Long before the discovery of his heart disease two years ago, Gov. Jim Edgar was known for his abstinence from alcohol and tobacco, his love of bicycling and a generally healthy lifestyle.
After chest pain led to balloon angioplasty to open his coronary arteries, Edgar seemed to embrace clean living with even greater zeal, attending a Pritikin camp to wean himself from his beloved bacon cheeseburgers, fried chicken and other down-home food favored at political rallies and picnics.
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The governor shed pounds from his already trim frame and became noticeably lean. His doctors regularly monitored his blood pressure, cholesterol and general vital signs. About the only thing he didn’t do was duck the stress of Springfield’s partisan politics.
So when Edgar required emergency coronary bypass surgery Thursday night, many people were shocked that someone who seemed to do everything right could still be stricken.
The truth is that, despite much publicity from some public health advocates, so-called risk factors like smoking cigarettes and having high blood pressure are associated with only about half of all heart attacks.
Some of the greatest risks for heart disease, such as being male, being older and having a family history of coronary illness, are unalterable. Other factors known to play a role, such as stress, are poorly understood and can be far more difficult to control than choosing an apple as a snack instead of potato chips.
“The quick answer is that you can modify your life to reduce your chance of a heart attack, but you’ll never reduce that risk to zero,” said Dr. Alan Garber, associate professor of medicine at Stanford University.
Saturday, Edgar continued what his physicians described as an encouraging recovery from quadruple-bypass surgery. He was alert and able to sit up to eat yogurt, juice and dessert gelatin. Edgar also took several steps around his room, doctors said.
In their enthusiasm for pointing out heart-disease risk factors, many advocates have oversold the benefits of lifestyle modification to the public, Stanford’s Garber said.
“Some efforts to persuade the public to change diet and lifestyle have oversimplified scientific facts in a way to lead people to believe there is more to be gained than there really is,” said Garber, who is an economist as well as a physician and who is writing cholesterol guidelines for the American College of Physicians.
“It’s difficult when you want to persuade people to change their habits to be even-handed in presenting scientific evidence, which is often much weaker than the public is led to believe.”
In the case of cholesterol, for example, the early strategy endorsed by public health advocates was for everyone to learn their cholesterol levels and work to lower them.
“One unfortunate aspect of that policy was to encourage a lot of younger people who were already jogging and eating low-fat diets to go to their doctors to learn their cholesterol levels and then worry about them,” Garber said.
“These people are already at such low risk that they don’t need to worry about cholesterol. It’s much more important to target people truly at high risk, such as those who’ve already had a heart attack, rather than the whole population.
“I think federal health officials now recognize that, and their approach has changed over time.”
Much of what science knows about coronary risk factors has been gleaned from studies that follow large groups of people over long periods, correlating information about lifestyle with illness and deaths.
The best known of these started in Framingham, Mass., in 1948 and enrolled 5,000 people. A second generation of more than 5,000 has been enrolled to continue the work.
That study has yielded solid evidence associating cigarette smoking with coronary disease and death, and it has found correlations with high blood pressure, high cholesterol, male gender, age and other factors.
In general, said Dr. Peter W. Wilson, director of laboratories for the Framingham study, these factors are associated with half the heart disease.
“There are a bunch of unknowns associated with the other half of heart disease,” he said. “Part of the thing is we don’t measure them that well, or don’t know what to measure.
“For example, someone may have normal blood pressure when it’s measured in a physician’s office, but when he’s sitting there in a traffic jam, his blood pressure goes way up. Then he gets (chest pain), and we’ve missed that. That could be borderline hypertension.”
Someone who eats sensibly and doesn’t smoke could have several “borderline” risks, such as slightly elevated blood pressure or cholesterol, Wilson said.
“If he had just two borderline risks, he would have a threefold overall increased risk,” he said.
But it is easy to look at studies and get the mistaken impression that the averages apply to everyone. Even though on average, people who try to reduce these risks may live longer, there are no guarantees that any individual will benefit.
“Life is a somewhat chancy process,” said Dr. Stephen B. Hulley of the epidemiology department at the University of California at San Francisco. “We don’t have the knowledge or tools to guarantee long life to every individual. All we can do is try to improve the odds.”
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The notion of risk factors and odds improvement has become quite popular in American medicine and much of Europe, but there are skeptics who think too much is being made from too little evidence.
Two University of Dublin scientists, Drs. James McCormick and Petr Skrabanek argued in the Lancet, a British medical journal, several years ago that the very term “risk factor” is flawed because it implies causes and effects that aren’t proven.
They cited 246 documented “risk factors” for coronary disease, including “not having siestas, snoring, having English as a mother tongue and not eating mackerel” all of which appear to be associated with elevated levels of heart disease.
But despite critics, most physicians caution against abandoning lifestyle changes and risk-factor reduction as mainstays in fighting coronary disease.
“I would not take the governor’s experience as anything to discourage me from recommending the healthy habits I have been advocating,” said Dr. Philip Greenland, chairman of preventive medicine at Northwestern University.
“From a scientific point of view, what (Edgar’s illness) tells us is that there’s more we need to know. But it doesn’t mean that what we do know should be thrown out.”