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A Better Way to Manage Risk

"If Americans adopted a vegetarian diet, the whole thing would disappear," Castelli says of the heart disease epidemic.

This 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.

"I 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."

The 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.

"The key is the LDL cholesterol," Castelli says.

MRI scan Clogged artery MRI scan clean artery      
An MRI scan of an aorta clogged with plague. To Alan's relief, his own aorta was squeaky clean.      

LDL 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.

The 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 for 130.

"I would rather see 80 or less, based on studies from places where people can't get this disease."

The 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?'."

Patients 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.

Photo of group dinner
Alan and Bob Castelli enjoy a heart-healthy meal with longtime Framingham residents  

"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 month."

Patients' 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.

"If the motor's running good," Castelli describes the attitude, "they don't look under the hood."

That's 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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