In the weeks after Thanksgiving leading up to the New Year, it’s often a time to think about the way we would like to change our behaviors, at home and in the workplace. We often make lists and resolutions about exercising more, better portion control at meals, ways to reduce stress, with an eye toward improving our own individual and family health.
As Rhode Island enters the new era of health care reform implementation, with the goal to improve quality, increase access and achieve more cost-effective solutions in the delivery of health services, many are also looking at the bigger picture: investing in prevention of illness has become an important tool to reduce medical costs.
In the fight against heart disease, the No. 1 cause of death for men and women in Rhode Island, Barbara H. Roberts, the director of the Women’s Cardiac Center at The Miriam Hospital, believes prevention is a critical component, writ large.
Roberts, an associate clinical professor of medicine at the Warren Alpert Medical School at Brown University, advocates for primordial prevention – preventing the emergence of risk factors in a population. For instance, if you want to prevent high blood pressure caused by high sodium intake, Roberts says it’s important to recognize that most sodium comes not from the saltshaker but from processed food. She offers her provocative views in an interview with PBN.
PBN: Why is the incidence of heart disease so high here in Rhode Island – and across the nation?
ROBERTS: Fully two-thirds of Americans now are overweight or obese and most do not exercise on a regular basis.
The incidence of cardiovascular disease is high because many people have risk factors for the development of the most common form, what doctors call atherosclerotic cardiovascular disease, in which deposits called plaque build up in arteries.
These plaques can cause symptoms such as angina by narrowing an artery supplying heart muscle. Or, the plaque can rupture, in which case a clot usually forms in the artery, totally interrupting blood supply. When blood supply to the heart muscle is interrupted, a heart attack occurs, unless the blood flow is restored promptly.
There are only two risk factors that we cannot modify, our family history and our age. Men aged 45 or more and women aged 55 or more are considered to be at increased risk.
All the other risk factors, such as smoking, high blood pressure, abnormal levels of blood fats (cholesterol and triglycerides), obesity, sedentary life style, diabetes and inflammation are avoidable or treatable.
PBN: Beyond surgical intervention and behavioral changes to a healthy lifestyle, what can be done to reverse this trend? Are there societal interventions needed?
ROBERTS: To lower the incidence of cardiovascular disease, prevention is critical. Any form of surgical intervention does not reverse the underlying process of atherosclerosis.
The approach to prevention must be multi-factorial. At the level of the individual, people must be encouraged to choose healthy diets, maintain a normal body weight, exercise regularly, avoid smoking and go for regular check ups to determine what their own risk factors are.
Primordial prevention refers to the prevention of the emergence of risk factors in a population. For example, high sodium intake contributes to the development of high blood pressure. Most sodium [in our diet] comes not from the saltshaker but from processed foods.
It is important that food companies be encouraged to lower the salt content of the foods they manufacture. If they do not do so voluntarily then the sodium content of foods should be subject to legislation.
When choosing which foods to buy, the healthy choice should be the easy choice. Today, the cheapest foods are processed foods that have been stripped of almost all their nutrients, and have added sugars and fats, often the most dangerous fats, trans fats, also called partially hydrogenated vegetable oil.
Trans fats raise the level of bad cholesterol and lower the level of good cholesterol. Because of food company lobbying, the food label can say zero trans fats if there is less than 500 mg. of trans fats per serving – but few [eaters] limit themselves to one serving.
If food companies and restaurants do not remove trans fats voluntarily, then this, too, could be legislated. All communities could devote resources to ensure that people have safe, attractive places to engage in exercise.
Taxes on cigarettes could be raised to discourage smoking, and there can be more stringent laws to limit smoking in public places. Instead of subsidizing corn (used in the manufacture of high fructose corn syrup, an almost universal sweetener) and beef and dairy farmers (cheese is loaded with saturated fat which raises bad cholesterol), the government could subsidize farmers who grow green leafy vegetables and other fresh produce that is now often prohibitively expensive for people living in poverty.
PBN: How important is the doctor-patient relationship in promoting changes in lifestyle?
ROBERTS: A good doctor-patient relationship is critical to promoting a healthy life style. No one is going to make what are sometimes very difficult changes in behavior if the doctor seems hurried and uncaring. Doctors must instruct their patients about their risk factors and how to go about improving them. An educated patient is more apt to be a motivated patient.
PBN: Your current practice at the women’s cardiac center at The Miriam Hospital, one of the foci is on primary prevention – treating risk factors to prevent heart disease. What are the most important risk factors for women? How important a factor is the reduction of stress in the workplace? A new study by Dr. Michelle A. Albert at Brigham and Women’s Hospital in Boston has linked stressful jobs to the incidence of the risk of heat attacks.
ROBERTS: There are two risk factors that increase risk for women more than men: smoking and diabetes. Smoking lowers the average age of first heart attack more for women than men. Diabetes increases risk three- to seven-fold for women, compared to two- to four-fold for men. In addition, in women, elevation of the bad cholesterol is less risky than it is in men. In women, elevations of triglycerides, and low levels of the good cholesterol are riskier than elevations of bad cholesterol.
Stress in the workplace increases risk in women according to a recent study out of Boston, especially if their jobs leave little room for decision-making. But men are not immune from the adverse effects of stress. For example, studies have shown that veterans who suffer from post-traumatic stress syndrome have a higher incidence of atherosclerotic cardiovascular disease.
Probably what is most important is how we react to stress. If we react to stress by overeating, smoking, taking drugs, drinking to excess, our health will suffer. If we react to stress with lots of exercise, stress reduction techniques like meditation, we will do better.
PBN: How have the demographics of caring for patients with heart disease changed? Has the burden shifted from middle age into the old population?
ROBERTS: Over the last 50 years or so we have seen impressive reductions in the cardiovascular disease death rate. As average cholesterol values have dropped and smoking rates have declined, the incidence of heart attacks in middle-aged people has declined.
In addition, we have more procedures, such as stenting and bypass surgery, which have contributed to lowering the death rate. Partially as a result of this, we have seen huge growth in the numbers of people living into their 80s and 90s. Life expectancy has increased, but cardiovascular disease is still the No. 1 cause of death for both men and women. People are living longer with cardiovascular disease, but still dying of it, albeit at more advanced ages.
