Unblame the Victim: Heart Disease Causes Vary

[Guest guest]

[This is more of a mainstream take on heart disease]

 

September 11, 2004

NEWS ANALYSIS

Unblame the Victim: Heart Disease Causes Vary

By DENISE GRADY

 

http://www.nytimes.com/2004/09/11/health/11clinton.html

 

Apparently, it is not enough that former President Bill Clinton has had his

chest sliced open, his breast bone sawed through and his heart stopped cold

and replumbed. He must also suffer the finger wagging and I-told-you-so's

of those who say he caused his heart disease by indulging in cheeseburgers,

cigars and too much work.

 

A television crew even reported on Mr. Clinton's eating habits from a

restaurant in Chappaqua, N.Y., as if it were the scene of a crime. Mr.

Clinton himself seems to have bought into the theory, confessing his

dietary sins in interviews before doing penance on the heart-lung machine.

 

But experts differ as to whether it is scientifically valid or fair to

assume that Mr. Clinton, who has a family history of heart disease, brought

on his illness. Studies of large groups show that diet plays a role in

coronary disease, but it is harder to prove that link in any individual

patient.

 

Nutritionists seem least inclined to let Mr. Clinton off the hook. Heart

surgeons, who earn their living from fixing up patients like him, tend to

blame his genes more than his taste buds and to doubt that his artery

blockages could have been prevented. Cardiologists fall somewhere between.

Psychologists and medical ethicists say the need to find fault reveals more

about the blamer than the person being blamed.

 

What is known scientifically, from studies that have surveyed large

populations over decades, is that rates of heart disease are higher in

people with high total cholesterol and high levels of L.D.L., the " bad

cholesterol. " And lowering cholesterol decreases death rates from heart

disease.

 

It is also known that in many people - but not all - eating a lot of

saturated fat and trans fat and being overweight can raise blood

cholesterol. Saturated fat comes mostly from animal products like fatty

meat and dairy foods; trans fat comes from the hydrogenated oils used to

make stick margarine and shortening.

 

Based on these findings, and the fact that heart disease is the leading

cause of death in the United States, it might seem as if the problem might

be solved if everyone would just give up cheeseburgers. But when it comes

to determining what drives cholesterol and heart-disease risk in any one

person, the calculus becomes more complex. There are healthy people with

high cholesterol, and heart patients with seemingly enviable readings.

 

In addition, a person's genetic makeup plays a powerful part in determining

cholesterol levels. To complicate matters further, people respond

differently to dietary fat. In some, a fatty diet will make cholesterol

shoot up. A lucky few can eat almost anything and still have low readings.

And though reducing saturated fat can help many people to lower their

cholesterol, it does not always do enough.

 

For people who need to lower their cholesterol, experts used to recommend a

six-month trial of diet alone, before prescribing medicines. But the

results were disappointing. For many people, the dietary changes would have

to be so extreme to get results that they could not stick with the program.

Now, experts advise trying diet alone for only three months, except for

people thought to be at high risk of a heart attack - they are urged to

start drug treatment right away, along with a better diet. That is partly

why so many people wind up taking statin drugs to lower their cholesterol.

 

In most people with heart disease, doctors cannot state with certainty how

much various risk factors are to blame, said Dr. William Cole, a

cardiologist at New York University.

 

" If there's a strong family history, that would be No. 1, and No. 2,

connected to the history, would be cholesterol,'' Dr. Cole said. " No. 3

would be diet. It's a combination and interaction of various risk factors,

and not just one that will put you at risk.''

 

Samantha Heller, a senior clinical nutritionist who works in cardiac

rehabilitation at New York University, said, " What you eat may worsen your

genetic tendencies, and if you don't have a genetic predisposition, you can

certainly increase your risk with lifestyle.''

 

Ms. Heller said eating saturated fat could cause inflammation in the artery

walls within hours after a meal in just about anybody, and lead to plaque

buildup in the arteries.

 

" Over time, this assault on the arterial wall is what causes heart

disease,'' she said. " It doesn't happen overnight.''

 

Dr. Gail Frank, a professor of nutrition at California State University in

Long Beach and a spokeswoman for the American Dietetic Association, said,

" I'm more inclined to believe ex-President Clinton's condition is very much

dominated by environment. We've seen him in the media so often coming out

of McDonald's.''

 

" Our body talks, " Dr. Frank added. " Even when we're eating those burgers

and fries and we're an ex-president of the United States, the body talks

and says at some point in time you cannot escape what you've done.''

 

But Dr. John Byrne, chairman of the department of cardiac surgery at

Vanderbilt University Medical Center, said, " I think it's just plain silly

to blame the patient.''

 

Dr. Byrne said he explained the course of the disease to patients by using

the analogy of a ship crossing the ocean. He tells them that each change

they make, like reducing stress or eating less saturated fat, will shift

the course of the ship a few degrees - but that none will turn the ship

around.

 

" I tell them, 'If you're on a course to coronary disease, it's not your

fault,' '' he said. " Eating an American diet will be a contributing factor,

but by and large the most powerful is a family history and genetic

predisposition, and it's just basically bad luck.''

 

Dr. Steven E. Nissen, a cardiologist at the Cleveland Clinic, said:

" Dietary indiscretion is a risk factor, but it is not the cause of coronary

heart disease. In the South Asian Indian population, there are vegetarians

who get coronary heart disease. What is important to remember is that a

genetic predisposition plus environmental factors cause this disease. If he

had eaten a different diet, that might have made it come later, but it

could have happened anyway.''

 

Staying on a statin drug to treat his high cholesterol might have helped

Mr. Clinton, Dr. Nissen said, noting that the former president had taken

one but stopped. Three years ago, Mr. Clinton's L.D.L. cholesterol, the bad

form, was 177 - " sky high,'' Dr. Nissen said.

 

Dr. Nissen wondered about the medical advice Mr. Clinton got in the past,

regarding his blood pressure, cholesterol and cigar smoking.

 

" Allowing the guy to temporarily take a cholesterol-lowering medication and

not keeping him on it is not a prudent thing to do,'' he said.

 

" If he had stayed on treatment, it could have made a big difference,'' Dr.

Nissen said. " But no one will ever know.''

 

Though dietary changes can also help patients to lower their cholesterol,

diet alone cannot do enough for most people, Dr. Nissen said, adding that

both drugs and diet are needed.

 

Regardless of whether French fries were Mr. Clinton's undoing, the frequent

references to his diet have had an unmistakably judgmental tone. That

tendency to blame patients for their illnesses is " emotionally destructive,

socially scapegoating and morally deplorable,'' said Dr. Larry Lachman, a

psychologist in Monterey, Calif., who counsels people with chronic illnesses.

 

It also makes little sense, Dr. Lachman said, in light of the genetic

component of many diseases. " You can't blame someone for their parents,''

he said.

 

As for the role of diet, Dr. Lackman said, its potential importance was not

recognized when people of Mr. Clinton's generation were young. Thus, for

many years they had no way of knowing they were eating things that might

harm them.

 

The impulse to blame the patient may also be a form of self-protection by

others, Dr. Lachman said. If they can tie someone else's illness to a

certain behavior, they can tell themselves that if they behave differently,

the same thing will not happen to them.

 

" For people to feel in control and not have overwhelming anxiety, they must

believe that for every event there is a cause,'' he said. " But sometimes

things happen by random, and that gets people really nervous.''

 

Dr. Stuart Finder, director of the Center for Clinical and Research Ethics

at Vanderbilt University Medical Center, said that even though public

figures like Mr. Clinton gave up much of their privacy, their medical

privacy ought still to be respected. And yet it is not.

 

" We want to know everything we can about these people, " Dr. Finder said,

" and there's this passing of judgment. It's not such a good reflection on

our society.''

 

On the other hand, he said, public figures have a unique ability to

influence others, and perhaps an obligation to do so when they can be of help.

 

" It would not be unreasonable, " Dr. Finder said, " to try to use this

situation for the public good, to try to teach the public, to have Clinton

say, 'Don't do what I have done.' ''

 

 

 

Lawrence K. Altman contributed reporting for this article.