When the leading cause of death comes knocking at your door, you still have options.

A study published in the New England Journal of Medicine earlier this month examined why fewer Americans are dying from coronary heart disease. It found that while 47 percent of the decrease was due to medical treatment, 44 percent was due to reductions in major risk factors.

That last part caught Connie Crawley's attention.

"I think we've seen this decrease in heart disease and mortality, and we've ascribed the reason to improvements in medical care after a heart attack," said Crawley, a University of Georgia Cooperative Extension nutrition and health specialist. "But if people make lifestyle changes, it's almost as effective."

Reducing major risk factors includes lowering total cholesterol and systolic blood pressure by diet or medication, decreasing or quitting smoking and increasing physical activity.

"The major thing that's reducing risks is that people don't smoke as much anymore," Crawley said. "Once you don't smoke, the other risk factors are a lot lower."

In 2000, 341,745 fewer people died from coronary heart disease than in 1980. But Crawley thinks the trend is going to change.

"I'm concerned that the numbers are going to increase again, with obesity on the rise and people getting diabetes in their teen years or finding out they're hypertensive when they're 20," she said.

The study was conducted by medical professionals from the Centers for Disease Control and Prevention and HealthPartners Research Foundation in the United States and from Newcastle University and the University of Liverpool in Great Britain. And it backs up Crawley's fears.

More people would have lived due to lowering their risk factors if they hadn't made other destructive choices at the same time. Weight gains and diabetes accounted for about 26,000 and 33,500 additional deaths, respectively, from heart disease in 2000.

Crawley has had to make changes herself. She looks healthy but was diagnosed with prehypertension a few years ago. To keep her blood pressure at an ideal level, she's made big changes, such as avoiding restaurants, and small ones, such as eating lower-sodium or salt-free bread.

"It really takes an effort for dietary intervention," she said.

For herself, she's more worried about salt than weight. But for others she's worked with, extra pounds are the issue.

"Even if people make it a goal to not gain more weight, it would be a good goal," Crawley said. "There's always this belief that you gain a lot of weight over the holidays, when it's only about 1 pound. But that adds up to 20 pounds in 20 years. People are gaining all the time. And it's the small increases over time that have the greatest impact."

Researchers are also finding that the fastest-growing group of people who are gaining weight are the morbidly obese.

"It doesn't seem like people are monitoring themselves," she said. "It seems like they just let it totally get out of hand and then want dramatic changes."

She recommends small changes to help lower the risk of heart disease:

• Identify and lower stress, which affects systolic blood pressure and can cause stress eating.

• Take steps to stop smoking.

• Lose weight. "Giving up one candy bar a day will add up to 10 to 20 pounds lost per year, if you don't substitute something else," Crawley said.

She stresses lowering weight because extra pounds increase stress on the heart, which can lead to increased blood pressure as the heart pumps harder to circulate blood. More weight can also lead to higher cholesterol and more plaque buildup on blood vessel walls, adding more to the heart's work load.

Ultimately, lowering your chance of dying from heart disease is "mostly going to have to be a combination of diet, exercise and medication on almost everything," Crawley said.