) Medical history Your Cardiac Rehab team looks at: o What happened to your heart o Other health concerns you have (this may include problems with your muscles or joints) 2) Exercise stress test results Your Cardiac Rehab team looks at: o Your level of fitness o Your heart rate and blood pressure during exercise Chapter 3 Aerobic Exercise pg. 18

25 o How your heart beats on the electrocardiogram (ECG) 3) Preferred way to exercise Your Cardiac Rehab team looks at: o What kind of aerobic exercise you prefer o What exercise equipment you have access to Your Tailored Exercise Prescription The exercise prescription that you receive will help you make the most gains in your health while keeping your heart safe. Exercise is Designed and Personalized For You Your Cardiac Rehab team prescribes your aerobic exercise prescription like the way your doctor prescribes your medicine. Like medicine, exercise needs to be defined, unique to you and may need to be changed over time. The FITT principle is used for your exercise prescription for this reason. FITT Principle F: Frequency- How often do I exercise? Try for 5 days per week If you do more than 5 days, you may: Strain your muscles or joints Feel more tired or unwell Have more irregular heart rhythms (skipped beats) If you do less than 5 days per week, you may not make the same gains in your health. If you want to do other types of daily exercise, talk to your Cardiac Rehab team first. I: Intensity- How hard do I exercise? Your Cardiac Rehab team will tell you how hard to work by giving you: 1) A target heart rate range Chapter 3 Aerobic Exercise pg. 19

26 Your target heart rate range tells you how fast your heart should beat while you exercise. Each person has their own target heart rate range Staying in your target heart rate range will help you exercise safely and improve your health Do not allow your heart rate to go higher than your target heart rate range Speak to your Cardiac Rehab team if you find it hard to increase your heart rate to your target range during exercise Beta blocker medicine lowers your heart rate. Your heart rate will likely be lower if you take your beta blocker medicine close to the time when you start to exercise Always use the Borg Rating of Perceived Exertion (RPE) scale and your pulse to know if you are putting in the right amount of effort 2) A walking speed/pace that is comfortable for you If you are walking for your exercise, your exercise prescription will tell you how far to go and how long it should take you If you walk on a treadmill, your exercise prescription will tell you at what speed to set the treadmill. These details will help you walk at a pace that is safe for you Four Ways to Check How Hard You Are Working Since it can still be a challenge to know if you are putting in the right amount of effort, there are 4 ways to check how hard you are working while you exercise: 1) Take your pulse and record it on your exercise diary. See Chapter 2 Safe Exercise for information on how to take your pulse and how to fill out your exercise diary 2) Use the Borg Rating of Perceived Exertion (RPE) scale. See Chapter 2 Safe Exercise for more information on how to use the RPE scale 3) Do the walk/talk test During your exercise, try talking to someone beside you. If you are very short of breath while you are talking, you might be working too hard Chapter 3 Aerobic Exercise pg. 20

27 It is okay to hear yourself breathe while you exercise 4) Watch for symptoms If you follow your exercise prescription, you should not have symptoms If you feel symptoms, slow down your exercise at once and follow the steps to manage your symptoms outlined in Chapter 2 Safe Exercise Speak with your Cardiac Rehab team if your exercise prescription needs to be changed T: Type- What kind of exercise will I do? Recall that aerobic exercise is sustained activity that uses the large muscle groups of your body. You will be prescribed exercise such as walking, biking or jogging T: Time- How long will I exercise for? At the start of your program, you may do 10 to 20 minutes of aerobic exercise. Over time you will be encouraged to progress gradually up to 30 to 60 minutes. The amount of time you exercise depends on the results of your exercise stress test, your medical history and your goals. How Your Exercise is Progressed Your Cardiac Rehab team gave you a written copy of your exercise prescription (see Figure 1. for an example of an exercise prescription). You will receive a new copy of your exercise prescription each time it is changed. It is important to fill out your exercise diaries so that your Cardiac Rehab team can progress your exercise safely. See Chapter 2 Safe Exercise for more information on how to fill out your exercise diaries. Since your exercise prescription is tailored for you, if you have questions or concerns about the level of the exercise, discuss it with your Cardiac Rehab team. It is not safe to increase the level of your exercise (pace and distance) without speaking to your Cardiac Rehab team. Chapter 3 Aerobic Exercise pg. 21

28 Figure 1. Example of an Exercise Prescription Exercise Prescription Name: Jane Doe Date: September 1 st WALK Warm Up: Walk at a pace slower than your prescribed pace for 5-10 minutes Workout: Walk 2 miles (3.2 km) in 40 minutes, 0 seconds Your training heart rate range is 102 to 114 beats per minute (bpm) or 17 to 19 beats in 10 seconds. Your Rating of Perceived Exertion (RPE) should not be higher than 14 Cool Down: Walk at a pace slower than your prescribed pace for 5-10 minutes Frequency: 5 times per week If you use a motorized treadmill for your exercise, manually set your speed on the machine as follows: Warm up: 2.7 mph for 5-10 minutes Workout: 3 mph for 40 minutes Cool down: 2.7 mph for 5-10 minutes Cardiac Rehab Team Member Chapter 3 Aerobic Exercise pg. 22

29 Chapter # 4 Angina Know what to do if you feel angina You will learn: 1) What angina is 2) How angina affects you 3) How to prevent and manage angina during exercise Chapter 4 Angina pg. 23

30 What is Angina? Angina is a warning sign that your heart is under stress. When there is not enough blood and oxygen getting to your heart (see Figure 1 below), you may feel pain or discomfort in one or more areas listed below. You may also feel shortness of breath, feel very tired (fatigue) or have nausea. You may feel pain (discomfort) in the: Chest Jaw Arms Upper back Throat Shortness of breath Fatigue 1A 1B Figure 1 A. In a blocked coronary artery the heart does not receive enough blood and oxygen. Figure 1B. In a normal coronary artery the heart receives enough blood and oxygen. Angina occurs when part of one of your coronary arteries (the arteries that bring blood and oxygen to your heart) is blocked. Your coronary arteries can get blocked when plaque collects over time. Plaque is a waxy substance made of fat, cholesterol and calcium. 3 Types of Angina There are 3 types of angina: stable, unstable, and silent Stable angina Stable angina may occur when you exercise too hard, when you feel stressed or after a heavy meal. You can predict when stable angina will occur. Most often, your symptoms last for 5 minutes or less and are relieved by rest or Nitroglycerin (a medicine that helps with angina). Chapter 4 Angina pg. 24

31 Unstable Angina Unstable angina may occur at any time even when you are resting or sleeping. You cannot predict when unstable angina will occur. Your symptoms can last for up to 30 minutes. Call 911 if you have unstable angina. An ambulance can take you to the Emergency Department. Do not drive yourself or have a loved one drive you to the Emergency Department. An ambulance is equipped with life-saving tools and medicine. Silent Angina (or Silent Ischemia) Silent angina (also known as silent ischemia) is when your heart does not get enough blood and oxygen, but you do not feel any symptoms. You will not know if you are having silent angina. A simple test called an electrocardiogram (ECG) will show if your heart is getting enough blood and oxygen. See Chapter 8 Your Heart & Heart Disease for more information about ECGs. Silent angina is more likely to occur if: You do not warm up before you exercise You have diabetes Be sure to warm up before you exercise. Safety Alert! Be sure to warm up before exercise to lower your risk of angina How Angina Affects You How you feel angina can differ from how others feel it. It is important to know how angina affects you. To be safe, answer the questions below and record your answers. You will need to be able to describe how angina affects you to notice if it changes. Where on your body do you feel angina? When do you feel angina? What are you doing when you feel angina? How long does your angina last? What takes your angina away? How often do you feel angina? Chapter 4 Angina pg. 25

32 When you describe how angina affects you, it is also important to rate how much pain or discomfort you feel when you have angina. Knowing how much pain or discomfort you feel will: 1) Help your doctor know how to manage your angina 2) Help you know if your angina is getting better or worse Rating of Perceived PAIN (Borg) Nothing at all Extremely weak (just noticeable) Very weak Weak Moderate Strong Very strong Extremely strong Figure 2. Borg rating of perceived pain scale The Borg Rating of Perceived Pain Scale (see Figure 2) can help you describe your pain or discomfort. The scale goes from 0 to 10 and some of the numbers have verbal ratings as well. Know How to Prevent and Manage Angina During Exercise There are many things you can do to help prevent angina during exercise. Take your cardiac medicines as prescribed by your doctor Warm-up for 5-10 minutes before you exercise. See Chapter 2 Safe Exercise for more details Follow your exercise prescription. See Chapter 3 Aerobic Exercise Prescription for more details If you get angina during exercise, follow the steps on the next page to make sure you keep your heart safe. Safety Alert! See your doctor if you: Experience a change in your symptoms Have new symptoms Feel angina more frequently or at a lower level of physical activity If you experience angina that does not go away after 3 sprays of Nitroglycerine, call 911. Chapter 4 Angina pg. 26

33 If You Feel Angina During Exercise Slow your exercise pace for 1 minute If angina does not go away If angina goes away Stop exercising, sit down and wait 1 minute If angina does not go away Continue exercising at that slower pace for 5 minutes Continue on if you have no angina Sit down and take your Nitroglycerine as prescribed by your doctor. Rest for 5 minutes If angina does not go away Take a second Nitroglycerine and rest for 5 minutes If angina does not go away Safety Alert! If angina goes away after taking 1 spray of your Nitroglycerine, talk to your doctor and Cardiac Rehab team to see if it is safe for you to return to your exercise the same day. Even if your angina goes away after taking 2 sprays of your Nitroglycerine, do not return to exercise the same day. Call your doctor if these symptoms are new or different for you. Take a third Nitroglycerine and rest for 5 minutes If your angina does not go away after your third Nitroglycerine, Call 911 for help Chapter 4 Angina pg. 27

34 Chapter # 5 Irregular Heartbeats Know what to do if you have irregular heart beats You Will Learn: 1) What an irregular heartbeat is 2) What causes irregular heartbeats 3) How to deal with irregular heartbeats Chapter 5 Irregular Heartbeats pg. 28

35 What Is An Irregular Heart Beat? A normal heartbeat is steady - one beat after the other. When you take your pulse, you are counting your heart rate and feeling the heart rhythm. An arrhythmia (also known as an irregular heartbeat) is when your heart beats too quickly or too slowly for you, or when your heart beats too early. If your heart: Is beating too quickly for you, your pulse count will be higher Is beating too slowly for you, your pulse count will be lower Beats too early, you may feel a pause in your pulse count Types of Irregular Heartbeats 1) Arrhythmias with a Slow Heartbeat When the electrical signal in your heart is slowed and your heart beats less than 60 times per minute this is known as bradycardia. This may occur if you have a heart block. 2) Arrhythmias with a Fast Heartbeat When the electrical signal in your heart is too fast and your heart beats more than 100 times per minute this is known as tachycardia. There are several examples of this: Atrial flutter, atrial fibrillation, supraventricular tachycardia (SVT) Ventricular tachycardia (VT), ventricular fibrillation (V-fib) 3) Arrhythmia with an Early Heartbeat Most people, even people without heart disease, get early heartbeats at some time. Early heartbeats happen when something (explained below) bothers your heart cells and causes them to send out a signal too early. This can cause the heart to beat early. Chapter 5 Irregular Heartbeats pg. 29

36 Causes of Early Heartbeats: Caffeine (coffee, tea, chocolate) Too much alcohol or binge drinking Smoking Stress Fatigue (being tired) and illness Hot, humid, cold and windy weather Not doing a proper warm up Not doing a proper cool down Doing more than your exercise prescription How to Record Early Heartbeats on Your Exercise Diary: Count the number of beats you feel over the 10 second count Count the number of pauses you feel For example, if you felt 12 beats over 10 seconds and felt 1 pause, record it as on your exercise diary When Should You Be Concerned? Most people with or without heart disease may experience irregular or skipped beats at some time. Occasional skipped beats are not a problem. If you feel unwell and have symptoms (such as angina, shortness of breath, light-headedness or dizziness) when you have the skipped or irregular beats, contact your physician and Cardiac Rehab team for further advice. What Are the Treatments for Arrhythmias? If you feel unwell and have symptoms (such as angina, feeling dizzy, shortness of breath, passing out) contact your doctor for further advice. We provide some of the common treatments for arrhythmias below. Your doctor will discuss the best treatment options for you. Chapter 5 Irregular Heartbeats pg. 30

37 Medicine Your doctor may prescribe you medicine to manage your arrhythmia. Common medicines prescribed for arrhythmias include: Digitalis preparations Calcium channel blockers Beta-blockers Cardioversion Cardioversion is a treatment where controlled electrical pulses are sent through your body to your heart. These electrical pulses trigger the heart to resume its normal rhythm. Surgery There are 4 types of surgery that may be used to treat arrhythmias. 1) Ablation This procedure can be used to destroy the cells that send out electrical signals to make your heart beat too quickly. 2) Maze Procedure This procedure stops bad electrical signals from moving through your heart (e.g., atrial fibrillation). 3) Pacemaker This procedure attaches a small device to your heart to help your heart maintain a normal rhythm. Chapter 5 Irregular Heartbeats pg. 31

38 4) Implantable Cardiac Defibrillator (ICD) This procedure attaches a small device to your heart to track and correct your heart rhythm. This device can detect when your heart is beating too fast and sends an electrical pulse to your heart to resume its normal rhythm. Your Resources 1. The Heart and Stroke Foundation at 2. The Mayo Clinic at: Chapter 5 Irregular Heartbeats pg. 32

39 Chapter # 6 Exercise & Cold Weather Know how to exercise safely in cold weather You Will Learn: 1) How your body responds to exercise in cold weather 2) How to exercise safely in cold weather 3) About places where you can exercise indoors Chapter 6 Exercise & Cold Weather pg. 33

40 Be Aware of How Your Body Responds to Exercise in Cold Weather How Your Body Responds to Exercise in Cold Weather Cold weather can put extra pressure on your heart. 1 A When you are cold, your body temperature lowers. Your lower body temperature causes the blood vessels near your skin to become narrow (see Figure 1 B below). This process causes blood to move away from the surface of your body to reduce heat loss. Although your body stays warmer, your heart has to work harder to pump blood 1 B through the narrow vessels. As a result: Your blood pressure may increase You may get symptoms of angina Irregular heartbeats Shortness of breath Figure 1 A. Blood vessel under the Feel dizzy skin at room temperature Figure 1 B. Blood vessel under the skin in cold temperatures Breathing in cold air can also cause your coronary arteries (the blood vessels that bring blood and oxygen to your heart) to become narrow. This is known as a spasm of the coronary arteries and may result in angina. Important! You can exercise outdoors in the cold weather if it does not make your heart work too hard. Do not exercise outdoors when the temperature is: below -10 C (15 F) or when the combined air temperature and wind chill is below this level. Chapter 6 Exercise & Cold Weather pg. 34

41 Along with cold temperatures, there are 4 more cold weather hazards that you need to be aware of: 1) Snow and Ice Do not walk on snow covered or icy roads. Walking through snow can increase your level of effort and make your heart work too hard. Walking on ice raises your risk of slipping and falling. 2) Headwind Do not exercise outdoors if there is a strong headwind. A headwind (when the wind is blowing toward you) increases the chance of feeling chilled. It can increase your level of effort and make your heart work too hard. 3) Rain and wet snow Wear proper clothing if you exercise outdoors in the rain or wet snow. Wet clothing will not keep you warm and you will lose body heat. 4) Rapid Weather Changes Bring an extra layer of clothing to exercise outdoors in case the weather changes. When the weather changes from sunny to cloudy, the temperature can drop by 7 o C. How To Exercise Safely In Cold Weather Follow these 7 safety tips when you exercise in cold weather. 1) Check the Weather Report Check the local outdoor temperature at the time of your exercise. Make sure the temperature is above -10 o C with the wind chill. Do not exercise outdoors: When the temperature is below -10 C (15 F) When the combined air temperature and wind chill is below -10 C (15 F) You can get the current temperature with the wind chill from your TV, radio, smartphone or computer. 2) Dress in Layers You can often exercise safely outdoors in the cold weather if you dress right. Dressing in layers can help trap warm air close to your body. Wear layers that will: Chapter 6 Exercise & Cold Weather pg. 35

42 a) Keep You Dry The first layer is to keep you dry. This layer is often called the base layer. A major function of your base layer is to move sweat away from your skin (this is called wicking). Clothes made from a dry wick material (a man-made fabric) is a good choice. You can find shirts, pants, briefs, and bras made from these fabrics that work well as a base layer. Did you know: A 100% cotton t-shirt is the worst type of clothing to wear next to your skin in cold weather? When cotton becomes wet with sweat, it sticks to your body. This means it cannot hold warm air close to your body so your body temperature will lower. Do not exercise in a cotton base layer. b) Keep You Warm The next layer is to keep you warm. A loosely woven wool sweater is a good choice. A loose weave helps to trap warm air close to your body. The oils found in wool help to keep you warm even when your shirt gets wet. c) Protect You Against Rain, Snow and Wind The outer layer protects your legs and upper body against rain, wet snow and wind. It is not ideal to exercise in the rain, wet snow and wind, but you should be prepared to in case the weather changes quickly. Choose an outer layer that is: Water resistant (repels water to keep you dry) Breathable (allows sweat and moisture from inside your clothing to escape) d) Protect Your Head, Hands and Feet Since 20% of body heat is lost from your head, it is important to wear a hat in cold weather. When you breathe cold air, it can cause angina. You can wear a face mask or a scarf over your mouth to help ensure the air you breathe is warmer. Mittens and socks, made from a tight weave wool blend, will protect your hands and feet from frost bite and skin damage. Wear your running shoes to exercise in the cold weather. Do not wear heavy winter boots. Heavy boots will increase your level of effort which makes your heart work harder. If you would like more traction on your shoes, you can attach traction aids to the bottom of each shoe. Chapter 6 Exercise & Cold Weather pg. 36

43 3) Drink Water Drink water before, during and after your exercise. Follow these guidelines to ensure you drink enough water: Drink 6-8 ounces of water (about 175 to 240mL) before exercise Drink 6-8 ounces of water (about 175 to 240mL) every 20 minutes during exercise and after you cool down Do not wait until you feel thirsty to drink Speak to your doctor if you have limits on how much fluid you can have each day 4) Reduce Your Speed and Distance Give your body time to get used to the cold weather. When the outdoor temperature drops quickly, exercise at a lower speed and for a shorter distance for at least one week Use your heart rate and the rating of perceived exertion (RPE) scale to help you adjust how hard you are working while you exercise. Slow your pace of walking if the weather is causing you to work harder Plan your outdoor route to be a short out and back route in case the weather changes during your exercise Ask your Cardiac Rehab team to help you adjust your speed and distance when you exercise in cold weather. 5) Do Not Shovel Snow Many people believe that shovelling snow is a great way to get exercise in the winter. But the effort required to remove snow is equal to non-stop jogging or running. This effort, combined with the added strain on your heart caused by cold weather, will put you at high risk for a heart event. Research says that the highest number of people going to the emergency room for heart problems and sudden cardiac death occur with the first heavy snowfalls of the year. Your risk of having a Chapter 6 Exercise & Cold Weather pg. 37

44 heart attack is higher if you have heart disease, a low level of fitness or if you had a stroke in the past. To protect your heart, ask someone in your household not living with heart disease to shovel the snow. If you do not have someone in your household who can shovel snow, some cities/townships offer a free snow removal service for people living with heart disease or a chronic health problem. Contact your local city/township office to inquire about the snow removal services offered to people living in your area. If your city/township does not offer a free snow removal service, you can also hire a snow removal service or a neighbour. 6) Watch for Symptoms Be aware of symptoms of angina, chest pain, feeling dizzy, irregular (skipped) beats or shortness of breath. If you feel any of these symptoms, slow down your exercise at once. If you have angina, follow the steps to manage angina (Chapter 4 Angina). Speak with your Cardiac Rehab team to see if your exercise prescription needs to be changed. 7) Take a Rest Day Take a rest day if it is too cold to exercise outdoors and it is unsafe to travel to a place where you can exercise indoors. Places Where You Can Exercise Indoors You may choose to exercise indoors in the winter. There are many options to choose from: 1) Health Club or Fitness Centre Health clubs and fitness centres provide indoor exercise equipment such as treadmills, stationary cycles and elliptical machines. Most health clubs and fitness centres allow you to enrol part-time or yearly. Talk to your Cardiac Rehab team for instructions on how to use indoor exercise equipment safely and to get an exercise prescription to use with these machines. Chapter 6 Exercise & Cold Weather pg. 38

45 2) At Home You can purchase exercise equipment to use at home. Talk to your Cardiac Rehab team if you plan to use home exercise equipment. Your Cardiac Rehab team can provide you with an exercise prescription to follow when you use your equipment. 3) Mall Walking Mall walking is a free option to exercise indoors. Talk to your Cardiac Rehab team for a list of maps available. 4) Community Centre Indoor Tracks Many community centres have indoor tracks that you can use. 5) Heart Wise Exercise-Approved Programs Heart Wise Exercise lists fitness centres that offer exercise programs that are safe and wellsuited for people living with heart disease or a chronic health problem. Many centres are now approved by Heart Wise Exercise. A fitness centre that has been approved will have people working there who know how to help people, like you, exercise safely. Your Resources 1) A great resource for more information about snow shovelling can be found at this website: df 2) Contact your local city/township office to inquire about the snow removal services available in your area. 3) For the City of Toronto, you may get more information about free snow removal services available to seniors and the disabled (includes people living with heart disease) by: a. Dialing 311 from a local telephone b. Go on line at Chapter 6 Exercise & Cold Weather pg. 39

46 4) The Weather Network can give you up to date weather conditions for the day. 5) Refer to the Tool Box section of this workbook for more information about Where Can You Do Your Exercise? 6) If walking in a mall, find the mall-map on our website Chapter 6 Exercise & Cold Weather pg. 40

47 Chapter # 7 Exercise & Hot Weather Know how to exercise safely in hot weather You Will Learn: 1) How your body responds to exercise in hot weather 2) How to exercise safely in hot weather 3) About places where you can exercise indoors Chapter 7 Exercise & Hot Weather pg. 41

48 How Your Body Responds To Exercise In Hot Weather When you exercise, your working muscles create heat. This heat is carried around your body through your blood. As your body temperature goes up, the blood vessels near your skin open up and your sweat glands work harder. When your blood vessels open up, it causes more blood to move toward the surface of your skin to release heat from your blood to the air. When heat is released and sweat moves away from your body, your body temperature drops. This is how your body tries to cool down and maintain a healthy temperature of 37 C. When you exercise in hot weather 2 things can happen that can cause your heart to work too hard: 1) The blood close to the surface of your skin cannot release heat because the air is too hot 2) When the air is humid (full of water), it is harder for sweat to move away from your body. Your body will keep sweating to try and cool you down. When you sweat a lot, you lose fluid from your blood. Less fluid in your blood makes your heart work harder to pump blood and oxygen to your working muscles When your blood cannot release heat, and sweat cannot move away from your body, you may overheat (raise your body temperature too high) and become dehydrated (lack fluid in your body). Overheating Symptoms of overheating include: Increased heart rate Undue fatigue Irregular (skipped) beats Feeling dizzy Chapter 7 Exercise & Hot Weather pg. 42

49 Dehydration Dehydration can occur in 3 stages. The third stage is the most severe. The following provides information on the signs and symptoms of each stage: Stage of Dehydration Stage 1 Heat cramps Can occur when you loose too much sodium (salt) from your muscle cells Stage 2 Heat exhaustion Can occur when you are exposed to high temperatures and you do not replace fluids Stage 3 Heat stroke Occurs when your body temperature has risen 39 C or higher This is a medical emergency Call 911 if you have heat stroke Signs and Symptoms Cramps occur in your calves and/or abdomen Early symptoms include fatigue and weakness leading to feeling dizzy, shortness of breath, nausea (feeling queasy) and vomiting You may not be able to sweat You may not be steady on your feet You may be confused and disorientated (lost your sense of where to go) and you may act strangely Know How To Exercise Safely In Hot Weather Follow these 8 safety tips when you are exercising in hot weather. 1) Check the Weather Report Check the local weather report at the time of your exercise, and note the temperature, humidity and the air quality (smog alerts and the air quality health index). Chapter 7 Exercise & Hot Weather pg. 43

50 Check the Heat Safety Index The Heat Safety Index can help you decide if it is safe to exercise and go outdoors. This index uses temperature and percentage of humidity (how much water is in the air) to create four safety zones: safe, alert, danger and emergency. To use this index: Find the current local temperature along the bottom of the scale Find the current percentage of humidity along the left hand border of the scale Find the point on the graph where these two points come together. See what safety zone this point is found in Follow the instructions in the what you do for each heat safety zone chart Heat Safety Index Take Heart, 2004; Dr. T. Kavanagh Chapter 7 Exercise & Hot Weather pg. 44

51 What You Do For Each Safety Zone Safe Alert Danger Emergency Exercise as usual Safe to exercise outdoors Decrease your exercise intensity Watch for symptoms No outdoor exercise Avoid going outdoors Check the Air Quality It is important that you check the air quality before you exercise outdoors. When you check the air quality you are seeing how much air pollution there is. Air pollution happens when many pollutants (a substance that is harmful to your health) are in the air. Air pollution is a health concern for all people. It is an even greater concern for people living with heart or lung disease, older people and younger children. When you check the weather report for air quality, look for: The Air Quality Health Index (AQHI) Air pollution can be measured by the AQHI. This index tells you the level of common air pollutants. In Ontario, the range for the index is 0 to 10. The lower the number, the better the air quality. If you live outside of Ontario, go to your local public health website to find out how your area lists the air quality index. Chapter 7 Exercise & Hot Weather pg. 45

52 Check the air quality index before you exercise outdoors then follow the instructions in the what you do for each air quality category chart. What You Do For Each Air Quality Category? Low Risk 1 to 3 Moderate Risk 4 to 6 High Risk 7 to 10 Very High Risk above 10 Exercise as usual Safe to exercise outdoors Decrease your exercise intensity Watch for symptoms No outdoor exercise Avoid going outdoors Consider rescheduling your outdoor exercise Smog Alerts Smog is a mix of air pollutants that often create a haze in the air. Smog can bother your eyes, nose and throat and cause coughing, wheezing and chest tightness. Environment Canada provides two levels of smog alerts: o A smog watch - issued when there is at least a 50% chance that smog will occur within the next 3 days o A smog advisory (warning) issued when there is a high chance that smog will occur within the next 24 hours Check for smog alerts prior to exercising outdoors. In Canada, smog is often worse between noon and early evening on hot, sunny days between May and September. Do not exercise outdoors during the late afternoon and early evening when smog is at its worst. 2) Dress for the Hot Weather Wear light-coloured and loose fitting clothing to help prevent overheating. Choose a fabric that helps sweat move away from your body. Dry wick (synthetic man-made) fabrics work best Chapter 7 Exercise & Hot Weather pg. 46

53 Wear a light-weight and light-coloured hat or visor to reflect the heat Wear running shoes 3) Do Your Warm Up and Cool Down Warming up and cooling down for 5-10 minutes will reduce your chance of getting symptoms such as angina, chest pain, feeling dizzy, irregular (skipped) beats and shortness of breath. 4) Drink Water Drink water before, during and after your exercise. If you exercise for up to 1 hour, follow the guidelines below: Drink 6-8 ounces of water (about 175 to 240mL) before exercise Drink 6-8 ounces of water (about 175 to 240mL) every 20 minutes during exercise and after you cool down Do not wait until you feel thirsty Speak to your doctor if you have limits on how much fluid you can have each day If you exercise for longer than 1 hour, talk to your Cardiac Rehab team about how much fluid you should drink. 5) Reduce your Speed and Distance Give your body time to get used to the hot weather. When the outdoor temperature goes up quickly, exercise at a slower pace and for a shorter distance for at least one week Use your heart rate and the rating of perceived exertion (RPE) scale to help you adjust how hard you are working while you exercise Plan your outdoor route to be a short out and back route 6) Check Your Medicines Your medicines may need to be changed when the weather becomes hot and humid. Some beta blockers may make it harder for you to sweat Chapter 7 Exercise & Hot Weather pg. 47

54 Diuretics (water pills) may cause a loss of a substance called potassium from your body. Potassium is also lost in sweat. Too much or too little potassium can cause irregular (skipped) beats Diabetes medicines may not work as well in hot weather leading to hypoglycemia (low blood sugar level) or hyperglycemia (high blood sugar level) Ask your doctor or pharmacist if your medicines should be changed in hot weather. 7) Do Not Drink Alcohol Before You Exercise Alcohol acts as a diuretic (makes you pee more often). Peeing often can lower the amount of fluid in your body. With less fluid in your body, there is less blood for your heart to pump to the rest of your body so your heart has to work harder. 8) Watch For Symptoms Be aware of any angina, chest pain, feeling dizzy, irregular (skipped) beats or shortness of breath. If you feel any of these symptoms, slow down your exercise at once. If you have angina, follow the steps to manage your angina (See Chapter 4 Angina). Speak with your Cardiac Rehab team to see if your exercise prescription needs to be changed. Places Where You Can Exercise Indoors 1) At a Health Club or Fitness Centre Health clubs and fitness centres provide indoor exercise equipment such as treadmills, stationary cycles and elliptical machines.. Most health clubs and fitness centres allow you to enrol part-time or yearly. Talk to your Cardiac Rehab team for instructions on how to use indoor exercise equipment safely and to get an exercise prescription to use with these machines. 2) At Home You can purchase exercise equipment to use at home. Talk to your Cardiac Rehab team if you plan to use home exercise equipment. Your Cardiac Rehab team can provide you with an exercise prescription to follow when you use your equipment. Chapter 7 Exercise & Hot Weather pg. 48

55 3) At the Mall Mall walking is a free option to exercise indoors. 4) Community Centre Indoor Tracks Many community centres have indoor tracks that you can use. 5) Heart Wise Exercise-Approved Programs Heart Wise Exercise lists fitness centres that offer exercise programs that are safe and well-suited for people living with heart disease or a chronic health problem. Many centres are now approved by Heart Wise Exercise. A fitness centre that has been approved will have people working there who know how to help people, like you, exercise safely. 6) Take A Rest Day If no indoor options are available, take a rest day. Your Resources 1) Heart Wise exercise facilities Look online to find a centre/facility in your community. 2) The Weather Network or Environment Canada can give you up to date weather conditions (including the air quality) for the day: or or 3) If walking in a mall, find the mall map on our website at: 4) See the Tool Box section of this workbook for more information about Where Can You Do Your Exercise. Chapter 7 Exercise & Hot Weather pg. 49

56 Chapter # 8 Your Heart and Heart Disease Know what happened to your heart You Will Learn: 1) How the heart works 2) About common heart problems and how to manage them Chapter 8 Your Heart & Heart Disease pg. 50

57 About Your Heart Your heart is a muscle that is about the size of your fist. It is slightly to the left of the centre of your chest. Each time your heart beats, it supplies your body with blood and oxygen. Your heart has: A pumping system An electrical system A blood supply Pumping System The pumping system of your heart is made up of 4 chambers and 4 valves. 4 chambers: Two chambers on the right side of your heart (right atrium and right ventricle) Two chambers on the left side of your heart (left atrium and left ventricle) 4 valves: Tricuspid, pulmonary, mitral and aortic valves o Open and close when your heart beats o Keep the blood flowing through your heart in one way Blood is pumped through these chambers and valves. The left ventricle is the main pump and sends oxygen rich blood to your brain and body. Each time your heart contracts (squeezes), it pumps blood into your arteries. The flow of blood passing through your arteries is what you feel when you take your pulse. Chapter 8 Your Heart & Heart Disease pg. 51

58 Electrical System Your heartbeat is controlled by electrical signals. These signals make your heart contract (squeeze) and pump blood out of the heart to the rest of your body. The passage of the electrical signal through the heart can be recorded on an electrocardiogram (see Figure 1). Figure 1. A normal electrocardiogram (ECG) Blood Supply Since your heart is a muscle, it requires its own blood supply so that it is able to contract (squeeze). Oxygen-filled blood is brought to the heart through the coronary arteries. There are four main coronary arteries (see Figure 2) Right coronary artery (RCA) Left main coronary artery (LCA) which splits into two branches: o Left anterior descending (LAD) artery o Circumflex artery Figure 2. Arteries of the heart Chapter 8 Your Heart & Heart Disease pg. 52

59 Common Heart Problems and How to Manage Them Heart disease refers to many types of heart problems. These problems can affect the way your heart beats and how blood moves into and out of your heart. Examples of heart disease include: Coronary artery disease Heart failure Valve disorders Arrhythmias (problems with the rhythm of your heart) Coronary Artery Disease Coronary artery disease is the most common type of heart disease. Coronary artery disease is caused when plaque (a waxy substance made of fat, cholesterol, and calcium) collects over time in your coronary arteries (the blood vessels that bring blood and oxygen to your heart). As plaque collects, it can narrow your coronary arteries and prevent blood and oxygen from getting to your heart. Plaque can start to collect as early as childhood. Risk factors for coronary artery disease include: High blood cholesterol (LDL cholesterol) Diabetes Smoking High blood pressure Lack of physical activity Stress, depression Obesity Family history Chapter 8 Your Heart & Heart Disease pg. 53

60 How Coronary Artery Disease Affects You Coronary artery disease can lead to angina and heart attacks. Angina Your heart needs blood and oxygen. When plaque makes your coronary arteries too narrow, not enough blood and oxygen can get to your heart (see Figure 3 below). A lack of blood and oxygen to your heart can cause pain or discomfort in your chest, jaw, arms, upper back, throat, and/or feelings of shortness of breath or fatigue. This is angina. Angina is a warning sign that your heart is under stress. See Chapter 4 Angina to learn more about angina. 3A 3B Figure 3A. Blocked Artery: Part of this coronary artery is blocked by plaque. The heart does not receive enough blood and oxygen Figure 3B. Normal Artery: Oxygen rich blood flows freely to the heart Heart Attack If your coronary artery is fully blocked, you may have a heart attack (also known as a myocardial infarction). A heart attack occurs when part of the heart does not receive any blood or oxygen and becomes damaged (see Figure 4). When your heart is damaged, it may not be able to pump blood as well. Figure 4. Heart attack in the front part of the heart Chapter 8 Your Heart & Heart Disease pg. 54

61 During a heart attack you may feel some or all of the symptoms listed below: Discomfort, squeezing, pressure, burning or a heavy feeling in your chest Discomfort in your neck, jaw, back, arms and/or shoulder Shortness of breath Sweating Nausea (feeling queasy) Feeling dizzy It is important to know that the symptoms of a heart attack can vary from person to person and between men and women. Although the symptoms listed above are the most common symptoms during a heart attack, some people may feel many of these symptoms while others may not feel any symptoms at all. Some people deny that they are feeling any symptoms. The symptoms of a heart attack can be like the symptoms of angina but more intense. Safety Alert! If your symptoms are not relieved by rest or Nitroglycerin, call or your local emergency department for help. If you are having a heart attack, it is important to get help from a doctor quickly to try to reduce the amount of damage to your heart. How Do I Know If I Have Coronary Artery Disease? There are many tests that can detect coronary artery disease. Some of these tests are included on the following pages: Chapter 8 Your Heart & Heart Disease pg. 55

62 1) Electrocardiogram (ECG) An electrocardiogram (ECG) measures the electrical activity in your heart. By looking at the pattern of electrical activity in your heart, your doctor can: Know if your heart rhythm is normal See if your heart is damaged from a lack of oxygen or a heart attack Figure 5. Electrocardiogram (ECG) 2) Echocardiogram An echocardiogram uses sound waves (ultrasound) to create a picture of your heart. Your doctor will be able to see the shape of your heart, the chambers and valves and how your heart contracts (squeezes). Figure 6. Echocardiogram 3) Holter Monitor A holter monitor tracks your heart rate and rhythm over time. Your doctor may send you for this test if you feel like your heart is beating too hard or too fast (heart palpitations) or feel dizzy. For this test, a healthcare professional will place sticky patches (called electrodes) on your skin. These patches are attached to wires that connect to a small machine. You will likely wear this machine for 24 hours. The holter monitor test is painless and you can move around as you would on a normal day. Chapter 8 Your Heart & Heart Disease pg. 56

63 4) Exercise Stress Test An exercise stress test can show how severe your coronary artery disease is and how much exercise you can do safely. You may complete this test if you have been told you have coronary artery disease. During an exercise stress test, you will walk on a treadmill or cycle on a stationary bike. Your heart rate and rhythm will be tracked by an electrocardiogram (ECG) while you exercise. Figure 7. Exercise Stress Test 5) Nuclear Stress Test A nuclear stress test shows if your heart is getting enough blood and oxygen and where your heart was damaged from a heart attack. For this test, a healthcare professional will add a small amount of a radioactive substance to your blood. The substance travels in your blood to your heart. A special camera that can see the substance will show how much blood is getting to your heart. You may have to do this test before and after you complete an exercise stress test. Figure 8. Nuclear Stress Echo 8A. A heart before exercise. The white line shows the blood that has travelled to the heart. This picture shows that enough blood and oxygen travelled to all parts of the heart. 8A 8B 8B. A heart after exercise. There is no white line here. This picture shows that there is less blood and oxygen at this part of the heart. Chapter 8 Your Heart & Heart Disease pg. 57

64 6) Stress Echo A stress echo will show if any parts of your heart do not get enough blood and oxygen while you exercise. For this test, you will complete an echocardiogram at rest and again during an exercise stress test. An echocardiogram uses sound waves (ultrasound) to create a picture of your heart. Your doctor will be able to see the shape of your heart, the chambers and valves and how your heart contracts (squeezes). 7) Angiogram An angiogram will show how much your coronary arteries have narrowed. For this test, a healthcare worker will insert a thin tube (called a catheter) into a blood vessel in your groin (femoral artery) or wrist (radial artery). The tube is pushed up to the coronary arteries at your heart. Next, a doctor will add a special dye into the tube and watch the dye move into your coronary arteries. Figure 9. Angiogram How is Coronary Artery Disease Treated? There are four ways to treat coronary artery disease: 1) Percutaneous Coronary Intervention (PCI) or Angioplasty Percutaneous Coronary Intervention (also known as angioplasty) is treatment used to widen your artery that is narrowed or blocked by plaque. For this treatment, a doctor inserts a thin tube (called a catheter) into the narrowed or blocked coronary artery. The doctor inflates a small balloon, found at the end of the catheter. As the balloon gets bigger, it presses the plaque outward into the wall of your artery. Chapter 8 Your Heart & Heart Disease pg. 58

65 2) Angioplasty with Stent An angioplasty with stent follows the same steps as described in Percutaneous Coronary Intervention (angioplasty), but includes a stent. A stent is a mesh tube that is placed in a narrowed artery to hold it open. In this treatment option, the balloon presses the stent against the wall of your artery. The catheter with the balloon is taken out of your artery and the stent remains to hold your artery open and improve blood flow to your heart. Figure 10. Angioplasty with stent 3) Coronary Artery Bypass Graft Surgery (CABG) Coronary artery bypass graft surgery is a treatment that allows more blood and oxygen to get to your heart. In this treatment, a surgeon takes a section of a healthy blood vessel from your leg, arm or chest and connects (grafts) it to your blocked coronary artery. The healthy blood vessel allows blood to take a new path around (bypass) the blockage. Figure 11. Coronary artery bypass surgery Chapter 8 Your Heart & Heart Disease pg. 59

66 4) Cardiac Medicines Many people who have coronary artery disease are prescribed cardiac medicines. Common cardiac medicines include: Anti-platelets, aspirin Cholesterol lowering agents Beta blockers ACE inhibitors Nitrates See Chapter 9 Cardiac Medicines for more information. 5) Exercise Doing regular exercise will decrease the chances of your coronary artery disease getting worse. Do aerobic exercise and resistance training as prescribed by your Cardiac Rehab team. See Chapter 3 Aerobic Exercise and Chapter 12 Resistance Training for more information. Other Heart Conditions Heart Failure The following is only a small amount of information about heart failure. If you have heart failure it is important that you understand how severe your medical condition is and how to best manage it. Learn what a normal feeling for you is and seek medical attention if you are not feeling like your normal self. Speak to your doctor and your Cardiac Rehab team for more information. What is Heart Failure? Heart failure is a type of heart disease that occurs when the chambers of your heart are damaged. When the chambers are damaged: 1) Your heart cannot pump enough blood and oxygen to the rest of your body Chapter 8 Your Heart & Heart Disease pg. 60

67 This means your body does not get the blood and oxygen it needs to work well 2) Your heart cannot fully relax to let blood return from the rest of your body to your heart This means that fluid collects in your lungs and other parts of your body such as your feet, ankles and legs What are the Symptoms of Heart Failure? Common symptoms of heart failure include: Shortness of breath Swollen feet, ankles and legs Sudden weight gain What are the Treatments for Heart Failure? Treatments for heart failure include: medicine, surgery, diet and exercise. Talk to your doctor to understand: Your medicines How much fluid you can drink When you should call your doctor or seek immediate medical attention What type of surgery is available to you Talk to your Cardiac Rehab team to understand: How to exercise safely How to lower the amount of salt (sodium) in your diet Valve Disorders There are 4 valves in your heart: tricuspid, pulmonary, mitral and aortic. Working valves are like doors that ensure that blood flows only one way through the chambers of your heart. Chapter 8 Your Heart & Heart Disease pg. 61

68 If you have a valve disorder, your heart may have to work harder and the valves may not be able to control the flow of blood through your heart. There are 3 types of valve disorders. 1) Stenosis or Narrowing The valve cannot open in the right way. If your valve has narrowed, your heart has to work harder to pump blood. Figure 12. Valves in the heart 2) Prolapse (falls out of place): If your valve is prolapsed, the flaps of the valve do not close smoothly. 3) Regurgitation If you have regurgitation, your valve does not seal when it closes. What are the Symptoms of Valve Disorders? The most common symptom of valve disorders is shortness of breath. You may also have chest discomfort, palpitations (feels like your heart is beating too hard or too fast), and/or feel faint. What are the Treatments for Valve Disorders? If your valve disorder is severe, you may require surgery to repair or replace your valve. Arrhythmia (Irregular Heartbeat) A normal heartbeat is steady - one beat after the other. When you take your pulse, you are counting your heart rate and feeling the heart rhythm. Earlier in this chapter you learned about electrical signals that cause the heart to beat. If there is a problem with how the electrical signal starts or moves through your heart, your heart may beat too slowly, too fast or too early. See Chapter 5 Irregular Heartbeats for more information. Your Resources 1) Heart & Stroke Foundation: or Mayo: Chapter 8 Your Heart & Heart Disease pg. 62

69 Chapter # 9 Cardiac Medicines Know what medicines you are taking Know why you are taking these medicines You Will Learn: 1) What cardiac medicines you are taking 2) The benefits, actions and common side effects of your medicines 3) Who to ask for more information Chapter 9 Cardiac Medicines pg. 63

70 Why Are Cardiac Medicines Important? People with heart disease often take medicines to improve and manage their health. Your doctor will decide on the best treatment combination of medicines for your condition and situation. Your pharmacist will then work with you to ensure that the medicines you use are the most effective. Some of these medicines need to be taken for the rest of your life. Side Effects Most patients experience side effects (an unwanted response) with some of their medicines. It s important to discuss any concerns you have with your doctor or pharmacist. You and your doctor can discuss the benefits of the medicine and potential side effects. MedsCheck Program - Medicines Shouldn't Be Confusing MedsCheck is a program that allows you to schedule a 20 to 30 minute one-to-one meeting with your community pharmacist to ensure that you are safely and appropriately using all types of medicine. And it s free! Just bring your OHIP card. The MedsCheck appointment is your chance to discuss how your prescription, over-the-counter and alternative medicines may be affecting each other. -Ontario Ministry of Health and Long-Term Care Classes of Medicines Medicines are divided into classes. Each class does something different to help manage your condition. On the following pages we have listed: The class of medicine The benefits of taking the medicine What the medicine does (the action) Side effects Common names of the medicines o Brand names are listed for information only. UHN s Cardiovascular Prevention & Rehabilitation Program is not recommending or endorsing any specific medicines Chapter 9 Cardiac Medicines pg. 64

71 1) Anticoagulants (blood thinners) Benefits Help prevent blood clotting to prevent harmful clots forming in the blood vessels Often prescribed to lower the risk of stroke in patients with artificial heart valves or atrial fibrillation Action Decreases blood clotting Side effects Nosebleeds, easy bruising or bleeding (gums) Common names Warfarin Coumadin Heparin (in hospital) Dabigatran (Pradax) Rivaroxaban (Xarelto) Note: If this medicine (e.g., Warfarin/Coumadin) is new, your doctor will send you for weekly or monthly blood tests to ensure you are taking the correct doses. Foods rich in vitamin K may interfere with these drugs, including green leafy vegetables. Avoid sudden changes in the amount you eat each day. 2) Antiplatelet Agents (blood thinners) Benefits Used to reduce the risk of dangerous blood clots forming in the body that may cause a heart attack or stroke May be prescribed for patients who are at risk of having a heart attack Action Prevent the blood platelets (cells) from sticking together and forming clots Side effects Easy bruising, nausea (upset stomach) Vertigo, ringing in ears (tinnitus), light-headedness Abdominal pain, bleeding ulcers (black tarry stool) Impaired kidney or liver function Common names Acetylsalicylic acid, ASA (Aspirin) Clopidogrel (Plavix) Ticlopidine (Ticlid) Chapter 9 Cardiac Medicines pg. 65

72 3) ACE Inhibitors Benefits May prevent further damage to the heart muscle after a heart attack Prescribed for patients with high blood pressure or heart failure Action Expands (opens up) blood vessels to lower blood pressure and improve the amount of blood the heart pumps Side effects Dry cough (very common) Rapid swelling of the lips or face Low blood pressure Dizziness, nausea, headache Common names Ramipril (Altace) Enalapril (Vasotec) Quinapril (Accupril) Fosinopril (Monopril) Trandolapril (Mavik) Perindopril (Coversyl, Aceon) Lisinopril (Prinivil, Zestril) 4) Angiotensin II Receptor Blockers/Inhibitors Benefits Prescribed for patients with signs and symptoms of high blood pressure and heart failure Prescribed when ACE inhibitors are not tolerated Action Keep blood vessels relaxed, which increases the supply of blood and oxygen to the heart muscle and prevents blood pressure from rising Side effects Nausea, headaches Low blood pressure (dizziness) Common names Losartan (Cozaar) Telmisartan (Micardis) Irbesartan (Avapro) Candesartan (Atacand) Valsartan (Diovan) Chapter 9 Cardiac Medicines pg. 66

73 5) Beta Blockers Benefits Lower blood pressure Reduce the chance of another heart attack or experiencing angina (chest pain) Prescribed for patients with abnormally fast heart rates (tachycardia) and irregular rhythms Action Lower blood pressure and make the heart beat more slowly and with less force Side effects Slow heart rate Low blood pressure Dizziness, headaches Worsening of asthma symptoms Masks signs of hypoglycemia (low blood sugar) Depression Sleep disturbance (nightmares) Sexual dysfunction (impotence) Lack of energy, fatigue Common names Atenolol (Tenormin) Sotalol (Betapace, Sotacor) Bisoprolol (Monocor) Metoprolol (Lopressor Betaloc, Toprol XL) Carvedilol (Coreg) Acebutolol (Monitan, Sectral) Timolol (Blocadren) Nadolol (Corgard) Chapter 9 Cardiac Medicines pg. 67

74 6) Calcium Channel Blockers Benefits Control high blood pressure Control irregular heartbeats Reduce angina (chest pain) Action Relax (open) blood vessels to improve blood flow to the heart Side effects Facial flushing Edema (ankle swelling) Headache, nausea, dizziness Common names Amlodipine (Norvasc, Lotrel) Diltiazem (Cardizem, Tiazac) Felodipine (Plendil) Nifedipine (Adalat, Procardia) 7) Diuretics (Water Pills) Benefits Help to manage high blood pressure Help to manage heart failure Action Help the body to get rid of extra fluid. This lowers the amount of work the heart has to do Reduce extra fluid buildup in the lungs, lower legs and ankles Side effects Low blood pressure Electrolyte imbalance (low potassium, low magnesium, low sodium) Common names Spironolactone (Aldactone) Furosemide (Lasix) Hydrochlorothiazide HCTZ Chlorothiazide (Diuril) Indapamide (Lozol, Lozide) Note Take this pill in the morning It will cause multiple trips to the bathroom during the day, but will help to avoid disruption to your sleep at night Chapter 9 Cardiac Medicines pg. 68

75 8) Nitrates Benefits Help relieve angina (chest pain) Action Relax (open) blood vessels to allow blood (and oxygen) to flow more easily Side effects Fainting or dizziness when sitting up or standing up too quickly Low blood pressure Headaches, flushing Common names Nitroglycerine sublingual or (Nitrostat) Nitropatch (Nitrodur, Transderm-Nitro) Nitroglycerine sublingual* spray or (Nitrolingual pump spray) Nitropaste (Nitrol) Hydralazine (Apresoline) Isosorbide dinitrate (Isordil) *sublingual means under the tongue Note Available in pills, spray, patches 9) Cholesterol Lowering Agents A. Statins Benefits Prescribed for patients with high cholesterol at risk of heart disease, stroke or diabetes Lower LDL (bad) cholesterol Raise HDL (good) cholesterol Lower triglyceride levels (TG) Action Prevent the liver from producing too much cholesterol Side effects Muscle pain, muscle weakness Abnormal liver function, allergic reaction (skin rashes) Heartburn, dizziness Common names Rosuvastatin (Crestor) Pravastatin (Pravachol, Pravigard) Simvastatin (Zocor) Atorvastatin (Lipitor) Lovastatin (Mevacor) Note Increased muscle pain and weakness can be a sign of a serious side effect and should be reported to your physician immediately Chapter 9 Cardiac Medicines pg. 69

76 10) Cholesterol Lowering Agents B. Resins Benefits Prescribed for patients with high cholesterol or those at risk for heart disease, stroke or diabetes Action Work inside the intestine, lowers the body s supply of cholesterol Side effects Constipation, gas, upset stomach Common names e.g., Cholestyramine (Questran, Questran Light) Note Any cholesterol-lowering medicine can cause muscle pain, muscle weakness, abnormal liver function, allergic reaction (skin rashes), heartburn, dizziness or abdominal pain. 11) Cholesterol Lowering Agents C. Nicotinic Acid Benefits Lowers LDL (bad) cholesterol Raises HDL (good) cholesterol Action Blocks the production of cholesterol in the body Side effects Flushing (reddening of skin), Itching, tingling, headache Common names e.g., Niaspan (Niacor) 12) Cholesterol Lowering Agents D. Fibrates Benefits Prescribed for patients with high LDL (bad) cholesterol and triglycerides and low HDL (good) cholesterol Action Block the production of certain types of cholesterol Increase HDL (good) cholesterol Side effects Stomach pain, gas, heartburn Common names Fenofibrate (Lipidil) Bezafibrate (Bezalip) Gemfibrozil (Lopid) Chapter 9 Cardiac Medicines pg. 70

77 Combination Therapy Some people may be prescribed combination drugs containing two different cardiac medicines. Some examples of the commonly prescribed medicines are: Drug Name Contains the Following Medicines Adalat XLPlus Nifedipine (calcium channel blocker) and ASA (anti-platelet) Coversyl Plus Perindopril (ACE inhibitor) and Indapamide (diuretic) Caduet Amlodipine (calcium channel blocker) and Lipitor (cholesterol lowering) Hyzaar Cozaar (ARB) and HCTZ (diuretic) Atacand HCT Atacand (angiotensin II receptor antagonist) and HCTZ (water pill) ASA = Acetylsalicylic Acid (Aspirin) ARB = Angiotensin II Receptor Blocker ACE inhibitor = Angiotensin Converting Enzyme inhibitor HCTZ = Hydrochlorothiazide Your Resources 1) Your local pharmacist can help you with the MedsCheck program or Contact INFOline or TTY ) The Heart and Stroke Foundation Home->Health Information -> Heart disease-> Treatment-> Medicines Chapter 9 Cardiac Medicines pg. 71

78 Section #2 Develop Skills to Take Care of Your Heart Chapter Topic Page # 10 Controlling Your Risk Factors Goal Setting & Action Planning Resistance Training Nutrition Fats, Cholesterol and your Diet Nutrition Benefits of Fibre and Plant Food Nutrition - Reading Food Labels Nutrition Sodium and Blood Pressure Stress & Your Heart Sexual Intimacy 144

79 Chapter # 10 Controlling Your Risk Factors Know what puts you at risk for cardiovascular disease You Will Learn: 1) What risk factors are 2) To identify your risk factors for heart disease 3) How you can control your risk factors Chapter 10 Controlling Your Risk Factors pg. 72

80 Risk Factors Risk factors are facts and habits that make you more likely to get a disease or make a disease you have worse. There are two types of risk factors: 1) Risk factors you cannot change or control are called non-modifiable risk factors: Age Gender Family history Ethnicity Your genes 2) Risk factors you can change and control are called modifiable risk factors: Low level of activity (this includes sitting too much) Not eating well (balanced, healthy food) Stress Smoking High blood pressure High cholesterol levels High blood glucose (sugar) levels Large waist size Modifiable Risk Factors for Heart Disease If you manage the risk factors that are within your control (your modifiable risk factors ), you will reduce your risk. Learn Your Modifiable Risk Factors The first step to control your modifiable risk factors is to know which risk factors you have. Once you know your risk factors, your doctor and Cardiac Rehab team can help you make lifestyle changes to control them. Chapter 10 Controlling Your Risk Factors pg. 73

81 What is a Risk Factor Profile Tool? When you look at the Risk Factor Profile tool (on the next page), notice how it: 1) Lists 8 modifiable risk factors 2) Shows you the healthy target for each risk factor 3) Has space for you to enter what you do compared to the healthy target 4) Will help you describe your modifiable risk factors How Do I Use the Risk Factor Profile Tool? Step 1: You will be given a copy of this tool during one of your exercise classes Step 2: Complete your Risk Factor Profile tool with your Cardiac Rehab team and your doctor Step 3: Notice what risk factors you have Step 4: Ask your family doctor and Cardiac Rehab team how they can help you control your risk factors Step 5: Bring a copy of your Risk Factor Profile tool to your appointments with your doctor Step 6: If you use the Risk Factor Profile tool over time, you will see how your efforts to make changes are helping to reduce your risk. Update your Risk Factor Profile every 3 to 6 months. Chapter 10 Controlling Your Risk Factors pg. 74

82 Modifiable Risk Factor Physical Inactivity Nutrition Stress Desirable Level My Level My Level My Level Daily Active Living (sit less, move more) Aerobic exercise Moderate to vigorous intensity, minutes 5 times/week Resistance training exercise Moderate intensity, reps, 2-3 times/week Fat: less than Sodium: Fibre: at least 30 30% of daily less than grams/day calories 1500 (<7% Cal from saturated fat; <1% mg/day Cal from trans fat) Coping well with: depression distress chronic stress sleep apnea disturbed sleep stressful life event lost sense of control To find out your heart stress risk, go to this website or see psychological services Smoking Avoid smoking and exposure to second hand smoke Blood pressure Less than 140/90 mmhg Living with diabetes: less than 130/80 mmhg Cholesterol LDL Less than 2.0 mmol/l or 50% or more reduction Cholesterol/HDL ratio Less than 4.0 HDL Greater than 1.0 mmol/l Triglycerides Less than 1.7 mmol/l Blood glucose Fasting blood glucose A1c 4 to 5.6 mmol/l Living with diabetes: 4 to 7 mmol/l Living with diabetes: less than 7% for most Waist size General guideline Men <102 cm (40 ) Women <88 cm (35 ) European, Sub- Saharan African, Eastern Mediterranean and Middle Eastern Men <94 cm (38 ) Women <80 cm (32 ) South Asian, Chinese, Japanese, South & Central American Men <90 cm (36 ) Women <80 cm (32 ) Chapter 10 Controlling Your Risk Factors pg. 75

83 What If I Have Many Risk Factors? Your risk for heart disease is higher when you have more than one risk factor. You will learn the number of modifiable risk factors that you have once you complete your Risk Factor Profile tool. There are certain groups of risk factors that can worsen your health and further increase your risk for heart disease. Metabolic syndrome is the name of a health problem that occurs when you have a certain group of risk factors. Metabolic Syndrome Metabolic syndrome is a group of certain risk factors that increase your risk of getting heart disease and diabetes. You have metabolic syndrome if you have 3 or more of the risk factors below and they are not controlled. High blood pressure Low HDL (good cholesterol) High triglycerides (a type of fat in your blood) High fasting blood glucose (sugar) Large waist size Once you complete your Risk Factor Profile your doctor will know if you have metabolic syndrome. Work with your family doctor and Cardiac Rehab team to control your risk factors. Emerging Risk Factors Emerging risk factors are the facts and habits that seem to lead to a disease but more research is needed to confirm if they do. Many research studies have been done to learn if there are other risk factors for heart disease. These studies found 8 emerging risk factors. 1) C-reactive Protein (CRP) C-reactive protein (CRP) is an inflammatory marker found in your blood. If you have CRP in your blood, it means that something harmful happened in your body (such as damage to your arteries) and now your body is trying to fix the problem. Chapter 10 Controlling Your Risk Factors pg. 76

84 2) Infection Viruses and other things that cause infection can damage your arteries. When your arteries are damaged, plaque can start to collect on the wall of your arteries. Unknown infections can also lead to heart failure. 3) Gum Disease Gum disease can happen because of lifestyle habits. These same lifestyle habits can lead to heart disease. 4) Homocysteine Homocysteine is a substance found in your blood. When your homocysteine levels are high, 3 problems may occur: Plaque can collect in your arteries More clots may form in your blood Your arteries may become stiff and hard All 3 of these problems make it hard for blood to flow through your arteries. 5) Calcium Content of Coronary Arteries Recall that your coronary arteries bring blood and oxygen to your heart. If you have a substance called calcium in your coronary arteries this means that you have plaque in your arteries. High levels of calcium in your coronary arteries may mean you are more likely to have a heart attack. 6) Ethnic Background People with ethnic backgrounds listed below get heart disease more often: South East Asians Chinese African Americans Aboriginal communities 7) Lp(a) Lipoprotein Lp(a) lipoprotein is substance found in your blood that is like LDL (bad) cholesterol. If you have a high level of Lp(a) lipoprotein, you may be more likely to get early heart disease. Lp(a) lipoprotein can also cause blood clots to form. Chapter 10 Controlling Your Risk Factors pg. 77

85 8) Early Menopause Women who go into early menopause are twice as likely to have a heart attack or stroke. How to Take Control of Your Risk Factors Recall that your modifiable risk factors are the risk factors that you can do something about. There are 4 things you can start doing to take control of your risk factors: 1) Take your medicines as prescribed by your doctor 2) Exercise regularly and be active everyday 3) Eat a healthy diet 4) Manage your heart stress risks Your Cardiac Rehab team made tip sheets that describe how to control each modifiable risk factor. These tip sheets will tell you: What the risk factor is The healthy target for the risk factor Why it is a risk factor What you can do to control the risk factor See Tool Box Risk Factor Tools for a Tip Sheet on each of the modifiable risk factors Your Resources 1) See Tool Box Risk Factor Tools section of this book for: a. A Tip Sheet on each of the modifiable risk factors b. Blood Pressure Tracking Form c. Blood Sugar Tracking Form 2) Heart and Stroke Foundation website on risk factors for heart disease: Chapter 10 Controlling Your Risk Factors pg. 78

86 Chapter # 11 Goal Setting & Action Planning Take control of your health by setting goals and building action plans You Will Learn: 1) The steps to set a goal and build an action plan 2) How to solve problems that may get in your way Chapter 11 Goal Setting & Action Planning pg. 79

87 Self-Management Part of living well, coping and thriving with a chronic health condition like cardiovascular disease means being an active self-manager. Being an active self-manager means learning and applying the skills to take care of your health. You have a key role in learning and applying these skills. What Does It Mean To Be A Self-Manager? 1) Make Healthy Lifestyle Choices To be a self-manager, you may need to make some changes. These changes may affect many areas of your life: Exercise habits Eating habits How you deal with stress and emotions Sleep habits Taking your medicine Areas other than your health 2) Get Support You are not alone in this. To be a successful self-manager, partner with others in your care. Get support from: Your health care team (i.e., your doctor, Cardiac Rehab team and other health professionals) Family and friends Others living with cardiovascular disease Research on Being a Self-Manager The thought of making changes in your life can seem like too much to handle and can sometimes even make you feel fearful. How can you: Be a self-manager? Take control of your health? Chapter 11 Goal Setting & Action Planning pg. 80

88 Make lifestyle changes? Research says that you should learn the skills of setting goals and building action plans. Steps to Change Research confirms that the best way to make changes in your life is to: 1) Define your vision 2) Set goals 3) Build action plans Define Your Vision Picture yourself in the future and ask yourself these questions: 1) What do you want to feel like in the future? Examples I want to feel good, feel healthy I want to have more energy I want to be happy I want to feel connected with family 2) What do you want to do differently in the future? Examples I want do all of the activities I need to do each day I want to be able to play with my grandchildren I want to be able to play golf or some other sport you like to do I want to volunteer Chapter 11 Goal Setting & Action Planning pg. 81

89 It is important to define your vision so that you know what you are working towards. In the next section you will learn how to set goals to help you work towards your vision for the future. Some people post their vision in a place in their home or office so they can see it each day and remember why they are working so hard on changing their lifestyle habits. Write your vision statement here: Example of a Vision Statement I want to have more energy and be healthy so that I can play with my grandchildren. Set Your Goals Once you have a vision for yourself, you may need to make changes in your life to meet your vision. Setting goals for this change is a way to help you get there. You may need to set a few goals to get to your vision. Steps to Change Define your vision Set goals Build action plans Chapter 11 Goal Setting & Action Planning pg. 82

90 Answer the following questions to set your goals: What has to happen to achieve your vision? There could be a few things. If we use the example of a vision to have more energy and be healthy, the following goals may help sleep better eat healthy exercise regularly manage stress As you achieve your goals, you will get closer to reaching your vision. Using the example above, as you start to sleep better, eat healthy, exercise regularly and manage your stress you will have more energy and be healthier. As you write your goals down you may feel overwhelmed by the amount of change you need to do to achieve your vision. You may be wondering where to start. It is important to pick one goal to get started. Do not try to make too many changes at once. Choose one goal to work on now, then answer the questions below. The one goal I plan to work on is: Example To exercise regularly 1) List the reasons why you want to reach this goal. Think about how your life will change if you reach this goal. Chapter 11 Goal Setting & Action Planning pg. 83

91 Write down your reasons why you want to reach your goal: Examples of reasons why exercising regularly is important I will feel better physically and mentally I will sleep better I will have more energy I will be able to carry the groceries from the car into the house more easily 2) How important is this goal right now? Circle a number on the scale below Not very important 10 Very Important It is important that you believe this is important to work on. Your rating should be 7 or higher to be successful. 3) How confident are you that you can achieve this goal? Circle a number on the scale below Not very confident 10 Very Confident It is important that you believe you can do this. Your rating should be 7 or higher to be successful. Chapter 11 Goal Setting & Action Planning pg. 84

92 4) How ready are you to work on this goal? Circle a number on the scale below I am not ready I am almost ready I am very ready 10 It is important that you believe you are ready to do this. Your rating should be 7 or higher to be successful. You are more likely to achieve your goal if you: 1. Believe your goal is important 2. Feel confident you can do it, and 3. Feel ready to work on the goal Making Your Goal Detailed Once you know your goal, write it down. To ensure your goal is detailed enough, ask yourself these questions: How will I know I have reached my goal? Example of Exercising Regularly I will know I have reached my goal to exercise regularly when I am walking for 30 minutes, 5 days each week Chapter 11 Goal Setting & Action Planning pg. 85

93 Can I do what it takes to reach my goal? Example of Exercising Regularly If I take it slow and start with 10 to 15 minutes of exercise 3 days per week and build up from there then I think I can do this! Is this goal going to help me reach my vision? Example of Exercising Regularly Yes, if I exercise regularly I will be fitter and healthier and have more energy to play with my grandchildren. When do I want to achieve this goal? (Have I given myself enough time?) Example of Exercising Regularly I want to achieve this goal in 3 months. This is a reasonable amount of time to talk to my Cardiac Rehab team about exercise, find out what kind of exercise I like, buy a pair of running shoes, figure out where I am going to exercise and slowly build the habit of regular exercise. Chapter 11 Goal Setting & Action Planning pg. 86

94 Building Weekly Action Plans & Problem Solving In the last section you learned how to set a goal(s) to help you achieve your vision for the future. In this section you will learn how to build weekly action plans to achieve your goal(s). Steps to Change Define your vision Set goals Build action plans Many people feel overwhelmed by the amount of change they need to make to get healthier. You may feel less anxious if you break what you need to do into smaller steps each week. Action plans will help you focus on what you need to do on a weekby-week basis. They outline the actions and behaviours you will take each week to get to your goal(s). Action Plans are: Related to the goal(s) you have set Detailed Action based, which means they outline what you will do Reviewed weekly Steps to Building Your Action Plan: Each week, answer the questions below: What am I going to do? When am I going to do it? Where am I going to do it? How much am I going to do it? How often am I going to do it? Chapter 11 Goal Setting & Action Planning pg. 87

95 This week I will Fill in the blanks: (what) (Example: walk) (when) (Example: after dinner) (where) (Example: around the block) (how much) (Example: 15 minutes) (how often) (Example: 3 days this week) What do you have to do in order to make what you want to do happen? Write what you need to do here: Using the example above I will need to schedule 3 days in my calendar How confident are you that you can carry out your action plan this week? Choose a number on the scale below. My confidence that I can do this plan is: not very confident 10 very confident Chapter 11 Goal Setting & Action Planning pg. 88

96 Remember: It is important that you believe you can do this. Your rating should be 7 or higher to be successful. If your rating is 6 or less, then you may want to learn more about the area you wish to target, or do more to prepare yourself to work on that area. Setting smaller action plans may also help you feel more confident and ready to get started. For example, you may adjust parts of your action plan such as how much or how often. Review Your Action Plan On a weekly basis, think about how you did with your action plan. Ask yourself: What went well with last week s action plan? What did not go as planned with last week s action plan? If you achieved your action plan that is great. Now make a new plan for the week to keep moving toward your goal(s) and vision. If something got in the way of achieving your action plan this week, don t worry. It can take many months up to a year to build healthy habits that last. An important skill to learn is how to problem-solve when you get off track. Problem solving is one of the ways you can take charge of your life and keep moving toward your goal(s). Problem Solving You may find that your weekly action plan does not always go as planned. Problem solving is a key skill to learn so that when problems come up, you know how to deal with them. Here are some steps to follow when things do not go as planned: 1) Describe the problem 2) What stopped you from doing your action plan? 3) Brainstorm and think about other ways to achieve your plan 4) Pick one idea to try 5) Build your next action plan 6) Try a new idea if the first idea did not work Chapter 11 Goal Setting & Action Planning pg. 89

97 Summary of Steps to Achieve Your Vision, Goals & Action Plans Chapter 11 Goal Setting & Action Planning pg. 90

98 Your Vision Your Goal Your Action Plan This week I will: (What) (When) (Where) (How much) (How often) My confidence rating that I can do this plan is: not confident at all totally confident Chapter 11 Goal Setting & Action Planning pg. 91

99 Chapter # 12 Resistance Training Know how to safely build the strength of your muscles You Will Learn: 1) What resistance training is and how it can help you 2) What equipment you can use and how your program is developed 3) How to progress your resistance training program Chapter 12 Resistance Training pg. 92

100 Resistance Training and How It Can Help You Resistance training is a type of exercise that improves the strength of the muscles in your body. This is done by lifting light to moderate weights (using dumbbell weights or a resistance training machine), using your body weight as resistance, or using exercise bands. Research says that doing resistance training 2-3 times per week can make your muscles stronger and able to work for a longer time. Doing both aerobic and resistance training can help you make the most gains in your fitness. How Resistance Training Can Help You As you get older, your muscles change. For many people, these changes begin as early as 30 years of age. As you get older: You lose about 30% of your muscle mass. You lose strength (since you have less muscle mass) The loss of muscle mass and strength that happens as you get older can worsen your health. The good news is that resistance training can slow down the process of losing your muscle mass and strength. Chapter 12 Resistance Training pg. 93

101 Resistance training can also: Improve your fitness Improve your balance and reduce falls Help you live on your own for longer Improve your mood and reduce depression Improve your sleep Resistance training also helps people manage chronic disease: Prevents and reduces joint pain and swelling with arthritis Reduces heart disease risk factors like, high triglycerides, high blood pressure Helps manage blood sugar and reduce complication from diabetes Decreases muscle pain and fatigue with fibromyalgia Improves the health of your bones to delay/prevent osteoporosis Who Can Do Resistance Training? Everyone can do resistance training. It is never too late to start. Tell your Cardiac Rehab team if you have any of the health problems listed below. Your team will prescribe a resistance training program that is safe for you. High blood pressure Abdominal or inguinal hernias that have not been repaired Glaucoma that is not treated Problems with your eyes from diabetes Muscle/joint problems Find it hard to get up from the floor What Kind of Equipment Can You Use? There is a variety of equipment for resistance training. The following options can be purchased: Chapter 12 Resistance Training pg. 94

102 Dumbbell weights or free weights are common pieces of equipment to use for resistance training. They can be purchased in different materials, including rubber, cast iron or plastic. Resistance training machines are the pieces of equipment usually found in a gym. They incorporate a weight stack and pulley system that gives you resistance against a fixed movement. Exercise bands can be used for resistance training and may be a good choice if you do not have a lot of room to store equipment. Each band colour equals a certain amount of resistance. The lighter the colour, the less resistance on the band. How Your Resistance Training Program is Developed The FITT principle that is used to design your resistance training program. Frequency Intensity Type Time Chapter 12 Resistance Training pg. 95

103 F: Frequency- How often do I exercise? For best results try for 2 to 3 times per week Make sure you take a rest day in between to recover I: Intensity- How hard do I exercise? Your Cardiac Rehab team will assess your fitness level and then tell you how hard to work during your resistance exercises by giving you the: 1) Amount of Weight to Lift Your Cardiac Rehab team will tell you how much weight to lift for each exercise you do. You might begin your program by using your body as resistance or by using a weight that you can lift 10 times. If you are using an exercise band, your team will tell you which colour of band to start with. 2) Number of Repetitions A repetition (rep) means doing the exercise 1 time. Example: 1 dumbbell row is 1 repetition; 10 dumbbell rows are 10 repetitions. 3) Number of Sets A set refers to a certain number of repetitions without stopping. Example: 10 dumbbell rows make 1 set. 4) Number of Circuits A circuit is a series of exercises. Example: A circuit could include 1 set of 10 repetitions for 10 exercises 3 Ways to Check How Hard You Are Working Since it can still be a challenge to know if you are putting in the right amount of effort, there are 3 ways to check how hard you are working while you do your resistance exercises: 1) Ensure You Can Breathe While Lifting the Weight Chapter 12 Resistance Training pg. 96

104 The weight is too heavy if you need to hold your breath to lift it. Do not lift weights that cause you to hold your breath. Holding your breath can increase your blood pressure 2) Use the Rating of Perceived Exertion (RPE) Scale Use the Borg Rating of Perceived Exertion (RPE) scale to rate your effort. Rate your effort when you complete the last repetition of each set. During resistance training, the best level for your RPE is between 11 and 16 See Chapter 2 Safe Exercise for more information on how to use the RPE scale 3) Watch for symptoms If you follow your exercise prescription, you should not feel unwell. You are working too hard if you feel any of the symptoms listed below: Angina Irregular heartbeats Feel dizzy Shortness of breath Muscle or joint pain If you feel any of these symptoms, slow down your exercise at once and follow the steps to manage your symptoms. Speak with your Cardiac Rehab team to see if your exercise prescription needs to be changed. T: Type- What kind of exercise is part of resistance training? Your resistance training program will include 10 exercises that are safe and will work all your major muscle groups. Your Cardiac Rehab team will work with you to decide what equipment (for example, dumbbells, weight machines or exercise bands) will work best for you to complete your exercises. Your Cardiac Rehab team may adapt these exercises to ensure they are safe for you. T: Time- how long do I exercise for? It will likely take you about 20 to 30 minutes to complete your program. Chapter 12 Resistance Training pg. 97

105 Safety Tips For Resistance Training Warm up by walking for 5-10 minutes before you begin your resistance exercises Use the proper technique for each exercise Perform exercises slowly and breathe in your normal way. Do not hold your breath. Lift the weight to a count of 2 and lower to a count of 3 Keep your RPE between 11 and 16 Rest for seconds between each set Cool down for 5-10 minutes when you finish your resistance exercises Stretch after you cool down Make sure you take a rest day in between to recover Stop your exercise if you have any symptoms of: angina, irregular heartbeats, feeling dizzy, shortness of breath or muscle or joint soreness Muscle Soreness and Stiffness Soreness and stiffness in your muscles is normal when you begin your resistance training. Soreness and stiffness may begin many hours after you do your exercises and can last up to 4 days. Do not train if the soreness or stiffness lasts longer than 4 days. This may be a sign that you have lifted too much weight or used the wrong technique. Discuss this with your Cardiac Rehab team before doing more. How to Progress Your Resistance Training Program It is important to progress your resistance training program to keep making gains in your health. As your muscles get stronger you will be able to do your exercises with ease. At this point you can either: 1) Increase the number of repetitions you do (lift the weight more times) 2) Lift more weight You will work with your Cardiac Rehab team to progress your exercise program. First, count how many repetitions you can do with ease then follow the steps described below: Chapter 12 Resistance Training pg. 98

106 You can progress your exercise program by doing more sets. Most people will begin their exercise program doing 1 set of each exercise. You can increase to 2 over many weeks. Talk to your Cardiac Rehab team about how to increase the number of sets you do safely. Using Exercise Bands If you are using exercise bands for resistance training, use the colour of the band to know which band is easier or harder to use. For common brands of exercise bands, the lightest colour is the easiest to pull and the band gets harder to pull as the colour gets darker. For example: yellow < red < green < blue < black To progress your resistance training program using exercise bands: 1) Follow the steps to increase repetitions 2) To increase the resistance of the band, choose the next darkest colour of exercise band Your Resources 1) Refer to the Exercise Tool Box for more information on buying exercise equipment Chapter 12 Resistance Training pg. 99

107 Chapter # 13 Nutrition: Fats, Cholesterol & Your Diet Know how different fats affect your health Learn how healthy fats in your diet keep your heart healthy You Will Learn: 1) The role of healthy fats in the body and identify food sources that can lower your blood cholesterol 2) To identify foods that have unsaturated, saturated and trans fats 3) How much saturated fat you are eating each day 4) To identify how to lower your triglyceride levels 5) How added sugar affects your body Chapter 13 Fats, Cholesterol & Your Diet pg. 100

108 What are Fats? Fats are also called fatty acids or lipids. Fatty acids or lipids in our body exist as three molecules put together, known as triglycerides. Most of the fat we need for life is made by the body. Some fats can only be received from our diet. These fats are known as essential fats because it is essential that we get them from food. Essential fats include Omega-3 fats. Why Is Fat Important? Getting enough fat in your diet is important for overall health. Restricting fat intake to very, very low levels is not recommended. We need fat for the following reasons: To absorb vitamins such as, vitamins A, D, E and K To keep our skin healthy To make sure we get enough essential fats (e.g., Omega-3) that are important for heart health Healthy fats (e.g., unsaturated fats from plant oils) can help lower LDL (lousy) cholesterol in your body Fat adds flavor to food and keeps you feeling satisfied longer after a meal What is Cholesterol? Cholesterol is a wax-like substance found in the body. Our bodies need cholesterol: To make vitamin D To make male and female hormones (testosterone and estrogen) To keep cell membranes (e.g., the wall that lines the cell) in our body healthy Eating foods high in saturated and trans fat leads to more LDL (lousy) cholesterol in the body. LDL cholesterol slowly builds up along the walls of the arteries. Over time, this can lead to plaque buildup that can narrow the space in our arteries. When blood is not able to flow to the heart or the brain, the result is a heart attack or stroke. Chapter 13 Fats, Cholesterol & Your Diet pg. 101

109 How Much Fat Do You Need? The Heart and Stroke Foundation and the American Heart Association recommend that less than 30% of our energy (calorie intake) comes from total fat. Saturated fat (the less healthy type of fat) should not be more than 7% of total calories. Saturated fats raise LDL (lousy) cholesterol in the body. 30% Calories from TOTAL fat 7% Calories from SATURATED fat What Does % of Calories Mean? Recommendations for the amount of total and saturated fat will be different for each person depending on age, gender and activity level. The following chart gives you a guide based on certain calorie levels. Men Women Daily Calories Recommended Daily Recommended Maximum Total Fat Intake Daily Saturated Fat Intake g* g** g* g** * Calculation: Number of calories per day x 30%=calories from TOTAL fat 9 calories/gram of fat= amount of TOTAL fat in grams for the day. Example: 1800 calories x 30%=540 9 = 60g **Calculation: Number of calories per day x 7%=calories from saturated fat 9 calories/gram of fat= amount of saturated fat in grams for the day. Example: 1500 calories x 7%=126 9 = 14g Chapter 13 Fats, Cholesterol & Your Diet pg. 102

110 Types of Fat There are three main types of fat found in the foods you eat: Total Fat 1. Unsaturated Fats (Plant Foods) 2. Saturated Fats (Animal Foods) 3. Trans Fats (Commercially Prepared, Processed) 1) Unsaturated Fats Found in plant foods and oils Healthy fats, but should be eaten in moderation 2 types: mono-unsaturated fats and poly-unsaturated fats See table on next page for examples of mono and poly unsaturated foods: Chapter 13 Fats, Cholesterol & Your Diet pg. 103

111 MONO-unsaturated Fats/Oils POLY-unsaturated Fats/Oils Lower ( ) LDL (lousy) cholesterol in your body Lower ( ) LDL (lousy) cholesterol in your body Increase ( ) HDL (healthy) cholesterol in your body Omega-3 fats: Increase ( ) HDL and lower ( ) triglycerides Examples are: - olive oil and olives Examples are: - walnuts - canola oil - ground flaxseed & flaxseed oil - natural peanut butter - hemp seed/hemp hearts - peanut oil and peanuts - chia seed/salba seed - avocado - canola oil - almonds - cashews - fatty fish: mackerel, salmon, unsalted herring, sardines (fresh or canned), trout. 2) Saturated Fats Raise ( ) LDL (lousy) cholesterol in your body Found mostly in all animal products and tropical oils such as: cocoa butter, palm oil, coconut and coconut oil, palm kernel oils All animal products have cholesterol See table on next page for examples of foods high in saturated fat: Chapter 13 Fats, Cholesterol & Your Diet pg. 104

112 Foods High in Saturated Fat Changes You Can Make Marbled or fatty meats: Corned beef, brisket, regular Ground beef, short or spare ribs Skin on chicken and turkey, chicken wings Bacon (all kinds) Sausages Goose or duck Breaded or battered foods High fat luncheon meats Choose leaner meats: Beef: round, sirloin, chuck or loin; lamb: leg, arm or loin; pork: tenderloin, leg or shoulder; veal: all trimmed cuts; extra lean ground beef Replace luncheon meats with low sodium canned fish or chicken/turkey packed in water Remove the skin from chicken and turkey Eat a smaller amount of meat Eat meat less often. Cook with dried peas, beans & lentils or with tofu and fish High fat dairy foods Whole milk (3.5%) High fat cheeses with more than 20% M.F. (milk fat) Yogurts with more than 2% M.F Butter Cream (any type) Lower fat dairy products Cheeses with less than 15% M.F. 1% or skim milk Low fat plain or fat-free, low sugar fruit yogurt Consider non-hydrogenated margarine, olive oil or avocado as a spread 3) Trans Fats Raise ( ) LDL (lousy) and lower ( ) HDL (healthy) cholesterol in your body Trans fats are also called partially hydrogenated vegetable oil or shortening What Are Trans Fats? Trans fats are produced when a healthy fat (e.g., oil) undergoes a chemical process known as partial hydrogenation Chapter 13 Fats, Cholesterol & Your Diet pg. 105

113 Food manufacturers add hydrogen atoms (hence the term hydrogenation) to a healthy oil (e.g., soybean, canola or olive). This process allows the liquid oil to become a solid and hard fat Hydrogenation prevents separation of the fat. It can also improve the texture and consistency of the product. Consider natural peanut butter. Natural peanut butter needs to be stirred before spreading. The oil separates from the crushed nuts, which you do not see with regular peanut butter Read the Ingredients List on the food label for partially hydrogenated or hydrogenated oils/fats. This is a clue that trans fat is in the product Foods With Trans Fats Found mostly in commercially prepared, processed food items: Changes You Can Make Replace commercially prepared, processed foods with healthy choices: Crackers and cookies Cakes, pie crusts, pastries, donuts Vegetable shortening, hard margarine French fries, potato and corn chips Deep-fried restaurant or fast foods Fruit and ¼ cup unsalted nuts Raw veggies and hummus Low fat, low sugar yogurt Whole grain crackers and low fat ricotta cheese Chapter 13 Fats, Cholesterol & Your Diet pg. 106

114 Example of a high fat meal compared to a lower fat meal: High fat meal: Food Amount Total Fat (g) Saturated Fat (g) Fried Chicken 4 oz (100g) 23 6 French Fries 2.5 oz Total fat: 99g Saturated fat: 33g Caesar Salad Whole Milk Side Order 1 cup (250 ml) Apple Pie 1 slice (1/8 pie) Ice Cream 1 scoop (1/2 cup) Healthy meal: Total fat: 21g Saturated fat: 7g Food Amount Total Fat (g) Saturated Fat (g) Roasted Chicken Baked Potato + Low Fat Sour Cream Green salad with olive oil 4 oz (100g) 1 potato 1Tbsp sour cream 2 tsp oil (10 ml) 1% Milk 1 cup (250mL) Baked Apple Low Fat Frozen Yogurt 1 scoop (1/2 cup) Lowering Triglycerides Triglycerides are a type of fat in your blood. They are referred to as storage fat. When we eat more calories than our body needs for energy, the body converts these extra calories into triglycerides High triglyceride levels can raise the risk of heart disease and increase your risk of heart attack Chapter 13 Fats, Cholesterol & Your Diet pg. 107

115 A safe target for triglycerides is: less than 1.7 mmol/l; (mmol/l is the unit of measure used to measure cholesterol and triglyceride levels in Canadian laboratories) My value is: mmol/l Improve Triglyceride Levels By: Lifestyle Changes Reason Examples 1. Reducing your intake of sugars, sweets and refined, processed carbohydrates A diet high in simple sugars and refined carbohydrates raises triglycerides candy desserts pastries soda pop sweet drinks juice jams/jellies/syrup chocolate honey crackers white rice white flour foods, e.g. white bread 2. Reducing alcohol intake Drinking too much alcohol will increase triglyceride levels, especially if mixed with juices or regular soda pop beer liqueurs wine champagne whisky rum brandy mixed drinks gin 3. Eating fish more often. Aim to eat fatty fish 2-3 times a week. Fish high in Omega-3 can: Lower triglyceride levels Reduce blood clotting Prevent heart attacks Reduce the risk of irregular heartbeat salmon flounder trout halibut haddock bass mackerel red snapper tuna Others sources of Omega-3 fats: walnuts canola oil spinach flax seed (ground) flax seed oil soy and soy-based products Chapter 13 Fats, Cholesterol & Your Diet pg. 108

116 Lifestyle Changes Reason Examples 4. Decreasing total fat and trans fat intake A diet high in saturated and trans fat will thicken the blood and increase the chance of clotting fast foods high fat cheese fried foods butter croissants chocolate bacon sausages shortening (vegetable) deli meats margarine mayonnaise convenience foods e.g., hot dogs, hamburger helpers or macaroni and cheese pastries, cookies, ice cream, desserts Added Sugars The American Heart Association defines added sugars as the sugars and syrups added to foods during the processing or preparation. The sugars and syrups that are added at the table are also added sugars Sugars that are locked in and naturally found in foods such as fruit, vegetables, milk and whole grains are healthy choices. These foods are recommended as part of a healthy diet High sugar intake from added sugars is linked to high triglyceride levels. High triglyceride levels in the blood increase the risk of diabetes and heart disease Chapter 13 Fats, Cholesterol & Your Diet pg. 109

117 The World Health Organization, the Canadian Diabetes Association and the American Heart Association recommend adults consume less than 10% of total calories from added or free sugars o For women, this would mean having no more than 100 calories or 6 teaspoons from added sugars each day o For men, this means having no more than 150 calories or 9 teaspoons from added sugars per day o 1 teaspoon has 4 grams of sugar Note: The information on food labels includes TOTAL sugars per serving in a product. This means that the number you see for Sugars on a food label includes the amount of sugar that is naturally present in foods AND added sugars. This makes it hard to know how much added sugars there are in foods and drinks. Sugar Appears in Many Different Forms: Molasses Fruit puree Liquid sugar Honey Juice Invert sugar Agave Cane sugar Dextrin Sucrose Maple syrup Sugar beets Dextrose Brown sugar Glucose-fructose Anhydrous dextrose High fructose corn syrup Brown rice syrup Malt syrup Fruit-juice concentrate Cane syrup Chapter 13 Fats, Cholesterol & Your Diet pg. 110

118 How Can I Reduce the Amount of Added Sugars In My Diet? Replace sugary drinks (e.g., regular soda, iced tea, juices, fruit drinks, sports drinks, energy drinks, etc.) with water, unsweetened herbal tea, reduced fat milk or unsweetened soy, rice or almond milk Add flavour to foods by using spices (e.g., ginger, cinnamon, nutmeg, vanilla extract) instead of sugar Choose plain yogurt instead of fruit or flavoured sweetened yogurt. Add fresh fruit, such as berries or chopped apple, to plain yogurt and breakfast cereals or oatmeal instead of sugar Read labels and the ingredients list. Choose breakfast cereals with no more than 6 grams of sugar per serving. Look for cereals with no added sugar. Buy unsweetened non-dairy milks, unflavoured instant cereals and tinned fruit in its own juice (versus syrup) Reduce sugar in recipes. You can cut the amount of sugar in a recipe by half for most baked goods. Substitute unsweetened applesauce for sugar in recipes (use equal amounts) Your Resources 1) See the Nutrition Tool Box for sugar content found in common foods 2) Eat Right Ontario: 3) Call to talk to a Registered Dietitian for free. 4) Heart and Stroke Foundation: 5) Dietitians of Canada: 6) Health Canada (Food Guide, Label Reading): Chapter 13 Fats, Cholesterol & Your Diet pg. 111

119 Chapter # 14 Nutrition: Benefits of Fibre & Plant Foods Learn how fibre can lower high levels of blood cholesterol, blood pressure and blood sugar You Will Learn: 1) How fibre can improve your health 2) To identify foods that are high in fibre 3) If you are getting enough fibre each day Chapter 14 Benefits of Fibre & Plant Foods pg. 112

120 What Is Fibre? Fibre is the part of the plant that your body cannot break down Fibre is only found in plant foods Two Kinds of Fibre 1) Soluble fibre Foods with soluble fibre absorb water. It causes foods to swell and thicken, becoming sticky and gel-like Foods with soluble fibre include: oats, legumes, barley, pectin-rich fruits (apples, pears, berries, citrus fruits, e.g., oranges), eggplant, squash, carrots, psyllium, flaxseed 2) Insoluble fibre: Foods with insoluble fibre do not absorb water. It is found in the skins of fruit and vegetables and the bran portion of whole grains Why Is Fibre Important? Fibre helps your digestive tract to be healthy by keeping you regular. As fibre passes through your digestive tract, it binds to fat and glucose, reducing absorption in the body. Fibre also helps to decrease the production of cholesterol by the liver Because you do not digest fibre, it makes you feel full longer, making meals more satisfying How Much Total Fibre Do You Need? Aim for grams of fibre every day. Increase fibre slowly over time. Spread your intake throughout the day. Increase your water intake to prevent gas and bloating Chapter 14 Benefits of Fibre & Plant Foods pg. 113

121 How Can You Get More Fibre? Start your day with a high fibre cereal. Try steel cut oats, Bran buds or Fibre 1 cereal. Add fruit Add ground flax, psyllium or oat bran on top of foods. Use them when you bake Plan your meals and snacks to always include fresh or frozen fruit and vegetables Aim to have half your plate vegetables. The more colour on your plate, the better Include legumes and beans to dishes. Put kidney beans or chickpeas in salads or rice dishes. Add lentils or black beans to soups. Replace ground meat with crumbled extra firm tofu in a chili or lasagna. Include a bean salad as a side dish To learn more about how to include beans/lentils in your diet please refer to the following pages, Cooking Tips for Legumes. Cooking Tips For Legumes Legumes include pulses, beans and lentils. Pulses refer to dried seeds (not fresh beans or peas). Soybeans and peanuts are different from pulses because they have more fat. Legumes Soybeans Peanuts Pulses Dried beans Dried peas Chick peas Lentils Fresh beans Fresh peas Chapter 14 Benefits of Fibre & Plant Foods pg. 114

122 Step 1: Buying and Storing Legumes/Beans Canned Legumes/Beans Dried Legumes/Beans Convenient and ready-to-use (no soaking required). Look for LOW SODIUM or NO SALT ADDED options. Thoroughly rinse and drain canned pulses to reduce your sodium intake. Need time to prepare. Found in bulk stores or in grocery stores (usually packaged in clear bags and found beside canned beans). Store in a container with a tight lid, in a cool, dark place. Storage: Enjoy your legumes/beans within a year of buying them. Store your cooked legumes/beans in the fridge for 1-3 days or in the freezer for several months. Step 2: Rinsing & Soaking Dry Legumes/Beans Rinse all dried legumes, beans and lentils before soaking Discard soaking water and rinse beans with cold water. Rinsing will help wash away the part of the bean that causes gas Which legumes, beans or lentils need to be soaked before cooking? Soaking required NO soaking required (just rinse) Dry beans, whole peas, Dry lentils, split peas chickpeas Step 3: Cooking Dry Pulses Cook dry legumes, beans and lentils using the stove, microwave, slow cooker or pressure cooker Use 3 cups (750 ml) of water for every 1 cup (250 ml) of soaked beans Chapter 14 Benefits of Fibre & Plant Foods pg. 115

123 For the Stove-Top Method In a pot, combine soaked beans and water and bring to water to boiling. Reduce heat and simmer To check for readiness, taste the bean for desired firmness Legumes, Beans, Lentils Beans minutes Cooking Time Peas - Whole - Split Lentils - Whole green - Split red 1 1 ½ hours minutes minutes minutes Chickpeas 1 1 ½ hour (Pulse Canada, 2012) Sample Menu How to Get the Recommended Daily Fibre Intake grams/day Breakfast Amount of Fibre (g) Steel cut oats, ¾ cup cooked 4.0 Blueberries, ½ cup 2.0 Soy beverage, 1 cup 0 Sliced almonds, 1 tablespoon 0.5 Hempseed, 1 tablespoon 1.0 Breakfast Total 7.5 Chapter 14 Benefits of Fibre & Plant Foods pg. 116

124 Lunch Spinach salad, 3 cups 0.5 Chickpeas, canned, low sodium, 1 cup 7.0 Cherry tomatoes, Banana 2.0 Whole grain bread, 1 slice 3.0 Homemade dressing, olive oil & balsamic vinegar 0 Water 0 Lunch Total 13.5 Dinner Grilled salmon, 4 oz (120 g) 0 Rapini, cooked, 1 cup 3.7 Quinoa, cooked, 1.5 cups 6.0 Water 0 Dinner Total 9.7 TOTAL FIBRE for the Day 30.7 Your Resources Cookbooks & Websites: 1) Spilling the Beans by Julie Van Rosendaal, Sue Duncan 2) US Dry Pea & Lentil Council: 3) Pulse Canada: 4) Eat Right Ontario: 5) Call to talk to a Registered Dietitian for free. 6) Heart and Stroke Foundation: 7) Dietitians of Canada: 8) Health Canada (Food Guide, Label Reading): Chapter 14 Benefits of Fibre & Plant Foods pg. 117

125 Chapter # 15 Nutrition: Reading Food Labels Learn how to quickly understand information on food labels and choose heart healthy foods You Will Learn: 1) About the different types of nutrition information on the label: Ingredient List, Nutrition Facts Panel, Nutrient Claims 2) How to use the Nutrition Facts Panel to choose heart healthy foods 3) How to use % Daily Value to see if there is a little or a lot of a nutrient in one serving of a packaged food Chapter 15 Reading Food Labels pg. 118

126 Look At the Label Three Places To Get Information 1) List of Ingredients All ingredients in the food are listed in descending order by weight. This means that foods contain more of the ingredients at the beginning of the list, and less of the ingredients at the end of the list. The ingredient list can help you look for specific ingredients and help you avoid those that you don t want to consume. The following is an example of a food that has a lot of sugar. INGREDIENTS: GLUCOSE-FRUCTOSE, CHICORY ROOT EXTRACT (INSULIN FIBRE), SUGAR, WHOLE GRAIN ROLLED OATS, PUFFED WHEAT, HIGH MALTOSE CORN SYRUP, WHOLE GRAIN BARLEY FLAKES, CHOCOLATE CHIPS (CHOCOLATE LIQUOR, SUGAR, COCOA BUTTER, MILK INGREDIENT, SOY LECITHIN, NATURAL FLAVOUR), CORN BRAN, PALM KERNAL OIL, CRISP RICE (RICE FLOUR, MALT EXTRACT, SUGAR, SALT), CANOLA OIL, WHEAT BRAN, GLYCERIN, COCOA, WHOLE GRAIN WHEAT, GRAHAM FLOUR, SOY LECITHIN, CORN STARCH, NATURAL FLAVOUR, MALTODEXTRIN, SALT, TRISODIUM PHOSPHATE, BHT. Chapter 15 Reading Food Labels pg. 119

127 2) Nutrition Facts These facts give you information about the amount of calories, fats, protein, carbohydrates and other nutrients in the food. Chapter 15 Reading Food Labels pg. 120

128 3) Nutrition Claims These tell you how diet can affect your health or give you information about a nutrient e.g., low fat. Examples of nutrition claims What it means Where you might see this claim BEWARE! Cholesterol free No cholesterol Low fat No sugar added An insignificant amount Indicates a very small amount Low fat (3 grams of fat or less/ serving) Granulated sugar has not been added to the product Potato chips Fruit bottom yogurt Juice Cholesterol only comes from animals Cholesterol free products may still be high in fat Low fat does not always mean low in calories Choose fat free yogurt with no sugar Juices are high in calories and have natural sugar Light Can be used in foods that are reduced in fat or calories (energy) Light peanut butter Can also refer to colour or texture e.g., "light" or "lite" olive oil Chapter 15 Reading Food Labels pg. 121

129 Chapter 15 Reading Food Labels pg. 122

130 Chapter 15 Reading Food Labels pg. 123

131 Chapter 15 Reading Food Labels pg. 124

132 Your Resources 1) Call to talk to a Registered Dietitian for free or visit: 2) Health Canada (Food Guide, Label Reading): Chapter 15 Reading Food Labels pg. 125

133 Chapter # 16 Nutrition: Sodium & Blood Pressure Most Canadians get too much sodium in their diet High sodium intakes are linked to high blood pressure and can lead to an increased risk for heart disease, stroke and kidney failure Learn how your diet can help lower your blood pressure You Will Learn: 1) The role of diet on blood pressure 2) To identify foods that are high in sodium 3) To identify hidden sources of sodium 4) If you are getting too much sodium each day 5) To identify foods that are high in potassium, magnesium and calcium Chapter 16 Sodium & Blood Pressure pg. 126

134 Why Reduce Salt? Canadians eat more salt (sodium chloride) and other forms of sodium than they need. Too much sodium in your diet is linked to high blood pressure and fluid retention. High blood pressure is a risk factor for heart disease. Keep your sodium intake to 1500 mg or less each day mg sodium is found in approximately 2/3 teaspoon of table salt. Sodium In the Diet Comes From Three Main Areas 1) Food that you eat naturally contains sodium 2) Salt added when cooking or added at the table 3) Salt that is added to foods during commercial processing How Do Most Canadians Get Their Salt? 10% from foods naturally consumed 10-25% from the salt shaker 75% from processed foods and meals eaten away from home Chapter 16 Sodium & Blood Pressure pg. 127

135 Sodium Content in Selected Restaurant Foods Food Portion Sodium (mg) Pepperoni pizza slice, large 295 g 1630 Bacon & 2 eggs 124 g 929 Big Mac 208 g 1020 Fries, small 70 g 190 Chicken caesar salad 317 g 1100 Oven roasted sliced turkey meat sandwich on whole wheat bread 236 g 1380 Check the Nutrition Facts on the Food Label for the Amount of Sodium in a Serving Nutrition Facts Serving Size 1 Serving (298g) Servings Per Recipe 1 Amount Per Serving Calories 180 Calories from Fat 50 % Daily Value* Total Fat 6 g 9% Saturated Fat 2.5 g 13% Cholesterol 10 mg 3% Sodium 60 mg 3% Total Carbohydrate 28g 9% Dietary Fiber 2g 8% Sugars 17g Protein 4g Vitamin A 25% Vitamin C 60% Calcium 4% Iron 8% *Percent Daily Values are based on a 2,000 calorie diet. Chapter 16 Sodium & Blood Pressure pg. 128

136 How Do You Lower Your Blood Pressure? 1) Limit or Do Not Eat Foods With Excess Amounts of Added Salt Many people get too much salt, even without a salt shaker. To get less sodium, eat: More fruits, grains, beans and vegetables that are not processed Fresh meats, fish and poultry Unsalted nuts and seeds 2) Eat more foods that contain potassium, magnesium and calcium Potassium is found in abundance in fruit, vegetables, fish and poultry. It is important to choose these foods without added salt Legumes, nuts, dark greens and whole grains are excellent sources of magnesium Dairy products, sardines, tofu, broccoli, kale and arugula are all high in calcium. Milk contains 300 mg of calcium per cup. Sardines contain 200 mg of calcium, but 500 mg of sodium per 4.5 oz serving. It is important to look for canned goods without salt. Choose canned fish packed in water. Broccoli and kale contain 70 and 90 mg of calcium in one cup cooked. Almonds contain 100 mg calcium per ounce 3) Cut Back On Alcohol One - two drinks a day will not likely raise blood pressure in men. One drink a day generally will not raise blood pressure in women. More than two drinks a day can raise blood pressure in most men and women. Chapter 16 Sodium & Blood Pressure pg. 129

137 4) Exercise Regularly Aerobic activity, like walking, is best for lowering blood pressure. Follow your exercise prescription as advised by your Cardiac Rehab team. Note: These strategies are often effective; you will need to work with your doctor to lower your blood pressure medicine. This should NOT BE DONE ON YOUR OWN. If you stop your blood pressure medicine all at once, it may be dangerous. Work with your doctor so s/he can change your medicine as your blood pressure falls. (Adapted from 2000 Food & Health Communication, Inc. 21 st Century Heart TM ) Stopping Hypertension With Your Diet The DASH diet stands for dietary approaches to stopping hypertension. This way of eating helps to lower your blood pressure. The DASH diet is an eating plan developed after good research was done to find out how diet affects blood pressure. It is a diet that: Is low in sodium Is rich in magnesium, potassium and calcium Has lots of fruits and vegetables Has low fat dairy products Includes whole grains, fish, poultry and nuts Has lower amounts of red meats, sweets, and sugar-containing beverages Food Group Daily Servings Grains and grain products 7-8 Vegetables 4-5 Fruits 4-5 Low fat dairy 2-3 Meats, poultry and fish 2 or less Fats and oils 2-3 Nuts, seeds, legumes 4-5 per week Source: National Heart, Lung and Blood Institute. For more information on the DASH diet: Chapter 16 Sodium & Blood Pressure pg. 130

138 How to Season Your Food Without Salt Blend these herb mixtures together and use them to season your food instead of salt. Favourite Food Flavouring 4 tbsp basil 4 tbsp oregano 1 tbsp garlic powder 4 tsp marjoram 4 tsp onion powder 2 tsp dill 2 tsp sage 2 tsp rosemary 1 tsp ground black pepper Blend all ingredients. Store in an air-tight container or fill an empty seasoning jar with holes large enough for easy shaking. All Purpose Flavouring 2 tsp garlic powder 1 tsp basil 1 tsp dill 1 tsp oregano 1 tsp powdered lemon rind Blend well and store in glass saltshaker. Add a few grains of rice to prevent caking. Herb Mix 1 tsp ground cayenne 1 tsp garlic powder 1 tsp basil 1 tsp mace 1 tsp dried parsley 1 tsp thyme 1 tsp onion powder 1 tsp black pepper 1 tsp sage Blend well. Substitute other herbs as desired. Chapter 16 Sodium & Blood Pressure pg. 131

139 Tips for Seasoning Without Salt Experiment with the following spices or herbs the next time you prepare or make any of the following: Food Spices or herbs Bread Cheese Fruit Salads Soups Vegetables Fish Beef Lamb caraway, marjoram, oregano, poppy seed, rosemary, thyme basil, chervil, chives, curry, dill, fennel, garlic chives, marjoram, oregano, parsley, sage, thyme anise, cinnamon, coriander, cloves, ginger, lemon verbena, mint, rose geranium, sweet cicely basil, borage, burnet, chives, French tarragon, garlic chives, parsley, sorrel (These are best used fresh or added to salad dressing. Otherwise, use herb vinegars for extra flavour.) bay, chervil, French tarragon, marjoram, parsley, savory, rosemary, fresh parsnip, celery stalk or celery root basil, burnet, chervil, chives, dill, French tarragon, marjoram, mint, parsley, pepper thyme chervil, dill, fennel, French tarragon, garlic, parsley, thyme bay, chives, cloves, cumin, garlic, hot pepper, marjoram, rosemary garlic, marjoram, oregano, rosemary, thyme (make little slits in lamb to be roasted and inset herbs.) Poultry Pork garlic, oregano, rosemary, savory, sage coriander, cumin, garlic, ginger, hot pepper, pepper sage, savory, thyme Tips for Choosing Low Sodium Foods Remember that unprocessed fresh foods such as fruits and vegetables contain lots of nutrients and are naturally low in sodium Chapter 16 Sodium & Blood Pressure pg. 132

140 CHOOSE products with less than 200 mg of sodium per serving, or less than 10% Daily Value. AVOID products that contain more than 400 mg of sodium per serving. LIMIT products that contain between mg of sodium per serving Pay attention to serving size. How big is the portion in comparison to how many servings you will actually eat? For example, breads and cereals are a significant source of sodium in our diets because we consume many servings a day All salts (table, Kosher, rock, sea, Himalayan) contain approximately 100% sodium chloride, so they contain the same amount of sodium. One teaspoon of salt is about 2300 mg of sodium. The Heart & Stroke Foundation recommends 1500 mg a day for adults In restaurants, ask about lower sodium options and request no salt be added if possible. Be wary of soups made with salty broths and salads with lots of toppings and dressing (Adapted from sodium101.ca) Your Resources 1) Eat Right Ontario: a. Call to talk to a Registered Dietitian for free. 2) Health Canada (Food Guide, Label Reading): 3) Sodium: 4) Nutrition Action Health Letter: Chapter 16 Sodium & Blood Pressure pg. 133

141 Chapter # 17 Stress & Your Heart Learn about the different kinds of stress and what you can do about them You Will Learn: 1) The 7 main causes of stress in patients with heart disease 2) How each stressor affects your heart 3) How to reduce stress Chapter 17 Stress & Your Heart pg. 134

142 The 7 Main Causes of Stress in Heart Patients Depression Stressful Life Events Sleep Apnea Chronic Stress Causes of Stress Poor Sleep Feeling Loss of Control Distress What Is Stress and How Is It Caused? Stress is a state of mental strain that puts pressure on your body. This pressure can lead to health problems that include high blood pressure, high cholesterol, unhealthy eating and social withdrawal Stress is common in heart patients. Research says that after a heart event, many people struggle with one or more stress problems below: 1) Depression 2) Sleep apnea 3) Distress 4) Poor sleep 5) Feeling loss of control 6) Chronic stress 7) Stressful life events Chapter 17 Stress & Your Heart pg. 135

143 Stress is Common in Heart Patients After your heart event, it is important that you focus on your mental health. It is common for heart patients to feel stressed, have anger, anxiety or be depressed. Stress puts your heart at risk. A Risk Profile tool was made to help you learn what causes your stress and what your stress risk is. If you complete the tool, you will get a report of factors that are stress risks for you. Knowing what causes your stress can help you choose what topics to focus on. You can then learn how to manage your stress. Your Risk Profile The Risk Profile tool on the Heart Stress Risk website can help you learn more about the stress you are feeling. The information you gain from this tool does not replace the advice you receive from your doctor. Read the consent form on the website to learn the benefits, risks and limitations of using this tool. Take Action! To learn what your stress risk is, follow the steps below: Step 1: Go to HeartStressRisk website: Step 2: Click on 'Your Risk Profile' (in the top menu of the website) Step 3: Complete the consent form Step 4: Answer the questions Chapter 17 Stress & Your Heart pg. 136

144 Stress #1 Depression If you are depressed, you may feel hopeless and no longer enjoy the things you used to like. Depression is not the same as feeling sad sometimes. With depression, the feeling of sadness is constant and lasts for a long time. Symptoms of depression (what you may feel) Sad Irritable (easy to bother) Hopeless Helpless Angry Unmotivated (don t feel Loss of appetite (no desire to eat) Poor sleep No interest in sex Lack of energy to do things you enjoy like doing anything) Effects On Your Body Being depressed puts you at a higher risk for having heart problems. When you are depressed, there are changes in how your brain and body function which can affect your heart. Depression can cause the chemical levels to be out of balance and that changes how your brain works and how you feel. e.g., Your blood may be more sticky (causing clots) e.g., Your body's immune system is less able to ward off viruses and bacteria e.g., You may have an increase in a stress hormone called cortisol in your body. e.g., You may get more irregular heartbeats. How to Reduce Your Risk from Depression If you are living with depression, it is important to find an action that works for you. Below is a list of methods you can try: Chapter 17 Stress & Your Heart pg. 137

145 1) Learn new skills Handle your feelings in more helpful ways Be proactive. This means do not delay doing things that need to be done Start each day by choosing something helpful you can do for yourself (e.g., exercise) 2) Change the way you connect and talk with people Connect with people you trust. Share how you feel. 3) Get Therapy and Counselling Work with a psychologist, social worker or therapist who works with people with depression 4) Find out about medicines that can help Talk to your doctor about what medicine may help you Stress #2 Sleep Apnea Sleep apnea is when you have pauses in your breathing or you have shallow breathing while you sleep. This pause can last 10 seconds to several minutes. It causes you to snore loudly. Not getting a good, deep sleep puts stress on your body and causes health problems. How Does Sleep Apnea Affect Your Heart? When you have sleep apnea your body's stress system works very hard. The level of oxygen in your blood drops lower. This causes problems in your brain, blood, immune system, heart and blood vessels. Makes you feel tired during the day Blood sugar (glucose) levels increase Makes your blood more prone to clotting Your body does not fight illness as well Causes plaque buildup in your blood vessels which can cause a heart attack Can cause irregular heartbeats Chapter 17 Stress & Your Heart pg. 138

146 Symptoms Many people have sleep apnea and do not know it. Here are four common signs of sleep apnea; 1) You snore loudly at night 2) You are very tired throughout the day 3) Someone else sees you stop breathing at night 4) You have high blood pressure To find out if you have sleep apnea, you will have to complete a sleep test at a sleep clinic. Stress #3 Distress When you have been facing stress in your life for a while, you may feel overwhelmed with emotions and feelings that can get in the way of your daily living. Everyone reacts in their own way to distress. Examples: Fatigue (feeling very tired often) Sadness Anxiety Avoiding social situations (not wanting to be around friends or family) Fear Anger Feeling moody What Causes Distress? You may become distressed when you are faced with stressors that place demands on you that you cannot cope with. Demands that cause distress can be: Trauma (e.g., having a heart attack, major car accident) Major life events (e.g., retirement, death of a loved one) Everyday stressors (e.g., paying bills, going to work) Health issues (being unwell) Chapter 17 Stress & Your Heart pg. 139

147 Research tells us that people who experience distress are twice as likely to die from heart attack or other chronic illness. It is important to work with a psychologist, social worker or psychotherapist to help you. Stress #4 Poor Sleep What Is Poor Sleep? Disturbed sleep is when you wake up often during the night, and you do this many nights in a row. Disturbed sleep is when you get less than 5 hours of actual sleep per night. Getting the ideal amount of sleep (7.5 hours) at night allows your body to function well over a 24 hour day. If you struggle with disturbed sleep, you are likely to have problems with "burn out" or emotional exhaustion across your daytime activities. How Does Disturbed Sleep Affect Your Heart? Your cardiovascular system needs a regular routine of rest at night so it is ready to be active the next day. When your sleep is disturbed at night, there is a breakdown in this "rest and restore" period. Disturbed sleep can cause problems with your blood sugar (glucose), insulin and stress hormones in your body. This can cause weight gain, high cholesterol levels and high blood pressure. Steps to Prevent Disturbed Sleep: Go to sleep and to wake up at the same time everyday Keep your room cool, dark and free of distractions (no computers, pets) Be active during the day, but don't exercise within 4 hours of bedtime Take one full hour to relax at the end of the day, just before bedtime Avoid caffeine, nicotine or alcohol 4-6 hours before sleep Avoid a lot of fluids before bed Make a sleep routine before bed like reading, listening to calm music, relaxation exercises Avoid a heavy meal 2 hours before sleep Chapter 17 Stress & Your Heart pg. 140

148 Stress #5 Feeling Loss of Control What Is Feeling Loss of Control? When you have deadlines, conflict in your life or surprise setbacks, you may feel you are losing control. It may be at work, at home, in relationships, or in financial matters. Feeling that you have no control can lead to anxiety or depression. Brainstorm Ideas to Make Your First Step for Change Choose a focus for change o Be aware of your sense of helplessness. Are you ready to take action? o Take 15 minutes and write down ideas about how you can change the problems you are facing o Do not criticize or judge any of your ideas o Rate each idea from 1-10 on how likely you will try the idea in the next week o Pick one idea that you rated as a 7 (or your highest one) and use it this week Stress #6 Chronic Stress What Is Chronic Stress? Chronic stress is when you experience stress that continues for weeks or months without a break. E.g. work, home, finances Having constant stress in any of these areas will make the stress risks to your health greater. How Does Having Chronic Stress Affect Your Heart? Chronic stress causes constant stress reactions in your body. Causing your heart rate and blood pressure to rise Causing plaque to build up in your arteries Chapter 17 Stress & Your Heart pg. 141

149 Causing your blood to become stickier (form clots) Research tells us that having ongoing chronic stress increases your chances of having a heart attack. Steps To Take To Lower Your Chronic Stress Choose one stress reduction skill to manage your stress o o o o o o Diaphragmatic breathing techniques (learning to breathe from your diaphragm or stomach) Progressive muscle relaxation skills or Yoga Visualization Affirmations Meditation Cognitive reframing (changing negative thoughts or learning to look at things differently) Take a stress reduction program If you are not seeing change, get help from a coach, counsellor or psychotherapist Stress #7 Stressful Life Events What are Stressful Life Events? Stressful life events occurring in the past year are big events like losing your job, death of a loved one, injury or illness. They are called stressful because they trigger a big reaction in your mental, emotional and physical systems in the body. Symptoms You might have a sense of disbelief, or be asking yourself, "Why me?" Chapter 17 Stress & Your Heart pg. 142

150 How Does Having Stressful Life Events Affect Your Heart? Stressful life events make your whole body work harder: Heart rate and blood pressure rise Plaque builds in the arteries. Blood becomes stickier (forms clots) Steps to Reduce Your Risk from Stressful Life Events Stressful life events cannot be controlled. Develop a stress hardy personality o Think about what your priorities are o Set goals on what you can control o Learn to say "no" to requests that do not fit your priorities o Take care of yourself o Practice meditation o Make time to be with your partner, your family or friends for support o Think about the positive events in your life Learn how to get a relaxation response in your body o Learn how to breathe from your stomach (diaphragmatic breathing) o Learn how to use muscle relaxation Your Resources 1) Heart Stress Risk website: and the Help Guide: 2) Time Management from the Inside Out 2 nd Edition (2004). Julie Morgenstern, Henry Holt Co: New York. 3) The Disease to Please: Curing the people pleasing syndrome (2001). Harriet B. Braiker, McGraw-Hill: New York. 4) The Relaxation and Stress Reduction Workbook. 6 th Edition (2008). M Davis, E Robbins Eshelman and M McKay, New Harbinger Publications: Oakland CA. Chapter 17 Stress & Your Heart pg. 143

151 Chapter # 18 Sexual Intimacy Find out what patients want to know about sexual intimacy You Will Learn: 1) To know when it is safe to have sex again 2) About how your medicine may impact your sexual health and function Chapter 18 Sexual Intimacy pg. 144

152 When Is It Safe To Have Sex Again? Since sexual activities are a key part of many people's lives, it is important to know when it is safe for you to do sexual activities again. Most people with little damage to their heart can get back to sexual activity within 2 to 3 weeks of going home from the hospital. If you have had a heart attack, your risk of having another heart attack while having sex is very low. Follow these tips to know if sexual activities are safe for you: If you can walk up two flights of stairs or walk briskly with ease, your heart should be safe during sex Speak to your cardiologist to confirm that sex is safe Types of Sexual Activities Sexual activities include all of the actions that allow people to feel pleasure in close contact (in body and mind) with each other. e.g., Holding eye contact, embracing, caressing, touching each other, massaging, oral sex, penetration, intercourse How Sexual Activities Affect Your Heart Recall that if you had a heart attack, your risk of having another heart attack during sexual activities is very low. Some sexual activities are safer than others, and these activities may be a good option while your body heals. Sexual activities that are often safer for your heart Caressing, touching each other, massaging, embracing, holding eye contact Your heart rate and blood pressure increase when you are aroused. During the sexual activities listed above, it is likely that your heart rate and blood pressure will remain at safe levels. During these activities, you can feel pleasure and share intimacy with your partner while keeping your heart safe Chapter 18 Sexual Intimacy pg. 145

153 Sexual activities that could make your heart to work too hard Intercourse, penetration, oral sex The sexual activities listed above may involve a moderate to vigorous effort (just like exercise). These activities can increase your heart rate and blood pressure to levels that are not safe for someone with a heart problem If your cardiologist has confirmed that these sexual activities are safe for you, slow down your body movement and do not hold body positions where you have to support your own body weight How Do My Medicines Affect My Sexual Health? Your sexual health includes your sexual function and your feelings toward sexual activities and intimacy. Your cardiac medicines can affect your sexual health by changing your sexual function and the way you feel about doing sexual activities. For example: Medicines you take to help with depression can lower your desire for sexual activities Beta blockers can affect how you perform during sexual activities For Men Erectile dysfunction What is Erectile Dysfunction? You may have erectile dysfunction. This means your penis may not get erect. This could be your medicines or it could be low levels of testosterone (a male hormone). It is common for testosterone to be low after a heart event. These low levels make it hard to get an erection during sex. What Can I Do? Medicines can be prescribed for men with erectile dysfunction. These medicines increase the blood flow to your penis. Warning: If you take a type of medicine for erectile dysfunction and Chapter 18 Sexual Intimacy pg. 146

154 use nitroglycerin (a drug to help your angina), your blood pressure can get so low that you could die. Always speak to your doctor and pharmacist before you try new medicines and be sure to bring your list of all your medicines with you. Do not use nitro if you are taking medicine for erectile dysfunction. For Women Vaginal Dryness What is Vaginal Dryness? You may have problems getting wet (natural lubrication) due to some of the medicines you take. This can make sex painful. What Can I Do? To treat vaginal dryness, you can buy personal lubricants at your local pharmacy. Longer time to orgasm Why Does It Take Me Longer To Have An Orgasm? Some medicines affect the flow of blood through your vagina. Less blood flow to your vagina means that area will be less sensitive. This means it may take longer to have an orgasm. What Can I Do? If it takes you longer to have an orgasm you (and your partner) can plan more time for foreplay. Taking the pressure off yourself (and your partner) to achieve an orgasm may make the intimacy you share less stressful and more enjoyable. Chapter 18 Sexual Intimacy pg. 147

155 Discuss Your Concerns About Sex With Your Partner and Your Cardiac Rehab Team If you feel that your sexual health is important to living well and you want to learn more about this, you are not alone. Many patients ask to learn more about their sexual health after a heart event. Common Questions and Answers: 1) Question: How do I talk to my partner about sexual intimacy? Answer: Talking to your partner about your needs, desires and fears about sex is important as you get back to sex after your heart event. Your partner will also have his/her own needs, desires and fears too. Here are some ways that will help you support each other: Listen to and try to understand each other s emotions What is your partner feeling? What are his/her fears? Let him/her know you understand. What he/she is feeling is real. You may be having the same feeling. Hear what your partner is saying. Listen and focus on his/her experience. Once you have understood where he/she is coming from, share your thoughts and feelings. Sharing each other s feelings and emotions help to build intimacy. This will help improve sex and intimacy for you. Offer support Let your partner know you support him/her. Support each other by: o Listening o Expressing that you hear each other o Normalizing each other s emotions ( I feel the same way ) o Problem solving together o Not being judgmental of each other o Being open minded o Working together Chapter 18 Sexual Intimacy pg. 148

156 2) Question: How do I deal with the fear and anxiety I feel about sexual intimacy? Answer: It is normal for anyone who has had a heart event to have anxiety, fears and even depression. Many patients need a few months for this to get better. If you struggle with these feelings, you may also find that your normal interests in sexual activity have gone. To decrease any anxiety or fear you have about getting back to sexual intimacy after your heart event: Talk to your cardiologist or family doctor Ask questions about risks, dangers and precautions to take You may be wondering "what if I have a heart attack during intercourse?" Ask yourself: how likely are these fears? What proof do I have to support these fears? What does my doctor say about these fears? Know that any fears or anxieties you have is your brain s way of protecting you from danger and help you to avoid taking risks. Fears are a normal part of getting better. Recognize your fears and address them. Ask your cardiologist or family doctor questions about risks, dangers and precautions to take when doing sexual activities. Knowing what activities are safe and not safe for you can help reduce your fear and anxiety. Talk about your fears with your partner. You and your partner can think about ways for you to slowly return to sexual activities. 3) Question: When is it ok to get back to sexual intimacy? Answer: Once you speak with your cardiologist and he/she says it is safe: Do what is comfortable for you. Let go of any fears or thoughts you may have at the time. Be in the moment. This helps to enjoy the closeness with your partner. Go slow. Getting back to your normal intimacy takes time. Chapter 18 Sexual Intimacy pg. 149

157 It is normal for anyone who has had a heart event to have anxiety, fears and even depression. Many patients need a few months for this to get better. If you struggle with this, you may also find that your normal interests in intimacy and sex have gone. 4) Question: How can I have sex safely? Slow down to reduce the work the heart has to do Avoid holding body positions during sex where you have to support your own body weight Try the spoon position for men and women. This is lying down with the man snuggled up behind his partner Have your partner on top to lower your effort If you return to sexual activity over time, you can avoid symptoms of angina. If you do get angina, talk to your doctor. If you are not ready for sexual activities like intercourse or penetration you can do other things for pleasure and intimacy like caressing, embracing or touching each other. A Final Word on Intimacy When you are ready to have sex, begin slowly. The goal is to get back to what is normal for you and your partner. You can try different things with your partner. Begin by doing things together that you enjoy. Massages Eye contact Holding hands These things help to make you feel safe. Enjoy your time together. Maybe reaching orgasm is not the goal right now. Reconnect emotionally, do enjoyable activities and trust that the physical intimacy and sexual activity will come back when it feels right. Chapter 18 Sexual Intimacy pg. 150

158 Section #3 Prepare for Life after Rehab Chapter Topic Page # 19 How Much Physical Activity is Good For You? Progress Your Exercise Program Relapse Planning Graduation 168

159 Chapter # 19 How Much Physical Activity Is Good For You? Know how much regular physical activity you need to do to get health benefits Reduce the amount of time you spend sitting You Will Learn: 1) The value of exercise 2) The impact exercise can have on the plaque in your coronary arteries 3) How you can sit less and move more during the day Chapter 19 How Much Physical Activity is Good for You? pg. 151

160 The Value of Exercise Research tells us that the more fit you are, the longer you can live. If you improve the function of your heart, lungs and muscles you will become more fit. Research also tells us that by becoming more fit; you can reduce your risk for diseases like heart disease. To get these health benefits you need to exercise regularly. What Are the Health Benefits of Regular Exercise? Increase how long you live Decrease your risk for heart disease, stroke, diabetes, cancers Improve your balance and decrease your risk of falling Keep good bone health Increase your muscular strength and endurance Improve your mood and how you feel Improve your energy Prevents plaque in your coronary arteries from getting bigger The Impact Exercise Can Have on the Plaque in Your Coronary Arteries You can make lifestyle changes to control your risk factors for coronary A B C artery disease. Making lifestyle changes can help the plaque stabilize (stay the same) or even regress (get smaller and better). See Figure 1. Regular exercise is one lifestyle change that can help plaque stabilize or regress. Figure 1. Plaque in the coronary artery can A progress (increase), B stabilize (stay the same size) or C regress (get smaller). Chapter 19 How Much Physical Activity is Good for You? pg. 152

161 How Much Exercise Do You Need to Do? Research studies have confirmed how much exercise you need to do to stabilize or regress the plaque in your coronary arteries. To cause the plaque in your coronary arteries to stabilize do: To cause the plaque in your coronary arteries to regress do: 150 minutes of moderate to vigorous aerobic exercise per week minutes of moderate to vigorous aerobic exercise per week Doing muscle and bone strengthening exercises (resistance training) 2 days per week will also help to improve your health. This means keep doing the resistance training program you started. Some people may be able to do the amount of exercise needed to stabilize or regress plaque, while others cannot. You may be living with other health problems that make it unsafe to exercise at the levels described above. If you cannot do 150 to 360 minutes of exercise each week, you can focus on other healthy habits that can help stabilize or regress your plaque. These healthy habits include taking your medicines as prescribed by your doctor. Important! Talk to Your Cardiac Rehab team about: How much exercise you can do safely What types of exercise are safe for you Moderate and Vigorous Exercise To stabilize or regress the plaque in your coronary arteries you need to do a certain amount of moderate to vigorous aerobic exercise. Keep in mind that you do not have to do the same type of exercise each day. Chapter 19 How Much Physical Activity is Good for You? pg. 153

162 Moderate aerobic exercise means doing things like: Dancing Brisk walking Games/sports Vigorous (more intense) aerobic exercise means doing things like: Running Walking/climbing briskly up a hill Fast cycling Fast swimming Competitive sports Sitting Less and Moving More Most adults spend about 10 hours a day sitting down. This is about 70 percent (%) of a waking day. Research shows that sitting for long periods of time is not good for your health. Your body slowly changes the longer you sit. For example: You burn fewer calories Your muscles get weaker You are at greater risk for diabetes, heart disease and certain cancers Take Action: Even if you exercise regularly, you still need to reduce the amount of time you sit. To break up your sitting time, it is helpful to think about when you sit most often during your day. You might sit when you: Eat breakfast and dinner Drive to work and back home Work at your desk Watch television, use a computer, talk on the phone, read Spend time with family and friends Chapter 19 How Much Physical Activity is Good for You? pg. 154

163 When you find yourself sitting, think about whether you are able to replace or reduce some of the time with standing or moving. This could be by: Breaking up sitting time by standing up or walking around for 2 to 3 minutes every 20 minutes. Setting an alarm on your computer or phone might help remind you to get up and move Standing while eating your breakfast or when reading the newspaper Doing household chores such as folding clothes, washing dishes or ironing, while watching television Parking farther away from work (or the mall) and walking the rest of the way On public transport, if you are able stand for part of the way Use the stairs more and the elevator or escalator less. If you are able, use the stairs to go up one floor or down two floors Keep a jug of water at your desk so you have to take regular breaks to go to the washroom. Do not do this if your doctor has advised you to restrict your fluids Aim to break up your sitting time slowly. Set small goals such as sitting less during your morning routine. Eventually, by just making a few changes to your daily routine, you will find that it is pretty easy to sit less and move around more. Important! If you are sitting for a long period of time, try getting up every 20 minutes and stand (or walk) for 2 minutes Your Resources 1) Go the following website and watch this video called 23.5 hours by Dr. Mike Evans. Chapter 19 How Much Physical Activity is Good for You? pg. 155

164 Chapter # 20 Progressing Your Exercise Program Know how you can progress your own exercise program when you graduate from Cardiac Rehab You Will Learn: 1) How to progress your exercise program and why it matters 2) When it is safe to progress your exercise program Chapter 20 Progressing Your Exercise Program pg. 156

165 What Does Progressing Your Exercise Mean? Progressing your exercise means changing it to make it more challenging. A change in your exercise prescription could mean changing the: Intensity of your exercise (making it more intense) Duration of your exercise (making it longer) Type (trying a different type of exercise) Why Should You Progress Your Exercise? Your body follows a rule of adaptation (over time it adapts or gets used to exercise). When you introduce something new to your body, like exercise, it might feel challenging at first. You may feel: A bit breathless Your exertion as hard work Your heart rate at the higher range of your training target levels You may have felt this in the first few weeks of your exercise program. But, after doing this for a few weeks, your body started to adapt or get used to this exercise and it started to feel easier. Your breathing was not as heavy, your exertion level lowered to a rating of light work and your heart rate during the exercise was a little slower. These are good signs that you are making progress. If you were to continue at that exercise level, you would maintain that level of fitness. To continue to make gains in your fitness level, something has to change in your exercise program. Throughout the program your Cardiac Rehab team progressed your exercise for you. For your aerobic exercise, every few weeks you may have received a new exercise prescription that had a change in either: How long you were exercising and/or How fast you were exercising Chapter 20 Progressing Your Exercise Program pg. 157

166 For your resistance training exercise, you were encouraged to increase: The repetitions of each exercise and or Increase the amount of weight you were lifting, once you found it easier Now, once you graduate from the program, it is important for you to be aware of when and how to progress your own exercise. How Do You Know if You Are Ready to Progress Your Exercise? You are ready to progress your exercise when: Your goal is to continue to make improvements in your fitness level Your rating of perceived exertion (RPE) is less than 11 (light work) on the scale Your heart rate during your exercise is below the training heart rate set by your Cardiac Rehab team You want to try a different activity You are not ready to progress your exercise when: Your current level of exercise is challenging (your RPE is greater than 14 or somewhat hard work) You feel ill You have had a change in your medical status (new symptoms, new diagnoses) You have had a muscle or joint injury You have had a recent change in your medicine. Wait to see how you feel with that medicine change You are getting used to exercising in new weather conditions Your heart rate during exercise is above your training heart rate set by your Cardiac Rehab team Chapter 20 Progressing Your Exercise Program pg. 158

167 It is a very busy time in your life or you are experiencing a major life event (e.g., moving, changing jobs) You are happy with your current level of fitness How Often Should You Progress Your Exercise Program? In the first 3 to 6 months of an exercise program, progression happens every two to three weeks if everything goes as planned. This stage is called the, improvement stage. After about 6 months of regular exercise, you will notice that improvements in your fitness may not happen as often and progression or changes in your exercise program will take place less often. You will likely be in what is called the, maintenance stage where the goal is to keep your exercise program going for the long-term. How often you progress your exercise program during the, maintenance stage will depend on what your goals are (if they have changed) and how much time you have to complete your exercise program. As you are now gearing up for graduating from the CV Prevention & Rehab program, you are likely in this maintenance stage. How Do You Progress Your Aerobic Training Exercise? The first step in progressing your program is to determine if you are ready to move forward. In Chapter 3 Aerobic Exercise, we discussed the important parts of your aerobic exercise program. You will recall that we follow the FITT principle for developing your exercise prescription: Frequency of your exercise Intensity of your exercise Type of exercise Time or duration of the exercise Chapter 20 Progressing Your Exercise Program pg. 159

168 Changes or progression in your exercise program could occur in any of these areas. But change them one at a time. Let s discuss how progression could happen in each element of the FITT principle. Frequency Five days per week is the goal for your prescribed exercise. You also want to make sure you are active every day. If you are currently not meeting the five times per week, consider increasing how often you exercise during the week as a way of progressing your program. Intensity The intensity of your exercise or how hard you exercise could be progressed. Remember that this part of your program should only be progressed if: Your rating of perceived exertion (RPE) is less than 11 (light work) on the scale Your heart rate during your exercise is below the training heart rate set by your Cardiac Rehab team You currently do not feel any symptoms of shortness of breath, angina chest pain, chest discomfort, muscle or joint aches or pains If any of the following statements are true, you are not ready to progress the intensity of your exercise: Your current level of exercise is challenging (your RPE is greater than 14 or somewhat hard work) You feel ill You have had a change in your medical status (new symptoms, new diagnoses) You have had a recent change in your medicine. Wait to see how you feel with that medicine change You are getting used to exercising in new weather conditions Your heart rate during exercise is above your training heart rate set by your Cardiac Rehab team You are happy with your current level of fitness Chapter 20 Progressing Your Exercise Program pg. 160

169 The type of exercise you do will determine how the intensity could change. Here are some examples for walking/jogging and cycling. Walking: increase the speed of your walk no more than 1 minute per mile pace each time you make a change or progress your program Walk/jog: increase how often you jog or increase the length of time you jog in your routine. If you were not given a jogging prescription by your Cardiac Rehab team, speak to your doctor before starting this type of exercise Cycling: increase the revolutions per minute or speed of your cycling or how much tension is on the fly wheel Time or Duration of Exercise The amount of time you spend doing aerobic exercise is important. The goal is to exercise between 20 to 60 minutes depending on your level of fitness, medical history and goals. The amount of time you exercise is usually the first step in progressing your exercise program and should happen before progressing the intensity. Type of Exercise You may want to try a new exercise. For example, you might want a cycling program added to your walking program. Variety is important especially if you feel bored with your program. Changing the type of exercise you do is a way of progressing your program. Be sure you find a new type of exercise that is safe for you to do before trying. How Do You Progress Your Resistance Training Program? To make sure you continue to challenge your muscles and make them stronger, it is important that you progress your resistance training program. This means that, as your muscles get used to the weight you lift, something has to change. This could be how much you lift or how many times you lift the weight. Chapter 20 Progressing Your Exercise Program pg. 161

170 Follow these steps when you are ready to progress your program: Remember: your RPE should never be any higher than 16 Important! Not all exercises progress at the same rate Each muscle group will be ready to progress at different times Do not progress if you don t feel comfortable when doing the exercise Chapter 20 Progressing Your Exercise Program pg. 162

171 Example of How to Progress Your Resistance Training (RT) Program Week of RT Program # of sets # of Repetitions Change in Weight Lifted Week 3 2 Start with 10 No change in weights Week 4 2 Increase to 12 No change in weights Week 5 2 Increase to 14 No change in weights Week 6 2 Increase to 15 No change in weights Week 7 2 Decrease to 10 Increase in weights Week 8 2 Increase to 11 No change in weights In this example, the person has increased their repetitions from 10 up to 15. They are now ready to increase the weight of their dumbbells and drop back down to 10 repetitions. This cycle repeats itself. When You Increase the Weight of Your Dumbbell Follow This Order: 1 pound2 pounds3 pounds4 pounds5 pounds 8 pounds 10 pounds 12 pounds 15 pounds 20 pounds 25 pounds 30 pounds 40 pounds 45 pounds 50 pounds When You Increase the Resistance of Your Exercise Band Follow This Order: Yellow band red band green band blue band black band Your Resources 1. Chapter 3 Aerobic Exercise in this book 2. Chapter 12 Resistance Training in this book Chapter 20 Progressing Your Exercise Program pg. 163

172 Chapter # 21 Relapse Planning Know what to do when your goals and action plans do not go as planned You Will Learn: 1) What a relapse is 2) What to do if things do not go as planned Chapter 21 Relapse Planning pg. 164

173 What is a Relapse? A relapse is when you return to old habits after making lifestyle changes. e.g., you have stopped doing your regular, planned exercise Lifestyle Changes Each week of your Cardiac Rehab program, you set goals and built action plans to make healthy lifestyle choices. Examples of these lifestyle changes include: Doing regular exercise Eating a healthier diet Managing your stress Taking your medicines as prescribed Quitting smoking Drinking less alcohol Making those changes was not easy. Keeping these changes can also be a challenge. Sometimes things get in the way of these new healthy habits. This chapter describes what you can do if you relapse. Preparing For a Relapse Slips or relapses often happen when you: Travel or go on holiday Get sick with a flu/cold Go through life stresses (a death in the family, moving, changing jobs, etc) Have an injury Are exercising during a change in weather conditions (e.g. during a heat wave) Most people who have made a change relapse once in a while. It is very normal. Now is the time to start thinking about how you can help prevent and manage a relapse. Chapter 21 Relapse Planning pg. 165

174 Prevent and Manage a Relapse If you have relapsed, follow the steps to manage a relapse. These steps will help you return to the healthy changes you made. Step 1: Reflect and think about why this change is important to you Thinking about the reasons you wanted to make a change will help you maintain your healthy habits. Each time you feel you cannot do it, think about why you wanted to make this change. Focus on 1 change at a time. Step 2: Be prepared and think about what triggers you to slip or relapse. Think about what might get in the way of your new lifestyle change. For some these may include: A stressful life event (like a job change, moving, emotional stress) A problem that keeps coming up that you struggle to solve A holiday Be aware of these triggers so that you can problem solve and plan ahead Step 3: Problem Solve Don t forget the steps to dealing with the barriers you may face along the way. When things don t go as planned work through your problem solving steps: What was the problem? Brainstorm and come up with other ways or ideas to achieve what you want to do Choose one idea to try Did it work? If not try another idea Ask for help (family, friends, experts) Chapter 21 Relapse Planning pg. 166

175 Step 4: Make Your Action Plans Making an action plan every week is a great tool to prevent relapses and keeps you on track toward reaching your goals. Remember to include in the plan the details about what you are going to do. See below to review how to build your action plan. My Action Plan This week I will (what am I going to do) (when am I going to do it) (where am I going to do it) (how much am I going to do it) (how often am I going to do it) To manage a relapse, follow the 3 steps below: Step 1: Reflect on the changes you made Step 2: Think about what triggered you to relapse Step 3: Problem solve My confidence rating that I can do this plan is: not confident at all totally confident Your Resources 1) Chapter # 11 Goal Setting & Action Planning 2) Speak to your Cardiac Rehab team, family or friends for support and help. 3) Speak with your Cardiac Rehab team about the workshops available at our program. Chapter 21 Relapse Planning pg. 167

176 Chapter # 22 Graduation Congratulations! Learn what you can do to stay healthy after Cardiac Rehab You will learn: 1) About the resources available to you after you finish the Cardiac Rehab program 2) How you can become involved in our Cardiac Rehab program as a support for new patients Chapter 22 Graduation pg. 168

177 Congratulations! You are a successful graduate of the Cardiovascular Prevention & Rehabilitation Program (Cardiac Rehab Program). Your commitment and dedication to the program has given you the best start to a heart healthy lifestyle. As a program graduate, you have knowledge, skills and resources to help you continue to live well, take care of your health, and thrive with your condition. Join other successful graduates in the Cardiac Rehab Alumni Programs that focus on heart healthy education, exercise, peer support and self-management. Read more about each program you can join below: Heart Health for Life The Heart Health for Life program offers a variety of cardiac rehab alumni programs, events and activities for you to include in your action plans for maintaining a heart healthy lifestyle. Access this website to find out more: Take C.H.A.R.G.E. Take C.H.A.R.G.E.is a group that offers education sessions. The sessions feature local health and medical experts who share their knowledge and expertise on topics that meet the graduates' information needs. Take C.H.A.R.G.E. education sessions and events are informative, interactive and fun. Access this website to find out more: Who Can Attend? All program graduates are invited to attend any Take C.H.A.R.G.E. education session or special event with a family member or friend. When Are Sessions Offered? Events are held every month, September through June. Is There a Fee? There is a small fee. Chapter 22 Graduation pg. 169

178 Where Can I Learn More? Past sessions are recorded and are on the Cardiac Rehab Alumni Channel website. The Heart Health for Life Team can provide you with more information about upcoming Take C.H.A.R.G.E. education sessions and special events. Cardiac Rehab Alumni Channel Take C.H.A.R.G.E. is the creator and host of Canada s first YouTube Channel developed specifically for our Cardiac Rehab graduates! The Channel is Canada s most accessible digital health information resource for cardiac rehab program graduates! The Cardiac Rehab Alumni Channel features recommended videos on nutrition, exercise, relaxation and stress reduction in addition to our innovative playlists exclusively featured in our Cardiac Rehab Program (Rumsey site) lobby. Cardiac Peer Support Group The Cardiac Peer Support Group is a peer-led support group, open to all program graduates. The group meets once a month at our Cardiac Rehab Program (Rumsey site). There is no fee for participation in this group. The Heart Health for Life Team can provide you with more information about upcoming meeting dates and times. Healthy Living Peer Support Group The Healthy Living Peer Support Group is a peer-led support group for program graduates who completed the Chronic Disease Self-Management Workshop. The group meets once a month at our Cardiac Rehab Program (Rumsey site). There is no fee for participation in this group. The Heart Health for Life Team can provide you with more information about upcoming meeting dates and times. Chapter 22 Graduation pg. 170

179 Stress Reduction Peer Support Group The Stress Reduction Peer Support Group is a peer-led support group open to program graduates of the Stress Reduction Workshop. There are two groups that meet once a month at our Cardiac Rehab Program (Rumsey site). There is no fee for participation in this group. The Heart Health for Life Team can provide you with more information about upcoming meeting dates and times. Alumni Yoga Program All program graduates can participate in the Alumni Yoga Program to relax, improve flexibility and balance. Monthly gentle chair and gentle mat yoga classes are offered at our Cardiac Rehab Program (Rumsey site). The Heart Health for Life Team can provide you with more information about upcoming alumni Yoga classes and fees. Staying on Track Consider participating in the Staying on Track program to use our Cardiac Rehab Program s (Rumsey site) indoor track and fitness equipment. A member of the Cardiac Rehab team is available to answer your questions. For your safety, a physician is always on-site during program times. Drop in or annual fee applies. Heart Wise Exercise Program The Heart Wise Exercise Program can help you transition from the Cardiac Rehab to fitness programs in your local community. The Heart Wise symbol identifies exercise programs that are safe and suitable for participants with heart disease or living with a chronic condition. The most current information about the Heart Wise Exercise Program is available from the University of Ottawa Heart Institute. Access this website to find out more: GoodLife Fitness Centres GoodLife offers recent graduates of our program a free 3-month membership. Speak with your Cardiac Rehab Supervisor (CRS) to learn more about this offer. Chapter 22 Graduation pg. 171

180 Pulse Check Program graduates can return for annual fitness assessments (stress test) at our Cardiac Rehab Program (Rumsey site). To use this service, you must be exercising regularly and have no new cardiac problems. This assessment includes cardiopulmonary fitness testing and a follow-up telephone call to discuss your results with one of our Cardiac Rehab Supervisors. The Pulse Check program can help to assess your fitness goals and progress, maintain up-to-date health records, and safely adjust your exercise prescription. There is no fee for this service. You will need a referral from your doctor. Heart Health for Life Champions Program graduates are Toronto Rehab s best cardiac rehab champions. As active and engaged volunteers, Heart Health for Life Champions contribute to the continued success and recognition of the Cardiovascular Prevention & Rehabilitation Program (Cardiac Rehab Program) as one of North America s leading academic rehabilitation science centres. Heart Health for Life Champions inspire and support current cardiac rehab participants. They often report that these interactions motivate them to maintain their heart healthy lifestyle. Volunteers provide peer support to current cardiac rehab participants, help organize special events, and provide administrative support to staff at our Cardiac Rehab Program. Talk to your Cardiac Rehab Supervisor to learn more about being a Heart Health for Life Champion. Wishing you continued good health in the future! Most Sincerely, Your Cardiac Rehab Team Chapter 22 Graduation pg. 172

181 Section #4 Tool Box Topic Tool Page # Exercise Tools Exercise Diary 173 Pulse Taking 175 Rating Scales 176 Where Can You do Your Exercise? 177 Measuring Your Exercise Route 179 Buying Exercise Equipment 181 Running Shoes 186 Heat Safety & Air Quality Index 188 Stretches 190 Nutrition Tools Food Diary 192 Serving Sizes 197 Shopping List 202 Sugar in Common Foods 205 Fibre in Common Foods 207 Sodium in Common Foods 209 Risk Factor Tools Your Risk Factor Profile 214 Blood Pressure Diary 215 Blood Sugar (Glucose) Diary 216 Tip Sheet Nutrition 217 Tip Sheet Blood Pressure 219 Tip Sheet Blood Sugar 221 Tip Sheet Cholesterol & Triglycerides 223 Tip Sheet Physical Inactivity 226 Tip Sheet Stress 228 Tip Sheet Smoking 230 Tip Sheet Large Waist Size 232 Goals Tools Vision, Goal, Action Planning Worksheet 235 Action Planning Worksheet 237 Medicine Tool My Cardiac Medicine List 238

182 Aerobic Training Diary Toronto Rehab, Rumsey Centre, 347 Rumsey Road (416) ext Fax (416) Toronto Western Hospital, 399 Bathurst Street (416) Fax (416) Name: Class Day and Time: Exercise Prescription: Date (month and day) Type of Exercise Distance (miles) Duration (minutes and seconds) 10 second pulse Before Exercise After Exercise RPE (number) Symptoms or Comments or Other Activities My Action Plan: This week I will Rating of Perceived Exertion (RPE) What do I want to do? 6 (what) 7 Very, Very Light What will I really be able to do 8 this week? (when) 9 Very Light My plan will include: (where) Fairly Light What I am going to do (how much) Somewhat Hard When I am going to do it (how often) Hard Where I am going to do it My confidence rating that I can do this plan is: 16 How Much I am going to do it Very Hard 18 How Often I am going to do it not confident at all totally confident 19 Very, Very Hard 20 Tool Box Exercise Tools Exercise Diary Page 173

183 Resistance Training Diary Exercises Other Exercise Date: Weight Reps & #Sets RPE Date: Weight Reps & #Sets RPE Date: Weight Reps & #Sets RPE External Heel Half Squat Chest Fly Abdominal Rotation Raise Dumbbell or Bicep Leg or Curl Triceps or or Bird Dog Row Leg Curl Curl Wall Push or Extension Lateral Toe Extension up Seated Curl Raise Press Medical Visits & Medicine Changes: List any changes in your medicine, hospital visits (emergency), doctor visits, lab tests etc. Visits & Reason Date Name of Service or Test or Procedure Name of Medicine Date of Change Dose (how much?) & Frequency (how often?) Tool Box Exercise Tools Exercise Diary Page 174

184 Exercise Tool Where to find your pulse: Pulse Taking 1. Wrist - below the base of the thumb (Radial Artery Pulse) o Place 2 to 3 fingers on your wrist below the base of your thumb o Apply light pressure until you feel a heartbeat 2. Neck below the angle of the jaw (Carotid Artery Pulse) o Place 2 to 3 fingers on the side of your neck beside your Adam's apple in the hollow area o Be careful you do not press too hard; there is a risk of becoming lightheaded How to count your pulse: You will need something to time yourself counting. Use a stopwatch or a second hand on your watch Count the number of beats you feel while you time yourself for 10 seconds When to take your pulse: Before you exercise (at rest) (before you warm up) Immediately at the end of your exercise (exercise rate) (before you cool down) Tool Box Exercise Tools - Pulse Taking pg. 175

185 Exercise Tool Rating Scales Rating of Perceived Exertion Scale (RPE) Very very light Very light Fairly light Somewhat hard Hard Very hard Very very hard Use the Rating of Perceived Exertion Scale (RPE) to rate how much effort you are using during your exercise. Record this on your exercise diary Rating of Perceived Pain Scale (RPP) 0 Nothing at all 0.3 Use the Rating of Perceived Pain Scale (RPP) if you experience pain during your exercise Record this on your exercise diary Extremely weak (just noticeable) Very weak Weak Moderate Strong Very strong Extremely strong Tool Box Exercise Tools Rating Scales pg. 176

186 Exercise Tool Where Can You Do Your Exercise? Outdoors Exercise outdoors when the weather is appropriate. It is important to make sure that you have measured your walking route. See your options on how to measure your route below. Indoor/Outdoor Track A walking track can help you measure your distance for walking/running You will need to know how many laps around the track is equal to a mile or kilometer Fitness/Gym/Recreation Facility Your local recreation centre or local gym will have all the exercise equipment you need for your program (e.g., treadmills, stationary cycles, elliptical machines, weight machines). You may consider getting an annual or part-time membership to meet your needs. Your Cardiac Rehab team can provide you with instructions on how to use these alternatives safely and provide you with appropriate exercise prescription guidelines for use with these machines Try to look for a Heart Wise Exercise facility o Fitness facilities with this symbol is like a check-mark for you to know that their programs: Encourage regular aerobic activity Incorporate a warm-up and cool-down with all their exercise Allow you to exercise at a safe level and have different options for your exercise Tool Box Exercise Tools Where Can You Do Your Exercise? pg. 177

187 Mall Mall walking is a great free alternative. A variety of measured mall maps are available to you in the centre. They can also be accessed on line at: Home Exercise Equipment: If you already have, or are thinking about buying a piece of home exercise equipment, speak to your Cardiac Rehab team. They can provide you with an exercise prescription to use on exercise equipment to substitute or replace your outdoor walking program. To learn more about the features of various types of home exercise equipment, see the information on Exercise Equipment in the Tool Box of this workbook. Tool Box Exercise Tools Where Can You Do Your Exercise? pg. 178

188 Exercise Tool Measuring Your Walking Route If your exercise prescription includes walking and/or running, there is a certain distance that is included. How do you know if you have walked that distance? There are a few ways to measure your walking route: Use the odometer on your car to measure the route Use an indoor or outdoor track. You will need to know how many laps around the track is equal to a mile or kilometer If walking in a mall, find the mall-map on our website at Walking_Maps_Combined_Walking_Maps-D5895.pdf Use a surveyor s measuring wheel to measure your distance. Talk to your Cardiac Rehab Supervisor about borrowing the wheel from the program Go to this website You can find the outdoor location of your route and measure it online. The website page will look like this: Tool Box Exercise Tools Measuring Your Walking Route pg. 179

189 Follow these instructions to measure your route on the Gmaps Pedometer Website: In the Jump To box, type in the exact address, city, postal code or the closest intersection to your walking route and click on go. Use the + or zoom level to find the exact starting point of your walking route. Use the up, down, left or right arrows to look at points on the map that aren t visible on the screen. Once you have found your starting point, press the Start recording button on the left side of the screen and then double-click on the starting point of your walking route on the map. Double-click the map every time you turn a corner. You should see a red teardrop-shaped icon on the screen while mapping your route. As you click on points, the Total distance box on the left side of the screen should be adding up the miles. If your course is a "there-and-back" route, click the Complete there and back route link on the left side of the screen once you reach the midpoint. If you make a mistake, simply click on the Undo last point box. To make a new route, click on Clear points and start over link. Routes can be saved and printed. In the top right hand corner of the map you can click on the Map, Satellite, Hybrid or Topo boxes to view different types of map images. Happy route marking! Tool Box Exercise Tools Measuring Your Walking Route pg. 180

190 Exercise Tool Buying Exercise Equipment Exercise equipment is great to use when the weather is too cold or too hot. Before buying the equipment ask yourself the following questions: What is my current fitness level now? What is my goal? Is the item safe for me to use? How much do I want to spend? Does the item have a warranty? How does this item compare to other equipment? Talk to your Cardiac Rehab Team to help answer these questions. Below is a list of various types of exercise equipment and information about what you should consider before buying. Treadmills Price: Treadmills vary in price. The difference in price is based on durability the extra features included (e.g., computer programming, hear rate monitors, etc.). The durability and construction of the treadmill is most important. Motor: It is important that the treadmill you purchase has a motor. Do not buy a manual treadmill. Manual treadmills make you drive the belt forward. The motor on the treadmill should be at least a 1.5 horse power motor. Turn on the motor of the treadmill and listen to much noise and vibration it makes. This will be important for you when you are listening to music or the TV while exercising! Tool Box Exercise Tools Buying Exercise Equipment pg. 181

191 Belt Widths and Lengths: The width of the belt is important for safety and comfort. Usually the width ranges from 17 to 22 and the lengths from 45 to 60. Emergency Shut Off: The treadmill you choose should have an emergency shut off. This allows the treadmill to shut off if you fall. Computer Feedback and Control Panel: The control panel of the treadmill should display speed, distance and time. Pre-programmed workouts may be an option that most treadmills have. They are not necessary. Heart Rate Monitors: Some treadmills have contact heart rate monitors. You hold on to a hand-rail and the treadmill reads your heart rate and displays it on the control panel. It is not as accurate as taking it on your own or through the use of a transmitter type heart rate monitor. Tool Box Exercise Tools Buying Exercise Equipment pg. 182

192 Stationary Bikes Price: Prices ranges for stationary bikes depend on how many features are included. Bike Styles: Choose a bike style best for you. This will depend on your comfort and any joint/muscle problems you have. Upright Style: set up and look is very similar to traditional outdoor bikes. Recumbent Style: these bikes have a wider chair/seat with a back support and the pedals are out in front of you unlike the upright bike where the pedals are below you. This style of bike is becoming more popular as the comfort of the seat is greater. Control Panel Features: You should be able to determine 1) the speed at which you are pedaling (revolutions per minute (RPM), kilometers per hour (KMPH) or miles per hour (MPH)), 2) the distance covered, 3) the time of cycling, and 4) what level/tension you are working at. Other important features: Foot straps Adjustable seat height so when seated, there is a 15 degree bend in your knee on extension Seat tilt Tool Box Exercise Tools Buying Exercise Equipment pg. 183

193 Elliptical Machines This machine is a great alternative for those wishing to have a non-impact aerobic work-out. It mimics walking or running and offers the option of incorporating the use of arm work as well. Style: It is important to try out the machine before buying. The size of machines and comfort can be different from each other. Some elliptical machines offer forward movement as well as backward movement. Control Panel Features: You should be able to determine 1) the speed at which you are moving (revolutions per minute (RPM), kilometers per hour (KMPH) or miles per hour (MPH)), 2) the distance covered, 3) time of exercise, and 4) the level of intensity at which you are working. Resistance Training Equipment There is a variety of equipment for resistance training. The following options can be purchased: Dumbbell weights or free weights are common pieces of equipment to use for resistance training. They can be purchased in different materials, including rubber, cast iron or plastic. They can also be purchased as a fixed or adjustable weight. Tool Box Exercise Tools Buying Exercise Equipment pg. 184

194 Resistance training machines are the pieces of equipment usually found in a gym. They incorporate a weight stack and pulley system that gives you resistance against a fixed movement. These machines can be purchased for home use as well. Exercise bands can be used for resistance training and may be a good choice if you do not have a lot of room to store equipment. If you need to, you can travel easily with this equipment. Each band colour equals a certain amount of resistance. The lighter the colour, the less resistance on the band. The darker the colour, the more resistance there is on the band. Heart Rate Monitors Monitoring your heart rate during exercise is important to make sure you are working at a safe intensity. Manually checking your heart rate is usually done by feeling your pulse on your wrist or neck and counting the beats you feel over 10 seconds. Sometimes this can be challenging. A heart rate monitor may be used instead. A belt with a transmitter is worn around your chest and sends the information to a watch that you wear on your wrist. You simply glance at your watch during your workout to know your heart rate. These monitors are very accurate. If you have an arrhythmias (irregular heart rhythms), it may not be accurate. Speak to your Cardiac Rehab Team before purchasing one. Tool Box Exercise Tools Buying Exercise Equipment pg. 185

195 Exercise Tool Running Shoes The best footwear for this program is running shoes. Cross trainers, court or walking shoes are not a good choice. We all have individual supportive and cushioning needs. The running shoe category is the best one to offer all these features. Most of these shoes are colourful. Get assessed by an experienced professional to determine your footwear needs. Features of the Running Shoe The uppers are typically a synthetic/nylon mesh combination. These materials offer the most breathability and flexibility and are very light weight. The midsole will look (and feel) different, depending on your supportive requirements. Feet that need support (low arch or flat feet) will have two or more different densities of material and/or a more firm medial (inside of the foot) device to support your foot though the stride. Feet that require cushion (high arch or ridged feet) will have single density, soft midsoles. Every good shoe in the running category will come with removable insoles. This allows for the use of orthotics and also the occasional washing. Remember, they are made of light weight foam that will shrink if you wash them in hot water. Wash them in cold water and by hand only. Tool Box Exercise Tools Running Shoes pg. 186

196 What to Keep in Mind When Purchasing Footwear Have your feet and gait (your walking stride) observed by a qualified salesperson. Call ahead of time and ask if there is someone that can check my gait. If they do not offer the service, call somewhere else. Be sure the salesperson watches you walk or run in the shoes. This will determine if a shoe is over correcting or under correcting your step. Without a gait analysis during the fitting process, it s just guesswork. Do not be fooled by a really soft, cushy feel. The softer the midsole, the less support the shoe has. Although some feet do require a highly cushioned shoe (high arched, rigid foot types), most people fall into categories that require more stability. Softer midsoles also tend to wear out more quickly. Fit is important. Do not settle for a shoe that is too roomy or tight fitting. Shoes are now available in a variety of widths to meet the needs of the widest or narrowest of feet. An ideal fit will be roomy in the toe box. This will allow your toes to spread comfortably and when toeing off in your stride. If a shoe is too snug around your toes, you run the risk of blistering or bruising. Aim for approximately 1 cm or ½ inch width of space between your longest toe and the end of the shoe. This extra space will also allow for swelling as you exercise, especially on those warmer days. Shoes will last 6 to 12 months or 800 to 1200km. This will vary according to your foot strike and/ or your weight. By: Running Free 708 Denison Street, Hwy 404 and Steeles Ave. area, Phone: Shop online at Tool Box Exercise Tools Running Shoes pg. 187

197 Exercise Tool Heat Safety & Air Quality Index From: Take Heart, 2004; Dr. T. Kavanagh Your Action Steps for Exercise for Each Heat Safety Zone Safe Alert Danger Emergency Exercise as usual Safe to exercise outdoors Decrease your exercise intensity Watch for symptom No outdoor exercise Avoid going outdoors Tool Box Exercise Tools - Heat Safety and Air Quality Index pg. 188

198 Air Quality Health Index When you check the weather report for air quality, look for: The Air Quality Health Index (AQHI) Air pollution can be measured by the AQHI. This index tells you the level of common air pollutants. In Ontario, the range for the index is 0 to 10. The lower the number, the better the air quality. If you live outside of Ontario, go to your local public health website to find out how your area lists the air quality index. Your Action Steps for Exercise for Each Air Quality Range: Low Risk 1 to 3 Moderate Risk 4 to 6 High Risk 7 to 10 Very High Risk above 10 Exercise as usual Safe to exercise outdoors Decrease your exercise intensity Watch for symptom s No outdoor exercise Avoid going outdoors Consider reschedulin g your outdoor The Weather Network or Environment Canada can give you up to date weather conditions (including the air quality) for the day: or or Tool Box Exercise Tools - Heat Safety and Air Quality Index pg. 189

199 Stretches Exercise Tool 1) Chest Stretch (Pectoral Muscle) Stand with your feet shoulder width apart Relax your shoulders and make sure they are not hunched up Clasp your hands behind your back (if you cannot clasp them, then place them behind your back) Looking straight ahead, open up the chest and squeeze your shoulder blades together Hold the stretch while continuing to breathe for seconds Ensure you feel a stretch, not pain/discomfort 2) Shoulder Stretch (Deltoid Muscle) Stand with your feet shoulder width apart, arms by your side Relax your shoulders and make sure they are not hunched up Take one arm and bring it across your chest Take the other arm and place it on your elbow to help hold it in position Ensure your arm is across your chest and not across your neck Hold the stretch while continuing to breathe for seconds Ensure you feel a stretch, not pain/discomfort Repeat to stretch the opposite shoulder Tool Box Exercise Tools Stretches Page 190

200 3) Thigh Stretch (Quadricep Muscle) Using a wall for support, stand sideways to the wall Take hold of your ankle, foot, sock, or pant leg as you bend your leg back from the knee (see figure) The knee should be facing down toward the floor and in line with the leg that is planted on the floor Hold the stretch while continuing to breathe for seconds Ensure you feel a stretch, not pain/discomfort Repeat to stretch the opposite thigh 4) Hamstring Stretch Using a wall or table for support, stand sideways to it Put all of your body weight on one leg and bend that leg Take the opposite leg and place the heel on the floor or on a small step with the toes pointed up. Keep this leg straight From this position, bend forward from the waist you will feel a stretch in the back of the upper leg that is straight Hold the stretch while continuing to breathe for seconds. Ensure you feel a stretch, not pain/discomfort Repeat to stretch the opposite hamstring 5) Calf Stretch Using a wall for support, face the wall standing with both feet close to it. Place your hands on the wall at chest height Take a step back with one leg keeping that leg straight and lean into the wall keeping the front leg bent Ensure both feet are facing forward As you lean into the wall, you will feel a stretch in the calf of the back leg Hold the stretch while continuing to breathe for seconds Ensure you feel a stretch, not pain/discomfort Repeat to stretch the opposite calf Tool Box Exercise Tools Stretches Page 191

201 Nutrition Tool Food Diary Tips for Keeping a Food Diary Keep track of what you eat for two (2) weekdays and one (1) weekend day Use a separate diary page for each day Use the sample food diary and the handout Serving Size guidelines to help you fill in your food diary o If you are a current participant of the Cardiac Rehab program, book an appointment with a registered dietitian to discuss your diary once you have filled it in. o When you book your appointment, hand in your diary. Be sure to write your appointment time on your food diary so the dietitian is prepared for your visit Tool Box Nutrition Tool Food Diary Page 192

202 Example: My Daily Food Diary Time of Day What I Ate (Please provide details) How Much? 8:00 a.m. -Whole grain bread with margarine -Banana, medium -1% milk -Coffee 2 slices, 2 tsps. 1 8 oz or 1 cup (250 ml) 1 tbsp cream, 1 tsp sugar 10:00 a.m. Apple, medium 1 1:00 p.m. - Sardines, canned, packed in lemon juice - Rye bread - Cherry tomatoes - Clementines 1 can (has 4 sardines) 2 slices of rye bread ½ cup or 6 2 4:30 p.m. - Plain 1% M.F. yogurt with added cinnamon - Unsalted almonds - ¾ cup - ¼ cup 7:00 p.m. Salmon, grilled with dressing Dressing: olive oil, lemon juice, spices Wild rice Spinach, steamed with mushrooms Broccoli, steamed, plain 6 oz 1 tbsp oil 1 cup, cooked 1 cups + 1 tsp oil 1 cup, no oil Summary Vegetables and Fruit - Milk & Alternatives Fats & Oils. - - Grains, Cereals and Starches - Meat & Alternatives.. - Other Foods (Include: cookies, candy, chocolate, etc.) Current Supplements and Dosage: Tool Box Nutrition Tool Food Diary Page 193

203 My Daily Food Diary Name: Group Colour: Class Day: Time of Day What I Ate How Much? Summary Vegetables and Fruit - Milk & Alternatives Fats & Oils. - - Current Supplements and Dosage: Grains, Cereals and Starches - Meat & Alternatives - Other Foods. (Include: cookies, candy, chocolate, etc.) My Daily Food Diary Tool Box Nutrition Tool Food Diary Page 194

204 Name: Group Colour: Class Day: Time of Day What I Ate How Much? Summary Vegetables and Fruit - Milk & Alternatives Fats & Oils. - - Current Supplements and Dosage: Grains, Cereals and Starches - Meat & Alternatives.. - Other Foods. (Include: cookies, candy, chocolate, etc.) My Daily Food Diary Name: Group Colour: Class Day: Tool Box Nutrition Tool Food Diary Page 195

205 Time of Day What I Ate How Much? Summary Vegetables and Fruit - Milk & Alternatives Fats & Oils. - - Current Supplements and Dosage: Grains, Cereals and Starches - Meat & Alternatives.. - Other Foods. (Include: cookies, candy, chocolate, etc.) Tool Box Nutrition Tool Food Diary Page 196

206 Nutrition Tool What is a Serving Size? Vegetables & Fruit, Aim for 7-10 Servings Daily One serving equals: Medium piece of fruit, the size of a tennis ball Green leafy veggies 250 ml (1 cup) Fresh or frozen fruit or cut vegetables 125 ml (1/2 cup) Dried fruit, 2 tablespoons Tool Box Nutrition Tool What is a serving size? Page 197

207 Grain Products, Aim for 6-8 Servings Daily One serving equals: Cooked grains (rice, oats, pasta, etc.) - 1/2 cup Breads (1 slice, ½ pita, ½ small bagel) - 30g Cereals (1/3 cup for bran type or 2/3 cup flaked) - 30g Mashed potato - 1/2 cup Potato, sweet potato, yam ½ medium Milk & Alternatives, Aim for 2-3 Servings Daily One serving equals: Unsweetened yogurt, 175g (3/4 cup) Skim milk, 1%, 2%, or soy, Cheese (15% MF or less), Plain or fruit flavour, Almond or rice milk 250ml (1 cup) 50g (1.5 oz) Tool Box Nutrition Tool What is a serving size? Page 198

208 Meat & Alternatives, Aim for 2-3 Servings Daily One serving equals: ¼ cup shelled nuts & seeds 60ml (1/4 cup) 75g or 2.5 oz fatty fish, lean beef, pork, chicken ortturkey Beans, lentils, peas ¾ cup (cooked or canned) Peanut or almond butters 30 ml (2 Tbsp) Oils & Fats, Aim for 2-3 Tablespoons Daily (There are 3 teaspoons in 1 tablespoon) One serving equals: 1 tsp of oil 1/8 avocado=1 tsp 1 tsp butter Or non-hydrogenated margarine Tool Box Nutrition Tool What is a serving size? Page 199

209 Tool Box Nutrition Tool What is a serving size? Page 200

210 Eating Well with Canada s Food Guide What is a Serving? Vegetables & fruit, 7-10 servings daily One serving equals: Medium piece of fruit, the size of a tennis ball Fresh or frozen fruit 125 ml (1/2 cup) (berries, grapes, etc) Cut vegetables (fresh or frozen) Green leafy veggies Dried fruit 125ml (1/2 cup) 250 ml (1 cup) 2 Tablespoons Milk & alternatives, 3 servings daily One serving equals: Skim, 1%, 2% Soy, almond, rice Canned milk Cheese (15% MF or less) Cottage Cheese (2%MF or less) 250ml (1 cup) 250ml (1 cup) 125ml (1/2 cup) 50g (1.5 oz) (1/4 cup) Yogurt, plain 175g (3/4 cup) or fruit with low sugar Kefir 175g (3/4 cup) Frozen yogurt 125 ml (1/2 cup) Grain products, 6-8 servings daily One serving equals Breads (30g serving) Bread slice, small dinner Roll 1 Small bagel, kaiser, english muffin, pita ½ Bread sticks, ryvita, wasa 2 Chapati 15 cm (6in) round 1 Hot dogbbun, hamburger bun ½ Melba toast rectangles 4 Rice cakes, rusks 2 Soda crackers 6 Cereals (30g serving) All-Bran type (1/3 cup) Flaked or crispy dry cereals (2/3 cup) Hot cereal, dry (2 Tbsp) Hot cereal, cooked 175mL (3/4 cup) Puffed type 250ml (1 cup) Shredded Wheat 1 biscuit Grains/ cooked Cooked rice, paasta, quinoa, barley, bulgur Popcorn, no butter Corn kernels Corn-on-the-cob 125ml (1/2 cup) (3 cups) (1/2 cup) ½ medium Starchy Vegetables Mashed potato (1/2 cup) Potato, sweet potato, Yym ½ medium Meat & alternatives, 2-3 servings daily One serving equals: 75g or 2.5 oz Meats & poultry Lean beef, lamb, pork 75g (2.5 oz) Ground beef, chicken, turkey (½ cup) Chicken, turkey, no skin 75g (2.5 oz) Fish & Seafood Fresh or frozen fish 75g (2.5 oz) Canned fish in water 75g (1/2 can) Clams, mussels, oyster 9 medium Shrimps 8-15 Scallops 6 Crab, lobster ½ cup Meat alternatives One serving equals: Eggs (limit 2-3 yolks per week) Poached or boiled egg 2 medium Cooked beans, lentils, peas ¾ cup Natural peanut butter 30ml (2 Tbsp) Tofu 150 g (3/4 cup) Shelled nuts & seeds 60ml (1/4 cup) Oils & fats One serving equals: 2-3 tablespoons/day Olive oil, canola, others 5 ml (1 tsp) Avocado 1/8 Butter or non-hydrogenated 5ml (1 tsp) margarine Cream cheese, 15ml (1 Tbsp) sour cream, salad dressing, mayonnaise Tool Box Nutrition Tool What is a serving size? Page 201

211 Nutrition Tool My Shopping List Keep a blank notepad with a magnet on the refrigerator. As you run out of items in your pantry, add them to the list so you don t forget them when you are ready to go shopping. Plan ahead. Think about your week. What meals will you make? Include food items on your list that you will need for those menus. Look at weekly flyers for sale items. Stock up. Always make sure your kitchen pantry is stocked with basic essentials. The lists below give you some tips on what you want to fill your cupboards with: Grains & cereals Steel cut oats High fibre cereals Low fat granola Quinoa Rice (brown, basmati, white, etc.) Whole grain couscous Barley Pasta, whole grain Whole grain rye, pumpernickel, multi-grain breads/pita Bulgur, couscous, or kasha Vegetables & fruit (fresh, canned, and frozen) Fresh or frozen vegetables: Always add 1 or 2 green vegetables to your list. Onions, tomatoes are commonly used in recipes. Always make sure you have them on hand. Include a total of 4 frozen or fresh vegetables (at least) for the week. Choose from the lists below: Broccoli Green beans Brussel sprouts Okra Green leafy vegetables: Spinach Swiss Chard Kale Bok Choy Collard or mustard greens Broccoli rabe/rapini Onions Tomatoes Mushrooms Cabbage, Nappa Cucumber Lettuce, romaine, leaf, Boston Potatoes Carrots, Squash Celery, regular or Chinese Cauliflower Tool Box Nutrition Tools My Shopping List Page 202

212 Canned vegetables: choose low-sodium or no-salt-added Canned tomatoes Tomato sauce or pasta Other canned vegetables Canned vegetable soup with reduced sodium Fresh or frozen fruit: Pick your favourite Apples Peaches Bananas Oranges Grapes Berries Pears Lemons/Limes Mangoes Dried fruit (raisins, prunes, dates) Milk & alternatives Lower fat (1%) milk or unsweetened soy, almond or rice beverage. Lower fat or reduced fat (15% or less) cheeses Lower fat (1%) plain yogurt ( unsweetened) Non-hydrogenated margarine or Butter Meat & alternatives Fresh or frozen unprepared meats: White meat chicken and turkey (no skin) Fish (not battered) Beef, round or sirloin Extra lean ground beef Pork tenderloin Meat alternatives: Tofu (or bean curd) Edamame (frozen) Beans & lentils (see list) Peanut or almond butter Eggs Nuts & seeds (see list) Tool Box Nutrition Tools My Shopping List Page 203

213 Beans and lentils (if canned, no-salt added) Lentils (all kinds) Black beans Red beans (kidney beans) Navy beans Black beans Pinto beans Black-eyed peas Fava beans Italian white beans Chickpeas (garbanzo beans) Dried beans, peas, and lentils (without flavoring packets) Nuts and seeds Almonds, unsalted Mixed nuts, unsalted Peanuts, unsalted Walnuts Sesame seeds Pumpkin seeds, unsalted Sunflower seeds, unsalted Cashews, unsalted Pecans, unsalted Baking items Flour, whole wheat Sugar Canned evaporated milk fat-free (skim) or reduced fat (2%) Cocoa powder, unsweetened Baking powder & Baking soda Cornstarch Condiments: Sauces, seasonings & spreads Olive oil (cooking and salad dressings; make your own). Vinegars (balsamic, apple cider, white) Mustard (Dijon, etc.) Mayonnaise Honey Herbs & spices Tool Box Nutrition Tools My Shopping List Page 204

214 Nutrition Tool Amount of TOTAL Sugar in Common Foods (includes naturally occurring and added sugars) 1 teaspoon of sugar = 4 grams Food Serving Size Amount of Total Sugar (g) Teaspoons of Sugar Sugar sweetened beverages Fruit juices 8 oz (250 ml) Iced tea 1 can (355 ml) 32 8 Regular soda (dark & light 1 can (355 ml) colas) Tomato juice 8 oz (250 ml) Cereals All Bran Buds 1/3 cup 8 2 (contains 11 g of fibre) Cheerios 1 cup (250 ml) 1 - (contains 1 g of fibre) Corn Flakes 1 cup (250 ml) 2 - Fibre 1 ½ cup (125 ml) 0 - (contains 14 g of fibre) Honey Nut Cheerios 1 cup (250 ml) 12 3 Raisin Bran 1 cup (250 ml) 17 4 Milk & Alternatives Chocolate milk 8 oz (250 ml) Almond, soy, rice beverage, 8 oz (250 ml) 20 5 flavoured (e.g. chocolate, vanilla) Ice cream, chocolate 1 cup (250 ml) 36 9 Yogurt, plain ¾ cup (175 ml) 13 3 Yogurt, fruit bottom ¾ cup (175 ml) 25 6 Tool Box Nutrition Tools Sugar in Common Foods Page 205

215 Unsweetened yogurt (made with artificial sweetener) Sugars & Sweets 100 g 8 2 Agave 1 tablespoon (15 ml) Brown sugar 1 tablespoon 12 3 (15 ml) Chocolate bar 1 bar (50 g) Hard candy 3 pieces (18 g) 12 3 Honey 1 tablespoon (15 ml) Jams & marmalades 1 tablespoon (15 ml) Jelly beans 10 beans (28 g) 20 5 Maple syrup Sauces & Condiments 1 tablespoon (15 ml) 12 3 Tomato sauce (jarred or ½ cup (125 ml) canned) Ketchup 1 tablespoon 3 1 (15 ml) Sweet n sour sauce 1 tablespoon 3 1 (15 ml) Alcoholic Beverages & Liqueurs Vodka cooler 1 bottle (390 ml) 12 3 Sangria 8 oz (250 ml) 20 5 Cocktail, daiquiri 8 oz (250 ml) Liqueur, coffee & cream 1.5 oz (45 ml) Dessert wine, sweet 4 oz (125 ml) Source: "Canadian Nutrient File 2010." [Accessed March 14, 2014]; USDA National Nutrient Database. [Accessed March 17, 2014] References: Johnson, R.K. et al. (Sept. 2009). Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement From the American Heart Association. Circulation. 120: Tool Box Nutrition Tools Sugar in Common Foods Page 206

216 Nutrition Tool Amount of Fibre in Common Foods Food Serving Size Total Fibre (g) Vegetables Artichoke, cooked medium 4.7 Asparagus, cooked 6 spears 1.8 Beans, green cooked 125 ml (½ cup) 5.6 Beets, skinless 125 ml (½ cup) 1.8 Broccoli, cooked 125 ml (½ cup) 2.0 Brussels sprouts, cooked 125 ml (½ cup) 3.0 Carrots, cooked 125 ml (½ cup) 2.2 Carrot, raw 1 medium 1.5 Collard greens, cooked 125 ml (½ cup) 2.8 Corn 125 ml (½ cup) 1.6 Eggplant 125 ml (½ cup) 1.3 Kale, cooked 125 ml (½ cup) 1.4 Okra, cooked 125 ml (½ cup) 2.1 Peas, green, cooked 125 ml (½ cup) 5.6 Pepper, green or red medium 1.1 Potato, white, with skin, baked 1 small 3.8 Rapini, cooked ½ cup 1.8 Spinach, cooked ½ cup 2.3 Spinach, raw 1 cup 0.7 Sweet potato, cooked, skinless 125 ml (½ cup) 1.7 Squash, cooked 125 ml (½ cup) 1.3 Turnip, cooked 125 ml (½ cup) 1.6 Fruit Apple with skin 1 medium 2.6 Apricots, raw, with skin Apricots, dried 60 ml (¼ cup) 1.2 Avocado 1/2 fruit 6.7 Banana 1 medium 2.0 Blueberries 125 ml (½ cup) 2.0 Figs, dried Fig, fresh Tool Box Nutrition Tool Fibre in Common Foods Page 207

217 Food Serving Size Total Fibre (g) Mango ½ fruit 1.9 Nectarine, raw with skin 1 medium 2.3 Orange 1 medium 2.3 Peach, raw with skin 1 medium 1.9 Pear, with skin 1 medium 5.0 Prunes, dried Plum, with skin 1 medium 1.1 Raspberries 125 ml (½ cup) 4.2 Strawberries 125 ml (1/2 cup) 3.0 Grains & Cereals Bran Buds (with Psyllium) 30 g (1/3 cup) 11.4 Barley, pearled, cooked 125 ml (½ cup) 2.0 Bread, whole grain 30 g (1 slice) 2.6 Brown rice, cooked 125 ml (½ cup) 1.1 Bread, rye 35 g (1 slice) 1.2 Bran cereal (non-flake) 30 g (1/2 cup) 10.1 Crisp bread crackers 3 crackers 5.0 Melba toast, whole wheat 6 crackers 1.5 Oat bran, cooked 175 ml (¾ cup) 5.1 Oatmeal, cooked 175 g (3/4 cup) 3.5 Cheerios 30 g (1 cup) 2.6 Pasta, cooked (whole wheat) 125 ml (½ cup) 2.1 Quinoa, cooked 125 ml (1/2 cup) 2.0 Meat Alternatives- Plant Proteins Almonds 24 g (1/4 cup) 2.5 Black beans, cooked 250 ml (1 cup) 5.2 Chickpeas, cooked 250 ml (1 cup) 4.0 Cashews 33 g (1/4 cup) 1.1 Edamame, (soybean, green, cooked) 125 ml (½ cup) 4.0 Flax seed, milled/ground 15 ml (1 Tbsp) 2.0 Kidney beans, cooked 250 ml (1 cup) 12.0 Lentils, cooked 250 ml (1 cup) 8.9 Lima beans 250 ml (1 cup) 8.0 Soybean, cooked 250 ml (1 cup) 11.4 Sunflower seeds, dry roasted 60 ml (1/4 cup) 3.0 Tofu, fried pieces 175 ml (¾ cup) 3.9 Source: "Canadian Nutrient File 2010." [Accessed March 23, 2013] Tool Box Nutrition Tool Fibre in Common Foods Page 208

218 Sodium In Processed Food Nutrition Tool Box Food Serving Size Sodium (mg) Fresh tomato 1 medium 14 Canned stewed tomato ½ cup 298 Tomato sauce ½ cup 721 Tomato ketchup ½ cup 1300 Food Serving Size Sodium (mg) Roast beef 3 ounces 46 Beef hot dog Beef jerky 2 strips 876 Corned beef 3 ounces 992 Food Serving Size Sodium (mg) Raw oats ½ cup 0 Cheerios 1 cup 217 Instant flavoured oatmeal 1 packet 240 Multigrain bagel Food Serving Size Sodium (mg) Soy beans, cooked ½ cup 1 Soy veggie ground round ½ cup 270 Soy veggie burger Soy sauce 1 tablespoon 1028 Tool Box Nutrition Tools Sodium in Common Foods Page 209

219 Sodium Content In Common Foods Food Serving Size Sodium (mg) Vegetables and fruit Fresh and most frozen vegetables contain very little sodium. Tomato sauce (plain or with vegetables), 125 ml (1/2 cup) canned/bottled Sauerkraut, canned/bottled 125 ml (1/2 cup) 496 Peppers (jalapeno, hot chilli), 30 ml (2 Tbsp) canned/bottled Pickles (sour, dill) 1 small Vegetables, all varieties, canned 125 ml (1/2 cup) Tomato juice and vegetable cocktail 125 ml (1/2 cup) 345 Stewed tomatoes, canned 125 ml (1/2 cup) 298 Sun-dried tomatoes 7 tomatoes 287 Pizza sauce 125 ml (1/2 cup) 246 Olives, canned 4 olives Grain products Grains such as rice, barley, quinoa, oats and wheat are low in sodium. Cereal Cream of wheat, all types, cooked 175 ml (3/4 cup) 370 Dry, all varieties 30 g Oatmeal, instant, cooked 175 ml (3/4 cup) Other grain products Crackers, all varieties, salted 30 g Bread roll (rye, French) 1 roll (35 g) Bread, all types 1 slice (35 g) Muffin (carrot, blueberry, chocolate chip) 1 small (66 g) Soda crackers, unsalted 10 (30 g) 230 Bagel, all varieties ½ bagel (45 g) Milk and alternatives Buttermilk 250 ml (1 cup) Cheese Cottage cheese (1%, 2%) 250 ml (1 cup) Blue 50 g (1 ½ oz) Processed cheese slices (cheddar, 50 g (1 ½ oz) Swiss) Feta 50 g (1 ½ oz) 558 Tool Box Nutrition Tools Sodium in Common Foods Page 210

220 Food Serving Size Sodium (mg) Cheese spread 30 ml (2 Tbsp) Cheddar, Colby, edam, gouda, 50 g (1 ½ oz) mozzarella, provolone, camembert Cottage cheese, fat free 250 ml (1 cup) 287 Meat and alternatives Fresh and unprocessed frozen meat, poultry and fish contain very little sodium. Bagged dried peas, beans and lentils contain little sodium. Meat Bacon, cooked 75 g (2 ½ oz) Bacon (back bacon/peameal, English 75 g (2 ½ oz) style bacon), cooked Ham, cured, cooked 75 g (2 ½ oz) Beef jerky 75 g (2 ½ oz) 976 Corned beef, canned 75 g (2 ½ oz) 754 Ham, reduced sodium, cooked 75 g (2 ½ oz) 727 Poultry Turkey bacon 75 g (2 ½ oz) 1714 Turkey, smoked 75 g (2 ½ oz) 747 Chicken/turkey, rotisserie/ready to serve, 75 g (2 ½ oz) barbequed Chicken/turkey, canned 75 g (2 ½ oz) Chicken nuggets or burger, cooked 75 g (2 ½ oz) Meat products Salami or pepperoni, all varieties 75 g (2 ½ oz) Ham or chicken, canned 75 g (2 ½ oz) Luncheon/deli meat, all varieties 75 g (2 ½ oz)/ 3 slices Wiener, frankfurter, all varieties, cooked 75 g (2 ½ oz) Chorizo (beef, pork) 75 g (2 ½ oz) 926 Sausage, all varieties, cooked 75 g (2 ½ oz) Luncheon/deli meat (pork, chicken), reduced sodium 75 g (2 ½ oz) 710 Salami or bologna, all varieties, reduced 75 g (2 ½ oz) sodium Ham, honey, cooked 75 g (2 ½ oz) 675 Liverwurst 75 g (2 ½ oz) Pate, canned 75 g (2 ½ oz) Blood sausage/blood pudding, cooked 75 g (2 ½ oz) 510 Tool Box Nutrition Tools Sodium in Common Foods Page 211

221 Food Serving Size Sodium (mg) Sausage, all varieties, reduced sodium, cooked 75 g (2 ½ oz) 441 Wiener, frankfurter, all varieties, reduced 75 g (2 ½ oz) 233 sodium, cooked Fish and seafood Mackerel or cod, salted 75 g (2 ½ oz) Anchovies, canned 75 g (2 ½ oz) 2751 Fish, all varieties, smoked 75 g (2 ½ oz) Herring, pickled or kippered 75 g (2 ½ oz) Shellfish (crab, shrimp, calamari, oyster, 75 g (2 ½ oz) lobster, mussels), canned or cooked Caviar (red, black) 75 g (2 ½ oz) 450 Fish sticks, cooked 75 g (2 ½ oz) 316 Fish (sardines, salmon, tuna, mackerel), 75 g (2 ½ oz) canned Meat alternatives Meatless (bacon, bacon bits), cooked 75 g (2 ½ oz) Baked beans, all varieties, canned 175 ml (3/4 cup) Refried beans, canned 175 ml (3/4 cup) Meatless (sausage, chicken, meatballs, 75 g (2 ½ oz) fish sticks, wiener, luncheon slices), cooked Legumes (dried beans, pea, lentil), 175 ml (3/4 cup) canned all varieties Vegetarian meatloaf or patty, cooked 75 g (2 ½ oz) 413 Pumpkin or squash seeds, salted, 60 ml (1/4 cup) 412 without shell Nuts (peanuts, almonds, cashews), 60 ml (1/4 cup) salted, without shell Egg substitute 125 ml (1/2 cup) 235 Other Salt (table, Kosher, pickling, sea) 5 ml (1 tsp) Salt, seasoned 5 ml (1 tsp) 1550 Yeast extract spread 2 Tbsp (30 g) 1322 Soy sauce 15 ml (1 Tbsp) Salt substitute, Cardia 5 ml (1 tsp) 1080 Tool Box Nutrition Tools Sodium in Common Foods Page 212

222 Food Serving Size Sodium (mg) Salt substitute, half salt 5 ml (1 tsp) 800 Sauce, teriyaki 15 ml (1 Tbsp) 700 Soy sauce, reduced sodium 15 ml (1 Tbsp) 608 Sauce (cheese, nacho cheese) 60 ml (1/4 cup) Oyster sauce 15 ml (1 Tbsp) 499 Salsa, all varieties 60 ml (1/4 cup) Sauce (steak, barbecue) 30 ml (2 Tbsp) Ketchup, yellow mustard or relish 30 ml (2 Tbsp) Sauce, teriyaki, reduced sodium 15 ml (1 Tbsp) 325 Capers, canned 15 ml (1 Tbsp) 258 Snacks Pretzels (soft, hard) 1 small or 50 g Cheese puffs 50 g Popcorn, flavoured or plain microwave 50 g (packaged) Popcorn, flavoured, reduced sodium 50 g 245 Corn nuts, all varieties 50 g Chips (tortilla, vegetable, potato, soy), all 50 g varieties Source: Dietitians of Canada (from Canadian Nutrient File 2011) Tool Box Nutrition Tools Sodium in Common Foods Page 213

223 Modifiable Risk Factor Your Risk Factor Profile Desirable Level Risk Factor Tool My Level My Level My Level Date: Date: Date: Physical Inactivity Nutrition Stress Smoking Blood Pressure Cholesterol Blood Glucose Waist Size Aerobic Exercise Resistance Training Exercise Fat: less than30% of daily calories (<7% Cal from saturated fat; < 1% Cal from trans fat) Daily active living Moderate to Vigorous intensity, minutes 5 times/week Moderate intensity, reps, 2-3 times/week Sodium: Fibre: less than at least mg/day grams/day Coping well with: Depression Sleep apnea Psychosocial stress Disturbed sleep Chronic stress Stressful life events Lost sense of control To find out your heart stress risk, go to this website or see psychosocial services Avoid smoking and exposure to second hand smoke Less than 140/90 mmhg Living With Diabetes: less than130/80 mmhg LDL Cholesterol/ HDL Ratio HDL Triglycerides Fasting Blood Glucose A1c General Guideline European, Sub-Saharan African, Eastern Mediterranean and Middle Eastern South Asian, Chinese, Japanese, South & Central American Less than 2.0 mmol/l or 50% or more reduction Less than 4.0 Greater than 1.0 mmol/l Less than 1.7 mmol/l 4 to 5.6 mmol/l Living With Diabetes: 4 to 7 mmol/l Living with Diabetes: Less than 7% for most Men <102 cm (40") Women < 88 cm (35") Men <94 cm (38") Women < 80 cm (32") Men <90 cm (36") Women < 80 cm (32") Tool Box Risk Factor Tools Risk Factor Profile Page 214

224 Risk Factor Tools Blood Pressure Diary Exampl e Date Time of Day Blood Pressure Comments 12/8 11:45 am 138/80 Stressful day at work Tool Box Risk Factor Tools Blood Pressure Diary Page 215

225 Risk Factor Tool Exercise Blood Glucose Diary Examp le Date Time Blood Glucose Before Exercise Blood Glucose After Exercise Comments 04/25 10:00 am If exercise is new for you Monitor your blood sugar levels before and after exercise for 6 or more exercise sessions If you have been exercising consistently over the past couple of months you may consider monitoring your blood sugar levels before and after exercise if: You are experiencing difficulty managing your blood sugar OR You are trying a new exercise prescription Tool Box Risk Factor Tools Blood Glucose Diary Page 216

226 Risk Factor Tools Tip Sheet: Nutrition Healthy Target Total Fat Intake Fibre Intake Sodium Intake Added Sugar Less than 30% of total calories per day, (<7% of calories from saturated fat and < 1% of calories from trans fat) grams per day Less than 1500 mg/day Women: up to 5 teaspoons per day Men: up to 9 teaspoons per day What Is a "Heart Healthy" Diet? A heart healthy diet is one that includes the following: Plenty of vegetables and fruits Healthy fats instead of saturated and trans fats Whole grains and cereals, beans and lentils Fatty fish at least twice a week A handful of unsalted nuts and seeds most days Lower fat dairy products What Does "A Fat Intake of Less Than 30% of Total Calories" Mean? The below are examples only and are not intended to recommend total calories to eat and drink each day. If you are a man and you eat and drink 1800 calories per day: Total fat for the day = 60 grams with up to 14 grams (approximately 3 teaspoons) from saturated (e.g., animal) fat Tool Box Risk Factor Tool Nutrition Tip Sheet Page 217

227 If you are a woman and you eat and drink 1500 calories per day: o Total fat for the day = 50 grams with up to 11 grams (approximately 2.5 teaspoons) from saturated (e.g., animal) fat Why is not eating well a risk factor? Not eating well can lead to: Weight gain High blood pressure High cholesterol What Actions Can You Take To Eat Well? Try to make one or two changes to start. Begin slowly and then over time make other changes Never skip meals. Include at least 3 meals a day. Start with breakfast Eat regularly during the day. A guide to follow is to eat every 4 to 5 hours. This can help to prevent hunger from building Include more plant-based foods. Have a fruit and/or vegetable, every time you eat a meal or snack. Cook with legumes or beans more often Choose whole grain breads and cereals, i.e. whole wheat pasta, whole grain bread, high fibre cereals Have fish instead of red meat more often Limit foods high in sugar, i.e. juice, regular pop, cookies, pies and other baked good items Speak to a registered dietitian for further guidance Speak to your Cardiac Rehab team to help develop your action plan Tool Box Risk Factor Tool Nutrition Tip Sheet Page 218

228 Risk Factor Tools Tip Sheet: Blood Pressure Healthy Target Less than 140/90 mmhg If you have diabetes: less than 130/80 mmhg What Is Blood Pressure? Blood pressure is a measure of the force of the heart pumping blood out against the walls of your arteries. Blood pressure is expressed as two numbers, such as 120/80, and is measured in millimetres of mercury (mmhg). The top number (systolic blood pressure) is the force of blood when the heart contracts and the bottom number (diastolic blood pressure) is the force of blood when the heart relaxes. Both numbers are important. Why is High Blood Pressure a Risk Factor? High blood pressure often has no warning signs or symptoms. For this reason, high blood pressure has been called a silent killer. Over time, high blood pressure can damage the walls of the arteries in your body. This damage can cause plaque to build up in the arteries, blocking blood flow to your heart. Untreated high blood pressure can also lead to kidney disease, stroke, and impaired heart functioning (heart failure). Other factors can increase blood pressure, including high salt diet, excess body weight and stress. Tool Box Risk Factor Tools Blood Pressure Tip Sheet Page 219

229 What Actions Can You Take to Control Your Blood Pressure? Know your blood pressure level. Keep records of your measurements during visits with your doctor. Take your blood pressure medication as prescribed and at the time prescribed, even if you feel well. Exercise 5 times per week, including aerobic training (walking, cycling, etc.) and resistance training 2 times per week (weights). Over time, regular exercise can lower your blood pressure. Maintain a healthy weight. Increase intake of foods that are high in potassium, calcium and magnesium such as: fruits, vegetables, nuts/seeds, whole grains, beans and lentils, and lower fat milk products. Reduce the amount of sodium in your diet to less than 1500mg per day. If you drink alcoholic beverages do so in moderation, i.e. men: no more than1-2 drinks per day or less than 14 drinks per week. Women: no more than 1 drink per day or less than 9 drinks per week. If you do not already drink alcohol, don't start. Learn relaxation techniques deep breathing, progressive muscle relaxation, visualization, and meditation - if you notice that stress increases your blood pressure. Speak to your Cardiac Rehab team to help develop your action plan. Tool Box Risk Factor Tools Blood Pressure Tip Sheet Page 220

230 Risk Factor Tools Tip Sheet: Blood Glucose (Sugar) Level Healthy Target Fasting Blood Glucose If you are living with diabetes Hemoglobin ba1c 4 to 5.6 mmol/l 4 to 7.0 mmol/l Less than 7.0% for most What is Fasting Blood Glucose (blood sugar)? Fasting blood glucose is the measure of blood glucose after you have not eaten for at least 8 hours. Fasting blood glucose is often measured first thing in the morning, after an overnight sleep. Fasting blood glucose can help you to know if you have diabetes or if you are at risk for diabetes Hemoglobin A1c (HbA1c) is the measure of blood glucose over the past 2 to 3 months Why is an Abnormal Blood Glucose a Risk Factor? High levels of blood glucose can increase your risk of getting diabetes and heart disease. An organ of the body called the pancreas releases a hormone called insulin. Insulin lowers blood glucose. It acts like a key that unlocks the cells in the muscles. This allows blood glucose to enter the muscle and use the blood glucose as energy for the body. Over time, excess weight can cause insulin resistance. Insulin resistance is when your body can no longer use insulin in this way. This means that high levels of blood glucose to stay in the blood stream. Tool Box Risk Factor Tools Blood Sugar Tip Sheet Page 221

231 If you have: o A fasting blood glucose higher than 5.6 mmol/l or o An HbA1c of higher than 5.5% With one or more of the risk factors in this chapter you may have pre-diabetes. Lifestyle changes including regular exercise and a healthy diet can delay or prevent diabetes by improving blood glucose levels. If you are living with heart disease, a fasting blood glucose test in recommended. Talk with your doctor about often this test should occur. If you have diabetes, talk with your Cardiac Rehab team about managing your blood glucose levels. What Actions Can You Take to Control Your Blood Glucose Levels? Know your fasting blood glucose level and HbA1c level. Talk to your health care team to know how often these tests should be done. If you have type 2 diabetes your target level for most people is below 7%. Avoid foods high in sugar content such as juice, sweets and simple sugars. Exercise 5 times per week. Include both aerobic training (like walking or cycling) and resistance training (like lifting weights). Exercise helps insulin get the sugar into your muscles to be used for energy. Be active every day. Contact a registered dietitian for further help. Speak to your Cardiac Rehab team to help design your action plan. Tool Box Risk Factor Tools Blood Sugar Tip Sheet Page 222

232 Risk Factor Tools Tip Sheet: Cholesterol and Triglyceride Levels Healthy Target Total Cholesterol HDL Cholesterol LDL Cholesterol Triglycerides Total Cholesterol HDL Cholesterol Ratio Less than 4.5 mmol/l Greater than 1.0 mmol/l Less than 2.0 mmol/l or a 50% reduction Less than 1.7 mmol/l Less than 4.0 What Is Cholesterol? Cholesterol is a lipid (fat) found in the blood, which our body needs. The body gets cholesterol from two sources: 1) The liver and 2) Animal food products we consume. Types of cholesterol: Cholesterol is carried in the blood by lipoproteins: Low density lipoproteins (LDL): the bad cholesterol High density lipoproteins (HDL): the good cholesterol What Are Triglycerides? Triglycerides are a form of fat carried in the blood that contributes to the fat that is stored in the body s tissue. High fat foods, sugar and alcohol contribute to high levels of triglycerides. Tool Box Risk Factor Tools Cholesterol & Triglycerides Tip Sheet Page 223

233 Why Are Cholesterol and Triglycerides A Risk Factor? Too much LDL cholesterol contributes to plaque formation (build up) in the coronary arteries. LDL acts as dump trucks, depositing cholesterol into the arteries causing blockages. A blockage makes it difficult for blood to pass through the vessels, which can lead to a heart attack. Low levels of HDL cholesterol also increase the risk for heart disease. HDL cholesterol acts like garbage trucks, taking cholesterol away from the arteries and eliminating it through the liver. High levels of triglycerides increase the risk of obesity, diabetes and heart disease. What Actions Can You Take to Control Your Cholesterol Levels? Know your cholesterol levels. Work with your doctor to decide how often you should be having blood tests and keep a record of your levels Take your cholesterol medication as prescribed. The statin class of drugs helps to bring your blood cholesterol levels into the desirable range, AND also works to remove plaque from the coronary arteries. This can contribute to regression of heart disease Exercise 5 times per week including aerobic exercise (i.e. walking, cycling, etc.), and resistance training exercise (weights) Increase your intake of soluble fibre. Have foods such as oats, ground flax seed, beans, and lentils Eat vegetables and fruit with every meal Tool Box Risk Factor Tools Cholesterol & Triglycerides Tip Sheet Page 224

234 Choose lower fat dairy products or alternatives Remove all visible fat from meats before cooking e.g., remove skin from poultry Avoid deep fried foods Include plant sterols (found in small amounts in fruits, vegetables, grains, nuts and seeds. Also added to foods such as margarine, juice, cereals) What Actions Can You Take to Control Your Triglyceride Levels? Eat less added sugars, sweets and refined, processed carbohydrates. Drink less alcohol Add fish to your meals more often. Aim to eat fatty fish that are high in Omega- 3s, 2 to 3 times a week Reduce how much saturated and trans fats you eat Contact a registered dietitian for further guidance. Speak to your Cardiac Rehab team to help develop your action plan. Tool Box Risk Factor Tools Cholesterol & Triglycerides Tip Sheet Page 225

235 Risk Factor Tools Tip Sheet: Level of Activity (how much you exercise) Healthy Target: Daily Aerobic Exercise Resistance Training Sit less and move more during the day Medium to strong effort, minutes, 5 times per week Medium effort, reps, 2-3 times per week What Does Level of Activity Refer To? Level of activity is how much exercise you do You are inactive if you do not get at least 30 minutes of moderate intensity (medium effort) exercise on most, if not all days of the week Being active and exercising are distinct o Being active can be unplanned. For example, walking to the bus stop, gardening, dancing, brisk walking, cycling, etc. o Exercise is planned, structured, scheduled and is done toward a goal. For example, walking 3 miles in 51 minutes on a measured route or treadmill, 5 times per week You can reduce your risk of heart disease by carefully planning an exercise routine Why Is Being Inactive A Risk Factor? Being inactive can add to high blood pressure, high cholesterol, diabetes, and obesity. Being inactive can cause plaque to form in your blood Vessels which can decrease blood flow. All of the above listed issues can lead to heart disease Being inactive on its own is as much of a risk for heart disease as smoking, high blood pressure and high cholesterol Tool Box Risk Factor Tools Physical Activity Tip Sheet Page 226

236 Sitting too much is a health risk Being active and doing planned exercise can control these conditions, and improve the health of your blood vessels What Actions Can you Take? Include both aerobic exercise and resistance training exercise (weights or resistance exercise bands) in your exercise program Both types of exercise training can help: decrease body fat, increase lean muscle mass, improve blood glucose levels and improve your fitness level Make a plan for both types of exercise training by using the F.I.T.T. principle (see below) Increase your activity levels slowly. Use the Rating of Perceived Exertion (RPE) Scale Create an action plan that will keep you active Ensure being active is part of your day- everyday Don t sit for too long at a time. Get up every hour and move or stretch Speak with your Cardiac Rehab team to help develop a safe plan The F.I.T.T. Principle: Aerobic Exercise Frequency: 5 times per week Intensity: Moderate * Time: minutes continuous or intermittent Type: activity using large muscle groups like walking, cycling, swimming *Speak to your Cardiac Rehab team for specific instructions for how much effort you should make. Resistance Training Exercise Frequency: 2-3 times per week (not back to back days need a rest day in between) Intensity: start with 1 set of repetitions * Time: will vary between minutes Type: 8-10 exercises that target all major muscle groups, using free weight, bands or machines *Speak to your Cardiac Rehab team for specific instructions for the amount of weight to lift. Tool Box Risk Factor Tools Physical Activity Tip Sheet Page 227

237 Risk Factor Tools Tip Sheet: Stress Healthy Target Cope well with all seven heart stress factors Depression Sleep apnea Psychosocial stress Disturbed sleep Chronic stress Stressful life events Lost sense of control Take 10 minutes to complete the questionnaire at to find your stress factors What Is Stress? Stress is your body s response to change. Stressors are the unwanted factors that bring about change. How we deal with and react to stress will determine how stress will affect our body. What Kinds of Change (Stressors) Can Lead To Stress? Changes in health, relationships, work, family, friendships, lifestyle, or your finances can lead to stress. Loss is often involved in these changes. High levels of stress or chronic stress can lead to anxiety and depression. Ongoing anxiety and depression are major stressors. Medical research has highlighted seven factors that each add to your overall stress level. The seven stress risks are: 1) Depression 2) Sleep apnea 3) Psychosocial distress 4) Disturbed sleep 5) Loss of the sense of control 6) Chronic stress at work or at home 7) Many stressful life events in the past year Tool Box Risk Factor Tools Stress Tip Sheet Page 228

238 Why Is Stress a Risk Factor? Most stress is not an instant problem. Stress that lasts for months at a time (called chronic stress) is a health concern. Each time you are stressed your body releases stress hormones (like cortisol) and over time this can negatively affect our health. Also, repeated peaks of your stressors will increase your overall stress level, and may increase your risk of a heart attack. How Do You Know If Your Stress Level Is High? You may already know that some of these heart stressors are high. To find out more, go online to and answer a series of questions to find the levels of each heart stressor. Or, make an appointment with the psychologist or social worker and they can help. Refer to module 7 for more information on these stress factors. What Actions Can You Take To Control Your Stress? Exercise 5 times per week, including aerobic exercise (i.e. walking, cycling, etc.) and resistance training exercise (weights). Regular exercise turns off the negative stress response and decreases the harmful effects of stress Pay attention to your eating habits. Stress can lead to poor dietary choices and habits Learn relaxation techniques deep breathing, progressive muscle relaxation, visualization, and meditation. You can learn more about these at Take notice of the stressors that occur repeatedly. Learn strategies to handle these differently Connect with others. Talk about what concerns you as well as what makes you happy Make small changes in how you respond to common stressors in your life. Distract yourself listen to music, read, watch TV, enjoy your hobbies and try to have a sense of humour Speak to your Cardiac Rehab team to help develop your plan of action. Take the Stress Reversal Workshop Tool Box Risk Factor Tools Stress Tip Sheet Page 229

239 Risk Factor Tools Tip Sheet: Smoking Habits Healthy Target 0 cigarettes per day Do not be exposed to second hand smoke What Is Smoking and Second Hand Smoke? Smoking tobacco (cigarette, cigar or pipe) or chewing tobacco increases the risk of getting or worsening heart disease. Second hand smoke can come from two places: 1) Smoke that comes from the tip of a burning cigarette, cigar or pipe 2) When a smoker exhales Both can increase the risk of getting heart disease or making your heart disease worse. Why Is Smoking and Second Hand Smoke a Risk Factor? Carbon monoxide and many of the other harmful chemicals in cigarette smoke cause health problems, including damage to your arteries. This damage can cause plaque to build up in your arteries, which blocks blood flow. Smoking increases your risk of blood clots and reduces the amount of oxygen in your blood. Smoking may also increase your blood pressure and make your heart work harder. Nicotine is a highly addictive substance that leads a smoker to continue to seek these harmful exposures. Second hand smoke contains the same chemicals and causes the same health effects listed above. There is no safe distance from a burning cigarette. Tool Box Risk Factor Tools Smoking Tip Sheet Page 230

240 What Actions Can You Take to Control Your Smoking, Your Cravings or Your Exposure to Second-hand Smoke? Smoking Cravings Start thinking about quitting consider the costs of smoking compared to the benefits Prepare to quit understand why you smoke and make a commitment to quit Quit set a quit date and identify your triggers to smoke. Stay smoke free prepare for any relapses Ask for help from your doctor or other healthcare professional for more information for counseling and/or aids There are three types of cravings: 1) Nicotine withdrawal symptoms include: feeling cranky, depressed, anxious, headaches, wanting to eat more (increased appetite) 2) Habits smoking can occur at the same time as another habit e.g., smoking and driving, drinking alcohol or coffee, after a meal, when stressed 3) Memories - reminders of how nice it is to relax with a cigarette Cravings and urges will come and go, but will go away in time Remind yourself it will pass Do something else like exercise when you have a craving Take deep breaths Avoid doing things that you did while smoking Second Hand Smoke Make your home and car smoke free Avoid places where smoking is permitted Talk to family members who smoke, and develop a plan together that respects both your environment Tool Box Risk Factor Tools Smoking Tip Sheet Page 231

241 Risk Factor Tools Tip Sheet: Waist Size Healthy Target Healthy target for waist size Men: less than <102 cm (40") Women < 88 cm (35") European, Sub-Saharan African, Eastern Mediterranean and Middle Eastern South Asian, Chinese, Japanese, South & Central American Men less than 94 cm (38") Women less than 80 cm (32") Men less than 90 cm (36") Women less than 80 cm (32") How To Measure Your Waist Size From Heart and Stroke Foundation: Clear your stomach area of any clothing, belts or accessories. Stand upright, face a mirror with your feet shoulder-width apart and your stomach relaxed. Wrap the measuring tape around your waist Use the borders of your hands and index fingers not your fingertips to find the uppermost edge of your hipbones by pressing upwards and inwards along your hipbones Tip: Many people mistake an easily felt part of the hipbone located toward the front of their body as the top of their hips. This part of the bone is in fact not the top of the hip bones, but by following this spot upward and back toward the sides of your body, you should be able to locate the true top of your hipbones. Tool Box Risk Factor Tools Waist Tip Sheet Page 232

242 Using the mirror, align the bottom edge of the measuring tape with the top of the hipbones on both sides of your body Tip: Once located, it may help to mark the top of your hipbones with a pen or felt- tip marker in order to aid you in correctly placing the tape. Make sure the tape is parallel to the floor and is not twisted Relax and take two normal breaths. After the second breath out, tighten the tape around your waist. The tape should fit comfortably snug around the waist without depressing the skin Tip: Remember to keep your stomach relaxed at this point. While still breathing normally, take the measurement on the tape. This is your waist circumference measurement. This method for measuring your waist circumference is best to determine your risk for heart disease and its progression. Why Is Your Waist Measurement a Risk Factor? Carrying weight around the middle of the body changes how the body uses fat and sugar. More fat that sits around your waist and close to the organs can lead to developing heart disease and other obesity related diseases which include Type 2 diabetes, hypertension and high cholesterol. However, positive lifestyle changes can improve your body composition, which can improve blood glucose levels, lower blood pressure and cholesterol. Tool Box Risk Factor Tools Waist Tip Sheet Page 233

243 What Actions Can You Take to Control Your Waist Size? Exercise 5 times per week, including aerobic training (i.e. walking, cycling, etc.) and resistance training (weights). The combination of both exercise training methods allows for the greatest changes in body composition Eat a healthy diet that is low in fat, low in salt, and high in fruits and vegetables, and fibre. Meet with a dietitian for further guidance. Refer to the Nutrition Tip Sheet for more information Changes in body composition take time and patience. Commitment to both a healthy way of eating and an effective exercise program is essential Tool Box Risk Factor Tools Waist Tip Sheet Page 234

244 Goals Tool Vision, Goal, Action Planning Worksheet See Your Vision Describe your best self What do you want to feel like in the future? What do you want to look like in the future? What do you want to be doing differently in future? Set Your Goal What do you have to do to achieve your vision? What change in your life has to happen? Are you ready to make this change? A good goal is specific, measurable, achievable, realistic and is timely Build Your Action Plan How are you going to achieve your goal? Each week, ask yourself: What am I going to do? When am I going to do it? Where am I going to do it? How much am I going to do it? How often am I going to do it? Each week ask, what went well? What did not go as planned? Problem-solve when your plan does not go as planned Tool Box Goals Tools Vision, Goal, Action Planning Worksheet Page 235

245 My Vision My Goal This week I will: My Action Plan (What) (When) (Where) _ (How much) (How often) My confidence rating that I can do this plan is: not confident at all totally confident Check in with yourself next week to see how your action plan went. Problem solve for things that did not go as planned. Then build your next action plan! Tool Box Goals Tools Vision, Goal, Action Planning Worksheet Page 236