The Best Medicine

No matter how many miracles doctors perform, coronary disease will never be brought under control unless the public pitches in. Says Cardiologist James Schoenberger, professor of preventive medicine at Chicago's Rush-Presbyterian-St. Luke's Medical Center: "We can't solve the problem with beta or calcium blockers, heart transplants, coronary bypasses or other forms of palliative medicine. The only solution is prevention." Easier said than done. Doctors disagree about the best way to go about it. Also, prevention requires the self-discipline to break some bad habits.

Over the years studies of large groups of people have identified several factors associated with an increased risk of heart disease. Men have a higher incidence of coronary-artery disease than premenopausal women. Whites in the U.S. suffer heart attacks with greater frequency than blacks or Orientals. The risk of developing heart disease is enhanced for diabetics and those with close family members who have died of heart attacks. Chances of an attack go up as a person grows older. Obviously, age, sex, race and heredity are beyond an individual's control. But there are other risk factors--high levels of cholesterol in the blood, cigarette smoking, high blood pressure, excess weight, stress and tension, lack of physical activity--that a person can do something about.

To reduce cholesterol levels most doctors recommend a very un-American diet. Says Dr. Jeremiah Stamler of Northwestern University: "We need more fruit, more vegetables, beans, fish, skim milk, lean meat and poultry. I'd like to see McDonald's have fresh orange juice as well as Coke, baked potatoes as well as French fries, yogurt instead of pie. If we could get more diet changes in the U.S. there would not be a big coronary problem in this country."

Skeptics disagree. While studies have shown that changes in diet can cut blood cholesterol, there is still no conclusive proof that these reductions prevent heart disease. Moreover, between 60% and 80% of the cholesterol in the blood does not come from food but is manufactured by the body. Eating fewer cholesterol-laden foods, argue critics of the diet-heart hypothesis, does not lower cholesterol levels enough to affect the rate of heart disease or attacks.

The cholesterol issue has been complicated in the past decade by new discoveries about the fatty proteins that carry cholesterol in the blood: high-density lipoprotein (HDL), low-density lipoprotein (LDL) and very-low-density lipoprotein (VLDL). HDL-cholesterol appears to be "good" cholesterol. Explains Dr. Antonio Gotto of the Baylor College of Medicine in Houston: "We think that high-density lipoprotein may work as a scavenger of cholesterol from the tissues, ridding the body of excess cholesterol." Research is under way to determine whether coronary disease can be fought more effectively by manipulating the levels of HDL and LDL.

Cigarette smoking is a top-ranking coronary culprit. It speeds up the heart rate, raises blood pressure and constricts blood vessels. Smokers in the U.S. are twice as likely as non-smokers to have heart attacks. And while tobacco users are most often warned about lung cancer, statistics show that their chances of developing fatal heart disease are three times as great. The American Heart Association estimates that more than 120,000 deaths from heart disease could be avoided each year in the U.S. if people gave up cigarettes.

As studies of air-traffic controllers have shown, stress is closely linked to high blood pressure, which in turn is tied to more serious heart disease. One way to reduce stress is through regular exercise, which tones the body and increases the efficiency of the heart and lungs. The case for exercise was made persuasively by a 20-year study of 17,000 Harvard alumni, age 35 to 74, by Stanford Epidemiologist Ralph Paffenbarger. He found that men who made a lifetime habit of regular exercise (say, strenuous swimming or jogging three times a week) had about half as many heart attacks as those who were sedentary. Even smokers, overweight men and those with high blood pressure or family histories of heart disease benefited from exercise. Despite the Harvard study, however, the value of exercise in preventing coronary disease has not been conclusively shown.

Preventive measures have largely been aimed at adults. But in the past few years there has been considerable interest in extending them to children. Says Dr. Charles Glueck of the University of Cincinnati College of Medicine: "If you want to prevent heart disease you can't start at the age of 45." Indeed, some researchers estimate as many as 5 million American children may have high cholesterol counts. Predicts Pediatric Cardiologist Dan McNamara of Baylor: "In the future there will be a time for a child's preventive cardiology checkup just as there now is a child's dental checkup."

Heart specialists contend that by studying family histories and taking blood pressure and cholesterol readings, they can pick out children with high risk of developing coronary disease. But many doctors consider such efforts premature since the efficacy of preventive measures has not been absolutely proved in adults. There is another concern as well. Says Pediatrician Neil Holtzman of Johns Hopkins Hospital: "By labeling children or young adults and letting them live under the ax of coronary heart disease for the rest of their lives, the anxiety that is generated may be worse than the possible benefits of the treatment itself."

Public enthusiasm for preventive measures has surged in recent years. San Francisco executives are stretching their muscles to the tune of Do Ya Think I'm Sexy?, while joggers crowd the indoor tracks of New York City Y.M.C.A.s day and night. More and more corporations are sponsoring physical fitness programs for their employees, often with the hope of improving cardiovascular health. A dramatic expression of national concern about heart attacks occurred when ABC's 20/20 program broadcast a test on coronary risk factors last February. The network asked viewers to rate themselves and send in the results. Some 40,000 responses were expected; instead, the Arizona Heart Institute, which devised the test, was deluged with 260,000 scores, some written on paper plates and restaurant receipts. Perhaps most heartening, one couple scrawled their scores on an empty heart-shaped candy box, explaining: "Because of your test, we threw out the rest."

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