How Low Can Ejection Fraction Be without Congestive HF?
Is it possible to have a really low ejection fraction and still not have congestive heart failure?
“There are two major types of congestive heart failure (CHF),” begins Norman E. Lepor, MD, cardiologist and internal medicine specialist Norman E. Lepor, MD, who’s with Cedars Sinai in Beverly Hills, CA.
“Half of the patients with heart failure symptoms that include shortness of breath with exertion, easy fatigue, a decrease in exercise tolerance and lower extremity fluid accumulation (edema) have what we call preserved or normal ejection fraction due to stiff and thickened ventricular walls.
“This condition is seen in patients who have poorly treated chronic hypertension [high blood pressure] and/or coronary artery disease.
“The other half of patients with heart failure have abnormal ejection fractions or what is called systolic dysfunction.
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“There is wide variance in the threshold of ejection fractions in these types of heart failure patients, but one could expect symptoms to occur when the ejection fraction is less than 40 percent.”
How does patient’s level of fitness factor into this?
Dr. Lepor explains, “Fitness plays a pivotal role in developing symptoms of heart failure.
“In patients who exercise regularly and maintain good fitness, have muscles that are more efficient and need less oxygen and nutrition to function.
“Therefore the better fit one is, the less symptoms such as easy fatigue or exercise intolerance they would have at any level of ejection fraction reduction.”
Having performed over 4,000 coronary angiograms and angioplasties, Dr. Lepor has focused on prevention and treatment of coronary heart disease.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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Top image: Shutterstock/Green Apple
Can Heart Problems Cause Sudden Weight Gain?
The kind of weight gain that heart problems can cause is not the same that’s caused by eating too much.
In fact, weight gain from chronic heart failure has absolutely nothing to do with body fat.
“Heart failure can lead to weight gain due to fluid retention most likely seen in the lower extremities, though much fluid can accumulate in the abdomen as ascites or in the chest as pleural effusions,” says cardiologist and internal medicine specialist Norman E. Lepor, MD, who’s with Cedars Sinai in Beverly Hills, CA.
In the lower extremities, the weight gain presents as swelling around the ankles and lower legs.
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This fluid retention can extend higher up in the legs and affect the groin area.
A person with chronic heart failure (formerly more commonly referred to as “congestive” heart failure) can gain five pounds of fluid weight in a single night.
This is why people with chronic heart failure are instructed to weigh themselves first thing every morning — and never skip a morning.
Why this Heart Problem Causes Sudden Weight Gain
Though fluid retention can be caused by a variety of illnesses, chronic heart failure is a very common cause.
Fluid in the lungs is called a pleural effusion, and this will show up on a CT scan or X-ray.
Dr. Lepor says that this fluid retention in heart failure patients is treated with diuretics and salt (sodium) restriction.
The diuretics, such as Lasix, treat the symptom, not the underlying disease process.
Another name for the fluid retention or “swelling” is edema.
The fluid can cause, for instance, an increase of eight pounds over a period of just several days — despite the patient not changing their eating habits.
Men and women with chronic heart failure are urged to also document their weight every morning to see if there’s any unexplained weight gain from week to week, not just day to day.
Not all people with chronic heart failure develop the edema in their lower extremities.
For some, the sudden weight gain could be in their abdomen (ascites; pronounced uh-sight-eez) or the pleural effusion (excess fluid around the lungs).
Having performed over 4,000 coronary angiograms and angioplasties, Dr. Lepor has focused on prevention and treatment of coronary heart disease.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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Top image: Shutterstock/Rocketclips, Inc.
Can Heart Bypass Surgery Prevent Congestive Heart Failure?
Are you wondering if coronary bypass surgery, aka CABG, can prevent the development of chronic heart failure?
- Heart failure may involve fluid buildup in the legs that needs to be controlled with medication.
- In other cases there is not an issue of fluid buildup, but the patient still needs to take great care to manage the condition.
Coronary Bypass Surgery Preventing Chronic Heart Failure?
“CABG and percutaneous interventions (angioplasty) can in some cases [sic] to preventing CHF in patients who have severe blockages in their coronary arteries that severely reduce blood flow and the delivery of oxygen and nutrition to heart cells by increasing blood flow,” explains Norman E. Lepor, MD, cardiologist and internal medicine specialist Norman E. Lepor, MD, who’s with Cedars Sinai in Beverly Hills, CA.
Why can’t CABG prevent congestive heart failure in ALL the patients who undergo this heart procedure?
Dr. Lepor explains, “Patients who do not seem to benefit from CABG or angioplasties to prevent CHF include those with milder disease (fewer blockages, blockages that are not in critical areas such as the ‘widow maker’ and less severe blockages.”
The widow maker refers to the left main artery in the heart, which supplies the left anterior descending (LAD) artery and left circumflex artery. Sometimes, however, this term refers only to the LAD.
If a blockage occurs to the left main artery, a significant portion of heart muscle will be left without oxygen.
If not treated promptly, a victim can suffer a quick death.
Other Ways to Help Prevent Chronic Heart Failure from Developing
How often do you check your blood pressure? High blood pressure is a big risk factor for the development of chronic heart failure.
Ideally, you should check your blood pressure at least once a week, or as advised by your healthcare provider.
Consistent tracking helps manage and reduce the risk of developing chronic heart failure.
Do you smoke? Then quit. Yes, it should be that easy for anyone who knows just how dangerous tobacco is.
While quitting can be challenging, there are many resources available to help, such as support groups, medications and counseling.
It’s important to remember that every attempt to quit is a step towards better health.
Seeking professional advice can provide additional strategies and support.
Do you exercise? No, not housework or walking the poodle, but REAL exercise: structured aerobics and strength training workouts. Get moving.
These three tactics not only fight off chronic heart failure but they also help prevent the need for coronary bypass surgery.
Having performed over 4,000 coronary angiograms and angioplasties, Dr. Lepor has focused on prevention and treatment of coronary heart disease.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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Top image: Freepik.com, peoplecreations
Can an MRA Detect Congestive Heart Failure?
An MRA (magnetic resonance angiogram) is often used to see if there’s anything wrong with the heart and associated structures.
If someone has an MRA, the report will include what the ejection fractions are for each ventricle.
This made me wonder if an MRA could detect and diagnose congestive heart failure, since I was thinking that a very low ejection fraction (such as under 35 percent) might mean CHF.
“MRI is the gold standard for determining ejection fraction,” says cardiologist and internal medicine specialist Norman E. Lepor, MD, who’s with Cedars Sinai in Beverly Hills, CA.
MRI stands for magnetic resonance imaging, so the MRA is a type of MRI.
Dr. Lepor adds that MRI is an intrinsic three-dimensional imaging modality. He further explains, “Echocardiography [ultrasound] is the modality most commonly used to determine ejection fraction.
“CHF is a clinical diagnosis that is based on symptoms and biomarkers such as BNP levels. Remember, half of patients with CHF have preserved ejection fractions.”
What would be abnormal on the findings?
Dr. Lepor explains, “Finding on MRI or echo can include enlargement of the heart chamber sizes, reduced ejection fraction in some patients, thickening of ventricular muscle thickness, leaky or stenotic [narrowed] heart valves, abnormal estimated pulmonary artery pressures, abnormal blood flow patterns from the left atrium to the left ventricular consistent with either diastolic or systolic dysfunction.”
An MRA to show heart function is an expensive procedure and is not used to screen for congestive heart failure.
Instead, it’s ordered by a cardiologist as a diagnostic procedure after the doctor finds, during an examination, something concerning and wants to pursue the cause.
In addition to ejection fraction values and the possibility of congestive heart failure, an MRA will show other details that can help a cardiologist understand what’s going on with the patient’s heart, such as any abnormally enlarged structures.
Having performed over 4,000 coronary angiograms and angioplasties, Dr. Lepor has focused on prevention and treatment of coronary heart disease.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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Top image: Shutterstock/Green Apple
Statins vs. High Doses of Niacin: Why Not Take B3?
Why are statins pushed when instead, it seems that the safer route is to just take high doses of niacin (vitamin B3) to lower cholesterol?
You may have read that niacin or niacinamide has a positive effect on cholesterol profile, and that some cholesterol drugs are “knockoffs” of vitamin B3.
“Although most people think of niacin as just a vitamin, if you give it in high enough doses (the doses you need to budge cholesterol levels), it actually becomes a drug,” explains Dr. Elizabeth Klodas, board certified cardiologist and co-founder of Step One Foods.
She continues: “And drugs have side effects. High dose niacin can make blood sugar control worse in people with diabetes and prediabetes. It can cause flushing and itching [though non-flush versions are available].”
Okay, so what if you have great blood sugar levels and use the non-flush version of niacin?
“It can affect liver function,” says Dr. Klodas. “It can cause muscle achiness. And if you take a look at the medical literature as a whole, niacin does not appear to be that effective in improving patient outcomes.
“So even though it may lower cholesterol, the net benefit is more neutral for niacin than for statins.
“The benefit data behind statins is actually quite strong, especially in individuals with heart disease, those with diabetes and those with persistently very high LDL (bad) cholesterol levels (over 190 mg/dL).
“I only use high dose niacin as a second-tier therapy in those patients with known heart disease who cannot tolerate statins and don’t recommend them for diabetics.
“Because the benefit data for primary prevention with statins (taking them as a purely precautionary step) is less robust, I always try to work hard with my patients to address their cholesterol profiles with lifestyle changes, especially diet.”
Diet for Improving Cholesterol, Rather than Statins and Niacin
The key is not letting your cholesterol profile become undesirable in the first place.
“If you take in enough food-based fiber, omega-3 fatty acids, antioxidants and plant sterols (and I have to emphasize that these nutrients need to come from REAL FOOD in its REAL FORM to be effective), chances are high that your cholesterol profile will improve,” says Dr. Klodas.
“Because my patients found it hard to modify their diet to get these nutrients in adequate amounts, I created Step One Foods to make it easy.”
Don’t let your cholesterol reach a point where you must decide between statins and niacin; practice preventive medicine via the right diet.
Trained at Mayo Clinic and Johns Hopkins, Dr. Klodas believes in first changing the diet, rather than taking pills, to improve cholesterol profile.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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Top image: Shutterstock/sirtravelalot
Lower Bad Cholesterol, Raise Good Cholesterol with Supplements
Why settle for drugs when you can lower your bad cholesterol and raise good cholesterol with natural supplements, minus side effects?
Don’t be fooled by brilliant ad campaigns for drugs — drugs that are among the best selling in the world.
Natural Supplements for Improving your Cholesterol Profile
Fiber. “Soluble fiber does have an effect on cholesterol,” says Shana Spence, MS, RDN, CDN, a registered dietitian nutritionist based in New York.
“Foods like oats, beans, Brussels sprouts, apples and carrots are all examples.”
But if you don’t care for these foods, a fiber supplement will help.
“How soluble fiber works is that while it digests, it actually attaches to the ‘bad cholesterol’ or LDL and removes them from the body,” continues Spence.
“Insoluble fiber is the kind that our body cannot digest, like in the skin of vegetables and fruits or grains. Insoluble just keeps us regular and our gut healthy.”
Green tea extract. “Green tea contains catechins, which are antioxidants,” says Spence. “EGCG is the most potent type (and the one most people have heard of) that is found and also extracted.
“There have been studies that show this particular antioxidant does help to lower LDL levels or ‘bad cholesterol.’
“To get this benefit, it’s actually recommended to take the capsule form or use the extract rather than just drinking tea, since there is only about 50-100 mg of catechins in the tea itself and 145-3,000 in supplement form, depending on which brand you purchase.
“The only thing to be mindful of is the caffeine level. For those sensitive to caffeine or for those who are pregnant it’s best to speak to a doctor.”
Niacin (vitamin B3). Spence explains, “Niacin actually works to raise the HDL levels of ‘good cholesterol’ in the body while decreasing your levels of triglycerides (a type of fat known for contributing to cardiovascular diseases).”
Niacin also lowers the bad cholesterol (LDLs).
“What niacin does best is promote digestion and also aiding the nervous system,” says Spence.
“As for treatments, niacin is most commonly used in people who have high cholesterol but can’t take statins.”
Omega-3 fatty acids. The safest and most practical source of omega-3s is the fish oil supplement.
Pantethine (vitamin B5). “Studies for this vitamin are unfortunately scarce,” says Spence. “Yes, some people have reported taking this for their cholesterol.
“Like niacin, pantethine has been found to increase HDL and decrease LDL in some.
“One particular study [Rumberger et al, Nutrition Research, 2011] found that in addition to the TLC diet, pantethine significantly decreased total cholesterol and LDL levels.
“The TLC diet focuses on foods low in cholesterol and saturated fats.
“However, the study was only 16 weeks and done on women. There is still a definite need for studies to give a definite yes on this one.”
Plant sterols (PS). Though plant sterols are found in just about all plants, the amount isn’t sufficient to impact cholesterol levels. A person, even a vegetarian, must ingest PS in concentrated form (supplements).
“Taking in around 1,000 mg of plant sterols twice per day with food has been shown to lower LDL (bad) cholesterol by as much as 15%,” says Dr. Elizabeth Klodas, a board certified cardiologist.
“Step One Foods have 1,000 mg of phytosterols per serving – so you don’t have to worry about taking the supplement.”
Policosanol. Works like statins by inhibiting the liver’s ability to make cholesterol; lowers LDL and may raise HDL.
Red yeast extract. “Red yeast rice contains a compound that is structurally similar to statin medications,” says Dr. Klodas. She adds that red yeast extract can also cause the same side effects as statins.
Tocotrienols. These antioxidants are found in barley oils and rice bran, and inhibit the liver’s ability to manufacture cholesterol.
Turmeric. Supplements are best, for potency.
Note. Supplements are available that contain many of the above compounds in just one tablet or capsule.
Shana Spence of The Nutrition Tea is committed to providing trending information and nutrition facts covering a wide range including nutrition for heart disease and diabetes, pediatric nutrition and healthful lifestyles.
Trained at Mayo Clinic and Johns Hopkins, Dr. Klodas believes in first changing the diet, rather than taking pills, to improve cholesterol profile.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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Top image: ©Lorra Garrick
Sources:
webmd.com/cholesterol-management/side-effects-of-statin-drugs
webmd.com/cholesterol-management/guide/high_cholesterol_alternative-therapies
drcarolyndean.com/magnesium_miracle/
scholar.google.com/scholar?hl=en&q=turmeric+lowers+cholesterol&btnG=&as_sdt=1%2C6&as_sdtp=
Is Female Pattern Baldness the Same As Male Mechanism?
Is there actually a difference in the mechanism that causes hair loss in women when compared to that which causes male pattern baldness?
Well, they are not the same, but the mechanisms can be similar, says Dr. Robert Dorin, DO, NYC-based hair care expert and restoration specialist.
He explains that “there does appear to be other factors contributing to female pattern loss not found in men.
“Unfortunately, we do not know what it is, but clearly there are other factors at play.
“This is why Propecia (a pill to block and lower DHT production in men ) is 70 percent effective and approved for use in men, but is not approved for effective hair loss doctors’ prevention in females, even at twice the normal dose; not to mention that it can cause birth defects in women who use it while pregnant during the first trimester of gestation in a male fetus.”
Propecia goes by the generic name of finasteride.
Of course, from a visible standpoint, female pattern baldness differs from male pattern baldness.
For some women, the first area to begin thinning is the part on the top middle or side of their head–wherever they prefer to wear a part.
Brushing the hair back so that it’s partless will mask this. However, this can then reveal — if not at that point, then eventually — thinning at the temples.
As time marches on, the pattern baldness in women takes on the form of diffuse hair loss, even though the part and temples may seem to show it most prominently.
In men, as we all know, make pattern baldness as it advances takes on that classic horseshoe pattern — after beginning with the proverbial shiny bald spot on the top back of the head.
Hair loss in women is often caused by mechanical means.
Avoiding mechanical insults to the hair root can go a tremendous way at preventing “balding.”
If you like ponytails, here are tips on how to prevent hair loss.
Dr. Dorin of True & Dorin provides creative hair loss solutions, including advanced hair transplant techniques and the latest in regrowth technology, to ensure that his clients achieve their desired results.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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Top image: ShotPrime Studio
What It Means to Feel Your Pulse Everywhere
“Feeling of the pulse at different locations in the body can be completely normal,” says Chester M. Hedgepeth, III, MD, PhD, Executive Chief of Cardiology at Care New England.
“Importantly, all the arteries in the heart conduct the pulse wave started in the heart.
“Pulses can be felt in the large arteries of the neck (carotid artery) and leg (femoral artery).
“Normal pulses can also be felt in the wrist (radial artery), temple (temporal artery) and even the stomach with deep palpation (aorta).”
The aorta is the body’s largest blood vessel, originating from the heart and extending down the abdomen where it eventually branches off into the femoral arteries in the thigh that supply the legs with oxygenated blood.
“Patients frequently describe feeling their palpitations [pulse] in different parts of the body,” says Dr. Hedgepeth.
“PVCs are commonly associated with this sensation, as they cause a premature firing of the heart’s electrical system.
“Many patients feel a skipped and ‘heavy’ beat because the heart is ejecting significantly more blood volume.
“This ‘heavy’ beat can often be felt in the temple, head or neck.”
In summary, there is nothing to be alarmed about if you feel your pulse anywhere or “everywhere” on your body.
- There is no cause for concern.
- You can relax and breathe easy about this.
Think of your arteries as conduits, kind of like if you were to place your hand on a metal water pipe inside your bedroom wall and feel it vibrating, but the source of the vibrating is a water generator down the street.
Dr. Hedgepeth also serves as a physician in the cardiovascular division and arrhythmia service at Brigham and Women’s Hospital, plus is an instructor of medicine at Harvard Medical School.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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Top image: Freepik/KamranAydinov
Always Feeling Heartbeat in Chest: Benign or Serious?
A cardiologist explains what it means to often feel your heartbeat in your chest.
This doesn’t refer to feeling your heart beating in your chest after you just did 20 squat jumps or ran hard on a treadmill.
This is about when this occurs in the absence of physical exertion — and anxiety, of course, which could really get the heart thumping good.
“Patients will commonly describe an abnormal sensation of feeling their heartbeat in the chest or an unpleasant awareness of your own heartbeat,” says Chester M. Hedgepeth, III, MD, PhD, Executive Chief of Cardiology at Care New England.
“This can be quite distracting. Fortunately, this is usually a benign finding.
“This sensation can be due to either forceful beating of the heart or due to increase in the heart rate (greater than 100 bpm while sitting still).”
Causes of Feeling Your Heart in Your Chest
Remember, that’s where this organ is located. Dr. Hedgepeth explains, “Forceful beating of the heart and/or increased heart rates leading to palpitations may be caused by anxiety, stress, panic attack or fear.
“Increased caffeine, nicotine levels or other stimulant use (e.g., diet pills, amphetamines, cocaine) are also associated with these types of palpitations.”
The so-called energy drinks can also produce this effect.
These drinks often contain high levels of caffeine, which can stimulate the heart and increase its rate.
Additionally, many energy drinks have other stimulants like taurine and ginseng that can also affect heart function.
For some people, these ingredients can cause the heart to beat harder or faster than usual, leading to a sensation of palpitations or a racing heart.
Dr. Hedgepeth continues, “Recent exercise and fever are common causes. Patients who might be dehydrated for any reason will often describe these types of symptoms.”
- Fill up on more water and less of the energy drinks.
- Cut back on caffeine; replace the diet pills with portion control and more exercise. Then see what happens.
Something of note: If you feel your heart beating in your chest, this doesn’t necessarily mean you’re feeling palpitations or PVCs, which are an irregular heart rhythm.
In fact, the beating may be quite steady and even-paced while you feel it in your chest.
In other words, you have no fluttering, but instead, just that strong awareness or sensation of a beating heart. The resting rate may even be normal during these experiences, too.
The more anxious you get over feeling your heartbeat in your chest — remember, the more this will make you “feel” it.
If your cardiac awareness, though, comes with other features such as lightheadedness, dizziness or chest pain, you should see a cardiologist.
Dr. Hedgepeth also serves as a physician in the cardiovascular division and arrhythmia service at Brigham and Women’s Hospital, plus is an instructor of medicine at Harvard Medical School.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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Top image: Shutterstock/Theerapol Pongkangsananan
Pain in Chest when Leaning Forward & Backward
A cardiologist explains the possible causes of chest pain when you lean forward and backward.
“Pain in the chest with leaning forward or backward is a symptom commonly associated with pericarditis,” says Chester M. Hedgepeth, III, MD, PhD, Executive Chief of Cardiology at Care New England.
“Pericarditis is an inflammation of the thin, protective membrane that surrounds the heart, and keeps it in its proper anatomic location. Inflammation of this membrane may cause chest pain.”
Dr. Hedgepeth says that “the inflammation in the lining around the heart could be related to a recent heart attack.
“Heart attacks can lead to an immune response that causes inflammation in the pericardial sac.
“You may hear your doctor refer to this type of post-heart attack pericarditis as Dressler’s syndrome.”
What if you haven’t had a heart attack yet are experiencing chest pain or discomfort (or a dull ache) when you lean forward and backward?
There are many possible non-cardiac causes.
“More commonly, this inflammation [periocarditis] is related to infection (virus, rheumatic fever or tuberculosis), cancers (lung, breast, renal cell cancer, Hodgkin’s disease and lymphoma), immune diseases such as lupus, recent radiation therapy to the chest area, or certain drugs,” explains Dr. Hedgepeth.
“Recent chest wall trauma, musculoskeletal injury and herpes zoster should all be ruled out.”
How is periocarditis diagnosed?
If you have pain in your chest when you lean forward and back, there can be many possible causes — linked to pericarditis.
The workup for a correct diagnosis is as follows.
1 Medical History and Symptoms Review: The diagnostic process begins with a detailed discussion of your medical history and symptoms.
The physician will ask about recent illnesses, autoimmune disorders or trauma.
2 Physical Examination: During the physical exam, the doctor will listen to your heart with a stethoscope.
A key finding in pericarditis is the pericardial friction rub — a distinctive, scratchy sound produced by the rubbing of the inflamed pericardial layers.
3 Electrocardiogram (ECG): An ECG records the heart’s electrical activity and may show changes typical of pericarditis.
4 Chest X-ray: A chest X-ray helps visualize the heart’s size and shape and can show the fluid accumulation around the heart.
5 Echocardiogram (Echo): This ultrasound test provides images of the heart and can detect the fluid and assess the thickness of the pericardium.
6 Blood Tests: These tests check for markers of inflammation and identify potential underlying causes, such as infection or autoimmune diseases.
7 Pericardiocentesis: If there is significant fluid accumulation, this procedure may be performed to remove and analyze the fluid, helping to diagnose the cause of the inflammation.
In some cases, CT scans or MRIs may be used for further evaluation.
Bottom line: Chest pain that comes when you lean forward and/or backward should never be ignored. Make an appointment with your doctor.
If this article provided you with helpful information or reassurance, please consider supporting my work through Ko-fi. Donations help me continue writing detailed medical content that’s easy to understand.
Dr. Hedgepeth also serves as a physician in the cardiovascular division and arrhythmia service at Brigham and Women’s Hospital, plus is an instructor of medicine at Harvard Medical School.
Lorra Garrick has been covering medical, fitness and cybersecurity topics for many years, having written thousands of articles for print magazines and websites, including as a ghostwriter. She’s also a former ACE-certified personal trainer.
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