The heart disease delusion, and who profits

This past Sunday, I was privileged to speak on a panel, addressing the fundamental importance of diet to heart health, at a session of the American College of Cardiology conference in Orlando, Fla. The ACC is a large organization, and its annual conference is a big draw. The result is a rather massive meeting, inevitably housed in a cavernous convention center. Orlando was no exception.

My wanderings through that vast and labyrinthine building prior to my session took me through the exhibition hall, where I snapped a photo, in a space that stretched to the limits of one’s gaze in every direction, of sleek displays, ranging from modest to grandiose, of drugs and more drugs, devices and technology and the instruments and procedures of revascularization. All of this vast display, and the implied, monumental mobilization of money, time, training, effort, pain, treatment, recovery, and resources of every description — were for a disease that virtually no one needs to get.

In the world’s five Blue Zones, people routinely live to be 100 in the absence of chronic disease, including coronary artery disease. This is attributable to lifestyle, which is in turn attributable to culture. But whatever the causes, and the causes of those causes of Blue Zone blessings, the fundamental message is perfectly clear: coronary artery disease as a mid-life rite of passage need not occur. The same compelling message issues from the Bolivian Tsimane, the wellstudied population of modern-day “hunter gatherers,” or foragers, in the Amazon. They have stunned researchers with their consistently pristine coronary arteries that show no signs of atherosclerotic degradation across the decades of their lifespan.

The populations above are not genetically homogeneous; they are quite diverse. Immunity to coronary disease is courtesy of culture and lifestyle, not ethnicity or some lucky assembly of genes.

This immunity can be conferred. When Ancel Keys first began his work, the premature death rate from coronary disease in Finland was one of the highest, if not the highest, in the world. When the lessons of Keys’ work were applied with fidelity in the North Karelia Project in that country, coronary disease rates dropped by over 80 percent , and average life expectancy increased by more than 10 years. Migration studies, such as Ni-Hon-San, involving the movement of people (in this case, Japanese) and their genes from one culture to another demonstrate the same: marked variation in disease rates as genes stay the same, but lifestyle and culture change.

America runs on coronary artery disease. Coronary artery disease is fully embraced in our culture as a veritable rite of passage. If, at a certain age, you don’t have a CABG scar for show and tell, or at least an anecdote about the particular intracoronary stent you’ve received, you are the odd man (or woman) out, the cultural anomaly. Real Americans, and increasingly real residents of all the world’s developed countries, get stents! One is all but embarrassed not to have one.

This is as tragic as it is unnecessary. My view of that exhibition hall, the massive scale of our cultural obeisance to an unnecessary disease of our own devising all but knocked the very wind out of me, and left me thinking of a single word in my momentary disequilibrium: delusion. The disease delusion.

Heart disease is the leading, proximal cause of premature death among women and men alike in the United States. The distal, or root causes, are a lifestyle also subordinate to the dictates of culture — a culture that runs on Dunkin; peddles multicolored marshmallows as part of a complete breakfast; and conflates the Olympics with a trifecta of fast food, junk food and sugar-sweetened beverages. The drug and device companies in that ACC exhibition hall are beneficiaries of so much coronary disease; so, too, are the many mainstays of our culture outside that hall that profit directly by its propagation.

In our one session at ACC2018, we spoke of the power of diet and lifestyle to prevent, treat, and reverse coronary disease. Although our session was packed to capacity, standing room only, we were nonetheless a tiny and atypical island in the mighty currents of calamitous cultural norms. The massively impressive aggregation of resources in that exhibition hall delivered the message loud and clear: Go ahead and assault your coronaries like everyone else does. It’s fine. It’s normal. We’ve got drugs and devices and doctors for that.

Preventive Medicine