50 Years Later, Heart Study Still Ticking
Fifty years ago, Walter Sullivan was a conventional American guy with a fairly typical American life. He lived in the suburbs with his wife and family and made a good living practicing law.
Sullivan thought nothing of chowing down a breakfast of fried eggs and bacon, buttered toast on the side. He poured heavy cream in his coffee and followed it up with a cigarette. Sullivan took his car everywhere: Why walk when you could ride?
“We never thought about diet or cholesterol, or anything like that,” said Sullivan, 83. Exercise was mowing the lawn.
But because he has spent the last half-century as a member of the longest, most comprehensive epidemiological assessment in medical history, Sullivan’s habits have changed. He long ago stopped smoking, he is careful about what he eats and, given the choice, he and his 86-year-old wife, Mary C. Sullivan, would rather walk than ride.
In that sense, the Sullivans, members of the Framingham Heart Study for 50 years and counting, are mirrors for a nation. Heart disease was epidemic in the late ‘40s--a fact of life, or, more often, death. But it was such a mystery that many people were said to have died of indigestion, and sudden deaths were known as apoplexy. “There was little, poor knowledge of what was happening,” said Dr. William Kannel, the study’s second director.
When researchers at the National Heart, Lung and Blood Institute launched what was originally envisioned as a 20-year project, they could never dream they were about to instruct an entire population in how heart disease was linked to cigarette smoking, obesity, inactivity, excessive stress--and now, as new, multigenerational DNA data are analyzed, genetic factors.
Framingham scientists changed the country’s vocabulary by coining the term “risk factor,” and by allowing words such as “cholesterol” or “fat content” to roll smoothly off the tongues of elderly Americans and elementary school students alike.
The identity of the town changed too: Framingham, once known for its straw hats, glued labels or rubber boots, now happily bills itself as the town that changed America’s heart.
Study’s Broad Influence
As the study keeps getting extended--it marks its 50th year this fall--Kannel said it’s virtually impossible to overestimate its influence. Although California’s Berkeley Growth Study has conducted behavioral research on 300 Californians for 10 years longer than the Framingham work, the latter study is distinguished both by its size and its epidemiological structure. The Framingham study has served as a model for more recent epidemiological research, such as the 36-year-old College Alumni Health Study out of Harvard and the University of Pennsylvania.
Framingham, said Kannel, “is one of the most widely quoted data sets in the world. If you go to a scientific meeting and you don’t see speakers presenting data from Framingham, you’d be at a very unusual gathering.”
Framingham scientists produced the first evidence that some heart attacks were “silent,” meaning they could cause terrible damage without producing pain. Another major finding was the connection between high blood pressure and strokes. Framingham scientists produced an overview of diabetes and its association to cardiovascular problems. They learned that menopause heightens the chance of heart disease. Just this year, Framingham researchers published a risk prediction formula that calculates a patient’s peril of developing coronary disease over the next 10 years.
Sullivan, who with his wife recently completed his 25th biannual heart study physical, was part of a citizens’ committee 50 years ago formed to encourage Framingham residents to join the fledgling study. Twenty miles west of Boston, the town was ringed by vegetable and dairy farms, and had a largely white, economically mixed population of about 28,000.
Scientists from the National Heart, Lung and Blood Institute, an arm of the National Institutes of Health, were attracted to Framingham because of its stability. Because it was not a one-industry town, its residents crossed many walks of life, and there was no single source of pollution. Framingham had also been home to a major tuberculosis study in the 1920s, so its population was known to be cooperative.
Volunteers between the ages of 30 and 60 were selected at random from the community, and 5,209 people--more than half the town’s adult population--signed up. Two-thirds of the original group have died, but only 3% of those first participants dropped out. Kannel, 74, said the study was prompted by “the recognition by the Public Health Service that there appeared to be a new, rising epidemic of coronary disease” in post-war America. With widespread immunization, once-fatal communicable diseases such as tuberculosis or typhoid were being controlled. By 1950, coronary heart disease was the nation’s leading cause of death. The epidemic peaked in 1970, and cancer is now edging in on heart disease as the country’s leading cause of death.
Architects of the Framingham project took the bold step of launching an epidemiological study, an approach used formerly only for infectious disease. This meant that a large group, or “cohort,” of healthy adults would be monitored at regular intervals. The study’s subjects would be examined, not diagnosed. They were not paid, but the outcomes of the state-of-technology tests they underwent were sent on to their own physicians--sometimes with lifesaving consequences.
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Framingham was the first major medical evaluation to include women. But far from some early burst of egalitarianism, Kannel said that decision was motivated by the recognition that “most of the people dying of coronary disease were men--and we said, ‘Hey, we’d better find out what’s protecting these women.’ ”
Every two years for the last half-century, subjects like the Sullivans headed to the heart study’s unassuming headquarters for a thorough battery of tests. Sometimes they shouted into big pipes to test lung capacity. Sometimes they ran on treadmills.
In 1971, the study was opened to a second generation, the sons and daughters of original volunteers. Attorney Robert Sullivan, now 56, immediately signed up. He had grown up with the sense that his hometown was playing a part in making medical history.
He recalled that in addition to asking what he ate each day, “in great detail,” the first questionnaire he faced asked how many times per week he exercised to the point of working up a sweat. “I remember writing, ‘Well, never,’ ” said Sullivan, who has since become the owner of a treadmill and a rowing machine.
Brothers’ Testimonials
As sons of original volunteers, Bob and Jeff Fair also eagerly enlisted in the new offspring cohort. Bob, now the 49-year-old owner of an insurance agency, figured that at the minimum, “it was a free physical,” so comprehensive that Fair figures each exam would be “worth about $2,500 in the marketplace.” Jeff, 51 and a fourth-grade teacher, took seriously the sense of family and community commitment to the project.
As a result of information found in the study, the Fair brothers said their mother’s arterial blockage was discovered, and she successfully underwent a quadruple bypass. Jeff said the study picked up his glaucoma, as well as some blockage in his carotid artery. Bob said it was a thrill to observe his own heart: “You can actually hear the slosh sound,” he said.
Both brothers said they hope their own children will be part of a lottery to choose a third generation of study subjects. If funding permits, the newest cohort will enter the program sometime in the next year or two. Generation III would join an “omni”--or multiracial, multiethnic--group which reflects the changing face of Framingham, much as that of the country around it. Framingham now has 78,000 residents, including a burgeoning Brazilian population and many Asian immigrants.
One of the new omni subjects, Jeannie Nakano, said she volunteered because “most health statistics today are based on homogeneous populations. The pool they draw from does not include me. For example, height and weight charts are different for those of Asian background. I wanted to make the study more reflective of the American population today.”
But her reasons were not entirely altruistic, Nakano conceded. “I’m 49 years old and I’m falling apart. I wear bifocals and my body is changing. These tests will help me monitor my own health.”
Just as significantly, said the study’s current director, Dr. Daniel Levy, new data gathered will be part of Framingham’s growing body of DNA-based genetic information. Beginning in the late 1980s, researchers began collecting blood specimens from surviving original participants and from the offspring generation. Soon the genome scan will be expanded to about 1,400 people.
Scientists at Framingham are using the new material to search for the molecular basis for disease. They are also hunting for undiscovered risk factors that may play a role in the development of heart disease. Soon they hope to locate regions on particular chromosomes and genes that are responsible for such disorders as hypertension or high cholesterol.
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“We have an enormous opportunity for genetic discovery here,” said Levy.
The study also has generated more than 1,000 important medical and scientific papers. Levy also noted its comparatively low cost. From 1950 through 1997, the study’s budget was $43 million. For the next eight years, the budget is $14 million. Most of the money comes from the federal government, but some comes from grants.
In Framingham, meanwhile, there is a sense that the study can never be separated from the identity of the town. Two of Walter and Mary C. Sullivan’s children travel from far away--Europe and Utah--to participate in the offspring cohort. Jeff Fair has grown up under the watchful eye of the heart study, and hopes his own children will one day have the opportunity to do the same. As for his brother, “I’d miss it,” Bob Fair said, “I’d be disappointed if they said the study was over.”
