Framingham Health Study Pays Dividends Over Half a Century

FRAMINGHAM, Mass. — Here’s how much things have changed in 50 years: Back then, an auto mechanic named Joe Pavia used to eat two jelly doughnuts on his coffee break every morning. And the really amazing part? He didn’t feel guilty about it.

Pavia was 34 at the time and, like people everywhere, he knew next to nothing about the stuff that hurts the heart--bad diets, high cholesterol, high blood pressure, cigarettes, diabetes and all other factors that are now part of the American consciousness.

If there were a single moment when all that began to change, it would probably be the fall of 1948, when Pavia and his wife, Lorraine, got an odd request: Would they agree to a free checkup every two years so doctors could listen to their hearts, run some tests and ask a lot of questions?

Pavia remembers what he thought at the time: “What do they want me for? I’m in perfect health.”

But that was just the point. After World War II, the country was beset with an epidemic of heart disease. By the time outwardly healthy men like Pavia hit their 50s and 60s, they were dying like never before. No one knew why.

So the federal government launched an unprecedented attempt to understand this killer. The idea: Go into one small town. Amass volumes of health facts on ordinary people in their 30s. Then watch what happens. Perhaps in time some link will emerge between the way they live and the fate of their hearts.

Pavia and his wife signed up, along with his brother and sister. In all, 5,209 healthy residents of Framingham--20% of the town’s population--agreed to the exams.

The result is the Framingham Heart Study, the longest major epidemiological project in medicine and certainly one of the most influential experiments ever.

“We have a 50-year legacy of scientific advancement, over 1,000 papers published to date,” says Dr. Daniel Levy, the study’s fourth director. “I’d like to think that the work from Framingham really has changed the lives of Americans and contributed to the public health of our nation.”

Few would argue with that. Indeed, it seems just about everything people know about what causes heart attacks and strokes, and what prevents them, comes from Framingham.

Experts stumble over superlatives to describe the study’s impact. “One of the seminal heart studies,” says Dr. Lawrence Appel of Johns Hopkins University. “A watershed event in the prevention of heart disease,” says Dr. Rodman Starke of the American Heart Assn.

Sentences that begin, “Framingham shows. . .” settle arguments wherever doctors gather to talk about heart trouble. But the study’s impact has been equally profound on the health practices of people who have never even heard of the Framingham Heart Study.

What makes Framingham impressive is how much it has changed. The depths of pre-Framingham ignorance when the Pavias got their call are now hard to comprehend. It went way beyond the effects of jelly doughnuts.

“Fifty years ago, people debated whether cigarette smoking had anything to do with heart disease, whether cholesterol and blood sugar were important,” says Dr. Lewis Kuller of the University of Pittsburgh. “What we take as truth today was far from obvious even in the 1970s. What Framingham did was to establish the relevance of these risk factors for heart disease.”

Even the phrase “risk factors” comes from the Framingham study. Dr. William B. Kannel coined the phrase in a medical paper published in the 1960s while he was director.

When Kannel began at Framingham in 1949, doctors thought any cholesterol level under 300 was perfectly fine. No one worried much about stratospheric blood pressures; lots of people had them.

Perhaps the study’s most important contribution, says Kannel, is showing that when it comes to health, average isn’t always good. One example of this is how Framingham changed thinking about the consequences of rising blood pressure as people get older.

When the study began, doctors assumed it was a necessary part of aging. Dr. Phil Wolf remembers the old rule that a patient’s systolic blood pressure, the larger first number in a reading, should equal his age plus 100. “I was taught in medical school that older people needed that higher pressure. If they don’t have it, that will cause fainting and strokes.”

The truth, Framingham revealed in 1971, is just the opposite. Rising blood pressure is worrisome at any age. The higher it gets, the greater the risk of strokes.

At the outset, the Framingham doctors recorded 80 variables, things like weight, electrocardiogram readings, exercise habits, cholesterol levels--anything that might remotely have an effect on the heart.

The study was scheduled to last for 20 years, and after 10 years, some patterns began to emerge. One of the first discoveries, published in 1959, was that heart attacks could be painless, leaving a scar on the heart but no symptoms.

Soon others piled up:

* Ten years before Wolf and Kannel found a link between blood pressure and strokes, the Framingham doctors discovered that high blood pressure appears to trigger heart attacks. That breakthrough was one of the pivotal pieces of evidence that led to the universal effort to spot high blood pressure and lower it with drugs, diet and exercise.

* Cigarette smoking is bad for the heart. The discovery was ammunition for the surgeon general’s landmark campaign against smoking.

* Too much cholesterol in the blood raises the risk of heart attacks, while high-density lipoprotein--HDL--actually protects against heart disease.

* Physical exercise lowers the risk of heart disease; being overweight increases it.

* Menopause abruptly increases the risk of heart disease.

* Atrial fibrillation, the seemingly harmless irregular beating of the heart’s upper chamber, is a powerful trigger of strokes.

* Diabetes is an important underlying cause of heart disease.

* Estrogen pills after menopause lower the risk of broken hips.

The U.S. Public Health Service chose Framingham because it was such a cross-section of America, at least white America, and close to Boston’s medical expertise. The town of 28,000 people, 18 miles west of the city, was a mix of blue-collar and professional, farmer and factory worker. There were Italians, Jews, Irish, French-Canadians.

Now Framingham, population 70,000, is home to Fortune 500 corporations and high-tech firms. But the Framingham Heart Study is probably its best-known product. Funded by the National Heart, Lung and Blood Institute and staffed largely by physicians from Boston University, the study has cost a total of $43 million.

The study’s biggest drawback is its lack of ethnic diversity. Because the study’s volunteers, like Framingham in 1948, are virtually all white, doctors cannot automatically extend the findings to blacks or Asians. The study is adding a new section, the Omni Study, of about 1,000 nonwhite Framingham residents.

It is the study’s second expansion. In 1971, as the original Framingham group reached 60, researchers recruited their children and spouses, 5,124 in all. Three Pavia daughters--Lois, Carol and Joanne--joined.

The Framingham doctors hope to add a third generation. The goal this time will be to go beyond heart disease and use the stored data and blood samples on children, their parents and their grandparents to track the genetic origins of all sorts of diseases.

If so, they probably will have little trouble recruiting the original group’s grandchildren. Framingham volunteers talk of the benefits of free medical tests--checkup reports go to the participants and their physicians--but they also take pride in being part of something important.

“It’s a badge of honor,” says Dr. Christopher O’Donnell, another study doctor. “Participants really feel this is something they do for their community.”

Only about 1% of the study’s surviving members have dropped out over the years. While about one-quarter of all the participants have moved out of state, most--like Pavia’s brother Frank, who lives in California--make a detour to Framingham for an exam whenever they travel near Massachusetts.

Faithfully every two years, Joe and Lorraine Pavia go to the study, housed in a former convent, for two or three hours of ultrasound scans, electrocardiograms, blood drawing and all the rest.

Over the years, the exams have revealed Joe’s own coronary artery disease and diabetes. But that’s not all the Pavias have learned from it. Like Americans everywhere, they have taken the lessons of Framingham to heart, switching to skim milk, cutting back on red meat, staying active and going easy on the jelly doughnuts.

“It’s helped us, and it’s helped a lot of people who weren’t in it,” says Lorraine, 82. “It makes us feel good to know we’ve done something for others.”