What is pulling your score down and what to do about it
Cholesterol
Your cholesterol is running high. It produces no symptom at any stage, which is exactly why it gets left alone for years while plaque quietly accumulates.
Start with the number nobody circled on your last lab report.
Total cholesterol
on your report
−
HDL
on your report
=
Your non‑HDL
the one that matters
Aim under 130 mg/dL, or under 100 if you are already high risk.
Non-HDL counts every particle that builds plaque, not just LDL. It is also the more trustworthy figure, because the LDL on most US reports is not measured at all. It is estimated by an equation that under-reports whenever triglycerides run high.
Olive or rapeseed oil instead of butter. Fish and nuts instead of processed meat. Swapping 5% of your daily calories this way is linked to about 10% fewer coronary events.
Psyllium husk, 10 g a day. Takes roughly 15 mg/dL off your non-HDL. Build up over two weeks with plenty of water.
In the trials, every 39 mg/dL of LDL removed was worth around 22% fewer major cardiovascular events.
Blood pressure
Your blood pressure is high enough to be doing damage, and low enough that you will never feel it. Every beat is pushing against your artery walls with more force than they are built for, stiffening them and thickening the wall of your heart over years. It is also the most responsive thing on your whole result. It moves in weeks.
Start here, because your reading is probably wrong.
What your arm position alone adds to your systolic reading
So measure it properly. Empty your bladder, sit quietly for five minutes, feet flat on the floor, back supported, arm resting on a table at heart level, and do not talk. Two readings a minute apart, morning and evening, for seven days. Throw away day one and average the rest. A single reading tells you nothing.
Check your cuff size before you buy a monitor. Measure around your upper arm. Above about 13.5 inches a standard cuff reads high, and above 17.5 inches it reads nearly 20 mmHg high. That is the difference between a normal result and a diagnosis.
Then change the food, not the shaker. The salt shaker is only 4.9% of the sodium you eat. About 71% was already in the food when you bought it, from packaged and restaurant meals.
Eat the DASH pattern. In people with high blood pressure it took 11.4 mmHg off systolic, which is what a first line medication does, and most of the drop appeared within the first week.
If you get a reading of 180/120 or higher, wait a minute and measure again. If it stays there and you have chest pain, breathlessness, weakness, or trouble seeing or speaking, call 911. If you feel fine, it is not an emergency, but call your doctor the same day.
Blood sugar
Your blood sugar is in the range where the damage starts well before anyone gives it a name. Diabetes gets diagnosed at an HbA1c of 6.5%, but your blood vessels do not wait for the paperwork.
Added risk of coronary heart disease, across the HbA1c range
baseline
+23%
+78%
+95%
5.0
5.7prediabetes begins
6.5diabetes begins
7.0
11,092 adults followed 14 years, risk shown against an HbA1c of 5.0 to 5.4%. New England Journal of Medicine, 2010.
Notice where the risk starts moving. It is climbing well before either of those two lines. More than 2 in 5 US adults sit somewhere on this scale without a diagnosis, and more than 8 in 10 of them have no idea.
Walk after you eat, within about half an hour. Across the trials, walking after a meal blunted the glucose rise while the identical walk taken before the meal did nothing at all. Two minutes is enough to matter, and walking beats standing. When you go matters more than how long or how hard.
Do not settle for one test. Checked against a full glucose tolerance test, HbA1c on its own picks up only about 30% of undiagnosed diabetes, and fasting glucose about 46%. Ask for both. If you have African ancestry, mention it, because sickle cell trait can push an HbA1c falsely low and it is carried by roughly 1 in 12.
And the one with hard evidence behind it. Losing 7% of your body weight and moving 150 minutes a week cut new cases of diabetes by 58% over three years. Being straight with you, that same trial ran 21 years and did not show fewer heart attacks. Do it to stay off the diabetes track.
This was a questionnaire, not a blood test. The next step is an actual HbA1c and fasting glucose. And if your numbers get worse while you are doing everything right, that is a reason to see a doctor, not a reason to try harder.
Sleep
Your sleep is working against the rest of your result, and the part that matters most is probably not the part you have been worrying about.
One week of sleep timing, same total hours in both
Regular
noonmidnightnoon
—reference
Irregular
noonmidnightnoon
1.88×the risk of cardiovascular death
Nearly 89,000 adults wearing activity monitors, most irregular compared with average. eLife, 2023.
In the same group of people, once regularity was accounted for, how long they slept added nothing further. Sleeping at scattered times appears to cost more than being a little short.
So anchor your wake time, not your bedtime. It is the end of the night you can actually control, and it sets your light exposure for the whole day. The same time on Sunday as on Wednesday. Catching up at the weekend is precisely what makes the pattern irregular.
Aim at 7 hours, not 8. Risk sits lowest around seven. Every hour below adds roughly 6%, and every hour above about 12%, though the long end mostly reflects people who are already unwell rather than harm from sleeping.
If you snore and wake unrefreshed, get tested rather than tidying up your habits. Between the ages of 50 and 70, 17% of men and 9% of women have moderate to severe sleep apnoea. No amount of sleep hygiene touches it.
If you are spending plenty of time in bed and still not sleeping, that is insomnia, and more time in bed makes it worse. Ask your doctor about CBT-I rather than adding hours. And if you are falling asleep during the day, or at the wheel, that needs an appointment now, not better habits.
Diet
Diet is the one flag on this page that moves all the others. Blood pressure, cholesterol, blood sugar and weight all answer to it, which is why the effort you put here goes further than effort aimed at any single number.
Grams of fibre a day, and where the benefit is
16 g, the US averageup to 29 g, where the benefit is
Reynolds et al, The Lancet, 2019. 185 prospective studies.
Every extra 8 g a day is associated with about 19% fewer cases of coronary heart disease, and the curve does not flatten anywhere in the range people actually eat. There is no point at which more stops helping.
A small handful of nuts, about 28 g. Associated with 29% lower coronary heart disease risk, and this is the rare food where a randomised trial lands in the same place as the population data. The benefit largely plateaus by around 20 g, so a handful really is enough.
Change what you buy, not what you decide. In a randomised trial, putting a better swap in front of people at the moment of choice shifted their basket about three times more than a nutrition label did. Telling them what everyone else buys did nothing at all. One good decision at the shop governs a fortnight of meals, and deciding well three times a day does not work.
Watch the processing, not only the numbers. When people were given ultra-processed and unprocessed meals matched as served for calories, fat, sugar, sodium and fibre, they ate 508 more calories a day on the processed version and gained nearly a kilogram in two weeks.
Build fibre up over two or three weeks with plenty of water rather than all at once. And if you take warfarin, keep leafy greens steady rather than suddenly eating far more, because vitamin K changes how much medication you need.
Physical activity
This is the flag where the first small change buys the most. Nearly everything else on this page rewards patience. This one pays out at the very start and then tails off.
Risk of dying, by daily step count
Dose-response meta-analysis, 57 studies. The Lancet Public Health, 2025.
Getting from 2,000 steps a day to 7,000 is associated with 47% lower mortality. Going on from 7,000 to 12,000 adds very little. The steep part of that curve is the part you are standing on.
And 10,000 was never a finding. It is the name of a pedometer sold in Japan in the mid 1960s, the manpo-kei, which translates as ten thousand step meter. Past 60, the benefit levels off somewhere between 6,000 and 8,000.
Two days a week is enough. In 89,000 adults wearing monitors, packing the whole week's activity into one or two days was associated with 27% lower risk of heart attack and 38% lower risk of heart failure. Compared directly against spreading it out, neither pattern won.
Strength work, 30 to 60 minutes a week in total. That is the entire effective dose, and it counts separately from the walking. Benefit peaks around 40 minutes a week and there is little more to gain past two hours. Two twenty minute sessions covers it.
Build up gradually rather than starting hard. In the hour after unusually heavy exertion, heart attack risk climbs steeply in people who never exercise and is close to flat in people who do it regularly, so the hazard is the sudden effort, not the exercise. Walking needs nobody's permission if you feel well. But chest tightness or pressure, breathlessness out of proportion to the effort, dizziness, or leg pain that arrives with walking and eases with rest all need a doctor first.
Weight
The number on the scale is not the number that predicts your risk. Where you carry weight turns out to matter more than how much of it there is.
Across 650,000 adults, every extra 2 inches of waist was associated with 7% higher mortality in men and 9% in women. That held at every level of BMI, including normal. Which is why a tape measure is worth more to you than a scale.
Where to put the tape
World Health Organization and NICE measurement protocol.
The spot matters more than you would think. Measuring down at the hip bone instead reads about 5.6 cm higher in women, which is enough on its own to shift you a whole category. Bare skin, tape level with the floor, read it at the end of a normal breath out, and do not pull it tight.
Five percent is where the returns are. Losing 5% of your body weight cuts the fat stored inside your liver by around 40%, alongside falls in glucose, insulin, triglycerides and blood pressure. You do not need a goal weight to collect most of that.
And lift something while you do it. Over six months of dieting, adults who added only walking lost 2.7 kg of lean tissue and 2.6% of their hip bone density. The ones who added resistance work lost 1.0 kg and almost no bone. Identical weight loss, very different body at the end of it.
If weight is coming off without you trying, that is a reason to see a doctor rather than a win. And if you take insulin, blood pressure tablets or diuretics, tell whoever prescribes them before you start, because doses often need lowering as the weight comes down.
Smoking
Cutting down is not a smaller version of quitting. As far as your heart is concerned, it is closer to doing nothing at all.
Risk compared with people who carried on smoking unchanged
897,975 smokers, followed six years. European Heart Journal, 2021.
People who quit had roughly a quarter lower risk of heart attack and of stroke. People who cut their smoking by half or more landed exactly on top of those who changed nothing.
The damage does not scale with the packet. One cigarette a day carries about 46% of the excess coronary risk of twenty a day in men, and 31% in women, because the harm runs through clotting and blood vessel function and those effects saturate almost at once.
So the useful question is how, not whether. Only 38% of American quit attempts use anything proven to work and just 7% involve any counselling. A patch plus gum or lozenge beats a patch alone by 27%. Varenicline roughly doubles your odds, and the psychiatric warning that put people off it was withdrawn in 2016 after a trial of 8,000 people.
Then pick a date and stop completely on it, with the medication already started. Stopping outright beat cutting down first, 22% against 15% still off cigarettes six months later.
It is not too late. Past 60, risk keeps falling with every year since you stopped. Expect this to take more than one attempt, since the familiar figure of seven is a serious underestimate, so treat a relapse as information rather than a verdict. And if you take medication for a mental health condition, tell your prescriber before your quit date, because stopping smoking changes how your body clears some of them.
Where each one landed
Opens your print dialogue. Choose Save as PDF. The printed copy carries your answers and the scoring source, and nothing that is being sold.
This is not a diagnosis, a prediction, or a substitute for medical care. It scores modifiable factors that are associated with cardiovascular health at a population level. It cannot tell you what will happen to you. Never start, stop or change a medication because of anything on this page.
Scoring follows the American Heart Association's Life's Essential 8, across all eight of its measures. Diet is asked as one overall question about the week's eating and mapped onto Life's Essential 8's five diet point levels, since the research instrument for diet is a sixteen item questionnaire.
For more than thirty years I ran community heart health programs across Ohio, in church halls, union halls, community centres and works canteens. My job was the part medicine has the least time for: sitting across from a real person, looking at their numbers, and working out which everyday habits were driving their blood pressure up. Then watching the readings come down, month after month, one small change at a time.
I'm retired from the programs now. I'm not retired from the cause.
Why the heart, and why me
My reason for caring started long before my career did. Heart disease moved through my own family. My father had high blood pressure and knew it. He felt entirely well, so he never dealt with it, and it killed him too early. My mother followed not many years later. I inherited the same tendency, holding a family hand of cards I didn't ask for. Somewhere in my thirties I decided I wasn't going to wait for it. I was going to understand it, manage it, and spend my life helping other people do the same.
What troubles me most about high blood pressure is how quiet it is. Nearly half of American adults have it. Most don't have it under control, and about 1 in 6 don't know they have it at all. In 2024 it was a primary or contributing cause of more than 680,000 deaths in the United States, and it does its damage for years while you feel perfectly fine. I've spent a lifetime on both sides of that fact: living it in my own family, and helping strangers rewrite the ending in theirs.
These days I keep a vegetable garden that grows more than any two people could reasonably eat, bake my own bread, and walk the same neighbourhood loop every morning. I own a blood pressure cuff I use more than strictly necessary, and I treat my numbers like a batting average.
Why I wrote this book
If blood pressure was flagged in your result above, you're exactly who I wrote it for.
The part of the story people are never told is that for most people, lifestyle is the first and most powerful lever on blood pressure. Getting it right can lower the number enough to reduce or delay medication for many, always alongside your own doctor and never instead of one. The habits themselves aren't secrets. The trouble is that nobody puts them in order, so people try to change everything at once, and conclude nothing works.
After thirty years of watching what actually gets a number down and keeps it down, I put the habits in the order that works and kept them simple, so you're never left guessing. And you don't have to take my word for anything: you track your own readings week by week and see for yourself.
How the eight weeks run
It's deliberately slow, because slow is what holds.
Week 1No changes at all. You learn to measure your blood pressure properly, because every decision that follows rests on readings you can trust.
Weeks 2 to 7One change a week, never more. Movement first, then the plate, with weight, sleep, alcohol and stress folded in, while your own readings tell you what's working.
Week 8When the number stops moving. It happens to nearly everyone around week five or six, and the book ends with exactly what to do about it.
Every weekThe honest line. The book says plainly when the answer isn't a habit at all and you need to see a doctor.
The record behind it
This is where a page like this usually shows you reviews. This edition is new to this site, so rather than dress anything up, here is the record it stands on.
30+years running community heart programs
100sof people coached through their own numbers
1change a week, never more, for eight weeks
What readers say
Really useful and easy to follow
I found this much easier to follow than most of the books I've read on blood pressure. Nothing felt extreme but very useful, and I liked adding things gradually rather than trying to change everything at once.
Don't usually leave reviews, but this book perfectly summarizes everything related to heart health. I especially liked the idea of measuring my blood pressure regularly and judging progress from my own readings rather than expecting a particular result. It made the book feel like a practical experiment rather than a lecture. Thanks Michael
Learned so many things about the heart from this book. It really opened my eyes to some of the habits I had that I didn't realise were doing me any good. I recommend it to anyone who wants to learn more about their heart health. Thanks a lot, Michael!
Michael SmithCardiovascular physiologist
Michael's guide to the lifestyle levers that move your numbers, in the order that works: movement first, then the plate, weight and stress folded in. One habit a week, and you track your own readings across the eight, so the proof is your own.
$20
30 day refund, no questions asked.
Questions people ask
Is this score a diagnosis?
No. It looks at the daily habits linked to heart health. It doesn't measure your actual blood pressure or cholesterol, and it can't tell you what will happen to you. A high score isn't a reason to skip your check up, and a low score doesn't mean something is wrong. It shows you where to start.
How does the book relate to the score I just got?
Your check looked at your heart health as a whole. The book zooms in on one of the biggest parts of it: your blood pressure. It gives you a simple, week by week plan for the daily habits that affect it, and you track your own readings as you go. If blood pressure was a weak spot in your result, this is the natural next step.
Can I follow it if I'm already on medication?
Yes. The changes in the book are things most people can do while staying on their current treatment. Don't change your medication because of the book, or because of anything on this page. A lot of readers use it for exactly this reason: they want to get the most out of the lifestyle side while staying on the care they already have.
What does it cost, and can I get a refund?
The book is $20. If it's not right for you, email me within 30 days and I'll refund you in full, no questions asked. So you can read it, give it a go, and decide for yourself.
