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Do We Rely Too Heavily on Medicine to Save Us? : Health: Think twice before you chomp into that second corn dog. Science is greatly lowering the number of deaths from heart disease but just as important is our move toward healthier lifestyles.

July 06, 1993|SHARI ROAN | TIMES HEALTH WRITER

For those who bypass red meat and butter, meditate each morning and lace up the Nikes after work, things are looking good.

Heart disease death rates have plummeted 40% in the past decade. And within the next five to 10 years, science may add four new strategies to its heart-disease prevention arsenal.

The drop in death rates so far is partly attributable to a decline in smoking, better control of hypertension and improved diets and exercise habits, says Dr. Edwin Jacobson, chairman of a recent conference on heart disease prevention sponsored by UCLA Extension.

"Part of the drop in deaths is due to better technology," he says. "But at least half of it can be accounted for by preventive measures."

But while the importance of lowering weight, blood pressure and cholesterol levels has been known for some time, it's the new research--into aspirin, hormone replacement therapy and the antioxidants vitamin E and beta carotene--that is so scintillating.

With so much in hand to prevent heart disease, experts are beginning to ask why 1.5 million Americans are still having heart attacks each year and half a million are dying from the disease.

"It may be that all of these gains (in reducing heart disease deaths) may be taken for granted," says Dr. Charles Hennekens, a Harvard University researcher and director of two major heart disease prevention studies in doctors and nurses. "The reality is still that coronary heart disease will kill one in three of us."

And while antioxidants may contribute to reducing heart disease, experts say the effects will be limited if Americans don't address some of the underlying causes first, such as a poor diet and sedentary lifestyle. Although exercise is one of the top prevention strategies for heart disease, an estimated 60% of American adults are sedentary and about one in five is obese.

"Most Americans may find drugs more easy to use," says Hennekens. "But it's the avoidance of a harmful lifestyle that can make the largest difference. If we are right about antioxidants preventing heart disease, the benefits they confer will still be small compared to stopping smoking, reducing cholesterol and controlling hypertension."

Clearly, changing lifestyle habits is frustrating for many people, experts acknowledge. And even groups like the American Heart Assn. have re-evaluated their earlier advice on prevention in order to make it more effective.

For example, instead of promoting a rigid exercise schedule of at least three times a week for 30 minutes, the association now urges people to simply incorporate moderate exercise into daily life.

"We and other organizations have gotten away from the idea that you have to go to an exercise club or gym. The idea is to build exercise in," says American Heart Assn. spokesman Howard Lewis.

As for diet, the most nagging problem for health experts is how to help Americans regularly eat lower amounts of fat and cholesterol. Thousands of Americans are still victims of harmful "yo-yo" dieting. Last year the National Institutes of Health reported that diets fail for the vast majority of people.

Some health experts are moving to the more extreme strategy promoted by Dr. Dean Ornish, director of the Preventive Medicine Research Institute in Sausalito and author of "Eat More, Weigh Less."

Ornish says that instead of limiting fat to 30% or less of the diet, it should be no more than 10%.

"The problem is that most recommendations don't go far enough," he says. "If you make small changes--say, go on a 30% fat diet--you have a sense of deprivation, but you are not getting much benefit. Your weight doesn't come down very much. Your cholesterol doesn't come down very much. But if a person makes comprehensive change, they generally feel so much better so quickly that the choices become so much easier for them."

A comprehensive prevention program must incorporate exercise and stress reduction, Ornish says.

"We have to address why we overeat, smoke or work too hard," he says. "If people can address their pain or loneliness head on, they are much more likely to embrace these other changes (diet and exercise)."

The tendency to ignore what causes heart disease in the first place has led Ornish and many other experts to downplay the effects that aspirin or the antioxidants might have.

"Taking aspirin is important, but only in the context of these other things coming first," Ornish says.

Within five years, Harvard University's Nurses' Health Study of 87,000 female nurses should yield information on whether aspirin, vitamin E and beta carotene help prevent heart attacks in women. The Physicians' Health Study, also by the university, already has shown that aspirin is good for men.

And within the decade, experts should have a recommendation about one of the most controversial and complicated heart disease prevention strategies: hormone replacement therapy for post-menopausal women. Preliminary evidence suggests hormone therapy may cut heart attack risk in women by half.

"The likelihood is that (research) will tell us this," says Dr. C. Noel Bairey Merz of Cedars-Sinai Medical Center, which is participating in the Heart and Estrogen-Progestin Replacement study. The study, which is still recruiting women to participate, will determine if those assigned to take hormones have fewer heart attacks.

The newer prevention strategies are at an "awkward age," Dr. Daniel Steinberg of UC San Diego cautioned in an editorial in the New England Journal of Medicine in May.

Although early research looks highly promising, he wrote, "we must not make exceptions to the rule that recommendations . . . must be backed by proof."

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