Co-written by Justin Birge, M.D.
"Ask not for whom the bell tolls; it tolls for thee" -- John Donne (1572-1631)
Heart Attacks and Strokes
Within hours of the news that Tim Russert, the host of Meet the Press, had died of a heart attack, physicians around the country received phone calls from reporters, columnists and concerned patients wondering how a privileged and well-connected 58-year-old man, who clearly had access to the best health care America has to offer, could get up in the morning, go to work, sit down at his desk, have a cup of coffee, cough once, stand up and die.
Yet what happened to Tim Russert happens more than 400,000 times a year in America. In fact it happens once every 60 seconds. But this kind of sudden death is a small fraction of the actual incidence of cardiovascular disease. For the majority there will be no quick deaths, but literally decades of congestive heart failure, difficulty breathing, dementias, dozens of medications and immeasurable suffering.
Much of this disease burden is associated with a new medical diagnosis, a diagnosis that was unheard of just a few years ago, but a diagnosis that is becoming more common not only for adults but for adolescence and even children: the metabolic syndrome.
The Metabolic Syndrome
As the name implies, the disease is a cluster of different conditions that taken together increase the risk of diabetes, heart disease and strokes. But basically, it is a medical condition that is largely the result of overeating and living a sedentary, inactive life. Today, weight is the new enemy and lack of exercise the new fatal disease.
To be diagnosed with "metabolic syndrome," a person must have at least three of the following five medical diagnosis or abnormal laboratory values: abdominal obesity, elevated triglycerides, low high density lipoprotein, elevated blood pressures, and high fasting blood glucose along with increased Insulin levels. Whatever the diagnostic criteria, to be diagnosed with metabolic syndrome is to be at a significant risk of early death.
A Short History of Medical Risks
Here is a basic statistical fact. Medical risks, like all risks, are additive or, put scientifically, are cumulative. The "absolute risk" of developing a disease is the sum of each of an individual's risk factors. The chance of having a heart attack or stroke is like any other set of risks -- for example, the risk of driving onto a freeway and having an accident. There is always some risk of crashing by entering the freeway, but the actual risk increases incrementally and substantially if you are drinking and driving, if your brakes won't work, if the suspension on the car is faulty, the windshield dirty, your headlights malfunctioning, or if you are on your cell phone or texting, daydreaming or simply not paying attention.
Speed, too, is a risk. At more than 65 miles an hour at the time of impact without seat belts, the risk of significant brain and spinal injuries is virtually assured. At more than 90 miles an hour death is a virtual certainty. Whatever else might be wrong, a diagnosis today of metabolic syndrome is like entering a freeway going more than 100 miles an hour.
The various individual risk factors for heart disease -- age, elevated blood pressures, high cholesterol, smoking and diabetes -- are well-known. Less known is the fact that these risk factors are additive. For example, smoking two packs of cigarettes a day instead of one pack, having a slight increase in blood pressure even below the standard normal range of 120/80, being 80 pounds overweight instead of 20 pounds or having a cholesterol level of 300 rather than of 150 increases the absolute risk of a heart attack or stroke. That ambulance that you hear coming down your street at 2 a.m. is not there because a neighbor fell down the basement stairs.
To understand how this happened we do have to know something about fat, and then a bit more about modern agriculture.
The Anatomy and Biochemistry of Fat
Until recently, fat cells were thought to do only one thing, and that was to store fat to be used as an energy source during times of famine. It is only recently that the new generation of medical researchers have begun to consider adipose (fatty) tissues to be their own organ system, but an organ that unlike any other bodily organ has the potential for unlimited growth. You can't grow another heart or replace a damaged kidney, but you can always grow more fat cells.
Unfortunately, fat cells do more than store fat for times of famine. In reality, fatty tissues are incredibly biologically active, producing an amazing number of hormones that influence metabolism, the vital organs, the appetite centers of the brain and behavior. Basically, as fat accumulates a person become less sensitive to the hormonal cues regulating appetite, satiety and the adequacy of total body energy storage. In short, the more fat cells, the more you want to eat. A system that works well in times of food scarcity is clearly dangerous in an environment of curly fries, "super-sizing" and the inactivity of five hours of television a day.
There is little doubt that our energy storage system works well in times of food scarcity but is clearly dangerous in the presence of caloric abundance. In reality, cravings for fatty foods and sugars becomes a metabolic disaster in an environment of curly fries, "supersizing" and five hours of television a day.
A New Normal: Our Agricultural-Industrial Complex
Agriculture has only been part of human history for approximately the last 10,000 years. The use of agricultural tools has been around for less than 500 of those 10,000 years, and only within the last 50 years has present day agri-business, with its emphasis on processed meats, fatty and sugar-rich foods along with salty snacks, been in place.
On a biochemical level, our cells and tissues have not adapted to our new food culture. Our bodies are as unfamiliar with sugared drinks, processed meats and potato chips as they would be if the oxygen levels in the air suddenly fell precipitously or carbon dioxide amounts quickly quadrupled. Life when faced with sudden and extreme changes can be unforgiving.
The Role of Physical Activity
Yet there is a question today as to how much of our deteriorating health revolves about our increasing waist sizes and how much depends of how we move and whether or not we keep moving. Yet in a very real way that question was settled more than 50 years ago in a British study entitled "Coronary Heart Disease in Transport Workers." In that research paper, published by the British National Health Service, tram operators were studied to determine the incidence of heart attacks and strokes. The drivers of the buses and trams were from the same economic and social class with the same life styles. They had the same body weights, same degree of smoking, same diet, same intake of alcoholic beverages and same amounts of coffee or tea.
What the researchers found was quite startling. The tram employees who walked back and forth collecting tickets had an astonishing decrease in the numbers of heart attacks and strokes compared to their colleagues who sat all day driving the buses.
At the same time as the tram operators study there were a number of studies in the U.S. referred to collectively as The Fat Farmer Study. The overweight farmers of half a century ago did not die of strokes or heart attacks, or did they go into heart failure. These farmers started to die in increasing numbers only when they bought their combines and began to sit all day.
A recent population study of more than 200,000 Australian adults has shown that prolonged sitting by itself, unrelated to weight or even any preexisting medical conditions, becomes a risk factor for "all-cause mortality," and that "high volumes of sitting time have possible associations with increased risk of obesity, cardiovascular disease, diabetes, and cancer." There is an increased mortality with "sitting during leisure time," "sitting in car time," "time while driving to work," "lengths of time sitting at school," "sitting while doing housework" as well as in those occupations that require long periods of sitting during working hours. Compared to weight gain alone, lack of simply not exercising or not moving clearly posses the greater medical threat.
Improving our health is not going to result from a fad or a pill. The vanity of weight loss alone should be replaced by walking at least 150 minutes a week along with a diet of nutritious, well-portioned foods. Nature if not yet medicine is trying to warn us when we feel the snugness getting dressed in the morning or sense that shortness of breath when we climb stairs that we had better stop weighing ourselves and just start moving. The Negro Spiritual might well have said it best: "It isn't what you don't know that does you in; it's what you think is so, but ain't..."