Subjects of Cardiac Study Not All Taking It to Heart

Stop in any fast-food restaurant on State Route 9 in Framingham during lunchtime, and you can be sure the tables will be jammed with people devouring burgers and fries.

Shop at Purity Supreme, Big D Discount or any other supermarket in town and you will not notice any dearth of customers stocking up on hamburger meat and steaks or a lack of smokers buying cigarettes at the registers.

Drive through downtown, past Town Hall, the courthouse and the tidy town common or along any of the quiet, tree-lined side streets, and you may see a few joggers. But no more than anywhere else these days.

World-Famous Heart Study

None of this would be surprising if this were any other town. But this is not any other town. This is Framingham, home of the world-famous Framingham Heart Study--the longest-running and most comprehensive study of its kind in medical history.

Since 1948, thousands of townsfolk have stopped by a special clinic every few years to undergo an extensive examination by doctors searching for clues to the causes of the nation’s leading killer--heart disease.

They give blood, blow into tubes, walk on treadmills, get their hearts checked with the latest gadgets and answer question after question about whether they have been sick, what they eat, how much they exercise and generally how they live their lives.

Because of their unusual dedication, most people everywhere now know that things like smoking, eating fatty red meat, being overweight and having high blood pressure and high blood cholesterol levels increase their chances of having or dying from a heart attack or stroke.

So you would think that the people in the study and their neighbors in this thriving suburb of about 68,000 about half an hour drive west of Boston would know all these things better than most people.

And knowing this, you would think they would exercise more, stay away from fatty meat and generally have unusually healthy life styles. And living that way, you would think that fewer of them would die from heart attacks and strokes.

You would be wrong.

“I think basically they have the same problems that everyone else has,” said Dr. William Kannel, a former director of the study who is still active in the project.

Take Brian Richards, 27, who sat at the crowded counter of the J & C Luncheonette on Hollis Street one recent afternoon finishing off a plate of macaroni and sauce on his lunch break from a local upholstering shop.

“It is a constant reminder you shouldn’t smoke, you should get exercise and you shouldn’t eat lousy food,” said the bearded, lanky Richards when asked about the study.

So how about you?

‘I’m Healthy Enough’

“Oh, I’m still smoking, I’m still eating lousy food, and I don’t exercise,” he said, grinning. “I guess I feel I’m healthy enough. I never go to the doctor.”

The people in Framingham are probably better informed than most about heart disease and strokes. But if you took a sampling of the customers eating lunch at the J & C or at Twin’s Bar-B-Que down the street, you could bet they are just about as likely to suffer a heart attack or stroke as anywhere else.

“It’s something they identify with, but they do not, I think, behave a lot differently than the general population,” Kannel said. “Maybe familiarity breeds contempt.”

Dr. William Castelli, the study’s current director, added: “I don’t think the fast-food places have suffered any by coming to Framingham. They’re just as bustling here as anyplace.”

When researchers began the study, very little was known about why people had heart attacks, which had become the leading cause of death in many Western countries.

They decided to take an approach that had previously only been used to study infectious diseases. By following a large group of people for a long time, they hoped to identify differences between those who developed the disease and those who did not.

The investigators picked Framingham because the town’s population of then about 28,000 people of mostly Irish and Italian descent was very stable and led fairly typical lives. Residents had also shown that they were unusually cooperative during an earlier tuberculosis study.

The 5,209 healthy men and women between the ages of 30 and 62 who agreed to participate went on to show that heart disease was not an inevitable part of life. The way they lived had a lot to do with whether they had a heart attack or stroke.

The study defined the concept of “risk factors” for coronary artery disease, a buildup of fatty material inside blood vessels leading to the heart that narrows the passageways and sets the stage for the arteries becoming blocked.

“In those days it was thought that everything had a cause,” said Kannel in an interview in his office at the Boston University School of Medicine, which runs the study with funding from the National Institutes of Health.

“We established the principle that this was the process of evolution of a variety of factors, some of which were living habits, some of which were personal attributes,” he said.

Along with what has now become a standard list of risk factors, the study also revealed that people with high-strung “Type A” personalities were more likely to drop dead from heart attacks, that a drink once in a while appeared to lower the risk, that men married to educated women had a higher risk and that many people had heart attacks and never even knew it.

In 1971, the researchers decided to extend the study to the children of the original participants. Although many lived elsewhere, 5,128 offspring and their spouses joined “Son of Framingham” to try to shed light on how much of the risk for heart disease was inherited.

The original members and the younger group underwent the same types of exams, although the offspring came in every four years. The younger subjects also walked on a treadmill as part of a stress test because they were more fit.

Being a member of the study became a source of pride for the town and the participants. Like royalty, the only way to get into the study was to be born or marry into it.

As new technologies have become available, they became part of the study. Participants now get to watch their heart valves “squish, squish, flap, flap” on a screen as they undergo examinations using sound waves known as echocardiograms.

The study, which now has an annual budget of about $2 million, continues to yield new information. Researchers, for example, recently found that people with high levels of a blood-clotting protein called fibrogen had an increased risk for heart attacks.

As the original participants aged and began experiencing many of the common problems of the elderly, the study also sprouted offshoots in which patients were used to investigate such ailments as hearing loss and arthritis.

The researchers would like to start studying a large number of the offspring of the offspring to extend the study into yet another generation. Several hundred members of the fourth generation have already been enlisted in a small study on diet and exercise.

“I would anticipate we would sort of remain a permanent listening post on these diseases to find out where we are going,” Castelli said.

In the meantime, the original participants and their children continue to show up day after day, five days a week at a big old white house where the study’s clinic is housed on Lincoln Street, about a 10-minute walk from the J & C Luncheonette.

The dropout rate has been extraordinarily low--less than 2%-- and about half the original subjects are still alive. Although some are in their 90s and many have moved away, they travel hundreds of miles--at their own expense--to undergo their examinations.

One recent morning, Charles Patten drove down from Kittery, Me., for his appointment. After urinating into a cardboard cup and handing it to a nurse, Patten dutifully stepped into a dressing room, stripped and donned a green cotton hospital gown for his two-hour exam.

Free Physical Exam

Like most of the participants interviewed, the 41-year-old Patten said his primary motivation for staying in the study was that he got an unusually thorough--and expensive--physical examination for free.

“After you reach 35, I think it’s a good idea to make sure everything is working well,” said Patten, whose parents were in the original study.

“If I walk away with a clean bill of health, I don’t think about it until they call me two years later,” said Patten, admitting that he does not exercise enough or watch what he eats and just recently stopped smoking cigars.

Members of Patten’s generation do tend to smoke less, exercise more and eat better than their parents. But it is not because they are in the study, Castelli and Kannel said. It is just that they continue to mirror trends in society.

Patten stepped into a room for his lung test. Nurse Norma Mailhiot pinched his nose with a plastic clip, handed him a hose that looked like it belonged to a vacuum cleaner and told him to blow into it until she told him to stop.

“Keep going! Keep going! Keep going!” she shouted until finally letting Patten stop, leaving him red-faced and coughing.

On a chair in the hallway outside, James Geehan, 64, of Tucson pulled his gown closed and carefully filled out a clipboard full of questionnaires.

“I feel its sort of a responsibility to keep the thing going,” said Geehan, who stopped by the clinic while visiting the area for other reasons. “My father died of heart troubles.”

In the waiting room outside, Arolyn MacNeil, 43, searched for her keys after completing her examination.

Helping Others

MacNeil, who grew up in Framingham and joined the offspring study because her parents were in the original study, admitted a big motivation to stay in the study was the free checkups. But she also said she feels like she is helping other people.

“It’s not only going to benefit me, but maybe my children and my children’s children,” MacNeil said.

She recently cut down on her smoking--from three packs a day to two--but that was only after her brother had a heart attack.

“That was a major scare,” said the gravelly voiced MacNeil.

Because the study is not designed to test ways of preventing heart attacks, the doctors and nurses who examine the participants do not actively encourage people to change their life styles. If they find something wrong with someone, they notify their doctor. But that is it.

“Basically we felt it unethical not to inform them of any abnormal findings,” Kannel said. “But by the same token, it would defeat the study if every time we found something abnormal it was immediately corrected.”

Kannel said the attitudes of the people in the study illustrate how difficult it is to get people to change their habits.

“I think it’s clear that simply identifying a problem does not make it go away,” he said.