Louisiana Living and Cardiovascular Disease
April 20, 1992, ended as any other typical day for attorney Barry Viosca. The self-described obsessive-compulsive workaholic went to bed late that night after a heavy dinner with a whole lot of stress on his mind. As usual, he was preoccupied with what he had scheduled for the morning, which happened to be contentious depositions in Alabama.
Around 1 a.m., something peculiar happened. Viosca awoke in a cold sweat, feeling extremely nauseous – “an unusual type of nausea,” he recalls. He drove himself to the emergency room but felt better upon arrival so, in typical headstrong fashion, promptly went home. Two hours later he was back, this time with chest pains. Doctors examined him and told him he needed to be admitted but still determined to make his depositions, he checked himself out against medical advice.
Fortunately, the family’s physician and lifelong friend intercepted him on the emergency room ramp before he had time to leave and talked some sense into him. The doctor took Viosca to a cardiologist and two hours later, the then-48-year-old, was undergoing quadruple bypass surgery.
“They told me I should’ve been dead,” says Viosca, whose arteries were 99 percent blocked. “They said I never would’ve made it to Alabama.”
If you’re like most Louisiana residents reading this, you’ve probably heard similar stories from friends and family. Perhaps you’ve even experienced one yourself. Unfortunately, cardiovascular disease (CVD) – which includes coronary heart disease or heart attack, as well as stroke – is all too common in this state. Though Louisiana ranks 28th in the nation in terms of population, the state ranks 9th in stroke-related deaths and has 12 percent more deaths due to heart disease than the national average.
Indeed, letting the good times roll comes with a price, and it’s often the heart that pays. This is a culture, after all, that created weekend-long festivals to celebrate such artery-cloggers as sausage and fried seafood; a culture that has an entire French Quarter street devoted to the overindulgence of alcohol; a culture that has one of the highest smoking rates in the country; and, a culture that has a population with a lower income level and less education than the national average, which means it’s less inclined to engage in pro-active wellness measures – for example, exercise.
“Something’s going on in Louisiana,” says Dr. Bill Newman, a professor of pathology at the LSU Health Sciences Center. “We’re at a greater risk here. Some people would like to imply that it’s diet. Others think it’s smoking or high blood pressure. All those are risk factors but there’s still a lot of mystery.”
So just how bad is heart disease in Louisiana? On one hand, it’s not as bad as it could be. When looking at CVD incident and death rates, Louisiana – perhaps surprisingly – does not top the charts, ranking 10th on the list behind neighboring Mississippi, Alabama and Arkansas.
In fact, when you break out the statistics for coronary heart disease and take them by themselves, Louisiana fares better than average, ranking 31st in the U.S. in terms of deaths due to heart attacks. What pulls the average down, however, is our incidence of stroke. We’re one of the worst, ranking 9th overall in the U.S.
That’s important, because high blood pressure is arguably the most significant risk factor of all when you’re talking about heart disease. It accounts for nearly 20 percent of CVD deaths in the state. Moreover, in Louisiana, nearly one in three adults suffer from it.
“You look at three things for risk factors: how risky is it, how prevalent is it and how reversible is it,” Dr. Paul Whelton, senior vice president of Tulane University’s Health Sciences Center, says. “High blood pressure meets the smell test for all three.”
Indeed, CVD is a serious health problem for the state, ranking as its number one killer. It’s also an expensive one: In 2003, heart disease was responsible for more than 91,000 hospitalizations in Louisiana and cost a whopping $2.4 billion in hospital charges alone. That doesn’t include the countless billions in doctors’ fees, rehab costs, home health care and missed work time.
Experts have a pretty good handle on risk factors that can contribute to heart disease, and on how to keep those risks to a minimum. Nevertheless, there are still a lot of unanswered questions. Like, why do blacks have more high blood pressure than whites? Why do men have more coronary artery disease than women? Why do we have so much more heart disease here than the native Inuits in Greenland, who also smoke heavily and consume a lot of high-fat food?
“I don’t think we have all the answers,” Newman says. “We don’t know what causes it, though we know what the risk factors are.”
Those risk factors are well known: family history, hypertension and so-called lifestyle choices that include smoking, diet, exercise and weight. All are significant and no one can say for certain which one is the most likely to cause heart disease. However, evidence suggests genetics and hypertension are two of the biggest contributors, and in Louisiana, we have a lot of hypertension and a large segment of the population predisposed to it.
“If you look at Louisiana, the contribution of African Americans is significant to our heart disease prevalence and death rates because they have more high blood pressure than other racial groups,” Newman says.
Statistics support that assertion. In 2002, the stroke death rate for blacks was one-and-a-half times higher than for whites. What’s more, black males had a higher age-adjusted stroke death rate than black females. Comparatively, white males and females had similar stroke death rates.
“What we see clinically is much more severe hypertension in black people and more diabetes in black people,” says renowned cardiologist Dr. Gerald Berenson, who earned a national reputation as lead investigator of the 33-year-long Bogalusa Heart Study. “We find severe hypertension, severe diabetes and severe renal disease.”
Dr. Gerald Berenson earned a national reputation as lead investigator of a 33-year-long Bogalusa Heart Study.
Berenson believes genetic factors are at work. He’s studied from 16,000-18,000 children over the past three decades, both black and white, and charted them as they’ve grown. Some of his first subjects are now middle aged. Some are dead.
Among his findings is the fact that black children have higher blood pressure than white children – two or three millimeters higher, on average. That suggests something genetic, as opposed to environmental or lifestyle-related, is contributing to their high rates of hypertension.
As to why they’re more susceptible to developing hypertension in the first place, Berenson and other researchers haven’t gotten that far. The picture is just unfolding. But it does help explain why, in a state whose population is nearly 35 percent black, the incidence of heart disease is higher than average.
Lifestyle factors play a critical role in the disease as well, and those cross gender and racial lines. For starters, there’s the diet; while statistical evidence on what Louisiana residents eat compared to the rest of the country is hard to come by, anecdotally we all know that the diet includes a lot of fried and fatty foods. Perhaps even worse, the state’s much-heralded, indigenous cuisine has a dangerously high salt content, a direct contributor to the hypertension that can lead to heart disease.
“The risk factors have to do with nutrition and physical activity,” says Whelton. “And we eat rich diets. We eat a lot of fat and a lot of salt.”
What’s worse, we don’t exercise enough. While experts say that’s a problem nationwide, Louisiana tends to lag behind the rest of the country when it comes to exercise in large part because of its low-income population. Quite simply, it’s hard to work out when you can’t afford a gym membership, don’t own a vehicle and are preoccupied with paying the rent and keeping the lights on.
“We do tend to exercise less here,” says Whelton. “What you find is in communities that have the wherewithal to worry about prevention they do exercise more. Communities that are more worried about day-to-day survival exercise less.”
With high-fat food consumption and little exercise come weight problems; and, not surprisingly, Louisiana’s statistics on obesity are also troubling. More than 60 percent of adults in the state are overweight or obese, while 25 percent of our children are as well – and it’s getting worse. Louisiana kids are 12 pounds heavier on average today than they were when the Bogalusa Heart Study began.
“During the decades of the 1970s and ‘80s, kids gained about five pounds,” Berenson notes. “During the ‘80s and ‘90s, they gained 12 pounds.”
That’s not good. While an overweight individual can be otherwise fit on the inside, evidence suggests that obesity is one of the risk factors for CVD. What’s more, obesity in childhood precedes insulin resistance, which is the leading cause of diabetes.
“We’ve learned that all of this starts in childhood,” Berenson says. “It helps explain why we have such a problem here.”
There’s one more piece of the puzzle that many experts argue is more important than diet and exercise: Smoking. Nearly 25 percent of adults in Louisiana smoke cigarettes and while many assume lung cancer is the greatest danger from smoking, it’s actually heart disease.
“I always mention cigarette smoking first on the list of risk factors because it kills more people with heart disease than it does with cancer,” says Dr. Jack Strong, a Boyd Professor at the LSU Health Sciences Center.
If there’s any good news to take from the otherwise sobering statistics on heart disease in Louisiana, it’s that progress is being made. Cardiovascular disease death rates over the past 15 years have declined in Louisiana, as they have nationwide, according to a 2005 report from the American Heart Association; but while this decline continues, the speed of the decline is slowing, which suggests that education and wellness programs may be reaching a saturation point.
“I think most people have a pretty good idea of what healthy foods and unhealthy foods are,” says Strong. “They just have to make a choice.”
Getting them to make the healthy choice remains a constant challenge. Whelton points to the anti-smoking campaigns of the past 30 years as one example of public education that works. Smoking is no longer socially acceptable in most segments of society – though a lot of people still do it – and it’s virtually forbidden in public.
“Take physicians, for example,” Whelton says. “In the 1950s and ‘60s, more than half the physicians in this country were smokers. Today, fewer than one percent is.”
Eating habits may be more difficult to change, Whelton concedes. Unlike anti-smoking campaigns, which had virtually wholesale support, the fast food industry works at cross-purposes from those trying to teach about diet and nutrition. Fast food ads saturate the airwaves, portion sizes grow ever larger and chain restaurants are ubiquitous.
“You look at fast food: It’s cheap, the restaurants are clean, they’re everywhere and you’re immediately satisfied after eating because the food is high in salt and fat,” Whelton says. “The only problem is it’s deadly, so we have to keep focused on the problem and education is the only way.”
After more than 30 years of studying heart disease in Bogalusa, Berenson is also convinced that public awareness is the most effective way to fight the problem. He had a pilot program under way in several New Orleans public schools and was making strides with it, until Katrina came. Since then, he has undertaken a similar initiative in Washington Parish.
“It’s more than just a school program,” he explains. “It really involves the whole community.”
When he was 48, Barry Viosca underwent quadruple bypass surgery to alleviate 99 percent blockage of his arteries.
The program targets approximately 7,000 students and begins in kindergarten. Much of the education takes place in the classroom, but topics are skillfully woven into the students’ subjects. Math, for instance, might include a lesson on caloric intake or percentage of fat grams.
There’s also a strong physical education component to the program, which strives to make exercise fun. More than 75 non-competitive exercises are taught both during the school day and after dismissal. Parents are included and, in fact, encouraged to participate. Getting them on board after all, is critical to keeping children on board.
As for diet, school cafeteria menus have been altered; portion sizes have been reduced, while healthier dishes have replaced those with high fat and high sugar contents.
In terms of outreach, parents receive a monthly newsletter to keep them up to speed on what’s going on. Parish leaders are also getting involved, lending a hand to help educate older students about the dangers of cigarette smoking and alcohol.
“It’s directed to the whole structure of the parish,” Berenson says. “It teaches kids to have respect for their bodies and addresses social problems, as well as diet and exercise.”
Berenson would love to see similar programs in other jurisdictions around the state, but he’s having a difficult enough time getting funds for the Washington Parish endeavor alone. The Washington Parish Council coughed up $50,000 – enough to hire two coordinators for one year – but future sources of funding remain uncertain.
“It’s what we need throughout the state,” Berenson says. “But it’s very difficult to pull it off.”
When Viosca thinks about education programs, he believes it could’ve helped make a difference in his situation, though he’s also convinced a genetic predisposition likely doomed him to suffer from heart disease.
“Our lifestyle definitely has a lot of do with it,” Viosca says. “Kids don’t exercise enough, they don’t walk enough, they don’t ride their bikes anymore. Certainly it makes a difference.”
Anything that makes even a little difference is worthwhile, he says. Having heart disease changes your life – and not for the better. It’s a constant presence, affecting your attitude and your decisions. It’s not, he says, a pleasant experience.
“It’s a real head game,” he says. “Everything you do, you do as though it’s your last time. You become very aware of your own mortality.”
Louisiana-Specific Statistics on Cardiovascular Disease
• Cardiovascular disease (CVD) is the #1 killer of all Americans and Louisiana residents
• 35% of all deaths in Louisiana are a result of CVD
• In 2002, approximately 15,000 Louisianans died due to CVD, 12% higher than the national average
• 18% of those total deaths were from stroke
• CVD kills more women than men in Louisiana, although the age-adjusted mortality rate is higher for men
• One in four Louisiana children is obese or overweight
• 61% of Louisiana adults are overweight or obese
• CVD death rates are higher for African Americans than for Caucasians
• CVD was responsible for more than 91,000 hospitalizations in 2003 and $2.4 billion in hospital charges in Louisiana
• In 2002, nearly a quarter of Louisiana adults – 24% – reported they currently smoke
*Source: American Heart Association Stroke Report, 2005