The last months of 2016 were marked by a pair of untimely deaths due to heart failure, one fictional and one real. In Manchester by the Sea, the story almost begins with the death of the protagonist’s older brother. As told, Joe in Manchester had been suffering from congestive heart disease for a few years. He died in middle age, leaving an estranged alcoholic ex-wife, and a teenage son in need of a parent.
When I saw this haunting movie, I reflected on how unusual it’s become, at least in my community, for men to drop from heart disease. It happens, but not so often. The NIH confirms the downward trend in fatal cardiac events in men and women. The way heart conditions are classified has changed, but one measure is that in 1950, the number of U.S. deaths attributed to coronary heart disease was 263 per 100,000 people in the population. The incidence peaked around 1968, at 338, and fell steadily at least to 2008, at 133 per 100,000. That’s a huge drop.
When I was a child in the 1960s my father told tales of men who died from myocardial infarctions. He was a physician who referred to those unfortunate events as “MIs”; most people call them heart attacks. My father was imperfectly fit. Yet seeing those events drove him to lose weight and walk more. He’d have his blood pressure checked periodically. He payed attention to his cholesterol. He lived to be 83 years old, but I can’t say or know if any of those lifestyle changes made a difference. Probably.
The CDC reports that heart disease remains the leading cause of U.S. deaths. From the government’s website: “High blood pressure, high LDL cholesterol and smoking are key heart disease risk factors.” These are all modifiable risks for heart disease; these can be alleviated by medication, dietary change and avoiding cigarettes. The agency reports that 49% of Americans have at least one of these three modifiable risk factors. In addition, having other medical conditions and “lifestyle choices” can put people at a higher risk for heart disease. The agency lists these contributors: diabetes; overweight and obesity; poor diet; physical inactivity; and excessive alcohol use.
The unsubtle message is that public health, including your health and lifespan, can be bolstered and even fortified by keeping your blood pressure in check, eating moderately, not smoking, being physically active and not drinking too much alcohol. These are all true, undeniable facts. Except maybe some experts would argue about what’s the correct blood pressure threshold above which medication is appropriate, or about how much drinking constitutes too much. But the gist of these pointers—that eating and drinking only in moderation, not choosing to inhale extra toxins and keeping fit tend to promote health—are for the most part incontrovertible.
So why is it so hard for so many people to stay on the treadmill?
This year, the Annals of Internal Medicine published an editorial titled "Exercise as Medicine." The authors wrote: “Despite the overwhelming evidence of the benefits of physical activity…only about one in five adults meets the Centers for Disease Control and Prevention physical activity guidelines.” They suggest that doctors might play a greater role: “Physicians and other healthcare professionals are among the most influential sources of advice regarding lifestyle changes, such as adopting a regular exercise program. Studies have demonstrated the feasibility and effectiveness of brief physical activity counseling in the primary care setting…Yet, only about one-third of adults say their physicians have advised them to exercise.”
Of course, I think it’s a good idea for physicians to talk with patients about fitness and exercise. They should ask about eating and drinking habits. I suppose they should ask about binging, too, given the emerging prevalence of eating disorders. They should discuss weight gain or loss. But physicians may lack the time or conversational skills needed to discuss lifestyle concerns in an effective and not off-putting way.
Providing infographics on nutrition, referring patients to Let’s Move or Weight Watchers, or suggesting an app to promote fitness can help, too. There are many terrific programs, and if they work, great. But the reality is that this kind of medical advice won’t always help, for two main reasons.
The first reason for advice failure—a.k.a. not listening—is social, and might be deemed economic: many people lack the resources to live in a healthy, doctor-approved sort of way. I’ve traveled to too many places in the United States where it’s hard to find vegetables that aren’t fried with bits of meat, or thawed after freezing with chemicals and processed mush, to know that food deserts are real. Similarly, there are cities where there’s nowhere to jog or even walk safely, or to swim. Joining a gym costs more than many people can afford, and not every city has a Y with a pool and spin classes. It’s easy to say people should be healthy. But another key resource is time: in some households, there just isn’t. People don’t exercise because they’ve got a job, caregiving and other responsibilities about which their physicians may not have a clue.
The second main reason is psychological. People can be self-destructive and punishing to themselves. Why lose weight if you feel hopeless, or have no reason to live, or just don’t care? Besides, bad behavior can be fun. People like to eat and drink. I’ve had roommates, including one of my favorites, a doctor-to-be in medical school, who smoked cigarettes. She was really smart and liked to smoke. I knew a young doctor in my lab years who’d step out of the research building, where he worked constantly and with career ambition, to light a cigarette. Once I asked him about it. “I don’t care if I live to be old,” he told me.
A related, psychological factor can be a kind of arrogance, a false sense of invulnerability and not needing to take care of oneself. Take our President-elect, Trump. He’s got all the resources in the world. Yet he loves junk food. When asked about his exercise habits, he told People magazine that he goes to rallies and stands and moves his arms around. He made similar remarks in a TV interview with Dr. Mehmet Oz. In that program, in which his weight and BMI were considered, Trump admitted that he “would like to drop 15 or 20 pounds.” But he hadn’t, at least not by then. A man might believe he is so exceptional, or has such “great genes,” or whatever, that he needn’t worry about his diet, or bother losing those pounds, or otherwise modify his lifestyle as other people do.
Which leads me back to the end of this year, 2016, and reality. A few days ago, the actress and mental health advocate Carrie Fisher died. She was 60 years old, and seemingly active. By all accounts, Fisher’s heart stopped while she was on a plane. We don’t know why. She became unconscious and received CPR. Upon arrival in Los Angeles, she was transferred directly to a hospital, where she died. Her mother, the actress Debbie Reynolds, died the next day at age 84, reportedly after a stroke. Reynolds may indeed have been heartbroken.
The medical details of the case are unknown. But the episode has people talking about Takotsubo cardiomyopathy, a heart condition which tends to affect women more than men. This infrequently occurs after extreme emotional stress, such as the death of a child. The heart swells so that it resembles an octopus trap, or so it seemed to the Japanese physicians who named this sad pathology.
There are many ways by which the heart can fail a human. In medical school, I learned that heart attacks can be triggered by blockage of an artery, so that the smooth muscle becomes depleted of oxygen and fails to squeeze; or by arrhythmias, when electrical signals cause the heart chambers to beat so irregularly or fast that they stop pumping well; or by rupture of a valve; or by any among a host of other, less common and some obscure conditions. When the heart stops working as it should, it “fails” to pump blood into the aorta and other vessels, including its own blood supply, and congestive heart failure ensues.
Not all forms of heart disease can be prevented. It’s impossible to say if the heart-related death in Manchester by the Sea, or in recent news, could have been avoided. So I will not conclude that everyone should honor the memory of Carrie Fisher, or Princess Leia, or 2016, by signing up for a gym membership and counting laps or miles. The question for the new year is not if there’s reason to exercise, or modify your habits, but if you want to do so.
For myself, I am hesitant about making resolutions. It happens I swim regularly and expect to continue doing so. But I am fortunate to have access to an indoor pool. No one is perfect. Striving for perfection can damage. So I’ll say this: I wish for everyone a low-stress 2017; that you have enough food to eat well, but not too much; that you find a way to exercise that’s pleasant, so that you don’t mind doing it; and that you feel well, so you can be productive and help others, and experience joy, wherever you are.
Cheers!
