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Perils of prosperity.

Temple bells dance in the breeze. Fruit- and vegetable-laden boats crowd canals at floating markets. Neatly uniformed youths trudge to school, satchels in hand. Shoppers bargain in a cloth-store alley on a hot, humid afternoon. Exotic durian fruits vent their putrid-sweet smell. Wide, nearly empty avenues anticipate more cars in the future. Pedestrian smokers are few. Small, skewed meat chunks dry-roast over a hot charcoal pot. Rich and poor alike throng the Mission Hospital. Tuberculosis? Yes. Accidents? Few. Cancer? Yes. Heart attacks? No! Bangkok, Thailand, the early 1950s.

Temple bells dance in the breeze. Most canals are filled in; the streets are widened for the traffic crunch. Neatly uniformed youths walk home from school, some with earphones, some munching ice-cream bars. Shoppers relax in air-conditioned malls. Exotic durian fruits vent their putrid-sweet smell. Cigarettes dangle from the lips of smartly dressed businessmen. At stoplights, motorcycles jockey for space between taxis, shiny imported cars, and chauffeur-driven sedans. The plate-glass door of a hamburger shop swings shut behind a customer. Rich and poor alike throng the Mission Hospital. Tuberculosis? Some. Accidents? Yes. Cancer? Yes. Heart attacks? Yes! Many! Bangkok, Thailand, the early 1980s.

The Western world knows that the people of developing countries just don't have heart attacks. Thirty years ago in Bangkok this was true. Even 25 years ago they were as rare as durian in December.

But today it's different.

In 1951, my surgeon-husband and I joined the staff of the 150-bed Bangkok Mission Hospital as eager young physicians. We soon recognized several "geographical" differences in disease patterns between the United States and Thailand. We saw no lung cancer and were surprised how little the Thai populace smoked. Few patients suffered gallbladder disease. Diverticulosis of the colon was nonexistent. Breast cancer in women and prostatic cancer in men were rare.

But most conspicuous of all was the complete absence of coronary heart disease with accompanying myocardial infarction (MI, "heart attack"). It wasn't that the hospital lacked equipment or laboratory tests to properly diagnose MIs. There just were no MIs. We simply had no sweating, short-of-breath patients with crushing chest pain. As a pathologist, I found no obstructing cholesterol deposits in postmortem coronary artery examinations.

Fellow pathologists in the United States were equally interested in these observations. In 1961, Dr. Albert Hirst from the pathology department of Loma Linda University School of Medicine visited Thailand to personally examine hearts from deceased patients. I arranged with the pathology departments of Bangkok's two large medical-school hospitals that he be allowed similar heart investigations on their autopsied patients.

Dr. Hirst inspected 108 hearts from patients who had died of various causes. He found an acute MI in only one heart and healed scars in but two others. His findings showed only a 2.7 percent incidence of myocardial infarction. Intrigued, he returned to the United States and examined 458 hearts from autopsies at the Los Angeles County General Hospital. He tabulated 97 fresh and healed MIs-a 21.1 percent heart attack rate-in stateside deaths. In 1961, therefore, the incidence in Americans was about eight times that in Thai residents.

Bangkok was our "home" for 17 years, until 1968, when our service was interrupted by a ten-year stay in the United States. Upon our return to Thailand in 1978, one of my tasks as pathologist was to review monthly the hospital's mortality lists, which record causes of death. I was astonished to find that 2 or 3 of the 15 to 20 deaths each month were due now to heart attacks. What had been happening in our absence?

The MI proliferation inspired Dr. Kittiporn Tantrarongroj, an associate physician, and me to make a continuing study from the hospital's medical records to determine the onset of the disease and its course. Unfortunately, records prior to 1958 had been destroyed. Even so, in 1958, there were yet few MIs.

Bangkok has a mixture of ethnic groups. Besides the Thai, at least 50 percent of Bangkok's population is Chinese, many of whom are well-to-do businesspeople. A growing community of Asiatic Indians, most of them prosperous merchants, are indigenous or immigrant residents. Might there be any ethnic difference in the occurrence of heart attacks among the Thai, Chinese, and Indian populations?

To investigate this, we tabulated the number of first heart attacks per 1,000 hospital admissions (men, women, and children) in each ethnic category separately. These totaled 481 cases over a 28-year period (1958-1985).

The findings were unexpected and startling. There were indeed ethnic differences: the Thai had few heart attacks, the Chinese increasingly more, but the Indians an appalling number. Did this indicate racial differences, or were other factors responsible?

The 28 years of this study were subdivided into six four-year periods. During the first four years, 1958-1961, both the Thai and the Chinese had only 0.3 MIs per 1,000 hospital admissions. But it was a different story for the Indians, who already at this date had 6.2 MIs per 1,000 admissions.

Just what was the significance of these figures compared to the incidence of the disease in the United States, where heart attacks are notoriously frequent? We decided to correlate the occurrence of MIs between the Bangkok hospital and a U.S. hospital, as Dr. Hirst had done 20 years before. We selected for comparison the 300bed New England Memorial Hospital in Stoneham, Massachusetts, where my husband and I worked during the 10 years between mission appointments.

While vacationing in New England for a month, I reviewed the charts of all MI patients admitted at this hospital between 1978 and 1981. 1 found 383 first myocardial infarctions, making an American incidence of 11.2 MIs per 1,000 hospital admissions. Now the 0.3 heart attacks per 1,000 Thai and Chinese admissions in Bangkok had more meaning! By comparison with the American rate, heart attacks were exceedingly rare among the Thai and Chinese. But Indians, with 6.2 per 1,000 admissions, had half as many Mls as Americans, even at this initial four-year period (19581961).

The rise in MIs began between 1962 and 1965 and continued to climb for the Indians and Chinese until 1982-85, when the Indian rate declined noticeably and the Chinese incidence fell slightly. The Thai rates changed comparatively little. The Chinese and Indian MI incidence peaked in 19781981, the Chinese at 11.8 and the Indians at an astounding 30.1 MIs per 1,000 hospital admissions.

Little wonder so many heart attacks appeared in our hospital statistics from 1978 on. The final tally indicates that the Thai have 23 percent the number of American MIs (still more than an eightfold increase over the 28-year period). Today Bangkok's Chinese have an incidence of the disease identical to the Massachusetts residents' rate. Heart attacks have increased 37-fold for the Chinese since 1958 ! Most deplorable of all is the Bangkok Indian statistic, which far outstrips the American heart attack rate by two times! Surely there must be a reasonable explanation for this mounting tragedy and the widely differing incidence among the city's populations.

Historically, what had taken place in Bangkok from 1958 to 1985 that might explain this epidemic of heart attacks? During the 1960s, because of American involvement in neighboring Vietnam, large numbers of U.S. servicemen, their dependents, and other government personnel streamed into Bangkok. This sudden deluge of prosperous Americans desired accommodation, not only in housing, but also in their usual lifestyles. Consequently, a responding building boom produced lovely, Westernized private residences, hotels, and restaurants.

Increased numbers of luxury hotels and restaurants catering to foreign tastes simultaneously ignited tourism from both Europe and America. Money began to flow into Bangkok. Local people could now afford cars-even at preposterous prices with 100 percent or more duties. The once-sleepy, slow-paced Oriental city picked up its tempo of living. To relieve traffic (currently reported at 1.7 million vehicles in Bangkok), the canals were filled and streets widened. The noise level became one 24-hour roar. Trucks, prohibited in the city during the day because of congested roads, thundered through the streets all night, discharging their produce to keep the expanding city alive, well-nourished, and pampered.

The one million population of 1950 grew with sonic speed as thousands of upcountry job-seekers poured into the city to make their fortunes. By 1989 the estimated city population reached 7 million.

Young people returning to Thailand from universities abroad brought with them knowledge in technology and an acquired taste for Western food. Overnight, typical American eating houses mushroomed-hamburger, steak, and pizza houses, as well as ice-cream and doughnut shops. Supermarkets displayed every type of American food imaginable-for twice the stateside prices. Soft drink and beer companies, in tune with the thirst-quenching needs of hot and perspiring patrons, flourished.

The Thai, Chinese, and Indian populace are all exposed to the same stress of an accelerated life, the same lack of exercise (with cars substituting for muscles), and the same Western food accessibility. Why then the difference in incidence of heart attacks among the three ethnic groups? What other so-called "risk factors" for MIs are at variance among them?

Americans have more hypertension than the Orientals. Diabetes, however, is a much more common disease in Bangkok than in the United States. The reasons for these variations are still unknown. Bangkok residents are now smoking more than before. Many Americans have quit, thanks to health education. Indians with the most MIs not only smoke the least, but they also have the lowest percentage of hypertension and diabetes. So just what is contributing to their heart attacks? The most noteworthy difference in the risk factors was the elevation of blood cholesterol (above 250 mg). An amazing 48 percent of Indian MI patients had high cholesterols, far surpassing the others, including Americans. A high blood cholesterol usually reflects the amount of fat eaten, which led us to scrutinize next the diets of Bangkok's three ethnic groups. Enjoyed prosperity would mean the enrichment first of their own cultural cuisines, and their diets vary considerably.

The typical Thai meal consists of a huge mound of polished white rice, together with a highly spiced curry made with a coconut cream gravy. Most curries are largely vegetables with small pieces of meat or chicken for flavoring-complete meals in themselves. Coconut is a chief ingredient in many desserts, but more frequently the meal is finished with fresh tropical fruit, found in great variety and abundance.

Chinese are famous for their elaborate dinners of ten or more courses. These feasts, formerly enjoyed only on festive occasions, become daily repasts for the Chinese businessman entertaining his customers or associates. The Chinese, gourmet cooks of the East, artistically arrange meats with a mixture of stir-fried vegetables. At one meal a diner may eat seven or eight different meats: pork, chicken, duck, beef, shrimp, lobster, fish, clams-all fried to perfection. When faced with ten dishes, he would likely choose the meat as a delicacy, leaving the everyday vegetables behind. Unrestricted monosodium glutamate and salty soy sauce enhance flavor. Dessert is simple-invariably boiled, sweetened lotus seeds or canned lichees, a Chinese fruit. The characteristic Chinese meal is, obviously, far richer in animal products and fat than that of the Thai.

But the Indian cuisine reaches the zenith in richness and spices. The Indians traditionally cook with milk and eggs in large quantities; the Thai and Chinese use eggs sparingly, and no milk. Prosperous Indians use great quantities of clarified butter (ghee) in the preparation of nearly every food. Gravy drenches the meat, a visible layer of fat floating on the surface. Vegetables are fried in ghee. Their flat, unleavened, whole-wheat bread may also be fried in ghee. Indians prepare their staples (lentils, garbanzos, or other beans) lavishly, eating them with white rice or their flatbreads. They love a great variety of such exceedingly sweet desserts as custards (made with milk, eggs, butter, and sugar), deep-fat-fried pastries, and cakes in syrups. By contrast, Indians have the most calorie-filled diet with easily more than 50 percent of calories as fat (compared to 40 percent fat in the typical American diet).

One might question why the marked drop for Indian MI occurrence during 1981-85. We have repeatedly heard that alarm spread over the Indian community at their frequent MI deaths. As a consequence, many families began replacing ghee with vegetable oil and margarine.

The obvious conclusion of this study is not new. It's just hard to face up to. The greatest risk in coronary heart disease is a high blood cholesterol resulting from eating too much rich, fatty food of animal origin. This relationship has been solidly shown by extensive U.S. statistical studies.

Happily, in America there has been a steadily falling incidence of heart attacks the past few years. Why? Americans have been cutting their consumption of cholesterol-rich animal products. Recent market surveys support this assumption by revealing a simultaneous drop in the sale of meat and dairy products.

Americans have other assets in eliminating MIs. They have become more exercise conscious and are quitting smoking. But in Bangkok, the populace inclines toward more meat, more fat, more sugar, more food. These dietary excesses, added to more stress and smoking, with less exercise, equal multiple coronary risks.

And it all comes back to the mother culprit-prosperity ! A Newstart in Bangkok

The Bangkok Mission Hospital has promoted smoking cessation and nutrition programs for years. More recently the hospital dedicated an entire floor of one wing to preventive medical care with trained health educators conducting popular classes in weight control, diabetes counseling, and stress testing. Now a new challenge faced the staff.

Because Thailand (actually only Westernized Bangkok) had now joined the "affluent" countries with a resultant boom in heart attacks, we considered a new health program that would both educate and treat these patients at risk. The NEWSTART program, developed and used in a number of stateside institutions affiliated with the Mission Hospital, filled our desperate need exactly. But who would have thought 20 years ago that the developing country of Thailand would ever need to prevent coronary heart disease ! NEWSTART, an acronym, explains well its multifaceted features. It requires, for most people, rather drastic changes in lifestyle: * Nutrition. Food heads the list in importance. A strictly vegetarian (fruits, grains, nuts, legumes, and vegetables) diet stresses low-fat and high unrefined carbohydrates. * Exercise. Next in importance is exercise. Beginning with calisthenics, the patients increase such exercise as walking, swimming, cycling, and gardening, as tolerated. * Water. Eight or more glasses of water a day provide good hydration; a variety of water treatments externally, given by expert therapists, stimulates circulation. * Sunshine. Sunbathing brings multiple benefits little appreciated, such as lowering of blood cholesterol, blood pressure, and pulse rate. * Temperance. Assistance in overcoming tobacco, alcohol, or appetite problems is given. * Air. City dwellers especially appreciate clear skies and pure, fresh air. "Negative ions" produced by abundant plant life are an elixir to the psyche. * Rest. Body biorhythms demand periodic good rest to handle stress and regenerate body tissues. * Trust. The Creator is also the "Re-Creator," and when we follow His laws of life and health, much benefit can be expected.

To have a NEWSTART program in Bangkok meant pulling together a team and planning a structured program. A young couple on our staff, Byron and Carol Reynolds, a physiotherapist and a nurse respectively, had spent several years at California's Weimar Institute. Being well-acquainted with NEWSTART, they suggested Dr. Sidney Nixon from Weimar fly out to join and supervise our program. Staff doctors Kittiporn Tantrarongroj, Ronald Gregory, and I composed the rest of the physician staff. Peggy Chau, a dietitian and health educator, prepared the menus. Five additional registered nurses, two hydrotherapists, a chaplain, and two cooks rounded out our team.

Finding a suitable site for the program became a major hurdle. A noisy, polluted city was not the place! Earlier, we had referred several patients to the Weimar Institute. Returning from a session in the States, Krit Asakul, the owner of Thailand's largest insurance company, insisted, "You must have a NEWSTART program here in Thailand. There are many who need this treatment and cannot afford to go abroad."

To assure us of his sincerity and approval, Krit took several of us in his limousine to many potential sites. At last we chose his cousin's beautiful resort, Nong Nooch Village, about 100 miles south of Bangkok on the Gulf of Siam. Nong Nooch, with its lovely acres of lawns and gardens, paths through extensive mango and coconut groves, immaculately kept swimming pool, artificial lake, and suitable housing, was the perfect site. Its location, only four miles from the clean sands and turquoise waters of the ocean, proved an added advantage.

One of the NEWSTART patients, a plump, hypertensive housewife, heard of the program over the radio and determined to give it a try-whatever the requirements. The first morning, her alarm clock rang at 5:30. She arose for a long drink of cool water and slipped into walking shoes. "The coolest part of the day, and I never realized before how exhilarated one feels taking a brisk walk as the sun rises! " she exclaimed.

An hour later, she and other guests assembled at tables under a flowering arbor, ready for Peggy Chau's breakfast special, topped off with a variety of wonderful tropical fruits. Although a Buddhist, she happily joined with the guests and staff for a meaningful discussion of the God of nature who desires that we "prosper and be in health. "

Then she rolled and stretched, following Byron's example in calisthenics. What was next? She pulled her schedule from her pocket-gardening, and then a hydrotherapy treatment. The hot, moist packs relieved her sore muscles, the deep massage felt great, and the cold shower made her alert for the physician's lecture at I 1. How sensible the program seemed, she decided, as the physicians daily explained in simple terms the basic causes for hardening of the arteries and how the various simple remedies of the program assisted in reversing the process.

"I wondered how a vegetarian diet could be exciting-but Peggy's ingenuity with varied Oriental dishes kept me satisfied, and believe it or not, I'm losing weight without being hungry! " she confided. The main meal at noon featured fiber-rich whole grains, legumes, attractively prepared, colorful vegetables, and occasionally a delicious fruit-filled dessert.

She had a doctor's consultation, blood pressure check, and weigh-in twice a week. The progress encouraged her to keep going. She wouldn't miss Peggy and Byron's daily demonstrations of healthful cooking and simple hydrotherapy treatments applicable at home. Her daily walking goal was five miles, and before long, she had reached it. She also elected to follow her physician's advice and walk instead of eating the light supper of fruit and whole-grain cereal foods.

Evening was the time for relaxation, warmth, and fellowship with a variety of entertaining programs provided by the talented and musical staff. By 9 p.m. a healthfully tired group, both patients and staff, was ready to call it a day.

In America, we often hear the complaint that people will just not change their lifestyles. This has not proved true for the many motivated Americans who have profited by the NEWSTART sessions. But now we wondered how the Bangkok residents would respond.

"It all makes sense!" our middle-aged homemaker said. "I don't ever plan to go back to my old ways. " Her blood pressure had come down to normal and she had shed seven pounds; her blood cholesterol had plummeted from 316 to 215; triglycerides, from 277 to 170; and fasting blood sugar, from 108 to 78.

"My arthritis is better too," she said, rubbing her knees. And no wonder, for her blood uric acid had dropped from a gouty 10.0 to a nearer-normal level of 8.1.

The participants quickly achieved demonstrable benefits, but to reverse the years of injury to blood vessels takes time and a continued healthful lifestyle.

"That makes ten kilometers [six miles] for me today," a turbaned Indian merchant said, grinning. "I'd rather walk like this and eat carefully than take one more shot of insulin for my diabetes!" He left Nong Nooch with a normal blood sugar and packed away his insulin for keeps.

All 47 participants in three separate sessions held during 1983 and 1984 felt equally rewarded and motivated. They were justly pleased to see high blood pressure, blood cholesterol, triglycerides, and fasting blood sugar levels all falling dramatically toward normal ranges. The staff had no lack of cooperation from the participants. All were eager to give such simple natural remedies a trial when they learned the rationale of the treatments.

Bangkok is no different from the United States. An enriched diet, no exercise, stress, and general neglect of basic health lead to degenerative diseases. For the vast majority, these diseases are not familial, not racial, not environmental, not infectious-but are preventable and are reversible. The most effective and rapid treatment is not drugs-but denial and continued lifestyle change.
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Title Annotation:heart disease in Bangkok
Author:Nelson, Ethel R.
Publication:Saturday Evening Post
Article Type:column
Date:May 1, 1990
Previous Article:Southwest skiing: lodes of fun.
Next Article:Putting your heart to the test.

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