Address given to the Dallas Rotary Club on May 19, 1999.

ne half of us in this room will die from cardiovascular disease! In the USA this year, cardiovascular disease will cost us $100 billion or approximately $625 for every adult over 20 years of age. And we are all paying these bills whether we have heart disease or not because 46 million Americans under age 65 have no medical insurance, and that number is increasing by 1.5 million each year. Atherosclerotic coronary artery disease—our most common cardiovascular disease—kills early. The average age of death from this condition in men is 60, and in women, 69. That means, of course, that half of the men with fatal coronary artery disease never reach their 60th birthday, the age of many of our best CEOs. And atherosclerosis, the medical word for “hardening of the arteries,” is not a hereditary disease. As we have learned from Brown and Goldstein of this city, atherosclerosis is of genetic origin in at most 1 of 200 persons and maybe in no more than 1 of 500! The rest of us determine whether we get it or not when we pull our chair up to the table 21 times a week. And neither is atherosclerosis a degenerative disease, as I was taught in medical school.

If cardiovascular disease is neither the consequence of our genetic makeup (with some exceptions) nor the consequence of our arteries simply wearing out, what is it due to and can we prevent or arrest it?

Before attempting to answer these 2 questions, perhaps it would be useful to review briefly what has been accomplished in cardiovascular disease this century. The recording of blood pressure did not begin until the first decade of this century. Its usefulness was first recognized in the operating room, and it did not become a part of the routine physical examination until about 1920. The frequent measuring of blood cholesterol did not begin until the 1950s. Although angina pectoris—transient chest pain with exertion—had been recognized in the late 1700s, it was not until this century that angina was clearly recognized to be the consequence of severe narrowing of the coronary arteries. Heart attack—or “acute myocardial infarction” as it is known medically—was believed to always be fatal, until 1912 when it was first diagnosed in a living person. It was not until the late 1920s, however, that acute myocardial infarction was commonly diagnosed clinically.

My father, the first cardiologist in the South, had a heart attack in 1937. Treatment consisted of complete bed rest in the hospital for 1 month, then bed rest at home for another 2 months, and gradual progression in physical activities for the next 9 months. That was standard. Four years earlier he had been president of the American Heart Association, so he knew the proper therapy for heart attack.

Then just 2 years later—1939—a pathology study demonstrated that an acute myocardial infarction healed in 2 months. Those 10 months at home for my father therefore were a waste. When his second and fatal attack occurred in 1941, the only therapy available was morphine, digitalis, and nitroglycerin. The hospital offered no more benefits than home, and that is where he chose to die.

When President Kennedy was killed in 1963, there were no coronary care units; no coronary angiography; no coronary bypass; no cardiac transplantation; no echocardiography; no nuclear cardiographic studies; no reported studies demonstrating the usefulness of lowering blood cholesterol; no beta blocker or calcium blocker drugs or cholesterol-lowering drugs or ACE inhibitors or thrombolytic drugs. Furthermore, no multicenter, placebo-controlled, double-blind clinical trials had been performed in heart disease. In other words, present-day cardiology has come about only in the past 35 years.

But can we afford present-day cardiology? The procedures take place in hospitals, by far the most expensive hotels in the world. All procedures are attempts to repair the wrecks. But can we prevent the wrecks from occurring in the first place? I say “yes,” but that “yes” is contingent on each of us doing our part. We cannot leave our cardiovascular health entirely to our physicians or to our hospitals. They are primarily in the repair business, not in the prevention business.

Now to the cause of atherosclerosis. Evidence connecting elevated blood cholesterol and atherosclerosis is solid. The link began in 1908 when some Russian physiologists fed egg yolks, essentially pure cholesterol, to rabbits and produced atherosclerotic plaques similar to those occurring in humans. Atherosclerosis, it turns out, is a disease affecting only herbivores. You can feed a dog or cat all the cholesterol and saturated fat you wish and you cannot produce an atherosclerotic plaque. Of course, when human beings eat large quantities of cholesterol and saturated fat, atherosclerotic plaques are produced in abundance. The next link came from the biochemists, who found cholesterol within the atherosclerotic plaques. Then it was learned that the higher the blood cholesterol level, the greater the chance of having symptomatic atherosclerosis, the greater the chance of dying from it, and the greater the quantity of atherosclerotic plaque at autopsy. In the past 10 years it has been unequivocally learned that lowering our blood cholesterol level, either before or after a heart attack, lowers significantly the chance of having a first or a repeat heart attack.

Cardiovascular preventive treatment through the years has focused primarily on decreasing the risk of developing atherosclerotic coronary artery disease rather than on preventing or arresting it. In 1970, the world's cholesterol guru stated that he did not worry about the total cholesterol level in a person over 50 unless it was >300 mg/dL, and yet only 1% of our population have levels this high and nearly 50% of us die from the disease. By 1980, the “worry level” was down to 240; by 1990, it was down to 200, and the “worry number” in my view will continue to fall. The average total cholesterol in persons aged 20 to 75 in the USA is now 212 mg/dL, and, nevertheless, nearly half of us die from cardiovascular disease.

What cholesterol number is needed so that no atherosclerotic plaques form in our arteries? Pediatricians do not talk in terms of decreasing the risk of measles, mumps, or whooping cough. They talk in terms of total prevention. We need to do the same with atherosclerosis. Evidence is strong that the total cholesterol number must be <150 mg/dL, and the low-density lipoprotein (LDL) cholesterol (the bad one), <100 for plaques not to form. Vegetarians have these numbers! When we are born our blood total cholesterol is about 75 and our LDL cholesterol is about 50. By 2 weeks of life, both of these numbers have doubled, and they usually remain at these doubled levels until we are 18, when both begin to rise.

What can each of us do to either prevent or arrest the atherosclerotic process in us? To bring our total cholesterol number to <150 we must considerably reduce the quantity of cholesterol, saturated fat, and calories we consume each week. Cholesterol comes entirely from animals and their products, about 45% from eggs and about 45% from cows, including their muscles, milk, butter, and cheese. Most of us now consume only about 300 mg of cholesterol daily, the equivalency of 3 toothpicks.

Our biggest problem is not the quantity of cholesterol we consume but the quantity of fat we consume. Although the percent of calories from fat has decreased in recent years, the quantity of fat consumed continues to rise because we are eating far more calories than in the past. About a third of the fat we consume comes from cows. A deck of cards weighs approximately 75 g. That should be our daily limit, and we all would be healthier if we could limit it to 50 g daily (<2 ounces).

And we need to decrease the quantity of calories consumed each week. This reduction, of course, is not easy for any of us, but you gentlemen and ladies are the leaders of this city, and you must set the example. No nation in the history of the planet has witnessed the degree of overweightness occurring in the USA. At least 60% of our adults are overweight, and half of them are frankly obese, meaning >20% over ideal body weight.

I'll give you my plan: I weigh each morning upon arising. My maximal weight number is 170 lbs (I am 6 feet tall), and if I am over 170 I am particularly careful that day. For breakfast I generally have a banana with grapefruit juice. For lunch I generally have 3 vegetables. For dinner I generally have what I wish. With rare exception, I limit flesh to fish. I avoid eating between meals and at bedtime, and I make desserts special occasions. I plan for holiday feasts or other special occasions by limiting calories before and after such events.

Why is control of body weight so important? The more we weigh, the sooner we die! Excess weight raises our blood cholesterol, our blood pressure, and our blood sugar, and it leads to many diseases, such as diabetes. The easiest way to control weight is to eat vegetables and fruits. Long-term pure vegetarians are lean, and they rarely have atherosclerosis. Furthermore, they have a very low frequency of high blood pressure, diabetes, certain cancers (including breast, bowel, and prostate gland), appendicitis, diverticulosis, gallstones, kidney stones, osteoarthritis, and osteoporosis. Vegetarianism is inexpensive medicine. Exercise producing fitness clearly makes us healthier, but exercise without reduction of caloric intake sheds few pounds. We have to walk or run 35 miles to lose 1 pound!

I doubt if many of us will leave this hall today and suddenly become pure vegetarians. But there is no reason why we need flesh 21 times a week. If we could reduce that to 5 or 7 times a week the health of this nation would skyrocket. And our cows would be much happier. Their holocaust continues. We have 100 million cows in the USA, and every day we kill 100,000 of them. We bring them into fenced lots their last 5 to 6 months of life and feed them 20 to 25 pounds of grain and soybean every day. Why? To make them fat so that they taste better. And then we kill them, and then they kill us! We also kill 300,000 hogs and about 15,000,000 chickens each day in the USA. McDonalds now has 25,000 outlets; a new one opens every 3 days somewhere in the world. And we wonder why we have so much atherosclerosis.

A word on the cholesterol-lowering drugs. They are called statin drugs. You know them as Mevacor, Pravacol, Zocor, Lescol, Lipitor, and Baycol. These are miracle drugs. They are to atherosclerosis what penicillin was to infectious disease. They can lower our LDL cholesterol by as much as 60%. And they are some of the safest drugs we have. We need not fear these drugs. They have the capacity to decrease heart attacks by >50%, and as a bonus, they also decrease the frequency of strokes by about 30%.

A short word on blood pressure. Stroke is mainly the consequence of elevated blood pressure. Heart disease, in contrast, is mainly the consequence of elevated blood cholesterol. Our blood pressure should be <135/85 mm Hg. If the pressure is elevated we need to take an antihypertensive medicine every day.

In summary, we all need to know our blood cholesterol number, and if it is elevated we need to get it down. It is the best personal insurance we can buy. We also need to know our blood pressure number, and if it is elevated we need to get it down. A stroke is worse than a heart attack, and it can be prevented. And losing weight lowers both blood cholesterol and blood pressure! We need to be as familiar with our cardiovascular numbers as with our investments. We can never enjoy the latter if we are not here.