A Better Way to Manage Risk
"If Americans adopted a vegetarian diet, the whole
thing would disappear," Castelli says of the heart disease
is where Castelli's new endeavor comes in. In 1995, Castelli
left the Framingham Heart Study to become medical director
of the Framingham Cardiovascular Center, just miles from the
heart study's home. Castelli considers the Cardiovascular
Center a thank-you gift to the people of Framingham.
worked on the Framingham study thirty years," he says. "I
never cured anyone, but the gift of the people of Framingham
is that they taught us the risk factors. We're looking for
a better way to manage risk."
majority of Castelli's patients have had a heart attack. Many
are in imminent danger of having another. To save these people's
lives, Castelli looks to the data.
key is the LDL cholesterol," Castelli says.
MRI scan of an aorta clogged with plague.
Alan's relief, his own aorta was squeaky clean.
stands for "low density lipoprotein," or- as Castelli calls
it- 'lethal' density lipoprotein. LDL is an important chemical
component of all cells, but too much of it in the blood stream
wreaks havoc. It irritates the lining of blood vessels, triggering
an immune response that actually does more damage to the vessel
wall than to the LDL. The LDL winds up stuck to the now ragged
vessel wall, and the deposit can quickly become a plaque or
blockage that interferes with normal blood flow.
National Heart, Lung and Blood Institute- the Framingham Heart
Study's Parent organization- has developed guidelines to help
determine how high is too high when it comes to blood LDL
levels. Castelli, however, takes issue with those numbers.
While he certainly applauds the emphasis on lowering LDL levels,
Castelli doesn't think the NCEP goes low enough by aiming
"I would rather see 80 or less, based on studies from places
where people can't get this disease."
Keeper of the Numbers
"It takes only two months of a healthy lifestyle
to reverse heart disease. Cardiologists call me up and
ask, 'What did you do?'."
who walk into the Framingham Cardiovascular Institute, says
Castelli, "become the keeper of their own numbers." Patients
receive a sheet of paper titled "My Score Card" in big, friendly
letters, with a less friendly list of abbreviated risk factors
down the left side: weight, Hdl chol., LDL chol., trygly.,
homocyst., Lp (a), Sys bp, Dias bp, Bld sugar, cigs/day, exercise,
calories, grams tot fat. . . Seventeen variables in all.
After a preliminary blood test, a patient fills out the sheet,
then compares his or her stats to the desirable numbers listed
down the right side of the sheet. Castelli prescribes diet
and exercise to lower each number.
and Bob Castelli enjoy a heart-healthy meal with longtime
"Low fat diets on average take about 2 weeks before you see
the numbers fall," says Castelli. "In the beginning we waited
exactly a month, and then have patients come back month by
numbers did fall dramatically, but not everyone was pleased
with Castelli's aggressive tactics.
"We did get into trouble with the HMO's," Castelli sighs.
"They brought us up on the carpet for ordering too many tests.
So, we have patients come back every 6 or 7 weeks instead
and the HMO's computers miss it."
But the HMOs' "if it ain't broke, don't fix it" stance, says
Castelli, is mirrored by patients themselves. Twenty percent
of heart attack victims never even fill their prescriptions
or re-visit a cardiologist. A study of HMO records in Cooperstown,
NY showed that absolutely no heart disease patients had managed
to get their numbers down to acceptable levels within a year
after suffering a heart attack.
the motor's running good," Castelli describes the attitude,
"they don't look under the hood."
why regularly scheduled visits with the nurses and the nutritionist
at his clinic are so vital to reversing and preventing heart
disease. But what if you haven't had the heart attack that
sends you to Castelli's office yet? A professor of preventative
medicine at Harvard Medical School for 34 years, Castelli
preaches to physicians and the general public alike about
the importance of diet and exercise to keeping those critical
numbers nice and low.
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