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RISK FACTORS There are several risk fac- tors for the formation of ath- erosclerosis.  Those which are not modifiable, include age, gender, race, and a family history of premature CHD (3,4).  The incidence of CHD increases with age and men typically present with symptoms of CHD on average 10 years earlier than women.  This "protec- tive effect" in women is felt to be secondary to the hor- monal state of women dur- ing menses, however this advantage gradually fades in menopause leading to a similar incidence of CHD in the elderly.  CHD rates are 30 to 70 percent higher among blacks than among whites of the same age up until age 74 and the current decline in CHD rates is much less apparent in blacks than in whites (5). The exact reason for higher incidence of CHD in blacks is not known, but perhaps hypertension, more com- monly found in blacks, may play a role.  Simply having a first degree relative with CHD is not enough to be classified as having a family history of CHD.  Since near- ly half of all Americans will develop cardiovascular dis- ease, it is the premature onset of CHD (defined as a male less than 55 years old or a female less than 65 total cholesterol is less than 200.  Reducing cholesterol, specifically the LDL choles- terol or "bad cholesterol," has been shown to lower the risk of coronary heart disease (10).   Diabetes is also a risk fac- tor for the development of CHD regardless of whether it is juvenile onset or adult onset, insulin dependent or not (11).  The risk of CHD appears to be increased approximately 3-fold in dia- betic men and perhaps even more in women (12-14). Obesity is associated with several other risk factors for CHD such as adult-onset diabetes, elevated choles- terol, and hypertension.  Its direct association with CHD is related to a certain pat- tern of obesity known as visceral obesity character- ized by a protuberant abdomen and a waist-to-hip ratio greater than 0.9 in men and 0.8 in women (14-16).   While physical inactivity in and of itself is not consid- ered a risk factor for the development of CHD, a reg- ular exercise routine appears to reduce the risk of CHD and therefore the lack of physical activity should be considered a modifiable risk factor (17). It is also worth noting that years old) within siblings or parents which increases the level of risk.  There are several risk factors that are modifiable including smok- ing, hypertension, elevated cholesterol, diabetes, obe- sity and physical inactivity. Smoking is one of the greatest risk factors for CHD and its cessation is one the most effective ways to reduce risk (6,7).  Even within the first year of quit- ting there appears to be a reduction in the incidence of CHD related events. Switching to a low-tar or low-nicotine cigarette does not appear to be of benefit. Hypertension (elevated blood pressure), is not only a risk factor for CHD but is the most common cause of stroke. Hypertension can be defined as a systolic (upper number) of 140 or greater or a diastolic (lower number) of 90 or greater (8). Its treatment leads to a reduction in CHD.   Elevated cholesterol (total cholesterol value of over 200) has been consistently shown to confer an increase risk of CHD.  This risk appears to exist throughout the whole range of elevated cholesterol val- ues and not just those near the top (9).  A desirable

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