Lifestyle in Heart Health and Disease

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Lifestyle in Heart
Health and Disease
This page intentionally left blank
Lifestyle in Heart
Health and Disease

Edited By
Ronald Ross Watson

Sherma Zibadi
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Contents

Contributors xiii Interventions Targeting Awareness of CVD

Acknowledgments xvii Risk Factors 15
Effectiveness of Interventions 15
Other Potential Strategies and Venues for
Part I Addressing Awareness of Risk Numbers 16
Recommendations 17
Overview and Mechanisms Conclusions 17
References 18
1. Cardiovascular Diseases, Obesity,
and Lifestyle Changes 3. Extension of Peer Support
John Kwagyan, Otelio S. Randall from Diabetes Management
Obesity and Cardiovascular Diseases 3
to Cardiovascular Disease
Coronary Heart Disease 4 Prevention and Management in
Biophysical Properties of the Arterial System 5 Primary Care and Community
Distribution and Correlates of Major CVD Settings in Anhui Province, China
Risk Factors in Obese African Americans 5 Xuefeng Zhong, Bert Potemans, Chanuantong
Ambulatory Blood Pressure Monitoring 6 Tanasugarn, Edwin B. Fisher
Diet and Physical Activity Intervention 7
Conclusion 8 Background on Peer Support 22
References 8 Formative Evaluation and Lessons for
Further Reading 10 Implementation 23
Recruitment 23
Peer Leader Selection and Training 23
2. Public Knowledge of PLSP Meetings and Activities 23
Cardiovascular Risk Numbers: Peers Link the Residential and Clinical and
Contextual Factors Affecting Promote Informal Mutual Support 25
Knowledge and Health Behavior, Variable Implementation Across CHSCs 25
and the Impact of Public Health Evaluation of Effectiveness 26
Campaigns Qualitative Evaluation: Advantages,
Disadvantages, and Barriers to
Jeffrey L. Kibler, Mindy Ma, Jacquelyn Hrzich,
Implementation 27
Roberta A. Roas
Cultural Influences on Support Within
Introduction 11 the PLSP 28
Conceptual Significance of the Health Emotional Support 28
Belief Model 11 Peer Leader Roles 28
Purpose of the Present Chapter 12 Importance of Organizational Support 29
Knowledge of Target Numbers and Sustainability, Adoption, and Extension to
Personal Levels for CVD Risk Indicators 12 Cardiovascular Disease 29
Blood Pressure 12 Adaptation of CVD Prevention Program 29
Lipids 13 Lifestyle Intervention and Peer-Led Group
Body Mass/Obesity 14 Activities 30
Blood Glucose 14 Roles and Contributions of Peer Group Leader 30

v
vi   Contents

Evaluation Lifestyle Education and Moving Beyond the Clinical Classification

Intervention Sessions 30 of Heart Failure at Rest: Does Heart
Program Acceptability by Health Failure With Reduced or Preserved
Professionals and Program Participants 31 Ejection Fraction Matter? 67
Reflections, Conclusions, and Future Traditional Classifying Models 67
Directions 31 Measurement Techniques for Cardiac
Standardization and Adaptability 32 Pumping Capability During Exercise in
References 32 Heart Failure 68
Invasive Approaches 68
4. Heart Health and Children Noninvasive Approaches 69
Heart Failure Classification: Basic and
Sandra Gilbertson, Barbara A. Graves
Advanced Measures of Cardiac Pumping
Introduction 35 Capability During Exercise 71
Tobacco Smoke Exposure 36 The Traditional Cardiac Pumping
Diet 36 Capability Model in Heart Failure 71
Physical Activity 37 The Advanced Cardiac Pumping
Body Weight 37 Capability Model in Heart Failure 74
Cholesterol 38 Impaired Cardiac Pumping Capability is
Blood Pressure 38 Exacerbated by Interactions With Non
Blood Sugar 39 Cardiac-Centric Factors in Heart Failure 77
Prevention, Screening, and Treatment of Summary 77
CVD in Children and Adolescents 39 Acknowledgments 78
Prevention: Smoke Exposure 39 References 78
Prevention: Nutrition 39
Prevention: Physical Activity and Inactivity 40 7. Exercise-Based Cardiovascular
Screening and Treatment in Primary Care 40 Therapeutics: From Cellular to
The Role of Caregivers and Families 41 Molecular Mechanisms
Conclusion 42
Siyi Fu, Qiying Dai, Yihua Bei, Yongqin Li,
References 42
Junjie Xiao
Further Reading 46
Cardiovascular Disease 87
5. Lifestyle Factors and the Impact Exercise Treatment 87
on Lifetime Incidence and Cardiovascular Adaptions to Exercise 87
Mortality of Coronary Heart Disease Cardiomyocyte Hypertrophy and Renewal 87
Protection of Cardiomyocyte Apoptosis
P.E. Puddu, A. Menotti and Necrosis 88
Historical Introduction 47 Angiogenesis 88
Short-Term Follow-Up Studies 48 The Underlying Mechanism of Exercise-
Lifetime Effects of Lifestyle and Effects in Induced Cardiac Growth 88
Very Elderly People 55 The IGF-1-PI3K(p110α)-AKT Pathway 88
Conclusions 58 Gp130/JAK/STAT Pathway 89
References 59 NRG1-ErbB4-C/EBPß Pathway 89
Nitric Oxide (NO) Signaling 89
MicroRNAs 90
Exercise-Based Protection for
Part II Cardiovascular Disease 90
Exercise and Physical Activity Myocardial Infarction 90
Myocardial Ischemia-Reperfusion Injury (I/R) 91
6. Expanding the Clinical Atherosclerosis 91
Classification of Heart Failure: Cardiomyopathy (Diabetic
Inclusion of Cardiac Function Cardiomyopathy, Dilated
During Exercise Cardiomyopathy, Cardiac Fibrosis) 92
Summary 92
Erik H. Van Iterson, Thomas P. Olson
Acknowledgments 93
Introduction 65 References 93
 Contents  vii

8. Exercise, Fitness, and Cancer Concurrent Exercise and Blood Pressure

Outcomes Effects 124
Acute, Immediate, or Short-Term Effects or
Tolulope A. Adesiyun, Stuart D. Russell Postexercise Hypotension 124
Introduction 99 Chronic, Training, or Long-Term Effects 125
Exercise and Future Cancer Risk 99 The Interactive Effects of Exercise and
Hypothesized Mechanisms of Preventive Antihypertensive Medications on Resting
Effect of Exercise on Cancer 102 Blood Pressure 126
Steroid Hormones—Women 102 Clinical Implications and New Advances
Immune System 102 in Exercise Prescription for Optimizing
Inflammation 103 Blood Pressure Benefits 127
Metabolic 103 Gaps in the Literature and Future Research
Obesity and the Risk of Developing Cancer 103 Needs in the Exercise Prescription for
Exercise and Mortality 103 Hypertension 129
Weight Gain During or After Conclusion 130
Chemotherapy and Its Effects 104 Key Points 130
Exercise During Chemotherapy 106 References 131
Safety 106
Exercise and Quality of life 106 10. Exercise and Cardiovascular
Impact on Aerobic Capacity 107 Disease: Emphasis on Efficacy,
Exercise and Fatigue 107
Dosing, and Adverse Effects and
Exercise, Prognosis, Recurrence and
Mortality 108
Toxicity
Ongoing Trials 108 Michael D. Morledge, Sergey Kachur,
Suggested Areas for Future Research 109 Carl J. Lavie, Parham Parto, James H. O’Keefe,
References 109 Richard V. Milani
Introduction 137
9. Exercise Prescription for
Efficacy 137
Hypertension: New Advances for
Dosing 138
Optimizing Blood Pressure Benefits Adverse Effects/Toxicity 143
Hayley V. MacDonald, Linda S. Pescatello Effects on CV Structure and Function 143
Impact of EEE on CHD 143
Introduction 115
Impact of EEE on Risk of AF 145
Hypertension is a Major Public Health
Risk of SCD with EEE 146
Problem 115
EEE Recommendations 147
Antihypertensive Effects of Exercise 115
Conclusions 148
Key Terminology and Basic Concepts 116
References 148
Hypertension 116
Prehypertension 116
Law of Initial Values 116 11. The Effect of Exercise Training in
The Blood Pressure Response to Acute Systolic and Diastolic Function
and Chronic Exercise 116
Ricardo Fontes-Carvalho, Eduardo M. Vilela,
Exercise Prescription (Ex Rx) 118
Pedro Gonçalves-Teixeira
Purposes of this Chapter 119
Systematic Review Methods 119 Introduction 153
Aerobic Exercise and Blood Pressure Cardiovascular Response to Exercise
Effects 119 Training in Healthy Individuals 153
Acute, Immediate, or Short-Term Effects or Brief Exercise Physiology 153
Postexercise Hypotension 119 Cardiovascular Effects of Different Types
Chronic, Training, or Long-Term Effects 121 and Intensity of Exercise 154
Dynamic Resistance Exercise and Blood Chronic Effects of Exercise Training in the
Pressure Effects 122 Cardiovascular System: From Molecular
Acute, Immediate, or Short-Term Effects or Mechanisms to "Whole-Pump" Effects 155
Postexercise Hypotension 122 Deleterious Effects of Exercise Training on
Chronic, Training, or Long-Term Effects 123 the Cardiovascular System 155
viii   Contents

Exercise Training After Acute Myocardial 14. Community-Based Maintenance

Infarction 156 Cardiac Rehabilitation
The Effect of Exercise Training on Systolic
Function 156 Sandra Mandic, Anna Rolleston, Garrick Hately,
The Effect of Exercise Training on Diastolic Stacey Reading
Function 157 Cardiac Rehabilitation Overview 187
The Effect of Exercise Training on Core Components 187
Functional Capacity 157 Phases 187
Exercise Training as Part of an Integrated Benefits 187
Cardiac Rehabilitation Program 157 Challenges 188
Exercise Training in Patients With Heart Failure 158 The Need for Community-Based
Effects of Exercise Training in Patients Maintenance Programs 188
With HFrEF 158 Community-Based Maintenance Cardiac
Effects of Exercise Training in Patients Rehabilitation 188
With HFpEF 159 Participants 188
The Effects of Cardiac Rehabilitation in Outcomes 188
Heart Failure 159 Adherence 189
Conclusion 159 Social Support 190
References 159 Special Considerations 190
Cultural Aspects 190
12. Lifestyle and Heart Diseases in Cultural Aspects of CR: Insights From
Choice Experiments New Zealand 190
CR in Rural Communities 191
José M. Grisolía
Examples of Community-Based
Introduction 163 Maintenance CR Programs 192
Methodology 163 Community-Led Cardiac Rehabilitation
Willingness to Pay 164 "Clubs" 192
Choice Experiments on Lifestyle Interventions 164 Take H.E.A.R.T. Program New Brunswick,
Diet 164 Canada 192
Physical Activity 167 Heart Guide Aotearoa in New Zealand 194
Lifestyle in General 168 The University of Auckland Health and
Conclusions 171 Performance Clinic, New Zealand 194
References 171 Recommendations for Setting up
Further Reading 173 Community-Based CR Programs 195
Challenges 195
13. Lost in Translation: What Does Summary 196
the Physical Activity and Health References 196
Evidence Actually Tell Us?
15. Determinants of Exercise
Darren E.R. Warburton, Shannon S.D. Bredin Ventilatory Inefficiency in Heart
Introduction 175 Failure With Reduced or Preserved
Shape of the Dose Response Curve: Does Ejection Fraction: Application of
it Matter? 175 Classical and Emerging Integrative
Health-Related Physical Fitness vs. Physical Physiology Concepts
Activity 178
Erik H. Van Iterson, Thomas P. Olson
International Messaging and Knowledge
Translation 180 Introduction 199
Why Does This Knowledge Translation Fundamentals of Ventilation: Toward an
Error Exist and What are the Effects? 182 Improved Understanding of Ventilatory
Conclusions 183 (In) Efficiency in Heart Failure 200
Acknowledgments 183 Physiologic Dead Space or Arterial Carbon
Disclosures 183 Dioxide? The Ventilatory Equivalent for
References 183 Carbon Dioxide in Heart Failure 200
 Contents  ix

(RE)Emerging Concepts and Mechanisms 18. Prevention of Cardiovascular

of Ventilatory Inefficiency: Application to Disease Among People Living
Reduced or Preserved Ejection Fraction With HIV: A Tailored Smoking
Heart Failure 201
Cessation Program Treating
On-Transient Kinetics of Ventilation and
Depression
Gas Exchange: Emerging Concepts in
Preserved Ejection Fraction Heart Stephanie Wiebe, Lousie Balfour,
Failure 205 Paul A. McPherson
Skeletal Muscle Afferents and Ventilatory
Unique Factors Impacting Smoking
Control in Heart Failure 206
Cessation Among PHAs 227
Summary and Concluding Remarks 207
Depression 227
Acknowledgments 208
Social Support 227
References 208
Smoking Cessation Among PHAs 228
The HIV-Tailored Smoking Cessation
Program 228
Part III Theoretical Framework 228
Alcohol, Tobacco, and Other Description of the HIV-Tailored
Drugs of Abuse Smoking Cessation Counselling
Program 229
16. Relationships of Alcohol Pilot Study Outcome Results 230
Change in Psychological Correlates of
Consumption With Risks for
Successful Quitting 230
Type 2 Diabetes Mellitus and Conclusions 231
Cardiovascular Disease in Men References 231
and Women
Ichiro Wakabayashi 19. Factors Associated With
Introduction 213 Tobacco Use Among Patients
Alcohol and Cerebro- and Cardiovascular With MCC: Multidisciplinary
Diseases 213 Visions about the Lifestyle on
Alcohol and Risk of Diabetes 215 Health and Cardiovascular
Alcohol and Glucose Metabolism 215 Disease
Alcohol and Glycemic Status 216
Alcohol and Obesity 217 Arise G. de Siqueira Galil, Arthur da Silva Gomes,
Adiposity-Related Indices and Diabetes 218 Bárbara A.B.B. de Andrade, Mariana M. Gusmão,
Modifications by Alcohol of Adiposity- Tatiane da Silva Campos, Marcela M. de Melo,
Related Indices and of Their Relations Eliane F.C. Banhato
With Diabetes 218 Introduction 233
Conclusion 219 Smoking, Cardiovascular Diseases, and
References 219 Multiple Chronic Conditions 234
Multidisciplinary Visions About the
17. Lifestyle Features and Heart Lifestyle on Health and Cardiovascular
Disease Disease 237
Multidisciplinary Team Versus Clinical
Vijay Singh, Ronald Ross Watson
Practice 237
Introduction 223 Experience of a Multidisciplinary
Risk Factors 223 Team in the Management of Smokers
Exercise 224 With Multiple Chronic
Smoking 224 Conditions 239
Body Weight 225 Future Perspectives 240
Diet 225 Final Considerations 240
Conclusion 225 References 241
References 226 Further Reading 244
x   Contents

Part IV The Magnitude of Prediabetes 268

Established Risks of Diabetes Mellitus 268
Social, Population, and Family Effects Emerging Noncardiovascular Risks of
on the Heart and Arteries Prediabetes 269
Prediabetes and Inflammation 269
20. Lifestyle Interventions in Patients Atherosclerosis and Inflammation 269
With Serious Mental Illness Prediabetes and Atherosclerosis 269
Prediabetes and Endothelial Dysfunction 269
Aaron Gluth, DeJuan White, Martha Ward
Prediabetes and Acute Coronary Syndrome 270
Background 247 Prediabetes and ST Segment Elevation
Efficacy of Lifestyle Interventions in the Myocardial Infarction 271
SMI Population 247 Prediabetes and Silent Myocardial
Other Important Studies 249 Infarctions 271
Keys to Success 249 Prediabetes and Potential Interventions 272
Unique Barriers 250 Conclusions 272
Future Directions 251 References 272
References 251
23. Mindfulness-Based Therapy and
21. Chocolate and Its Component’s Heart Health
Effect on Cardiovascular Disease
Kathleen P. Ismond, Cecilia Bukutu,
Katha Patel, Ronald Ross Watson Sunita Vohra
Introduction 255 Introduction 275
Background 255 Tobacco Smoking 276
History of Chocolate in Heart Health 255 Diabetes Mellitus (Types 1 and 2) 278
Origins 256 Hypertension 280
Chocolate Production 256 Obesity 281
Chocolate and Cardiovascular Disease: An Nutrition 281
Epidemiological Focus 257 Physical Inactivity 282
Chocolate Consumption and Blood Pressure 258 Summary 282
Chemical Composition of Chocolate’s References 282
Cocoa Beans 259
Lipids 259 24. Lifestyle Impact and Genotype-
Minerals 259 Phenotype Correlations in
Polyphenols 260 Brugada Syndrome
Cocoa Polyphenols and Cardiovascular
Disease 260 Houria Daimi, Amel Haj Khelil, Khaldoun
Mechanisms of Flavanols and Cocoa on Ben Hamda, Amelia Aranega, Jemni B.E. Chibani,
the Body 260 Diego Franco
Endothelial Function and Nitric Oxide 260 Introduction 285
Antioxidant Effects 261 BrS genetics and the Genotype-Phenotype
Antiplatelet Effects 262 Correlation 285
Antihypertensive 262 Factors Precipitating and Modulating the
Summary 263 ECG and Arrhythmias in BrS 286
References 263 Hyperthermia 286
Further Reading 266 Diet and Electrolyte Imbalance 286
Leisure Activities and Sports 286
22. Prediabetes: An Emerging Risk Alcohol and Drugs of Abuse Intoxication 288
Factor for Coronary Artery Disease Tobacco Smoking and Nicotine
Intoxication 288
Richard B. Stacey, Veronica D’Ambra, Petro Gjini
Medications to be Avoided in BrS 288
Introduction 267 Conclusion 288
History of Prediabetes 267 References 289
 Contents  xi

25. Social Relationships and The Impact of Trace Elements on Coronary

Cardiovascular Health: Artery Diseases 297
Underlying Mechanisms, Life References 300
Course Processes, and Future
Directions 27. Decompressive Hemicraniectomy
for Severe Stroke: An Updated
Courtney Boen, Yang C. Yang
Review of the Literature
Introduction 291
Theresa L. Green, Janine Pampellonne,
Social Relationships and Cardiovascular Health 291
Lee Moylan
Overview 291
Physiological Pathways 292 Background 301
Behavioral Mechanisms 293 The Review Process 301
Psychoemotional Processes 293 Methods 301
Life Course Processes 293 Results 303
Gaps in the Literature and Directions for Primary Study Characteristics 303
Future Research 294 Quality of Life 303
Conclusion 295 Caregiver Outcomes 304
References 295 Discussion 305
Conclusions 305
26. Trace Elements and Coronary Appendix Review Matrix for Literature
Artery Disease Review 306
References 311
Ayşegül Bayir
Introduction 297 Index 313
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Contributors
Numbers in parenthesis indicate the pages on which the authors’
­contributions begin.
Tolulope A. Adesiyun (99) Division of Cardiology,
Department of Medicine, Johns Hopkins School of
Medicine, Baltimore, MD, United States
Amelia Aranega (285) Department of Experimental
Biology, University of Jaén, Jaén, Spain
Lousie Balfour (227) Department of Psychology, The
Ottawa Hospital, University of Ottawa, Ottawa, ON,
Canada
Eliane F.C. Banhato (233) IMEPEN Foundation, Faculty
of Medicine, Federal University of Juiz de Fora;
Department of Psychology, Higher Education Center of
Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
Ayşegül Bayir (297) Faculty of Medicine, Emergency
Department, Selçuk University, Konya, Turkey
Yihua Bei (87) Cardiac Regeneration and Ageing Lab, School
of Life Science, Shanghai University, Shanghai, China
Khaldoun Ben Hamda (285) Cardiology Service,
Fattouma Bourguriba Hospital, Monastir, Tunisia
Courtney Boen (291) University of Pennsylvania,
Philadelphia, PA, United States
Shannon S.D. Bredin (175) Physical Activity Promotion
and Chronic Disease Prevention Unit, University of
British Columbia (UBC), Vancouver, BC, Canada
Cecilia Bukutu (275) Institutional Research and Program
Development, Concordia University of Edmonton,
Edmonton, AB, Canada
Jemni B.E. Chibani (285) Biochemistry and Molecular
Biology Laboratory, Faculty of Pharmacy, University of
Monastir, Monastir, Tunisia
Tatiane da Silva Campos (233) IMEPEN Foundation,
Faculty of Medicine, Federal University of Juiz de Fora,
Juiz de Fora, Minas Gerais; Faculty of Nursing, State
University of Rio de Janeiro, Rio de Janeiro, Brazil
Arthur da Silva Gomes (233) IMEPEN Foundation,
Faculty of Medicine, Federal University of Juiz de Fora,
Juiz de Fora, Minas Gerais; Department of Biomedical
Sciences, Federal University of Fluminense, Niterói,
Rio de Janeiro, Brazil
Qiying Dai (87) Department of Cardiology, The First
Affiliated Hospital of Nanjing Medical University,
Nanjing, China; Metrowest Medical Center,
Framingham, MA, United States
Houria Daimi (285) Department of Experimental Biology,
University of Jaén, Jaén, Spain; Biochemistry and
Molecular Biology Laboratory, Faculty of Pharmacy,
University of Monastir, Monastir, Tunisia
Veronica D'Ambra (267) Department of Internal
Medicine, Section on Cardiology, Wake Forest
University School of Medicine, Winston-Salem, NC,
United States
Bárbara A.B.B. de Andrade (233) IMEPEN Foundation,
Faculty of Medicine; Institute of Human Sciences,
Department of Psychology, Federal University of Juiz
de Fora, Juiz de Fora, Minas Gerais, Brazil
Marcela M. de Melo (233) IMEPEN Foundation, Faculty
of Medicine, Federal University of Juiz de Fora, Juiz de
Fora, Minas Gerais, Brazil
Arise G. de Siqueira Galil (233) IMEPEN Foundation,
Faculty of Medicine, Federal University of Juiz de Fora,
Juiz de Fora, Minas Gerais, Brazil
Edwin B. Fisher (21) Peers for Progress and Department
of Health Behavior, Gillings School of Global Public
Health, University of North Carolina at Chapel Hill,
Chapel Hill, NC, United States
Ricardo Fontes-Carvalho (153) Cardiology Department,
Gaia Hospital Center, Vila Nova de Gaia; Department
of Surgery and Physiology, University of Porto, Porto;
Unidade de Investigação Cardiovascular (UnIC), Porto,
Portugal
Diego Franco (285) Department of Experimental Biology,
University of Jaén, Jaén, Spain
Siyi Fu (87) Cardiac Regeneration and Ageing Lab, School
of Life Science, Shanghai University, Shanghai, China
xiii
xiv Contributors
Sandra Gilbertson (35) Mosaic Life Care, St. Joseph, MO,
United States
Petro Gjini (267) Department of Internal Medicine,
Section on Cardiology, Wake Forest University School
of Medicine, Winston-Salem, NC, United States
Aaron Gluth (247) Division of Hospital Medicine,
Department of Psychiatry and Behavioral Sciences,
Emory University, Atlanta, GA, United States
Pedro Gonçalves-Teixeira (153) Cardiology Department,
Gaia Hospital Center, Vila Nova de Gaia, Portugal;
Department of Surgery and Physiology, University of
Porto, Porto, Portugal
Barbara A. Graves (35) Capstone College of Nursing,
University of Alabama, Tuscaloosa, AL, United States
Theresa L. Green (301) Queensland University of
Technology; Royal Brisbane and Women’s Hospital,
Brisbane, QLD, Australia
José M. Grisolía (163) Department of Applied Economics,
Universidad de Las Palmas de Gran Canaria, Las Palmas
de GC, Spain
Mariana M. Gusmão (233) IMEPEN Foundation, Faculty
of Medicine, Federal University of Juiz de Fora, Juiz de
Fora, Minas Gerais, Brazil; Institute of Human Sciences,
Department of Psychology, Federal University of Juiz
de Fora, Juiz de Fora, Minas Gerais, Brazil
Amel Haj Khelil (285) Biochemistry and Molecular
Biology Laboratory, Faculty of Pharmacy, University of
Monastir, Monastir, Tunisia
Garrick Hately (187) University of Otago, Dunedin, New
Zealand
Jacquelyn Hrzich (11) College of Psychology, Nova
Southeastern University, Fort Lauderdale, FL, United
States
Kathleen P. Ismond (275) Department of Pediatrics,
University of Alberta, Edmonton, AB, Canada
Sergey Kachur (137) Department of Graduate Medical
Education, Ocala Regional Medical Center, Ocala, FL,
United States
Jeffrey L. Kibler (11) College of Psychology, Nova
Southeastern University, Fort Lauderdale, FL, United
States
John Kwagyan (3) Howard University College of Medicine,
Washington, DC, United States
Carl J. Lavie (137) Department of Cardiovascular Diseases,
John Ochsner Heart and Vascular Institute, Ochsner
Clinical School-University of Queensland School of
Medicine, New Orleans, LA, United States
Yongqin Li (87) Cardiac Regeneration and Ageing Lab,
School of Life Science, Shanghai University, Shanghai,
China
Mindy Ma (11) College of Psychology, Nova Southeastern
University, Fort Lauderdale, FL, United States
Hayley V. MacDonald (115) Department of Kinesiology,
The University of Alabama, Tuscaloosa, AL, United
States
Sandra Mandic (187) University of Otago, Dunedin, New
Zealand
Paul A. McPherson (227) Department of Psychology, The
Ottawa Hospital, University of Ottawa, Ottawa, ON,
Canada
A. Menotti (47) Association for Cardiac Research, Rome,
Italy
Richard V. Milani (137) Department of Cardiovascular
Diseases, John Ochsner Heart and Vascular Institute,
Ochsner Clinical School-University of Queensland
School of Medicine, New Orleans, LA, United States
Michael D. Morledge (137) Department of Cardiovascular
Diseases, John Ochsner Heart and Vascular Institute,
Ochsner Clinical School-University of Queensland
School of Medicine, New Orleans, LA, United States
Lee Moylan (301) Royal Brisbane and Women's Hospital,
Brisbane, QLD, Australia
James H. O'Keefe (137) St. Luke’s Mid America Heart
Institute, University of Missouri-Kansas City, Kansas
City, MO, United States
Thomas P. Olson (65, 199) Department of Cardiovascular
Medicine, Mayo Clinic, Rochester, MN, United States
Janine Pampellonne (301) Queensland University of
Technology, Brisbane, QLD, Australia
Parham Parto (137) Department of Cardiovascular
Diseases, John Ochsner Heart and Vascular Institute,
Ochsner Clinical School-University of Queensland
School of Medicine, New Orleans, LA, United States
Katha Patel (255) University of Arizona, Mel and Enid
Zuckerman College of Public Health, Tucson, AZ,
United States
Linda S. Pescatello (115) Department of Kinesiology,
University of Connecticut, Storrs, CT, United States
Bert Potemans (21) Vårdcentral Rättvik, Rättvik, Sweden
P.E. Puddu (47) Department of Cardiovascular, Respiratory,
Nephrological, Anesthesiological and Geriatric
Sciences, Sapienza University of Rome, Rome, Italy
Otelio S. Randall (3) Howard University College of
Medicine, Washington, DC, United States
Stacey Reading (187) Department of Exercise Sciences,
University of Auckland, Auckland, New Zealand
Roberta A. Roas (11) College of Psychology, Nova
Southeastern University, Fort Lauderdale, FL, United
States

Anna Rolleston (187) Faculty of Medicine and Health
Science, University of Auckland, Auckland, New Zealand
Stuart D. Russell (99) Division of Cardiology, Department
of Medicine, Johns Hopkins School of Medicine,
Baltimore, MD, United States
Vijay Singh (223) University of Arizona, Mel and Enid
Zuckerman College of Public Health, Tucson, AZ,
United States
Richard B. Stacey (267) Department of Internal Medicine,
Section on Cardiology, Wake Forest University School
of Medicine, Winston-Salem, NC, United States
Chanuantong Tanasugarn (21) Department of Health
Education and Behavioral Science, Faculty of Public
Health, Mahidol University, Bangkok, Thailand
Erik H. Van Iterson (65, 199) Department of Cardiovascular
Medicine, Mayo Clinic, Rochester, MN, United States
Eduardo M. Vilela (153) Cardiology Department, Gaia
Hospital Center, Vila Nova de Gaia, Portugal
Sunita Vohra (275) Department of Pediatrics, University of
Alberta, Edmonton, AB, Canada
Ichiro Wakabayashi (213) Department of Environmental
and Preventive Medicine, Hyogo College of Medicine,
Nishinomiya, Japan
Contributors  xv
Darren E.R. Warburton (175) Physical Activity Promotion
and Chronic Disease Prevention Unit, University of
British Columbia (UBC), Vancouver, BC, Canada
Martha Ward (247) Department of Psychiatry and
Behavioral Sciences; Department of General Medicine,
Emory University, Atlanta, GA, United States
Ronald Ross Watson (223, 255) University of Arizona,
Mel and Enid Zuckerman College of Public Health,
Tucson, AZ, United States
DeJuan White (247) Department of Psychiatry and
Behavioral Sciences; Department of General Medicine,
Emory University, Atlanta, GA, United States
Stephanie Wiebe (227) Department of Psychology, The
Ottawa Hospital, University of Ottawa, Ottawa, ON,
Canada
Junjie Xiao (87) Cardiac Regeneration and Ageing Lab,
School of Life Science, Shanghai University, Shanghai,
China
Yang C. Yang (291) Lineberger Comprehensive Cancer
Center, University of North Carolina at Chapel Hill,
Chapel Hill, NC, United States
Xuefeng Zhong (21) Anhui Provincial Center for Disease
Control and Prevention, Hefei, China
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Acknowledgments

The work of Dr. Watson's editorial assistant, Bethany L. Stevens, in communicating with authors, editors, and w ­ orking
on the manuscripts was critical to the successful completion of the book. It is very much appreciated. Support for
Ms. Stevens' and Dr. Watson' editing was graciously provided by the Natural Health Research Institute (http://www.natu-
ralhealthresearch.org) and Southwest Scientific Editing and Consulting, LLC. The encouragement and support of Elwood
Richard and Dr. Richard Sharpee was vital. Direction and guidance from Elsevier's staff was critical. Finally, the work of
the librarian at the Arizona Health Sciences Library, Mari Stoddard, was vital and very helpful in identifying key research-
ers who participated in the book.

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Part I

Overview and Mechanisms

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Chapter 1

Cardiovascular Diseases, Obesity,

and Lifestyle Changes
John Kwagyan, Otelio S. Randall
Howard University College of Medicine, Washington, DC, United States

OBESITY AND CARDIOVASCULAR DISEASES

Subjectively, obesity is defined as excess weight or excess body fat. Objectively, obesity is defined by a body mass index,
BMI ≥ 30 kg/m2. Globally, more than 1.5 billion persons are overweight, and the prevalence of obesity has doubled since
1980 [1]. Current reports on the prevalence in the United States estimate that 35.5% of adult men and 35.8% of adult
women are obese [2]. Disparities in prevalence among race have been noted with rates higher among minority populations.
For the African American population, the age-adjusted rates are 49.5% compared with 39.1% in Hispanics and 34.3%
in Caucasians [2]. In recent years, there has been a rise in obesity-specific cardiovascular disease (CVD) morbidity and
mortality [3,4]. There is also the concern of dramatic increase of the prevalence and magnitude of obesity in children and
adolescent [5,6]. Obesity has been linked with major cardiovascular disease risk factors including hypertension, diabetes
mellitus, and dyslipidemia [7–10].
A report by Fontaine et al. [11] indicated a marked reduction in life expectancy due to obesity with significant differ-
ences observed between races. In the study, it was reported that the maximum years of life lost for the young adult obese
African American man was estimated to be 20 years compared with 13 years for Caucasians. In another study, Fontaine
et al. [12] reported the impact of obesity on the health-related quality of life and indicated more impairment in obese per-
sons when compared with the general population. The pattern of the results indicated that, as weight increases, the quality
of life related to the physical domains becomes adversely affected. In the general population, the prevalence of these risk
factors increases progressively with increasing BMI [7,13–15]. Randall et al. [15] reported a major finding in a cohort
of obese African Americans that suggests a threshold of between 30 and 35 kg/m2 for maximal appearance of CVD risk
factors, after adjusting for age and sex. The implication of the results from the study is that preventive measures need to
be implemented before reaching the threshold BMI, and there is the need to curtail the incidence of risk factors sooner
rather than later. Fig. 1 provides a conceptual pathway for the development of various CV outcomes including diabetes,
myocardial infarction, congestive heart failure, left ventricular hypertrophy, and stroke. The pathway clearly suggests the
autonomous influence of obesity in the development of these risk factors and associated CV outcomes.
Coexistence of obesity related cardiovascular disease risk factors including hypertension, diabetes, and dyslipidemia is
termed the metabolic syndrome [16–19]. Clinically, the metabolic syndrome is described according to the Third National
Cholesterol Education Program Adult Treatment Panel (NCEP ATP III) when at least three of the following five features are
present: abdominal obesity reflected by a large waistline and characterized with waist circumference > 102 cm (40.2 in.) in
men and >88 cm (34.6 in) in women, low high-density lipoprotein (HDL) cholesterol level defined as HDL < 40 mg/dL in
men or < 50 mg/dL in women, high serum triglycerides (TG) defined as TG ≥ 150 mg/dL, high blood pressure (BP) defined
as ≥ 130/85 mmHg, and high fasting serum glucose (BS) defined as ≥ 110 mg/dL. The metabolic syndrome, an important
marker for atherosclerosis—hardening and narrowing of the arteries—including premature coronary artery disease and
cardiovascular mortality affects about 25%–35% of the US adults [18–20], and the age-specific rates increased rapidly. A
person's risk for heart disease, diabetes, and stroke increases with the number of metabolic syndrome risk factors, and the
risk of having metabolic syndrome is closely linked to obesity and a lack of physical activity. There is the report that, in
the future, metabolic syndrome may overtake smoking as the leading risk factor for heart disease (https://www.nhlbi.nih.
gov/health/health-topics/topics/ms). The prevalence in 50-year-old persons was >30% and that in persons aged 60 years
and above was 40%. Epidemiological studies [18] show a highest prevalence of the metabolic syndrome in Hispanics and

Lifestyle in Heart Health and Disease. https://doi.org/10.1016/B978-0-12-811279-3.00001-X

© 2018 Elsevier Inc. All rights reserved. 3
4 PART | I Overview and Mechanisms

lower in Caucasian and in African Americans. Haffner and Heinrich [20] explained that the lower prevalence of the meta-
bolic syndrome among African Americans may be explained by the two separate lipid criteria defined by the NCEP (high
triglycerides and low HDL cholesterol), which offset the higher rates of hypertension and glucose intolerance observed in
this ethnic group. Among the African Americans, the metabolic syndrome has been linked with increased insulin levels,
elevated blood pressure, dyslipidemia, and endothelial dysfunction [16–18]. In a sample of adolescents, the prevalence of
the metabolic syndrome was estimated at 6.8% among overweight adolescents and 28.7% among obese adolescents [20].
Cherqaoui et al. [21] recently noted in a two-factorial analysis that even in the so-called metabolically healthy but obese,
the state of the phenotype appears to be only transient. The finding of increased risk of death or cardiovascular events for
obese individuals suggests that gaining excess weight is associated with risk that may accumulate over time, even before
metabolic and cardiovascular signs become apparent in laboratory tests.

CORONARY HEART DISEASE

Heart disease remains the leading cause of death in the United States [22,23] and worldwide. Overall, heart disease ac-
counts for about one in four deaths. Coronary heart disease (CHD) affects 15.5 million Americans with a prevalence of
6.2% and is responsible for one in seven deaths in the United States [2]. For the African American and Hispanic, however,
the morbidity and mortality rate is disproportionally high [22,23]. From 2006 to 2010, the age-adjusted prevalence of coro-
nary heart disease (CHD) in the United States declined overall [23] from 6.7% to 6.0%. However, while declines from 2006
to 2010 were observed across all racial/ethnic groups, the prevalence among Blacks rose in the same period. For Whites, the
rates declined from 6.4% to 5.8% and for Hispanics from 6.9% to 6.1%. Among Blacks, the rate increases marginally [23]
from 6.4% to 6.5%. It is reported that genetics, environment, lifestyle, and access to health care are the major contributing
factors to the negative outcomes seen in African Americans [24]. Coronary heart disease is a multifactorial disease, and a

Pathways to major cardiovascular events

Obesity
Risk factors

Solution(s):
Hypertension Life style changes
Hypertension
Dyslipidemia Low Salt, Low caloric diet, Low Hyperlipidemia
Diabetes mellitus sugar drinks, Exercise, Less
Hyperglycemia
stress, Medication compliance
Central obesity
Obesity
Inactivity
Hyperuricemia
Tobacco
Overeating Excessive
alcohol

Hypertensive CVD Cardiomyopathy

Atherosclerosis

Systolic Diastolic
dysfunction CHF dysfunction

Coronary artery disease

Carotid artery disease CVA MI Arrhythmias CKD LVH ISH ADA
Peripheral artery disease
Renal artery disease
CVA: cerebrovascular accidents; MI: myocardial infarction; CKD: chronic kidney
disease/stroke; LVH: left ventricular hypertrophy; ISH: isolated systolic hypertension.
ADA: Aorta dissections & aneurysm;
Maroon color indicates the major cardiovascular events
FIG. 1 Risk factors affecting the developmental pathway to major cardiovascular disease events.
Source: Ethnicity & Disease © 2015. (Kwagyan et al.). Published by ISHIB. Printed with permission. All rights reserved.
 Cardiovascular Diseases, Obesity, and Lifestyle Changes Chapter | 1 5

measure of the overall disease risk is necessary and has been derived from the Framingham Heart Study [22], a prospective
epidemiological study of cardiovascular diseases. Elevated blood pressure and lipid levels are known to be associated with
an increasing risk of cardiovascular disease (CVD) and are part of the Framingham score algorithm.
High serum cholesterol is a known risk factor and a treatment target in primary and secondary prevention of CHD.
Results from the MESA study [25] observed that in a cohort free of CHD, there was no significant difference in the preva-
lence of dyslipidemia among African Americans, Hispanics, and Caucasians. The report showed that African Americans
and the Hispanic group were 30% less likely than Caucasians to have their dyslipidemia under control. When these metrics
were adjusted for socioeconomic status and health care access, there was attenuation of the disparity, implying that biologi-
cal differences alone were not responsible for the differences in control.
Hypertension or high blood pressure is a common disease in which blood flows through the blood vessels (arteries) at
higher than normal pressures. It is the major risk factor for atherosclerosis and by far the leading risk factor for the develop-
ment of CVD and the leading cause of death and disability [26–28].
Over time, consistently high blood pressure weakens and damages the blood vessels, which can lead to severe clinical
complications including but not limited to the development of heart failure, heart attack, chronic kidney disease, cognitive
changes, eye damage, and stroke, to list a few (NHLBI site). The prevalence and incidence of hypertension and
hypertension-related complications are reported to be disproportionately higher among African Americans than other eth-
nicities [29,30]. This has been linked with low social economic status, the lack of access to health care, and a higher non-
compliance with prescribed medication usage.

BIOPHYSICAL PROPERTIES OF THE ARTERIAL SYSTEM

While high blood pressure is a major risk factor for cardiovascular events, the role of pulse pressure, an independent pre-
dictor of arterial stiffness, is modestly emphasized. Pulse pressure, a marker of the biophysical properties of the arterial
system, has been demonstrated in observational and longitudinal studies to show a direct association with carotid athero-
sclerosis [31,32], left ventricular mass [31], white matter lesions [33], and heart failure [34]. A report by Randall et al.
[35] discussed the effect of intensive blood pressure control on cardiovascular remodeling in hypertensive patients with
nephrosclerosis and showed that, after covariate adjustment, a higher pulse pressure is associated with increased risk of
CV outcome (relative risk = 1.28 and CI = 1.11–1.47) and development of LVH (relative risk = 1.26 and CI = 1.04–1.54).
Although an association between increased BMI and elevated blood pressure has been established [36,37], limited data
exist on the relationship between BMI and PP. Martin and colleagues [38] examined the relationship between BMI and
PP in older adults with isolated systolic hypertension and reported PP to increase with BMI values greater than 30 kg/m2,
while pulse pressure decreased with increasing BMI values less than or equal to 30 kg/m2. Randall et al. [39] and Kwagyan
et al. [40] showed a closer significant correlation between pulse pressure and BMI than between systolic blood pressure
and BMI. These studies further reported that diet and exercise program averaging 10% reductions in BMI, translated
into a significant improvement in pulse pressure, stroke volume, a measure of the amount of blood the heart pumps per
beat, and arterial compliance, the ratio of stroke volume to pulse pressure. In a recent study, Kwagyan et al. [40] showed
in multivariate models in obese African Americans that pulse pressure is associated positively with increasing BMI
(P < .01), systolic blood pressure (P = .01), diabetes mellitus (P = .04), and age above 50 years (P = .01) and negatively
with heart rate (P = .04). There was also a strong correlation between pulse pressure and systolic blood pressure (r = 0.67
and P < .01) and no correlation between pulse pressure and diastolic blood pressure (r = 0.02 and P = .83). In multiple
regression analysis, pulse pressure correlated positively with systolic blood pressure (P < .01) and BMI (P < .01) and
negatively with heart rate (P = .02). Fig. 2 shows the relationship of pulse pressure with number of metabolic syndrome
components.
As expected, the figure depicts a positive relationship between the number of components and pulse pressure. The
results indicate that CVD risk factors including hypertension, dyslipidemia, and diabetes that are also features of the com-
ponents of the metabolic syndrome constellation impact negatively on arterial vascular properties, as reflected in increased
pulse pressure, suggesting that the metabolic syndrome is detrimental to vascular health.

DISTRIBUTION AND CORRELATES OF MAJOR CVD RISK FACTORS IN

OBESE AFRICAN AMERICANS
Randall et al. [41] examined the distribution and correlates of major CVD risk factors in 515 obese African Americans, with
average age ± SD was 48.3 ± 9.9 years and BMI of these individuals was 42.9 ± 6.8 kg/m2 (see Table 1). Of these individu-
als, 27% had dyslipidemia, 56.9% had hypertension, and 24.1% had diabetes mellitus. These rates are higher than those
found in the African American population by the third NHANES survey. The study noted that, after adjusting for age and
6 PART | I Overview and Mechanisms

70

PP mmHg
60 56.1
53.7
52.4

50
42.6

40

30

20

10

0
1 2 3 4 or more
Number of metabolic syndrome components
FIG. 2 Relationships of pulse pressure (PP mmHg) to number of metabolic syndrome components.

TABLE 1 Prevalence Rates of the CVD Risk Factors of Hypertension, Dyslipidemia, and Diabetes Mellitus Across BMI
Categories
BMI Category

30–34.9 35–39.9 40–44.9 45–49.9

Risk Factors (N = 86) (N = 125) (N = 110) (N = 92) 50+ (N = 105) Total (515)
No risk factor 26 22 29 29 27 26

Dyslipidemia 26 34 29 26 19 27

Hypertension 63 62 53 48 63 57

Diabetes 20 29 22 20 30 24
mellitus

Data are percent.

sex, there were no significant differences in the prevalence rates of these risk factors according to increasing BMI, suggest-
ing a threshold of between 30 and 34.99 kg/m2 for maximal appearance of these risk factors. Ninety-nine percent met the
metabolic syndrome criteria for waist circumference, 40% met the criteria for BP, and 37% for HDL. Thirty-nine percent
had exactly two features of the metabolic syndrome, and 36% were diagnosed with it. The proportion of participants who
met the MS criteria for HDL and those diagnosed with it increases significantly across BMI categories. In particular, a lo-
gistic regression analysis showed that in these obese individuals, a 5 kg/m2 rise in BMI increased the risk of the MS by 44%.

AMBULATORY BLOOD PRESSURE MONITORING

Several studies support the prognostic significance of 24 h ambulatory blood pressure monitoring [24–32]. This offers a
convenient means of obtaining a large number of repeated BP measurements on each subject and thereby increases the
statistical power of detecting significant hemodynamic changes. The diurnal variation of ABP provides a measure of the
percentage of BP readings that are elevated, the extent of BP fall during sleep, and thus the overall BP load. Although a
nocturnal fall in BP is usual, various groups of individuals including Blacks, diabetics, and subjects who have developed
 Cardiovascular Diseases, Obesity, and Lifestyle Changes Chapter | 1 7

left ventricular hypertrophy (LVH) or renal damage have been noted to have little or no nocturnal fall [24,42–44]. Both
observational and longitudinal studies alike have shown that target organ damage accompanying hypertension is closely
related to 24 h ABP. Individuals with a lack of a significant nocturnal fall in BP has been linked to more serious target organ
damage and higher incidence of cardiovascular complications than those with a nocturnal fall [45–48]. Kwagyan et al. [49]
reported in a cohort of obese African Americans that 44% were nondippers in any BP component, with dipping defined as
those who exhibit a reduction in average BP by at least 10% from the day to night. The proportions of dippers in SBP were
17%, DBP 54%, and MBP 40%. Ninety-nine percent of SBP dippers were also DBP dippers. Consistent with other studies,
the report showed that increasing BMI correlated negatively with DBP dipping (P = .01). Systolic BP dipping correlated
positively with HTN (P = .02) and HR (P = .06) and negatively with DM (P = .02). The higher percentage of nondipping in
these obese African Americans is alarming. A lifestyle change in these obese populations is necessary to improve dipping
status and CV health. Evaluation of nocturnal fall in DBP may be of clinical relevance, and more research is needed to
establish its prognostic value. The high rate of nondipping in this obese population reinforces the need to reduce BMI and
improve hemodynamic and lipid profiles through therapeutic lifestyle changes. This is likely to shift nondippers to dipper
status and reduce the potential risk for target organ damage.

DIET AND PHYSICAL ACTIVITY INTERVENTION

The modifiable environmental factors that have been clearly shown to correlate with blood pressure levels and CVD risk
are salt intake, physical activity, and excess body weight [39]. A key element of prevention is therefore to identify those
individuals most likely to have cardiovascular events and intervention strategies for reduction of associated risk factors.
Preventive measures, such as physical activity and nutritious low-salt and low-fat diets, particularly diets low in cholesterol
and saturated fats, have been investigated and established to reduce the risk of hypertension and CHD. Kwagyan et al.
[49] examined the effect of participating in a diet-exercise program on cardiovascular risk factors and CHD risk prediction
among obese African Americans. Variables included in the estimate of CHD risk prediction were age, systolic BP, diastolic
BP, total cholesterol, HDL, cigarette smoking, and diabetes. Table 2 showed the average percent changes in anthropometric,
hemodynamic, and lipid measures after 6-month diet and exercise intervention from the study.

TABLE 2 Anthropometric, Hemodynamic, and Lipid Profiles at Baseline and 6 Months (N = 129)
Baseline Six months Percent Change P-value
Variable

BMI (kg/m2) 42.5 ± 1.8 37.9 ± 1.5 −10.8 <.01

Waist circumference 118.4 ± 4.2 110.8 ± 3.7 −6.4 .02

(cm)

Systolic BP (mmHg) 131.9 ± 2.2 124.2 ± 1.9 −5.8 .02

Diastolic BP (mmHg) 79.8 ± 1.6 76.2 ± 1.3 −3.6 .05

Pulse pressure (mmHg) 52.3 ± 1.4 48.0 ± 1.2 −8.2 <.01

Heart rate (bpm) 82.7 ± 1.9 76.6 ± 2.1 −7.4 <.01

Glucose (mg/dL) 111.0 ± 8.0 101.4 ± 11.6 −5.7 .24

Total cholesterol (mg/dL) 224.2 ± 8.6 212.6 ± 8.6 −5.2 .10

LDL (mg/dL) 137.7 ± 7.8 126.8 ± 6.3 −7.9 .01

HDL (mg/dL) 56.4 ± 2.3 61.8 ± 3.2 +9.6 <.01

Smokers (number (%)) 1(3.4) 1(3.4) 0 1

10-year CHD risk

Women 6% 4% −33.3 <.01

Men 16% 13% −18.5 <.01

Source: Ethnicity & Disease © 2015. (Kwagyan et al.). Published by ISHIB. Printed with permission. All rights reserved.
8 PART | I Overview and Mechanisms

The results show an 11% decrease in BMI, an 8% decrease in LDL, and a 10% increase in HDL. The LDL/HDL ratio
decreased from 2.3 to 2.1, while the total cholesterol/HDL ratio decreased from 4.4 to 3.4. The initial 10-year CHD risk,
as per the Framingham risk calculator, was 6% in women and 16% in men. The 10-year CHD risk prediction decreased on
average from 6% to 4% for women and 16% to 13% for men. This was accomplished by the improvements in BMI (kg/
m2), waist circumference, blood pressure, LDL, and HDL. The results clearly highlight the importance of continuous and
persistence adherence to lifestyle changes to risk reduction and cardiovascular health (see Fig. 1). Implementing similar
programs that are culturally sensitive across minority groups could significantly improve cardiovascular health and CHD
risk for an at-risk population at lower costs than long-term pharmacological treatment.

CONCLUSION
In cardiovascular research, the primary objective is to identify and attempt to prevent or reduce the onset of risk
factors that are predictive of cardiovascular disease morbidity and mortality. Obesity, and the related condition, the
metabolic syndrome, are noted to be risk factors for the development of CVD [50]. The prevalence of the major
CVD risk factors is disproportionately higher among minority populations, in general and particularly among obese
individuals. Obesity is a multifactorial condition, with some individuals suffering from an endocrine disease or from
genetic propensity. Many individuals, however, have developed the condition from poor eating habits and less or no
physical activity and have become an epidemic in minority populations. Management of obesity, metabolic syndrome,
and CVD risks consists primarily of modification or reversal of the root causes and direct therapy of the risk factors.
Moreover, the high prevalence and increasing incidence of obesity, the metabolic syndrome, and associated cardio-
vascular risk factors in adults and children emphasize the need to focus on obesity reduction in this population. There
is the report that, in the future, metabolic syndrome may overtake smoking as the leading risk factor for heart disease
(NHLBI site).
The first strategy involves weight reduction and increased physical activity, both of which can improve all components
of the CHD risk profile and components of the metabolic syndrome. Lifestyle changes are the most important target for
decreasing these risk factors. As we have discussed and others have shown that this can be achieved through a successful
diet and exercise program and likely at less cost in the long-term than through pharmacological means [39,40]. Education
and awareness are of the utmost importance in ensuring success with the diet an exercise program [51]. Understanding why
they are overweight, the consequences of excess weight and the associated deliberating complications should be empha-
sized in educational programs.
In conclusion, we emphasize that with the rise in prevalence and incidence of obesity and associated conditions world-
wide and particularly the high onset of the obesity and the metabolic syndrome among children and the adolescent, earlier
intervention through lifestyle modification to stop this epidemic will have potential benefit to the society now and the
future. This includes regularly engaging in physical activity; consumption of low-salt, low-fat diet; consumption of fruits
and vegetables; and refraining from high sugary foods and drinks. Other healthy lifestyle changes include managing stress,
having a good night sleep, quitting smoking, and adhering to prescription medication.

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10 PART | I Overview and Mechanisms

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[46] Redon J, Campos C, Narciso ML, Rodicio JL, et al. Prognostic value of ABPM in refractory hypertension. Hypertension 1998;31:712–8.
[47] Mancia G, Parati G. Ambulatory blood pressure monitoring and organ damage. Hypertension 2000;36:894–900.
[48] Staessen JA, Thijs L, Fagard R. Predicting cardiovascular risk using conventional versus ambulatory blood pressures in older patients with systolic
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[49] Kwagyan J, Retta TM, Ketete M, Bettencourt CN, Maqbool AR, Xu S, et al. Obesity and cardiovascular diseases in a high-risk population: evidence-
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[50] RVega GL. Obesity, the metabolic syndrome, and cardiovascular disease. Am Heart J 2001;142:1108–16.
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2003 22.

FURTHER READING
[1] Masuo K, Mikami H, Ogahara T, Tuck ML. Weight gain-induced blood pressure elevation. Hypertension 2000;35:1135–40.
Another random document with
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indifferent if it had not been accompanied by another, which
suddenly brought the artist into the light, and was the success of the
Salon of 1874.
During his last holiday at Damvillers, Bastien-Lepage had
conceived the idea of painting the portrait of his grandfather, in the
open air, in the little garden which the old man loved to cultivate.

Grandfather Lepage.
By Jules Bastien-Lepage.
The grandfather was represented seated in a garden chair,
holding on his knees his horn snuff-box and his handkerchief of blue
cotton. His striking face stood out well detached from the
background of trees; the black velvet cap sloping jauntily towards his
ear gave effect to the shrewd Socratic face; his blue eyes twinkled
with humour; the nose was broad and retroussé; the white forked
beard spread itself over an ancient vest of the colour of dead leaves;
the hands, painted like life, were crossed upon the grey trousers.
Before this picture, so true, so frank, of such marvellous intensity
of familiar life, the public stood delighted, and the name of Bastien-
Lepage, unknown before, figured the next day in the first place in the
articles on the Salon.
 II.

It was in front of this picture that I first met Jules. Having looked in
my catalogue for the name of the painter, I was delighted to find that
he was from the Meuse, and born at that same Damvillers where I
had once lived.
The heavy soil of our department is not fruitful in artists. When it
has produced one it takes a rest for a few centuries.
Since Ligier Richier, the celebrated sculptor, born at the end of the
fifteenth century, the Meuse could only claim credit for the painter
Yard a clever decorator of churches and houses in the time of Duke
Stanislas; so I was quite proud to find that Bastien-Lepage was a
fellow countryman of mine. A few moments later a mutual friend
introduced us to each other.
I saw before me a young man, plainly dressed, small, fair, and
muscular; his pale face, with its square determined brow, short nose,
and spiritual lips, scarcely covered with a blond moustache, was
lighted up by two clear blue eyes whose straight and piercing look
told of loyalty and indomitable energy. There was roguishness as
well as manliness in that mobile face with its flattened features, and
a certain cool audacity alternated with signs of sensitiveness and
sparkling fun and gaiety.
Remembrances of our native province, our common love of the
country and of life in the open air, soon established kindly relations
between us, and after two or three meetings we had entered upon a
close friendship.
The portrait of the grandfather had won for him a third medal, and
had ensured him a place in the sunshine.
It was not yet a money success, but it was a certain degree of
fame; he might go back to his village with his heart at rest, his head
high. The State had just bought his picture, La Chanson du
Printemps (The Song of Spring), and orders were beginning to come
in.
In 1875 Bastien-Lepage reappeared in the Salon with La
Communiante (The Communicant) and the portrait of M. Simon
Hayem, two excellent works which gave, each in its way, a new mark
of his originality.
The portrait of M. Hayem was best liked by men of the world;
artists were most struck by La Communiante.

The Communicant.
By Jules Bastien-Lepage.
 This young girl’s simple awkward bearing, as she stands out from
a creamy background, with all the stiffness of her starched white veil,
naïvely opening her pure hazel eyes, and crossing her fingers, ill at
ease in the white gloves, is a marvel of truthful painting. It reminds
one of the manner of Memling and of Clouet, though with quite a
modern feeling. It is interesting, as being the first of those small,
lifelike, characteristic portraits, in a style at once broad and
conscientious, which may be reckoned among the most perfect of
this painter’s works.
At the time of these successes in the Salon, Bastien joined in the
competition for the Prix de Rome. The subject chosen for 1875 was
taken from the New Testament—L’Annonciation aux Bergers (The
Annunciation to the Shepherds).
I remember as if it were yesterday that July morning when the
gates of the Palais des Beaux Arts were opened, and the crowd of
eager inquirers rushed into the hall of the competition.
After a few minutes Bastien’s picture was surrounded, and a buzz
of approval arose from the groups of young people gathered round
that work, so real, so strongly conceived and executed that the other
nine canvases disappeared as in a mist.
The artist had understood and treated the subject in a manner
utterly different from the usual style of the Academy. It was familiar
and touching, like a page of the Bible. The visit of the angel had
surprised the shepherds sleeping by their fire in the open air; the
oldest of them was kneeling before the apparition, and prostrated
himself in adoration; the youngest was gazing with half-closed eyes,
and his open lips and hands, with fingers apart, expressed
astonishment and admiration. The angel, a graceful figure, with
childlike almost feminine head, was showing with outstretched arm
to the shepherds, Bethlehem in the distance surrounded by a
miraculous halo.
This picture, which has both the charm of poetic legend and a
manly grip of real life, was executed with uncommon grace and
vigour; its very faults contributed to the realization of the effect aimed
at.
 Most of those who saw this work of Lepage declared that he
would carry off the Prix de Rome with a high hand; yet the jury
decided otherwise. It was an older and more correct competitor who
was sent to the Villa Medicis at the cost of the State.
For a moment Bastien-Lepage was troubled and discouraged by
this decision. Not that he felt himself strongly attracted towards
Rome and Italian art, but he knew that many people judge of an
artist by his success. Among the people down in his province and in
his own family the Prix de Rome would have been considered as an
official recognition of his talent, and he regretted, above all, not being
able to give this satisfaction to his relations, who had undergone so
many privations in order to maintain him at Paris. That he did not
soon forget this unmerited check, we may gather from this fragment
of a letter to a friend:
“I learned my business in Paris, I shall not forget that; but my art I
did not learn there. I should be sorry to undervalue the high qualities
and the devotion of the masters who direct the school. But is it my
fault if I have found in their studio the only doubts that have
tormented me? When I came to Paris I knew nothing at all, but I had
never dreamed of that heap of formulas they pervert one with. In the
school I have drawn gods and goddesses, Greeks and Romans, that
I knew nothing about, that I did not understand, and even laughed at.
I used to say to myself that this might be high art; I wonder
sometimes now if anything has resulted from this education….”
However, he did not consider himself beaten. The following year,
at the same time that he was exhibiting his portrait of M. Wallon, he
went in again for the Prix de Rome competition. This time it was less
for his own sake than to give a satisfaction to his family and friends.
He did not enter with any real feeling into this competition, the
subject for which was: Priam suppliant Achille de lui rendre le corps
de son fils Hector (Priam begging Achilles to restore to him the body
of his son Hector). This picture, though a vigorous composition, tells
almost nothing of the deep and poignant emotion of this episode of
the Iliad.
 Once more he failed to gain the prize, but this time he did not take
it much to heart. He was occupied with more absorbing prospects:
his last visit to Damvillers had bent his mind toward another ideal.
Whatever he might say, his studies in the school had not been
without their use to him. They had developed in him the critical
faculty. His repugnance to factitious and conventional art had driven
him with more force to the exact and attentive observation of nature.
At Paris he had learned to compare, and to see better. The
Meuse country, so little heroic, with its low hills, its limited horizons,
its level plains, had appeared to him suddenly more attractive and
more worthy of interest than the heroes of Greece and Rome. Our
labourers driving the plough across the field; our peasant women
with their large liquid eyes, prominent jaws, and widely opening
mouths; our vine-dressers, their backs curved with the labour of the
hoe, had revealed themselves to him as models much more
attractive than those of the atelier. It was a work for a great artist to
bring out the poetry pervading the village folk and their belongings
and to give it a real existence, as it were, by means of line and
colour. To represent the intoxicating odour of the mown grass, the
heat of the August sun on the ripe corn, the life of the village street;
to bring into relief the men and women who have their joys and
sorrows there; to show the slow movement of thought, the anxieties
about daily bread on faces with irregular and even vulgar features;—
this is human art, and consequently high art. This is what the Dutch
painters did, and they created masterpieces. Bastien, while lounging
among the orchards of Damvillers and the woods of Réville, resolved
that he would do as they had done, that he would paint the peasants
of the Meuse.
The list of studies begun or completed at this time shows us the
progress of this dominant idea: La Paysanne au Repos (The
Peasant Woman Reposing), La Prairie de Damvillers (The Meadow
at Damvillers), the two sketches for the picture Les Foins (The Hay),
Les Jardins au Printemps (Gardens in Spring), Les Foins Mûrs (Ripe
Grasses), L’Aurore (Dawn)—all these canvases bear the date of
1876.
 It was in the autumn of the same year that we carried out a long-
talked-of plan for making an excursion together on foot into the
Argonne. I went to join him in September at Damvillers.
Thanks to him, I saw with a very different feeling the town that
formerly I thought so dull. Cordially and hospitably received in the
house at the corner of the great square, I made the acquaintance of
the father, with his calm, thoughtful face; of the grandfather, so
cheerful in spite of his eighty years; of the mother, so full of life, so
devoted, the best mother that one could wish for an artist. I saw what
a strong and tender union existed between the members of this
family whose idol and whose pride was Jules.
We set out along with one of my old friends and the painter’s
young brother. For a week we walked with our bags on our backs
through the forest country of the Argonne, going through woods from
Varennes to La Chalade, and from Islettes to Beaulieu. The weather
was rainy and unpleasant enough, but we were none the less gay for
that, never winking when the rain came down, visiting the glass-
works, admiring the deep gorges in the forests, the solitary pools in
the midst of the woods, the miles of green and misty avenues at the
foot of the hills.
Jules Bastien was always the leader. When we arrived at our
resting place in an evening, after a day of walking in the rain, he
almost deafened us with scraps of café-concert songs, with which
his memory was stored.
I seem still to hear in the dripping night that voice, clear and
vibrating, now silent for ever….
As we went along he told me of his plans for the future.
He wanted to tell the whole story of country life in a series of large
pictures: hay-making, harvest, seed-time, the lovers, the burial of a
young girl…. He also wanted to paint a peasant woman as Jeanne
d’Arc, at the moment when the idea of her divine mission is taking
possession of her brain; then, a Christ in the Tomb.
Together we made a plan for publishing a series of twelve
compositions: Les Mois Rustiques (The Months in the Country), for
which he was to furnish the drawings and I the text.
From time to time we stopped at the opening of a wood or at the
entrance of a village, and Jules would make a hasty sketch, little
thinking that the wild and simple peasants of the Argonne would take
us for Germans surreptitiously making notes of their roads and
passes. At Saint Rouin, while we were looking on at a Pilgrimage,
we had nearly been taken as spies. I have told this story
elsewhere.[1] The remembrance of it amused us for a long time.
After eight days of this vagabond life we separated at Saint Mihiel,
where Bastien wished to see the group of statues of the sepulchre,
the chef d’œuvre of Ligier Richier, before beginning his Christ in the
Tomb.
Shortly afterwards he gave an account of this visit in a letter to his
friend Baude, the engraver:
“Our too short walk through the Argonne has been very
interesting, and ended with a visit to the grand chef d’œuvre of Ligier
Richier at Saint Mihiel. You must see that some day. I have seen
nothing in sculpture so touching. France ought to know better and to
be prouder of that great Lorraine artist. You will see a photograph of
this masterpiece when you come to me….”
He had scarcely been six weeks at Damvillers again when he lost
his father, who was suddenly carried off by pulmonary congestion.
Death entered the house for the first time, and it was a rude shock
for a family where each loved the other so well.
“We were too young to lose such a good friend,” he wrote to me;
“in spite of all the courage one can muster, the void, the frightful void
is so great, that one is sometimes in despair….”
“… Happily remembrance remains (letter to M. Victor Klotz), and
what a remembrance it is! … the purest that is possible;—he was
goodness and self-abnegation personified; he loved us so!… What is
to be done? We must try to fill the void with love for those who
remain, and who are attached to us, always keeping in mind him
who is gone, and working much to drive away the fixed idea.”
 And indeed he did work furiously: at Damvillers, at a Job that
remains unfinished, and at Paris at the full-length portrait of a lady,
which was exhibited in the Salon of 1877.
He had left the Rue Cherche Midi and had settled in the Impasse
du Maine, where his studio and his apartment occupied one floor of
a building, at the end of a narrow neglected garden, whose only
ornaments were an apricot tree and some lilac bushes.
His brother Emile, who just then came to an end of his study of
architecture in the school, lived with him.
His studio was very large, and was simply furnished with an old
divan, a few stools, and a table covered with books and sketches. It
was decorated only with the painter’s own studies and a few
hangings of Japanese material.
I used to go there every morning at this time to sit for my portrait.
I used to arrive about eight o’clock, to find Jules already up, but
with his eyes only half awake, swallowing two raw eggs, to give
himself tone, as he said.
He already complained of stomach trouble, and lived by rule. We
used to smoke a cigarette, and then he began to work. He painted
with a feverish rapidity, and with a certainty of hand quite
astonishing. Sometimes he would stop, get up and roll a cigarette,
would closely examine the face of his model, and then, after five
minutes of silent contemplation, he would sit down again with the
vivacity of a monkey and begin to paint furiously.
The portrait, sketched in during the snows of January, was almost
finished when the apricot tree began to put on its covering of white
flowers in April.
 The Hayfield.
By Jules Bastien-Lepage.
Immediately after the opening of the Salon, Bastien packed up his
baggage and fled to Damvillers to prepare for his great picture Les
Foins (The Hayfield), which occupied him all the summer of 1877,
and of which he gave me news from time to time.
“July.—I shall not say much about my work; the subject is
not yet sufficiently sketched in. What I can tell you is that I am
going to give myself up to a debauch in pearly tones: half-dry
hay and flowering grasses; and this in the sunshine, looking
like a pale yellow tissue with silver threads running through it.
 “The clumps of trees on the banks of the stream and in the
meadow will stand out strongly with a rather Japanese
effect….”
“15th August.—Your verses are just the picture I should
like to paint. They smell of the hay and the heat of the
meadow…. If my hay smells as well as yours I shall be
content…. My young peasant is sitting with her arms apart,
her face hot and red; her fixed eyes seeing nothing; her
attitude altogether broken and weary. I think she will give the
true idea of a peasant woman. Behind her, flat on his back,
her companion is asleep, with his hands closed; and beyond,
in the meadow, in the full sun, the haymakers are beginning to
work again. I have had hard work to set up my first ideas,
being determined to keep simply to the true aspect of a bit of
nature. Nothing of the usual willow arrangement, with its
branches drooping over the heads of the people to frame the
scene. Nothing of that sort. My people stand out against the
half-dry hay. There is a little tree in one corner of the picture
to show that other trees are near, where the men are gone to
rest in the shade. The whole tone of the picture will be a light
grey green….”
“September.—Why didn’t you come, lazy fellow? You
would have seen my Hay before it was finished. Lenoir, the
sculptor, my neighbour in the Impasse, liked it. The country
people say it is alive. I have little more than the background to
finish. I am going to harness myself to the Reapers, and to a
nude study of a Diogenes the cynic, or rather, the sceptic….”
Les Foins was sent to the Salon in 1878. It had a great success,
though it was warmly discussed.
In the hall where it was placed, among the pictures which
surrounded it, this picture gave an extraordinary sensation of light
and of the open air. It had the effect of a large open window.
The meadow, half mown, went back bathed with sunshine, under
a summer sky, flecked with light clouds. The young haymaker sitting
drooping in the heat, intoxicated with the smell of the hay, her eyes
fixed, her limbs relaxed, her mouth open, was wonderfully real.
There was nothing of the conventional peasant whose hands look as
if they had never touched a tool, but a veritable countrywoman
accustomed from childhood to outdoor work. One felt that she was
weary with fatigue, and glad to breathe a moment at her ease, after
a morning of hard work in the sun.
This picture of life in the fields, so carefully studied, so powerfully
rendered, had a considerable influence on the painting of the day.
From the time of this exhibition many young painters, many foreign
artists especially, threw themselves with enthusiasm into the new
way opened out by Bastien-Lepage, and, without intention on his
part, the painter of the Meusian peasants became the head of a
school.

[1] See La Chanson du jardinier in Sous Bois.

 III.

Bastien did not allow himself to be spoiled by success, but

continued his life of assiduous labour and conscientious research.
He divided his time between Paris and Damvillers, giving the larger
part to his village.
We have a long list of his works done in 1878 and 1879. Portraits
of M. and Mme. Victor Klotz and of their children, of MM. de
Gosselin, of M. A. Lenoir, of M. de Tinan, of the publisher George
Charpentier, of Emile Bastien, of Sarah Bernhardt, and lastly that
Saison d’Octobre, or, Recolte des Pommes de terre (October, or The
Potato Harvest) which is the companion picture to Les Foins (Hay).
This was in a graver key, with warm yet sober colours, and an
exquisite savour of the country in the late summer; it was powerfully
executed and full of health and serenity.
The portrait of Sarah Bernhardt and The Potato Harvest, less
discussed than The Hay, made a deep impression on the mass of
the public.
 Sarah Bernhardt.
By Jules Bastien-Lepage.
Dating from this time, Bastien’s success, both artistic and
monetary, was secure.
His first care was to let his friends at Damvillers join in his good
fortune.
They had been with him in his difficulties, they should now share
his pleasure, and he brought them to Paris in the summer of 1879.
He was happy to return to them, in all sorts of kind attentions, a little
of what he owed them for so much affectionate devotion. He was
grateful to them for having believed in him in his time of difficulty as a
beginner, and he experienced a tender pride in being able to show
them that they had not been mistaken.
When he received his first important gains he took his mother to a
large shop and had silks for dresses spread out before her. “Show
some more,” cried he. “I want Mama to choose the best.” And the
poor little mother, frightened at the sight of black satin that could
stand upright of itself, in vain protested that “she would never wear
that.” She was obliged to give way.
He took his grandfather through the avenues of the Bois and the
principal boulevards, expecting that he would be delighted; but in this
direction his zealous efforts failed utterly. The old man remained
indifferent to the splendours of Parisian luxury and to the scenery in
the theatres. At the opera he yawned openly, declaring that all this
commotion was deafening, and he went back to Damvillers
determined that they should never take him away again.
After having seen his people into the train for their return, he set
out for England, where he painted the Prince of Wales.
Decorated in the following July, he hastened to Damvillers to
show his red ribbon to his friends, and also to go on with the work he
loved best.
He had managed to arrange a studio in the spacious and lofty
granaries of the paternal house, and there he worked hard.
He hoped at last to realize his dream, so long deferred, of painting
a Jeanne d’Arc. He had meditated much on this subject, and we
have often spoken of it.
His idea was to paint Jeanne in the little orchard at Domrémy at
the moment when she hears, for the first time, the mysterious voices
sounding in her ears the call to deliver her country.
To give more precision to the scene, Bastien wished to show,
through the branches of the trees, the “blessed saints,” whose voices
encouraged the heroic shepherdess.
In this I differed from him. I maintained that he ought to suppress
these fantastic apparitions, and that the expression of Jeanne’s face
alone should explain to the spectator the emotion caused by the
hallucination to which she was a prey. I reminded him of the sleep-
walking scene in Macbeth: the doctor and the chamber-woman, I
said, do not see the terrible things that dilate the pupils of Lady
Macbeth, but from her face and gestures they know that there is
something terrible; the effect is only the greater, because, after
having perceived this, the imagination of the spectator increases it.
Suppress your phantoms and your picture will gain in sincerity and
dramatic intensity.
But Jules held to the personification of the voices, and our
discussions ended without either the one or the other being
convinced. Nevertheless, my objection had impressed him, and he
wanted to show his work to his friends before it was quite finished.
 Joan of Arc Listening to the Voices.
By Jules Bastien-Lepage.
“Come,” he wrote to me, about the 15th of September, “F. is quite
disposed to come; he really wants to come to Damvillers. Everything
will go beautifully. You will see my picture of Jeanne d’Arc well
advanced, and somebody coming from Paris will do me no harm….”
“If you knew how I work (letter to Ch. Baude) you would be less
surprised. My picture is getting on, and getting on well; all, except
the voices, is sketched, and some parts are begun. I think I have
found a head for my Jeanne d’Arc, and everybody thinks she
expresses well the resolution to set out, while keeping the charming
simplicity of the peasant. Also, I think the attitude is very chaste and
very sweet, as it ought to be in the figure that I want to represent; …
but if I am to see you soon, I prefer to leave you the pleasure of
surprise and of the first impression of the picture; you will judge of it
better, and you will be able to say better what you think of it….”
Jeanne d’Arc appeared in the Salon of 1880, with the portrait of
M. Andrieux. It did not produce all the effect that Jules expected. The
picture had its enthusiastic admirers, but also passionate detractors.
The critics attacked first the want of air and of perspective; then, as I
had foreseen, the voices, represented by three symbolical
personages, too slightly indicated to be understood, and yet too
precise for apparitions. But the public did not do justice to the
admirable figure of Jeanne, standing, motionless, quivering, her eyes
dilated by the vision, her left hand extended, and mechanically
fingering the leaves of a shrub growing near.
Never had Bastien-Lepage created a figure more poetically true
than this Lorraine shepherdess, so pure, so human, so profoundly
absorbed in her heroic ecstasy.
The rapid and brilliant success of the young master had ruffled the
amour propre of many; they made him pay for these precocious
smiles of glory by undervaluing his new work. He had hoped that the
medal of honour would be given to his Jeanne d’Arc; this distinction
was given to an artist of talent, but whose work had neither the
originality, nor the qualities of execution, nor the importance of
Bastien’s picture. He felt this injustice strongly and went to London;
there the reception and appreciation of English artists and amateurs
consoled him a little for this new mortification.
The two years that followed were fruitful in vigorous work of
different kinds: Les Blés Mûrs (Ripe Corn), the London Docks, The
Thames, Le Paysan allant voir son champ le dimanche (The
Peasant Going to Look at his Field on Sunday), La Petite Fille allant
à l’école (The little Girl Going to School); the portraits of M. and of
Mme. Goudchaux, of Mdlle. Damain, of Albert Wolff, and of Mme.
W., La Marchande de Fleurs (The Flower Girl); last of all, the two
great pictures Le Mendiant (The Beggar), and Père Jacques,
exhibited in the Salon in 1881 and 1882.
 His stay in London and the reading of Shakspeare had inspired
him with the idea of painting one of the heroines of the great poet,
and in 1881 he went back to Damvillers full of a project for painting
the Death of Ophelia.
“I have been painting hard” (letter to Ch. Baude, August, 1881),
“for I want to go away and travel for two or three weeks. At the end
of September you will come and see us. That is settled, is it not?
Shooting, amusements, friendship. Since my return I have painted a
haymaker and worked at a little picture of an interior: The Cuvier à
Lessive (The Washing Kitchen); all the detail requires much time.
Besides I have begun and already advanced a large picture of
Ophelia. I think it will be well to do something as a contrast to my
Mendiant (Beggar). It is to be a really touching Ophelia, as
heartrending as if one actually saw her.”
“The poor distracted girl no longer knows what she is doing, but
her face shows traces of sorrow and of madness. She is close to the
edge of the water leaning against a willow; upon her lips, the smile
left by her last song; in her eyes, tears! Supported only by a branch,
she is slipping unawares; the stream is quite close to her. In a
moment she will be in it. She is dressed in a little greenish blue
bodice, and a white skirt with large folds; her pockets are full of
flowers, and behind her is a river-side landscape. One bank under
trees, with tall flowering grasses, and thousands of hemlock flowers,
like stars in the sky; and in the higher part of the picture, a wooded
slope; and the evening sun shining through birches and hazel
bushes; that is the scene….”
This picture was never finished. The landscape and flowers were
rendered as the artist wished, but the face and the costume of
Ophelia recalled his Jeanne d’Arc too much.
Bastien-Lepage no doubt saw this, and for this reason put the
picture on one side to return to his peasants.