My lament is literal, not figurative. As a humanist, I might well have cause to lament the figurative state of the American heart, too: the roiling churn of diverse “isms” that are the new normal, disfiguring and pockmarking the ideals and values a big-hearted land of inclusiveness has long beamed to the world. But my lament is literal. To paraphrase an NBC News headline that stated the case bluntly: almost half of all Americans have heart disease.
So, my fellow Americans: feel that thump in your chest? Now, flip a coin. You are in one camp or the other.
Actually, I think the situation is quite a bit worse than that. The statistics in play here refer only to adults, and thus ignore the earlier, inchoate versions of all the same risks in our children. They refer only to overt evidence of cardiovascular disease, not to the risk factors for risk factors that are on plain display long prior.
Do a more expansive version of much the same math, in other words, and the conclusion is far bleaker. If you are an American adult, and have a heart, either it is in some state of sad peril, or you and your vitality are the anomaly- consigned to the enviable region of rounding error. Nice to have a bit of company there.
The statistics in question come from a report entitled Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association, published yesterday (1/31/19) in Circulation. As detailed in the full report, the work represents a year-long effort by a multidisciplinary group of experts with the American Heart Association, the National Institutes of Health, and other government agencies to compile and disclose the most current data on heart disease, stroke, and cardiovascular risk factors in the U.S.
As implied by the NBC News headline, and others just like it, the salient implication is an increase in the prevalence of cardiovascular disease over recent years, and a related increase, albeit modest, in cardiovascular deaths.
Let that sink in for a moment- in this age of emergency angioplasty and drug-eluting stents; of newly devised bioengineered agents to inhibit platelets and lower lipids; of robotic surgery, and CT-based calcium scoring- cardiovascular deaths have gone up.
We in preventive and lifestyle medicine have long noted that despite the profound limitations of modern medicine with regard to promoting health or vitality, it is astonishingly good at forestalling death. That is the very reason we have so much “chronic” disease; what used to kill us now meets its match in the CCU or ICU. The result is generally a stalemate: the disease and treatment go on together, for years or even decades.
In that context, even a slight rise in cardiovascular death is truly startling, and alarming.
Such alarm bespeaks high drama, and indeed, I believe this report- running to 473 pages and covering the Heart Association’s check list known as Life’s Simple 7 (smoking, physical activity, diet, weight, cholesterol, blood pressure, and glucose control) as well as sleep and other topics notable for including social determinants of health- signifies just that. But before affirming the drama, and exploring the implications of it, there is one welcome reason to dial it down a notch.
As noted prominently in much of the media coverage of the AHA report, the definition of high blood pressure was altered between this report and the last. The threshold was formerly set at 140/90, but has been revised down to 130/80. As a result, millions of Americans who didn’t meet criteria for high blood pressure before, now do. This is not a change in actual condition; it is a change in cataloguing. We saw just such an overnight bump in the prevalence of obesity years ago when that definition was revised.
But while there is an argument there for mitigating our alarm, the counter-argument is rather robust as well. The definition of high blood pressure, or “hypertension,” was not revised downward without reason. The most recent evidence suggests that what was once considered the high-normal range of blood pressure is associated not only with increased risk of heart attack and stroke, but with dementia as well. The new approach to cataloguing BP is well justified. Stated differently: we are not over-diagnosing cardiovascular disease now; we were under-diagnosing it all along. The wake-up alarm stands.
So, let’s concede without reservation, this is dramatic. Gather in any room with adult friends, family, co-workers, or strangers for that matter. A cinema; supermarket; church, temple, or mosque; the bank; a school; a party; shopping mall or…football stadium. Look around. Half of everyone there has some form of cardiovascular disease and will suffer chronic infirmity, premature death, or both as a result of it. Look in the mirror, too- because you could well be with that half.
That, though, is not the claim to drama here. The true claim to drama is that almost none of this disease needs to happen. Almost none.
More than a quarter century ago, a report on much the same topic- chronic disease and premature death in America- made clear that 80% or more of it all could be eliminated simply by not smoking, being active, and eating reasonably well. With attention to the full list of “root causes” of premature death, even more of it could be eradicated. In the years since, that message has only ever been reaffirmed in the peer-reviewed literature. Populations like the Blue Zones, and the Tsimane, show us that cardiovascular disease does not need to happen as we age- a profound insight that first inspired the inimitable efforts of Ancel Keys. The experience in North Karelia, Finland, shows that what we know about the prevention of heart disease by lifestyle means can be introduced and made to work in beleaguered populations- like our own.
Roughly half of us all- meaning half of you reading this now- have cardiovascular disease in one form or another, whether you know it yet or not. Many in the other half have earlier versions of all the same risk factors, and will trade camps in the fullness of time. This is the sad state of cardiovascular health in America now. It is increasingly the sad state of the modern world as well.
But let us take heart, not lose it, over this provocation. We have long known how to leverage lifestyle to eradicate this scourge. Knowledge is power the moment we decide to translate what we have long known into what we routinely do. This report is simply a reminder that now- would not be too soon.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and current President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.