The Doctor Weighs In

"Most heart attacks in women are preventable," is the headline of an article posted on NBC.com.  The article describes a study, published in the Archives of Internal Medicine, that was done by the researchers at the Karoinska Institute in Sweden.  Dr. Agneta Akesson and colleagues looked at the diet and lifestyle patterns of almost 25,000 postmenopausal women.  At the time of enrollment none of the women had heart disease, diabetes or cancer.

The researchers asked the women to fill out "food frequency" questionnaires to identify how often they ate 96 different foods.  The researchers analyzed the data and found four major dietary patterns:

• Healthy - vegetables, fruits, and legumes
• Western/Swedish - red meat, processed meat, poultry, rice, pasta, eggs, fried potatoes, and fish
• Alcohol - wine, beer and some snacks
• Sweets - sweet baked goods, candy, chocolate, jam, and ice cream

Other information collected included family history of heart disease, education level, physical activity, and body measurements.

The women were followed for an average of 6 years.  During that time, 308 women had heart attacks.  The investigators found that two of the dietary patterns (healthy and alcohol) were associated with a decreased risk of heart attack.  Women who drank less than a quarter ounce of alcohol daily (that is just a splash in the bottom of your glass) and ate lots of veggies, fruit, whole grains, legumes, and fish had a 57% lower risk of having a first heart attack.  That is a whopping big difference.

If women added three other healthy lifestyle habits into the mix (not smoking, being physically active, and avoiding too much weight gain), they had a 92% lower risk of heart attack.  In other words, most heart attacks in women are preventable by making healthy lifestyle choices.

Now, it is one thing to say, eat healthy, drink in moderation, exercise and maintain a healthy weight.  It is quite another thing to actually do all of those things over the course of an entire lifetime.  On the other hand, if you look at the amount of money the US (and, indeed, the entire world) spends to treat cardiovascular disease, I believe you would find there is enough there to buy each and every person a personal cook and a personal trainer (I believe this is the secret to Oprah's weight loss and maintenance).

I say this tongue in cheek, but it does make the point that we aren't spending our "health" care dollars on the right things.  We spend generously to fix disease, but we are very stingy when it comes to funding health.   It is time to get this right.  There aren't enough dollars in any treasury to treat all of the heart disease we are going to see as a result of the global epidemic of obesity and physical inactivity.  This must be  a top priority of policy makers and health reformers.  Studies, like the Karolinska study, should be used to promote changes in public policy - such as healthy school foods, ensuring that all neighborhoods have access to fresh fruits and vegetables and that they have safe places where kids and adults can move their bodies (without worrying about getting shot in the process).

Every politician, health reformer, and policy wonk ought to know about this study and others that prove that healthy lifestyles mean fewer heart (expensive) attacks - not just in women, but in men as well.  The bottom line is most heart attacks are preventable!

We were watching tonight a great program on PBS about Billie Jean King and her wonderful tennis career. Her 1973 match, or dare I say grudge match, against Bobby Riggs, was a delight to the eyes and the soul. We relished her strategy of running ragged this aging fool from one end of the court to the other. There she was: a skilled, rebellious young woman facing a male chauvinist who taunted her to test her mettle against his. But the match had a much larger meaning; it was emblematic of the new generation, of a new world upending the old order and its tired prejudices, not in a bloody revolution fought in the streets—but in a fair, civilized match on the tennis court. How many of you remember a single feminist demonstration? but we all remember this historic match; such was its impact.

However riveting her life story was, what caught my attention was her secret weapon: her tremendous ability to focus, to remain calm under pressure, in fact to relish stressful situations. As she herself said, minutes before a match all her anxieties and insecurities would be replaced by determined calm and focused planning. How could she do that?

It’s all in your head

The neurons in our brain talk to each other through chemicals that are called neurotransmitters. One of those is called dopamine, and its function is invaluable; when we have a pleasurable experience of any kind, dopamine is released. We thus learn to associate this experience with reward and pleasure and tend to repeat it. This is important to our brain’s unconscious decision- making. Just think of it: if on every occasion that we encountered a delicious meal, or a glass of wine, or making love, we had to gingerly try it first to see if we liked it—we would be paralyzed with indecision. Billie Jean King did not have to convince herself that she loved the game every time she stepped on the court—her brain had already made this decision for her.

What happens when dopamine levels in the blood are elevated?

The physiological and psychological effects of elevated dopamine are wonderful: a sense of optimism, exhilaration, even euphoria; a sense of increased energy that can escalate to hyperactivity, sleeplessness, loss of appetite, increased heart rate and hyperventilation. As part of this behavioral complex, there are a few other traits: extremely focused attention, motivation and goal-directed behavior. Do you recognize these as ‘symptoms’ of falling in love? Can the pounding heart be the reason for the association of love with the heart? Can it explain the rapt attention of the young lover earnestly listening to her mate’s nonsense?

What about Billie Jean’s uncanny ability to focus on the game? She loved the game, she was in love with it. And I’d bet her dopamine levels were sky high as well.

It is a cliché that love made the world go round. Unfortunately, my friend, I hate to disillusion you—it’s all in the dopamine.

Dov Michaeli MD, Ph.D

The recent posting by Dr. Salber describing the ostensible superiority of wine drinking over beer or spirits reminded me that I actually saw with my own eyes one of the confounding factors of the study, namely, lifestyle differences.

In the mid-80's, I was a visiting scholar at the University of Turku (also called Oulu ) where the study was done.
OuluOn weekend nights the streets were littered with drunks asleep (comatose is a more apt description of their state) on the sidewalks, the gutters, and the roads. It was a sobering sight to behold: well-dressed, seemingly upright citizens, mostly men, wallowing in the mud. I asked my colleague, a surgeon at the University hospital, what was the drink of choice. It was vodka, he said. What about beer? That’s for kids. And wine? Only women and intellectuals drink wine; and they rarely get drunk.

I remember thinking at the time: these people are not going to live very long. In fact, the three most common causes of their demise were heart disease, liver disease, and accidents (like being run over by a car while sleeping on the road). So, anybody who has been to Oulu would tell you—this is not a good study, and scientists who live in Oulu should have known better.

Wine is good for you

True, but up to a point. Studies have shown that men who drink up to 2 glasses of wine a day, and women 1 glass a day (sorry, life is not fair) are less prone to coronary disease and cardiac events.

The mechanism of such a blessed effect of wine is not really understood. Several studies have shown that wine (especially red, some claim) causes elevation of HDL, the “good” cholesterol.

But don’t forget a big caveat: Our eagerness to believe in something can color our judgment. The facts however, cannot be changed by beliefs, however ardent.

Is all “good” cholesterol the same?

In March of last year Pfizer withdrew the experimental drug torcetrapib from clinical trials because it caused excess mortality due to cardiovascular events over the placebo. That was quite a shock, because the drug was designed to elevate HDL (good cholesterol) levels. Why the drug caused higher mortality we do not know yet, but one theory is gaining prominence: not all HDL is born equal.

There are most likely variants of HDL that are actually “bad” cholesterol. Ansell and his coworkers (Circulation, vol.108, pp. 2751-2756, 2003) studied people who had very high HDL levels, but still developed heart disease. In lab assays they found that these people’s form of HDL promoted deposition rather than removal of cholesterol from the artery walls. Could it be that Pfizer’s ill-fated drug promoted the wrong kind of HDL? Quite likely.

HDL is actually a family of particles, varying in their protein components, size, and other parameters. In the heart of Tuscany (the wine country of Italy ) there is a village where people were found to have very low levels of HDL, but were not prone to heart disease. Aha! The protective effect of wine, you might eagerly conclude. But what about other villages in the area? They too drink, but have “normal” levels of cardiovascular disease (and normal levels of HDL). So what gives?

A toast to Milano

It turns out that the people in this village have a variant of a protein that is part of the HDL particle, called Apo A-1. The variant, Apo A-1 Milano is apparently responsible for the protective effect, despite the low levels of HDL in the blood. In fact, Nissen and his colleagues from the Cleveland Clinic showed that five infusions of this protein shrank plaques in the arteries (Nissen et al. J. Am. Med. Assoc. vol. 290, pp. 2292-2300, 2003).

What this study shows us is that our classification of HDL as “good cholesterol” should be reconsidered. There is probably “good” and “bad” HDL cholesterol. As scientists almost invariably say at the end of a paper: more work needs to be done.

Nothing is simple…

Dov Michaeli MD, Ph.D

Would you believe it? I found this report on a three-decade study of wine drinkers on Wine Spectator Online. The study itself was published in a respected peer-reviewed medical journal, the Journal of Gerontology. The results are the stuff wine-marketers (and wine lovers) dream about: Wine drinkers had a lower mortality rate compared to drinkers of other alcoholic beverages.

No, the study was not performed in California's Napa Valley nor in the Loire Valley in France. Rather it was done in Finland (there's wine in Finland?) by Timo Strandberg and colleagues, researchers at the University of Oulu. At the start of the study in 1974, 2,468 businessmen and male executives, ages 40-55, were assessed at the Institute of Occupational Health in Helsinki for cardiovascular risk factors and alcoholic beverage preferences.  Only 131 of these men did not use alcohol, 455 did not report a single beverage preference, and 694, 251, and 937 preferred beer, wine, and spirits, respectively.

 The researchers tracked these men down for a re-assessment in 1985 and again in the year 2000. As you can imagine, some of these guys were a bit “long in the tooth” by the end of the study. Others had died or just dropped out (of the study).  Study subjects were included in the final calculations only if they were constant in their preference for one type of alcohol (e.g., wine, beer, or spirits) over the others.  By the time of the second stage of the study, in 1985, only 1,369 men were available to be reassessed. Some dropped out of the study, some changed alcohol habits and 93 of the men had died. By the time of the final calculations, in 2002, there were 1,127 men left in the study who drank three or less drinks per day and had not changed their drinking preferences over the course of the study.

Here are the results:

The men remained pretty constant in their choice of alcoholic beverage and there was not a significant difference in the amount they drank between the different beverage groups.

 Men with wine preference had the lowest total mortality of the three groups due to lower cardiovascular mortality. Compared to the spirits drinkers, wine drinkers had a 34% lower total mortality.  Beer drinkers had a 9% lower mortality than spirits imbibers.  Should we break out a bottle of pinot to celebrate the good health of wine drinkers? 

Best keep the cork in the bottle for now. There are some confounding variables. It turns out wine drinkers had healthier habits than beer and spirits guzzlers. They exercised more and smoked less, both factors associated with better health and lower mortality.   In other words, it may not have been the wine that led to a good long life, rather wine drinkers might be more health conscious.

Here's how the Strandberg, the lead researcher, sums it up:

"Is it the drinker rather than drink characteristics, as healthier men preferred wine?" It could also be that "spirit preferrers may lead a more dangerous life, with more risk factors, and all hidden aspects may not be culled in an epidemiologic study." What he is pointing out, rightfully so, is that care has to be taken in interpreting the results of this type of study.

Oh well. It did sound too good to be completely true -- kind of like reading that dark chocolate lowers blood pressure, but only if you don't eat so much that you get weight-related hypertension. 

Back to the fruits and veggies.

Pat Salber, MD