A collection of postings on a range of issues is available on our website (www.mjacksongroup.ca). This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.
The New York Times includes an article: “7 Habits for a Healthy Heart” by Anahad O’Connor
Here are some excerpts:
Worldwide, heart disease and strokes are the leading causes of death. They’re also the leading killers of Americans, accounting for one out of every three deaths in the United States.
But there’s good news, too. About 80 percent of all cases of cardiovascular disease are preventable. You can lower your risk markedly by making some changes to your lifestyle including doing some things that are easy, simple and even enjoyable.
Regular exercise improves nearly every aspect of your health.
A Magic Pill
Dr. Michael Emery, a sports cardiologist, tells his patients that there is one magic pill that can improve nearly every aspect of your health and well-being, and especially your cardiovascular health: exercise.
Large studies have consistently found a strong and inverse relationship between physical activity and heart disease.
Clinical trials have also shed light on the precise reasons exercise strengthens the heart:
- It enhances the cardiorespiratory system.
- It increases HDL cholesterol.
- It lowers triglycerides, a type of fat that circulates in the blood.
- It reduces blood pressure and heart rate.
- It lowers inflammation and improves blood sugar control.
- It increases insulin sensitivity.
Best of all, exercise is the type of medicine that appears to produce benefits no matter how small the dose.
What to Aim For
Anything is better than nothing. But the ideal dose of exercise for adults, according to the Centers for Disease Control and Prevention, is as follows:
- 150 minutes of moderate-intensity aerobic exercise a week.
- 2 sessions of about 30 minutes each of resistance training a week.
You can spread the aerobic activity throughout the week however you like, such as 30 minutes five days a week, or 50 minutes three days a week. Examples include running, swimming, brisk walking, riding a bike, playing basketball or tennis, and doing yard work. As for strength-building activities, ideally, you should set aside at least two days a week for 30 minutes of exercise that works the major muscle groups, such as the legs, back, shoulders and arms. What counts as strength training? Lifting weights, using resistance bands, doing bodyweight exercises like yoga, push ups and sit ups….
If you’re ready for more intense workout sessions, you should aim for:
- 75 minutes of vigorous aerobic exercise a week.
- 2 sessions of at least 30 minutes each of resistance training a week.
Vigorous exercise should get your heart rate up to 70 to 85 percent of your maximum heart rate. Not sure what that is? Here’s how to calculate it.
Exercises like running, swimming laps, playing basketball or cycling fast are good options. If these amounts sound like a lot more than you’re used to, keep in mind that you’re not alone. Only half of Americans get the recommended amount of aerobic exercise each week, and only 20 percent meet the guidelines for both aerobic and resistance exercise. But studies show that people who do just 50 minutes of vigorous aerobic exercise each week (instead of the recommended 75 minutes) still lower their risk of dying from cardiovascular disease by half compared with people who avoid it altogether. People who do small amounts of moderate exercise that fall short of the guidelines see benefits, too.
“Any amount improves cardiovascular morbidity and mortality, even if it’s just getting out of your chair and taking a walk,” said Dr. Emery. If you can’t get to the “sweet spot,” he said, that’s “not a reason to not do it because you’re still gaining way more benefit than if you were sitting on the couch and not doing anything.”
Get Your Blood Pressure Checked
Make sure your heart isn’t working harder than it should be.
Avoid High Blood Pressure
High blood pressure, also known as hypertension, puts mechanical stress on the walls of your arteries, causing them to narrow and stiffen. The stress can increase the development of plaque and ultimately cause your heart muscle to get weaker and thicker over time. It can also cause blood vessels in your brain to rupture, leading to a stroke.
Ideally your blood pressure should be no higher than 120/80. The top number is your “systolic” pressure, the pressure when your heart is contracting, and the lower number is your “diastolic” pressure, when your heart is at rest. Keeping those numbers in check is critical.
Hypertension is a leading cause of heart attacks, and the single-most important risk factor for strokes. Almost a third of the adult population in the United States has the condition but about 20 percent of them don’t know it.
You’re especially vulnerable to hypertension if you:
- Are older. The prevalence of the disease increases sharply with age, from 7.3 percent of people between 18 and 39 to as high as 65 percent of people 60 and over.
- Are black. About 40 percent of black adults have the condition, compared with 28 percent of non-Hispanic whites, 25 percent of Asian Americans and 26 percent of Hispanic adults.
- Have diabetes. Two thirds of adults with Type 2 diabetes have hypertension.
- Have other, complicating conditions, such as sleep apnea, kidney disease, obesity, high levels of stress and heavy alcohol consumption. When your blood pressure climbs above 120/80, you may have pre-hypertension. If your blood pressure reaches or exceeds 140/90, then you have full-blown hypertension. Blood pressure fluctuates throughout the day. It can rise or fall in response to caffeine, stress, alcohol or even the last meal you ate. So you need to measure it on at least two or more occasions to get an accurate idea of your average blood pressure. If your numbers are consistently high then the importance of getting your blood pressure down into the normal range can’t be overstated.
A large study published last year in The Lancet found that for every decrease of 10 in your systolic blood pressure reading, you lower your risk of stroke by 27 percent, your risk of heart failure by 28 percent and your risk of heart disease by 17 percent.
If your doctor finds that your blood pressure requires treatment with medication, then you have a number of options. Some of the drugs available include ACE inhibitors, calcium channel blockers, diuretics and beta-blockers.
How to Lower Your Blood Pressure
If you have hypertension, here are some things you can do to improve your numbers:
- Lose weight. The famous, long-running Framingham Heart Study found that excess weight accounted for roughly 26 percent of all cases of hypertension in men and 28 percent of cases in women. Being overweight increases the amount of work your heart has to do to pump blood throughout your body.
- Moderate your alcohol intake. Overconsumption can increase blood pressure. So try to consume no more than two drinks a day if you’re a man and one drink a day if you’re a woman.
- Exercise. Not surprising, right? A meta-analysis of randomized controlled trials published in the Journal of the American Heart Association found that both aerobic exercise and resistance training significantly lower systolic and diastolic blood pressure.
- Watch your salt and your sugar intake. The World Health Organization recommends keeping your salt intake to no more than five grams per day to reduce hypertension. The average intake in many countries is double that amount. Studies have found that a high sugar intake is also linked to hypertension.
Know Your Cholesterol
While cholesterol is not the only thing that matters to your heart health, it’s important to keep an eye on your levels.
Understanding the Numbers
Cholesterol isn’t the only driver of heart disease. But it plays a big role, and you should know whether your numbers put you at high risk.
Here’s what you should look for:
- HDL cholesterol: This is considered protective. Higher HDL levels correlate with better cardiovascular health.
- LDL cholesterol: High LDL is strongly linked to heart disease. Low LDL is better for cardiovascular health.
- Triglycerides: A type of fat that circulates in your blood stream. You want this number to be low. Elevated triglycerides are linked to both heart disease and diabetes.
When Do You Need Statins?
In the past there was a disproportionate amount of attention paid to cholesterol. Doctors would typically prescribe cholesterol-lowering drugs like statins based on a person’s LDL cholesterol number alone.
But the most recent guidelines call for doctors to take a more holistic and personalized approach, one that views cholesterol as just one factor along with things like age, gender, race, blood pressure and smoking history when determining a person’s cardiovascular risk.
In fact, if you’re 40 or older, you can use your cholesterol numbers, blood pressure and other personal information to determine your 10-year risk of having a heart attack or stroke by typing them into the American College of Cardiology’s risk calculator. Be warned, though, the risk calculator isn’t perfect. Some leading cardiologists argue that in certain cases it can overestimate a person’s risk, leading many people to mistakenly think they need statins.
If you have high cholesterol, then you should discuss it with your doctor. Diet, exercise and lifestyle changes can improve your numbers. But it may not be enough. And when that’s the case, then a doctor can help you interpret your numbers, your family history and your personal risk to determine whether or not a statin makes sense. “That discussion is an important one to have,” said Dr. Lloyd-Jones. “I think statins are incredibly effective and safe. But they’re not one size fits all. We need to put them in the right context as we’re doing the decision-making.”
Eat Your Way to Lower Cholesterol
There are also many foods you can eat that can help improve your cholesterol levels. They include:
- Fatty fish, which lowers LDL and triglycerides.
- Walnuts, almonds and other nuts. They increase HDL and lower LDL.
- Soybeans, tofu and soy milk can slightly lower LDL.
- Apples, strawberries and citrus fruits contain pectin, which helps reduce LDL.
- Olive oil and other unsaturated fats.
- Beans, vegetables and flaxseeds, which contain a lot of soluble fiber, and may lower LDL.
- If you have high triglycerides, then one simple dietary change you can make is to cut back on empty carbs. For most people, triglycerides are driven largely by carbohydrate consumption. Removing sugar, bread, pasta, fruit juices and other refined carbs from your diet should lower your triglycerides.
Know Your Blood Sugar Level
Routinely checking your fasting blood sugar can help you monitor another factor in your heart disease risk.
How to Lower Your Blood Sugar
So what should you do if your blood sugar levels raise some red flags? The first thing you should do is consult with your doctor to determine whether you have a medical issue. But there are also things you can do on your own to improve your blood sugar control – and they’ll sound familiar: exercise and eatingsmart.
There are also some surprising things that can contribute to chronically high blood sugar or throw off a test.
Here are some to be aware of:
- Not getting enough sleep.
- Being overweight or obese.
- Consuming alcohol or caffeine.
- Birth control pills, antidepressants, nasal decongestants and other medications.
- Hormonal changes during menstrual cycles.
- Chronic stress or illness.
Get All the Numbers
Your routine blood tests should measure not only your cholesterol and triglycerides, but also your fasting blood sugar levels. That’s because many rigorous studies have found that chronically high blood sugar increases mortality and increases the risk of heart attacks and strokes. A high fasting blood sugar level can also signal that you have Type 2 diabetes or its precursor, pre-diabetes.
And diabetics are four times more likely to die from heart disease.
Your blood sugar levels should be measured after you’ve fasted for at least eight hours overnight. According to the Cleveland Clinic, here’s what you need to know:
- A normal fasting blood sugar level is less than 100 milligrams per deciliter.
- A fasting blood sugar level between 110 and 125 mg/dL is considered pre-diabetes.
- If you have two separate blood sugar readings that are greater than 126 mg/dL than you may have Type 2 diabetes.
One of the drawbacks of a fasting blood sugar test is that it provides only a snapshot of your glucose levels at a single point in time. Another test that offers a better indication of your average blood sugar levels over time is the A1C test. It measures the amount of glycated hemoglobin in your blood, which indicates your average blood sugar levels over the past three months. A1C tests are often used to diagnose diabetes.
Here’s what you need to know:
- An A1C score below 5.7 is considered normal.
- An A1C in the range of 5.7 to 6.4 is indicative of pre-diabetes.
- A score of 6.5 or above indicates diabetes.
A Heart Healthy Diet
Don’t get confused by conflicting studies on the best foods to eat — keep things simple with a straightforward system.
Understanding the Research
- Nutrition and its effects on heart health tends to ignite heated debate. The problem is that many of the claims about which foods and diets are best for you are based on weak evidence.
- But there is a way to simplify things that cuts through all the noise and confusion, said Dr. Dariush Mozaffarian, a cardiologist and dean of the Tufts Friedman School of Nutrition Science and Policy. Dr. Mozaffarian has published numerous studies on foods and cardiovascular risk and has singled out foods that are backed by hard data from rigorous clinical trials. Ultimately he has found that most foods can be separated into three categories:
- Those that are good for your heart.
- Those that are bad for you.
- Those that are essentially neutral.
Foods that you should seek out and eat often:
- Plant life, such as nuts, seeds, legumes, whole grains, beans and avocados.
- Fruits and vegetables with no added sugar or preservatives.
- Seafood, including shellfish and especially oily fish like wild salmon, sardines and mackerel. (Mercury levels can be high in some kinds of fish, so learn which types are of particular concern.)
- Fermented foods, like yogurt, kimchi and tempeh.
- Healthy fats like olive oil.
You’ll see that the “good” category contains a lot of plant-based foods. “These are foods that contain bioactive phytochemicals that are there to help protect a plant’s new life,” Dr. Mozaffarian said. “They have things that our bodies need as we age. We need their anti-inflammatory, pro-health phytochemicals and nutrients.”
This first category also contains some other foods that have been shown in compelling studies to be strongly beneficial, like fish, which contains omega-3 fatty acids, and yogurt, which has probiotics that support gut health
Foods to avoid:
- Foods with added sugar, such as soft drinks, fruit juices and candy.
- Refined carbohydrates such as breakfast cereals, granola, white bread, bagels, crackers and pasta.
- Processed meats, such as deli meats, salami, hot dogs and ham.
- Packaged foods that are loaded with salt, sugar, trans fats, preservatives and other additives and artificial ingredients. Some examples are frozen entrees, potato chips, chicken nuggets, granola bars, microwaveable meals, canned soups, instant noodles and boxed snacks.
The foods in this “bad” category are those that you should limit because there is strong evidence that they negatively impact cardiovascular health, Dr. Mozaffarian said.
It consists of three groups: starch and sugar, highly processed meats and packaged foods. Most people understand that sugary drinks and other sources of added sugar can be harmful. But Dr. Mozafarrian calls starchy, refined carbohydrates like bagels and pasta “the hidden sugar in the food supply” because they contain long chains of glucose that essentially act like sugar in the body (sugar contains glucose and fructose). “And there’s five times more starch in the food supply than sugar,” he said.
Foods to be consumed in moderation:
- Red meat
Try the Mediterranean Diet
The best example of a heart healthy diet is one that follows a Mediterranean approach. A large clinical trial published in The New England Journal of Medicine in 2013 found that people assigned to a Mediterranean diet had significantly fewer heart attacks, strokes and deaths from heart disease than a group assigned to follow a conventional low fat diet. The foods that formed the bulk of the Mediterranean diet were things like olive oil, nuts, seafood, fruits, poultry, beans and vegetables.
The National Institutes of Health has a free cookbook you can download with dozens of delicious recipes designed to promote heart health. Some of the recipes are Mediterranean-inspired. But there’s also plenty of Latin, American and Asian flavors.
Maintain a Healthy Bodyweight
It’s not just excess fat, but the type of excess fat that contributes to your heart risks.
Another Reason to Reduce Your Pounds
Excess body fat isn’t just dead weight. Fat cells release many substances that increase inflammation, promote insulin resistance and contribute to atherosclerosis, the hardening of arteries.
So it should be no surprise that obesity is among the leading causes of cardiovascular morbidity and mortality. That is especially the case for people who have a lot of visceral fat, the type that accumulates deep inside your abdomen around your internal organs.
Visceral fat is much more dangerous than subcutaneous fat, the kind that resides just below your skin (you can pinch your subcutaneous fat with your fingers). It’s not entirely clear why but visceral fat is far more toxic to your body and especially to your cardiovascular system. An easy way to get a sense of the amount of visceral fat you carry and your risk is by measuring your waist circumference. According to Harvard Medical School, here’s how to interpret your waist circumference to determine if you’re in the healthy range.
- Low Risk: 31.5 inches or less
- Intermediate Risk: 31.6 to 34.9 inches
- High Risk: 35 inches or greater
- Low Risk: 37 inches or less
- Intermediate Risk: 37.1 to 39.9 inches
- High Risk: 40 inches or greater
Why B.M.I. Doesn’t Always Work
Another barometer you can use to determine your amount of visceral fat is your body mass index, or B.M.I. This calculation estimates your body fat based on your height and weight. You can determine your number by using the N.I.H.’s B.M.I. calculator.
The American Heart Association defines an optimal B.M.I. as one that is below 25, which is the threshold for being overweight. But keep in mind that B.M.I. is a blunt instrument. People who have a lot of muscle mass, for example, might have a B.M.I. over 25 even if they have a low body fat percentage. And people who are thin but carrying a lot of visceral fat might have a B.M.I. under 25 even though they are technically high risk.
Having a normal B.M.I. is a good starting point but it doesn’t necessarily mean you’re in the clear. Dr. Gina Lundberg, an assistant professor of medicine at Emory University School of Medicine and clinical director of the Emory Women’s Heart Center, said she has patients who are “skinny fat”: They have a normal B.M.I. but their blood pressure is high, they have low muscle tone and their cholesterol and other heart disease risk factors are out of whack. Dr. Lundberg said that having a normal B.M.I. does not mean you don’t have to be health conscious. “Just because someone looks healthy on the outside does not necessarily mean that they’re healthy,” she added. “They still have to go to the doctor, have an examination and be evaluated.”
Smoking and the use of tobacco products isn’t just bad for your lungs, it’s bad for your heart, too.
Just Don’t Smoke
This one should be a no-brainer. But it can’t be stressed too highly because it’s still an extremely common cause of heart disease. In fact, the American Heart Association found that many top experts rank smoking and use of tobacco products as the most important cardiovascular risk factor. The rate of tobacco use in the United States peaked more than a half century ago, when almost one in two adults were smokers. Decades of public health efforts have helped lower that number significantly. But today roughly 36.5 million Americans – equivalent to about 15 percent of the population – continue to smoke. That is still a lot of people.
It’s the reason smoking remains the single largest preventable cause of death and disease in the country. Nationwide, it causes about one in every five deaths annually.
Smokers have double the risk of having a heart attack, and triple the risk of having a stroke compared with nonsmokers. E-cigarettes have also been linked in preliminary research to increased cardiovascular risks.
Quitting will immediately lower your risk. Studies have found that smokers who have heart disease experience a 50 percent reduction in subsequent heart attacks or sudden cardiac death when they quit.
To find resources that can help you or any friends or family members quit, you can contact the following health groups: American Cancer Society Toll-free hotline: 1-800-227-2345 American Lung Association Toll-free hotline: 1-800-586-4872 National Cancer Institute Toll-free hotline: 1-877-448-7848
Or use these websites or apps:American Heart Association “Get Ready to Quit Smoking” “Create My Quit Plan” page at smokefree.gov. QuitGuide: A free app that keeps you motivated, provides tips and ways to beat cravings, and helps you monitor your progress quitSTART: This free app gives you customized tips and inspiration to keep you from lighting up. It also helps you manage cravings, and can get you back on track after a slip-up.
Working to prevent heart disease doesn’t mean focusing only on the big things. There are plenty of other things you can do – some small, some fun, some weird, and some mundane – that can boost your cardiovascular health.
Get a Pet
Several years ago a panel of heart experts reviewed decades of data on the cardiovascular benefits of owning pets. They concluded that there was evidence from both large observational studies and small clinical trials that owning pets, and dogs in particular, could lower your risk of heart disease. Why? It could be a lot of things. For one, people who own dogs are more likely to get outside and take walks. But studies have also found that dog and cat owners tend to form such strong bonds with their pets that being around them lowers their heart rates and blunts the owners’ responses to stressful events.
Stress is normal. It’s a part of life and can even be good for you in small doses. Exercise for example is a type of short-term stress that improves health. But chronic stress, especially the mental and emotional kind, can take a toll on your heart. It can depress your immune system, increase your risk of high blood pressure, and eventually contribute to heart attacks and strokes. While stress is unavoidable in modern life, it doesn’t have to make you sick.
Optimize Your Sleep
Do you snore? Do you find yourself tired and fatigued throughout the day? Do you have difficulty concentrating, irritability and decreased alertness? Do you find you can’t get through the day without a steady stream of caffeine?
These are some of the signs that you might have a sleep disorder, an issue that afflicts an estimated one-third of the country.
A sleep disorder can not only impair your quality of life, but significantly impact your cardiovascular health.
Sleep apnea in particular – a condition in which a person experiences pauses in breathing at night – is strongly linked to heart disease. According to Harvard Medical School, untreated sleep apnea can increase your risk of dying from heart disease nearly fivefold.
Dr. Lundberg at Emory said that the importance of getting a good night’s sleep to protect your heart is often overlooked. “If you wake up not feeling refreshed or your partner says they hear you snoring, that needs to be evaluated at the doctor,” she said. “It could be causing serious heart problems.”
How to Get a Better Night’s Sleep
How do you become a more successful sleeper? Grab a pillow, curl up and keep reading to find out.
In recent decades, many studies have looked at the effects of meditation on cardiovascular risk factors. While the research is not definitive, there is some evidence that meditation can lower blood pressure and blunt the body’s response to stress. The best part about meditation is that it’s easy to learn and has no side effects. It can also help with many other aspects of health (including sleep). So why not give it a try?
Meditation is a simple practice available to all, which can reduce stress, increase calmness and clarity and promote happiness. Learning how to meditate is straightforward, and the benefits can come quickly.
Get to Know Your Dentist
Most people don’t think there’s any connection between their oral health and their cardiovascular health. But they’d be wrong.
Many studies have found that gum disease increases your likelihood of having heart disease. A systematic review and meta-analysis published in The Journal of General Internal Medicine found that periodontal disease increases the risk of coronary heart disease by 24 to 34 percent. One reason might be the presence of harmful bacteria in the mouth, which not only causes gum disease but also promotes systemic inflammation throughout the body. Whatever the mechanism, it’s a good idea to get regular dental checkups.
Eating plants is clearly good for your heart. But drinking them in the form of tea isn’t so bad either. Many large studies have linked regular tea consumption to cardiovascular benefits.
And smaller studies have suggested it may have something to do with the unique and potent compounds tea often contains, especially varieties like green, oolong and herbal teas.
For example, researchers have found that there are compounds in tea that lower inflammation, protect the endothelial cells that line the arteries, and have favorable effects on blood lipids. If you have a habit of drinking sugary beverages or diet drinks throughout the day, consider swapping those beverages with unsweetened tea.
Take a Hike … in the Forest
The Japanese have a term, shinrin-yoku, that loosely translates to “forest bathing.”
It involves taking a leisurely visit to a forest and walking among the trees and plants; it is promoted as a way to achieve relaxation. They also believe that plant compounds circulating in the forest air provide a number of health benefits. The practice has been put to the test in many studies over the years and scientists have found some evidence that walking in nature can lead to slight cardiovascular benefits, like reduced blood pressure and lowered stress hormones and pulse rates. Whether it’s a result of the aerobic exercise alone, the mental relaxation, or the plant compounds in the air – or a combination of all three – is unknown. But taking a walk in the park is certainly good for your heart.
But, Know the Symptoms
Even if you’re doing all you can to avoid cardiovascular disease, you should still know how to recognize the symptoms of a heart attack or stroke.
The classic symptoms of a heart attack are unbearable pain or discomfort in the center of your chest that lasts several minutes, and which comes and goes in waves. This is also known as the Hollywood heart attack, which is depicted in films as someone clutching their chest and dropping to the floor. But that’s not always the warning sign. In fact according to the American Heart Association there are many other common symptoms to look for, including the following:
- Discomfort in your arms, back, stomach, neck or jaw. The pain can come on suddenly or it can start gradually and come and go.
- Shortness of breath that occurs for no apparent reason. It can feel as if you just sprinted down the street and can’t catch your breath.
- Breaking out in cold sweats and experiencing nausea or lightheadedness.
- Fatigue that is inexplicable. You may feel so tired that you have trouble getting up and walking even if you are not sleep deprived and haven’t done anything exhausting.
For a long time, doctors thought that men and women experienced different heart attack symptoms.
But then it was discovered that men and women actually experience many of the same symptoms – they just tend to describe them differently, said Dr. Lundberg. “Men would point right to their chest and say they have pain,” she said. “Women would say different things. They’d say, ‘I have pressure and tightness in my chest or burning.’” As a result, it was not uncommon for doctors to dismiss the symptoms described by women as heartburn or indigestion. But experts are trying to educate both doctors and the public to recognize the differences in what to look for in men and women.
“One of the important things we’ve done was to re-educate physicians so that when they’re talking to women about possible symptoms, they know to ask them more than, ‘Are you having chest pain?’” said Dr. Lundberg.
“You have to say, ‘Are you having chest tightness, pressure, heaviness or shortness of breath?’ It’s not the same thing as saying, ‘Are you having chest pain?’”
The classic symptoms of a stroke are typically very striking. The American Stroke Association uses the acronym FAST to describe them:
- Face drooping: One side of the face droops or feels numb.
- Arm weakness. One arm will feel weak or numb and difficult to lift up.
- Speech difficulty: Look for slurred or confused speech patterns.
- Time to call 911: If those symptoms appear separately or together, it’s time to call for help.
There could also be other signs that a stroke is occurring. A person may experience a very severe and sudden headache, confusion and trouble seeing out of one or both eyes. Or the person may feel dizzy and have a loss of balance or coordination and difficulty walking.
If you suspect that you or someone else is having a stroke or a heart attack, the critical thing is to act fast. Have your symptoms checked by a doctor or call 911.
The heart association says that calling paramedics is often the smartest thing you can do because they can begin treatment up to an hour sooner than if you drive to a hospital by car, and they can revive someone whose heart has stopped.
Ken Pope, Melba J.T. Vasquez, Nayeli Y. Chavez-Dueñas, & Hector Y. Adames
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“Tell me, what is it you plan to dowith your one wild and precious life?”—Mary Oliver’s poem “The Summer Day”