Erin Spain: This is Breakthroughs, podcast from Northwestern University Feinberg School of Medicine. I'm Erin Spain, executive editor of the Breakthroughs newsletter. Last year, Dr. Donald Lloyd-Jones was named physician of the year by the American Heart Association. Through his research and practice as a preventive cardiologist at northwestern, Dr. Lloyd-Jones is chasing a big goal, to improve and preserve the heart health of Americans one patient at a time. Here he is accepting the physician of the year award, June 20, first 2017.
Dr. Lloyd-Jones: For me, it is an incredible gift to be a physician and Thursdays, when I'm in clinic with my patients, and having those one-on-one interactions, it's really special to be there at a moment in their lives when they're uncertain or they're perhaps facing a difficult procedure or a difficult decision and to help them through that. That is just an incredible gift. What's really amazing about working with the American Heart Association is that I can have an impact beyond what happens in that room. As special as that is, through my research, through my work in the Heart Association and the advocacy and the kind of ramifications of the research that we get to project through the Heart Association, it's really, that's another gift to be able to have an impact perhaps on, on others and the whole population's health is is really quite special.
Erin Spain: Dr. Lloyd-Jones joins me today. Thanks so much for being here.
Dr. Lloyd-Jones: Thanks, Erin. It's great to be with you.
Erin Spain: That was a pretty special moment last year.
Dr. Lloyd-Jones: It was an amazing moment. My wife was there with me and a lot of people I respect and to be honored in that way by an organization that is really changing the health of Americans in a very positive way was one of the highlights of my life.
Erin Spain: Well, you know, I heard an antidote about you that sort of sums up one of the reasons why you were selected for this award. Can you tell me you had a patient who was experiencing some high blood pressure for the first time and you were able to sort of track down the reason why that happened and you did something about it beyond medication or lifestyle change? Tell me about this.
Dr. Lloyd-Jones: So this was kind of one of those times when when being a physician you have to be a detective as well. So this is a very healthy young woman who had followed for, she'd had some minor heart problems, but we checked in once a year, and she came into the office and was complaining of headaches and had checked her blood pressure once it was quite high and in the office day her blood pressure was 170/90. And for a healthy lean young woman that just didn't really jive. And so I really pushed on, you know, had she been taking any new medications? Was there anything else that was different? And got into what her lifestyle pattern was and she, she's on the road a lot and has to travel around the Chicago region and every day she would stop at a certain, I'll it fast food restaurant for lunch and, and every day she would have a bowl of soup, And there are people among us, and as we age it becomes most of us who are actually quite sensitive to sodium to salt and most commercial soups, those that we don't make it home have a ton of sodium in them. And so I, you know, I made a simple suggestion rather than, than going right to medication if we could just try to cut out the bowl of soup every day for lunch and see how things went. And, and I saw back about a week later and her blood pressure was back down to stone cold, normal 115 over 60. She felt much better. Her shoe size had actually decreased amount of size and a half. So he got a big hug because she got to buy some new shoes. But that's the kind of thing that, that's really important to understand context with our patients when, when something's changed. But as you're alluding to, you know, through my work with the Heart Association at the time, I was the midwest affiliate board president for the Heart Association and I was able to reach out to the leadership of this particular restaurant to say, "Hey, this is something that I recently experienced. Maybe it's not the best thing for your patrons to be serving things that might be affecting their health in this way." And you know, fortunately they had actually been working on a campaign to try to improve the health and the content of their menus. And I think was something that helped motivate them to, to instill change. You know, I, I think I would've have had that opportunity without my work through the Heart Association to kind of maybe have a slightly bigger impact. And that's pretty special.
Erin Spain: Tell me about this ongoing effort that you have to educate people about their ideal cardiovascular health.
Dr. Lloyd-Jones: So, again, through my work with the Heart Association, about a decade ago now, I was asked to lead a group of just superstar volunteers, and we had the opportunity to, to think about prevention in a new way. The Heart Association had challenged us to say, yes, we want to continue our decades long goal of reducing deaths due to cardiovascular diseases and stroke, but we also want to add a new layer and that is, we want to try, try to start promoting cardiovascular health. So not just preventing disease and death, but promoting health. And so they tasked us with a pretty important question and that was, how do you define cardiovascular health? You know, I think we all have a general sense of what that might look like, but, but when you have to operationalize the definition that the Heart Association and others can then use for research for programs for policy, it's a little bit of a tougher nut to crack. So, we were able to look at a lot of literature, a theme consistently emerged and and interestingly, much of that research had been done here at Northwestern Feinberg School of Medicine. Interestingly enough, a started by one of my idols, Dr. Jerry Stamler , who is going to turn 100 in the next year.
Erin Spain: And he is still publishing?
Dr. Lloyd-Jones: He's still publishing. He still has grants from the National Institutes of health. He has followed the Mediterranean diet for decades and decades because he understood the health benefits of a diet and eating pattern that's really focused on vegetables and fruit, leaner proteins, whole grains, and low fat dairy. And if you, if you do that and you cook in healthy oils, include healthy fats that come from nuts and seeds, you really can't go too far wrong. So, you know, I think a lot of his rich research and of course research for many other people has, has really helped us understand no question that lifestyle, starting with a healthy eating pattern is really critical to promoting not just our cardiovascular health, but our overall health. And the other components that we discovered that lead to ideal cardiovascular health included, of course, participating in physical activity, trying to get 150 minutes a week of moderate activity, which could just be a brisk walk, doesn't have to happen all at once. It can happen in chunks as little as 10 minutes at a time. Of course, avoiding cigarette smoking, keeping a lean body weight, and then getting with your doctor and knowing your numbers can you have optimal levels of cholesterol, blood pressure and blood sugar and the more of that package that you can maintain towards middle age, the better your outcomes will be. And over the last decade we've been able to do a lot of research to understand just how powerful construct this is.
Erin Spain: And these are seven sort of different areas that you've called Life's Simple Seven, right? That's correct. And, but most people are not hitting these and America. What percentage of people are actually have ideal cardiovascular health?
Dr. Lloyd-Jones: Yeah. So when the American Heart Association rolled out our construct of ideal cardiovascular health in 2010 as part of their goal for this decade to improve cardiovascular health in all Americans, they did a survey and whereas about 39 percent of Americans proposed that they were an ideal cardiovascular health, most of the research indicates that fewer than two percent of Americans have ideal cardiovascular health. And so much of that actually is about our unhealthy eating patterns. But of course all the other of the seven components contribute some as well.
Erin Spain: So diet really is something that most Americans can hone in on.
Dr. Lloyd-Jones: It's pretty foundational to everything that we do because of course diet works through weight and it works through our cholesterol levels. It works through our blood pressure and kind of affects everything that we do. So, you know, if, if there's one thing people should focus on out there, it's that, but I think the important thing about improving your cardiovascular health that we've learned is it's never too late to try and even just picking one thing and improving that one thing you'll see real benefits in terms of not only reducing your cardiovascular risk, but also reducing risks for cancer, for dementia, something a lot of my patients worry about. For degenerative joint diseases, arthritis and many, many other things. So, it really is like the Fountain of Youth.
Erin Spain: When you're not calling up CEOs of Fast Food chains and your advocacy work with the American Heart Association you're a scientist here at Northwestern and you're leading some major initiatives. You're the chair of preventive medicine, the senior associate dean for clinical and translational research and the director of NUCATS, Northwestern University Clinical and Translational Sciences institute. Tell me about this path through research. I know when you began your career as a physician scientist, you are working on a pretty famous study.
Dr. Lloyd-Jones: Yeah, I was very fortunate to, to do my training in Boston at mass general and one of my mentors, went out and I assumed the leadership role at the Framingham heart study and so when it was my opportunity to do some research during my training, I followed him out there and it was really transformative for me just as that study has been transformative for I think the world. Many people may not have heard of Framingham, but it really is probably the most famous medical study ever. It started in 1948 with a group of 5,209 residents of Framingham, Massachusetts. Not a racially or ethnically diverse, 100 percent Caucasian, but very diverse in their socioeconomic status. so they had a sort of gentlemen horse farmers, they had, a sort of white collar managers in some of the mills in Framingham and then they had blue collar workers from those mills as well. So quite a diverse sample in that sense. And they didn't publish the first paper until about 1961 years, holding onto that data for a long time. It would never happen today. Well, you know, they didn't have computers shares their data and, and took a while to gather some of the information. But, they defined the term risk factor in that first paper. They really put on the map the things that we now understand is risk factors and that we understand as part of the concept of ideal cardiovascular health. Really defining for the first time the relationships between blood pressure and outcomes, smoking a cholesterol levels, those sorts of things that now are part of a routine office visit. Wisely, they've, they've kept the study going by enrolling successive generations of those related individuals and their spouses. So Framingham is now really the premier study where we can understand both the genetic influences on chronic diseases of aging, but also the environmental influences that happen within a family, if you will. And so, I was fortunate early in my career to be able to work as a research fellow and then to stay on as a staff researcher and get tremendous mentoring to understand how to do population science and to think about prevention.
Erin Spain: And you've been able to replicate a lot of that here at Northwestern. And you mentioned risk assessment. That is sort of a theme that comes up again and, and again in your research. How well can we now predict who's going to experience a cardiovascular event based on this whole, all this body of research and all the other ones that we have been able to collect over the past few decades?
Dr. Lloyd-Jones: Yeah. Well Framingham just started it. We now have many, many population based studies that allow us to understand the risk for developing, for example, cardiovascular diseases like heart attacks and strokes. And we have fairly sophisticated equations that can predict an individual's 10-year risk of having a heart attack or stroke. And you know, we call that kind of short-term risk because if someone's had high short term risk, we might want to intervene more intensively. And particularly think about medications, but we can now also actually predict their lifetime risk. So if you're a healthy 40-year-old or 50-year-old, what's the chance that you'll have a major cardiovascular event during your remaining lifespan? With the really reams of data that we've been able to collect from these multiple studies over time. My group has, has put together what we call a synthetic cohort, meaning we can now understand the entire life course of the development, the mechanisms and the outcomes from cardiovascular disease. So we've got an actually pretty good at predicting. However, prediction is like being a weatherman. you know, people want to know is it going to rain or is it not, will they have a stroke or not? We can provide probabilities. We can kind of put someone in a bucket to say, yeah, you're in a high risk group or you know, as things are today, you're in a very low risk group. Keep it up, good work. But we need extra tools to help refine decision making for people who are kind of in the middle, in the gray group. And I think that's where some of our research can inform clinical practice guidelines to help patients and doctors make better decisions.
Erin Spain: You're pretty involved with some of these guidelines and changing guidelines, updating guidelines based off of new evidence found in these studies. Can you tell me a little bit about that process? What's it like to go through the committees and the work groups and then announce to the world, okay, what you've known for normal blood pressure that's going to change.
Dr. Lloyd-Jones: Again, through my work with the American Heart Association and the American College of Cardiology, those are the two professional societies that are responsible for putting out the major clinical practice guidelines. And I've been fortunate to be involved for the last decade in, in most of the major prevention guidelines that they put out. The process of making a guideline is actually very intensive and very interesting. We start with asking key questions, what is new that we need to address in guidelines that will help doctors and patients make better decisions and improve outcomes obviously. So we ask those key questions and then we go to the published literature because the published literature is the data that has undergone strict peer review, so it's vetted, it's solid, we understand those strengths and weaknesses of the data and we only take the highest quality evidence to include in deliberations about what recommendations should be once we've done that, what we call systematic review of the evidence, we create evidence statements and then those lead directly to recommendations that we make for doctors and patients. But not all recommendations are equal. We make class one, class two and class three recommendations and you know, here we're getting into the sausage making guidelines, right? But, it's really important to understand and when I talk to physicians about "what do I need to know about a new guideline?" You should really pay attention to the class one and the class three recommendations. Class one means we have a lot of evidence that doing this and the benefit will far outweigh any potential risks. Class three recommendations mean don't do this because we have lots of evidence to suggest that either doesn't work or it might be harmful. So those are the kind of extremes of recommendations and, and, and we try to focus on those because that sets the floor of good practice. The class two recommendations mean that yeah, benefits going to exceed risk, but you should be thoughtful about when and whom you're going to apply those recommendations. And then we, we try to provide a set a sense to the practitioners of just how much good evidence is behind each of these recommendations.
Erin Spain: In the last year you've been involved with two new guidelines that have made a lot of news. One is for blood pressure, ones for cholesterol. Tell me about that. That's right.
Dr. Lloyd-Jones: Well, so it had been about five years since the prior round of guidelines had come out for both of these very common problems. And so in 2017, the AHA and ACC updated their guidelines for blood pressure, which included, as you said earlier, a new definition of hypertension which cut a lot of people's attention. And then most recently, just a month ago, in November of 2018, we rolled out new cholesterol management guidelines, both of which focus on reducing risk. We get so caught up on, on numbers and what numbers mean, but the overall goal here is we want to reduce people's risk for having heart attacks and strokes. And that's really the bottom line of how the guidelines target their recommendations.
Erin Spain: And then it's a step further with some of your research. Share with me the results of your most recent paper in JAMA that took account of the new guidelines for high blood pressure and hypertension. What did you find?
Dr. Lloyd-Jones: Well, that's right. You know, I think the purpose of guidelines is to put out there what we understand based on today's evidence, what is best practice. And then if the system works, scientists poke and prod and they push and they do new studies to say, does that really hold up? Does it hold water when we expand it to new new groups or new populations, or we, you know, take it to its logical conclusion. And then five years or so from now, we'll have enough new evidence that the paradigm will change and we'll need to make new recommendations. That's exactly what happened with hypertension, with the new definitions that came out in 2017. The old definition, if you will, of hypertension had been if your systolic blood pressure, that top number was 140 millimeters of mercury or higher, or if the bottom number was 90 millimeters of mercury higher measured on more than one occasion, you know, kind of consistently not just a one off looking through all of the evidence that had accrued over the prior five to 10 years, it was quite evident that people below that range, we're actually accumulating, irreversible damage to their heart, into their blood vessels as they transitioned to higher blood pressure levels. So as they transition through the 120s and the 130s, they were actually accruing damage that was going to be hard to fully reverse. Couldn't put the horse all the way back in the barn. The other new evidence that came out was a couple of important trials suggesting that rather than, you know, once you have hypertension and we put on medication rather than trying to reduce blood pressure levels down to less than 140 on that top number, we should actually try to get people to less than 120 if it's possible, if it's safe and if they can tolerate it, because those patients have fewer heart attacks and strokes when we target that lower number with medication and other treatments. So that body of evidence, both the sort of upstream risk that damages accruing at lower levels and that we should be treating people to lower levels than other guidelines that targeted suggested we really needed a paradigm shift. And so, the new guidelines in 2017 recommended that the definition of hypertension should now be 130 or higher on the top, 80 or higher on the bottom.
Erin Spain: Patients and the media all kind of had a lot to say about this.
Dr. Lloyd-Jones: They did a change is hard. And I think, you know, one of the things people point to as well, you know, this meant that instead of about 31 percent of Americans being labeled as hypertensive, now 46 percent of American adults were labeled as hypertensive. It feels big. Is it really true that, that almost half the population, you know, has elevated blood pressure that puts them at risk. And the answer is, you know, it's not about the level, it's about the risk. And it's true that that half the population has levels that are putting them at risk when you put that blood pressure number in the context of whatever else they might have diabetes or smoking or obesity or physical activity problems that starts to add up and put people at risk. And so we need people to be much more aware now the guidelines did not recommend treatment for everybody over 130, but at least greater awareness and greater focus on trying lifestyle as a first measure.
Erin Spain: And this paper that you put out in JAMA, it did take a look at, a younger set of people and was able to predict, tell me a little bit about that.
Dr. Lloyd-Jones: That's right. So, so last month we again trying to push the paradigm and understand it. We applied the new definition of hypertension to a younger population than had previously been studied, a really people from age 18 to 30 and onward. And what we showed was that even in that young adult group, this new definition of hypertension was identifying people, if they were already in the elevated or a true hypertension group, identifying people on the fast track for a cardiovascular event. And so, you know, that again kind of extends the paradigm earlier recommendation said, focused on middle age and older people. This suggests that we really got to be paying attention to even in our younger adults.
Erin Spain: It's becoming more and more important to intervene at a young age and promote heart health basically at birth. How easy is it to reverse damage in young people who maybe didn't start off life with the best habits?
Dr. Lloyd-Jones: Yeah, I think it's important to say over and over and over again, it's never too late to try to change to try to improve things that might be putting you at risk. But it's also certainly fair to say that the earlier we do that at the younger age at which we change unhealthy habits or make some sort of other adjustment that that can improve risk and the more successful we're likely to be. Young people are more plastic. They can repair damaged much more easily. So that, yes, while we're accumulating exposure to cholesterol, blood pressure, the earlier young folks make a change in their habits that keep blood pressure, lower cholesterol low, the less damage there will be and the more likely they are to actually be able to avoid what could be coming down the road. So it's very important, especially I think to get our kids off to healthy starts with keeping them active, helping them understand, appreciate and enjoy a healthy eating pattern. And keeping their weight lean. Very, very critically important because that really starts the whole life cycle off on a much stronger footing. Even kind of our current research takes us back into preconception and gestation. It's incredibly important for our moms to be healthy even before they get pregnant because the environment that the fetus is exposed to in the uterus starts to program how they handle calories, how they interact with the environment. So moms that are taking in too many calories or perhaps or are overweight before they get pregnant are setting up their kids in ways that they'll handle calories differently and are more prone to obesity as they age as well.
Erin Spain: I know the obesity epidemic is something that you're very interested and talking about and trying to educate the public about. And really it's obesity that it's going make it difficult for a lot of people to sort of hit that ideal cardiovascular health.
Dr. Lloyd-Jones: That's right. Because, like diet obesity works through so many of these other factors that contribute to our cardiovascular health. You know we talk completely appropriately about the public health emergency that the opioid epidemic rep represents, but the true public health problem facing this nation for the next many decades is the obesity epidemic. This is an epidemic that we've never seen in human history and it's unfolding right here in this country. We're the most obese and overweight nation in the world in history. Since 1985, we've gone from fewer than 10 percent of Americans being obese now to more than 35 percent being obese and another 40 percent being overweight.
Erin Spain: So almost everyone.
Dr. Lloyd-Jones: But it's not normal and it does have an impact on health. Diabetes, arthritis, heart failure, heart attacks, strokes, even some cancers are related to obesity. So this is something that's going to play out, unfortunately, over the longterm and in our population.
Erin Spain: And you said it's not normal, but it's sort of becoming the new normal to people in society.
Dr. Lloyd-Jones: I think perceptions have changed unfortunately, you know, to sort of adjust to what we see every day, but it's incredibly important to sort of reset and help patients understand. You know, it's hard of course to, to lose weight and sustain it, but it's remarkable how little weight loss is required to improve health, as little as five to 10 percent of body weight and some patients that might be, you know, as little as 15 or 20 pounds, if you can get it off and keep it off, can have remarkable effects on a lot of these things that we've been talking about today.
Erin Spain: If you could leave us with a few little bits of healthy advice, I'm trying to lose some weight. What what else would it be?
Dr. Lloyd-Jones: It Is really important again to, to launch our children in healthy ways, particularly if there is a family history. Don't let them be exposed to secondhand smoke, don't let them start smoking. And that's a real problem in the age of vaping. A new area. Yeah. So many of our kids are getting hooked on nicotine with these very powerful, addictive forms of nicotine delivery that unfortunately, I suspect many of them are going to transition into good old fashioned tobacco smoking. So that, that's something really got to crack down on, I think the FDA is starting to pay enough attention to this, but there's a lot of work to be done. Physical activity, you know, healthy eating patterns, really critically important. And again, if you can launch them successfully, that really does trump an awful lot of what might put one at risk genetically. And then there will be a small segment of the population that does need to work with their doctor, may need medication early in life to, to fix what our genetic situations like something we call familial hypercholesterolemia, people who have genetically extremely high levels of cholesterol. We've got to find those people, get them on medication early. But the rest of us who are luckier know, I think really can do an awful lot with our lifestyle.
Erin Spain: Thank you so much for all this helpful advice today. And to find out more about Dr. Lloyd-Jones research, you can head to our website, Feinberg.northwestern.edu.