I’ll be honest — on my first day of medical school I could not have told you exactly what a heart attack was.  I knew it was due to some kind of blockage, but I didn’t know exactly where, how, or why.  I’m not sure anyone still knows yet exactly why, but research continues to bring us closer to at least some of the answers.  At a certain point though, I did put it together, and that, dear readers, is what I’m going to discuss today.

The heart is a house with four rooms.  Two rooms, the right atrium and left atrium (plural: atria), serve as entryways; and the other two rooms, the right and left ventricles, are the main rooms.  Blood enters the right atrium, moves through the tricuspid valve to the right ventricle, and is then pumped to the lungs, where it receives oxygen.  The blood returns to the heart via the left atrium, passes through the mitral valve to the left ventricle (the largest room), and is then pumped into the aorta (the largest blood vessel in the body), from which it spreads through the entire body, taking oxygenated blood to all the cells.

Think of the heart as having plumbing, electricity, and carpentry.  Diseases of the heart can usually be traced back to some problem in one of these systems.  In other words, some heart problems are due to the plumbing, others to faulty wiring, and still others to either the material itself, or how it is put together.   

Heart attacks happen in the plumbing.  Blood vessels that surround the heart provide it with its very own blood supply.  If blood cannot flow easily through those vessels, the heart muscle will not receive the oxygen it needs to function. 

Just as blood leaves the left ventricle and enters the aorta, some of it is diverted into small arteries that feed the heart itself.   These small arteries are called the coronary arteries.  [“Coronary” means “heart.”]  This efficient system reminds me of an airline’s warning to put on your own oxygen prior to assisting those around you.  The heart makes sure to take blood for itself first.

In most people, the largest of the coronary arteries heads to the front of the left ventricle as the “left main.”  The left main has a large branch, called the “left anterior descending,” that goes straight down to the left ventricle.  A smaller branch, the “circumflex,” wraps leftward around the back.  A second coronary artery is called the “right coronary artery.”  It feeds the right atrium and ventricle, which are smaller because they pump their blood only to the lungs.  The lungs are a lot closer and comparatively easy to reach than the rest of the body, whose blood is pumped by the left ventricle.

What is a heart attack?  A blockage in the coronary arteries.  You could have a heart attack in one of the tiny, last branches of the coronary arteries.  Or you could be extremely unlucky and have a heart attack in the “left main,” or “left anterior descending” arteries.  Cardiologists call these blockages “widow makers.”  Now you know why:  These are likely to be disastrous, because every bit of the heart muscle beyond the blockage suddenly loses its blood supply.  You know how much it hurts to keep your arm up high in the air and compromise its blood supply?  That’s why a heart attack hurts so much. 

The likelihood of developing a blockage rises rapidly if you have diabetes, hypertension, obesity, high insulin levels, low HDL, high triglycerides, or large amounts of small, dense LDL.  Add to these a sedentary lifestyle.  Being physically active markedly decreases your likelihood of developing a blockage.

What else can go wrong?  

Problems in the electrical conduction system affect the timing of heart muscle contractions.  Imagine, just for an instant, how important it is for the atria to contract before the ventricles.  An instant is about how much time your heart has to get this exactly right with each squeeze.

Problems in the “carpentry” affect the valves or muscles of the heart, which is really a specialized pump made mostly from muscle.  The pump has two phases to its function: squeezing and relaxing.  The muscle can become enlarged and floppy.  That makes it hard to squeeze.  Or it can become stiff and shrunken, which makes it hard to relax.  Both affect the heart’s ability to pump efficiently.  We treat these difficulties with different medicines, depending on the exact problem. 

Illnesses of the heart can be congenital, which means you are born with them, or they can be caused by an injury, be it biological (like a virus or bacteria) or chemical (like a vitamin deficiency).  Illnesses can affect a valve, like rheumatic heart disease, which usually damages the mitral valve.  Or, like longstanding alcohol abuse, they can affect the entire heart muscle.
 
Questions?  Ask away!
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I spent the morning in the garden.  I put in a new blueberry bush, and spent several hours trimming, pruning, and weeding.  New lettuce is coming up, and one of these days we’ll have sweet and hot peppers, cucumbers, tomatoes and squash (zucchini, butternut, and spaghetti) in abundance.  I am looking forward to seeing how the watermelon, cabbage and cauliflower turn out.  After many years of a nice little garden, filled mostly with herbs and a few vegetables, I finally have the garden I’ve always dreamed of having.  Alongside the garden, under a beautiful slender magnolia tree tucked into a corner of the house, sits a little table with 2 chairs.  Late in the day the garden is flooded with light, but I can sit in the shade under the magnolia, and drink a glass of iced tea.  It hardly sounds like Cleveland, Ohio.  But it really is.

Lately I’ve been meeting lots of people who are being charged with working on reversing the childhood obesity epidemic.  It looks like we’re finally getting the message:  If present trends continue, we expect 30% of current 10-year-olds to become diabetic.  From so many standpoints, that is not okay.  The cost of suffering on that scale will be staggering.  

This week I was remembering the children who used to come along with their parents to their appointments at my former job.  I cared for many adult patients, and taught them to decrease their risk of becoming diabetic and/or obese.  My patients were very pleased to discover that their pants were fitting better and better, their complexions looking healthier and smoother, their double chins disappearing very quickly once they began to make smart (and relatively simple) changes in their diets.  But they also noticed that they themselves weren’t the only ones to benefit.  An additional, unexpected side benefit was that their children were losing weight and becoming healthier as well.  

I taught patients to increase the nutritional density of the meals they were eating and, when possible, to take more pleasure in preparing and eating their meals.  Patients slowly changed the way they shopped and cooked those meals.  Some of my patients cooked only for themselves.  But some of them weren’t preparing meals for just themselves.  They were feeding everyone in their family, including, of course, the children.  So when they changed their own purchasing and eating patterns, the children did, too.  And once the children began to eat differently, their bellies, too, began to disappear. 

Abdominal obesity, you may recall, is a marker for high insulin levels, which increases one’s risk of developing diabetes, high blood pressure, and coronary artery disease (heart attacks).  The bigger your belly, the greater your risk.  And vice versa.  The risk shrinks with your belly.

The children are the thing I’ve been thinking about this past week.  It came to me just this week that the unit of change for our society’s obesity problem is not the individual.  It is the family. 

The person who is responsible for purchasing and preparing meals is the one to be identified and supported.  This person, often the mom but not always, is the one who, ultimately, will effect the greatest change in a family’s way of eating.  

We can begin to move resources in this direction, providing education and support for the individual in each family who maintains primary responsibility for purchasing and preparing meals.  This is a way to establish a foothold in communities across the United States so that we can begin to reverse the diabetes and obesity epidemics.  Remember:  the time to think about healthy eating is not when you start dinner but, rather, when you make your grocery list or start shopping.  Shoppers, start your engines!
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I once knew a guy named Jeff, from Montreal, who used to say, “First I fry up the onions and garlic, and then I decide what to make for dinner.”  These recipes remind me of that guy. 

These recipes were all contributed by Molly Singer, Harvard Class of 2012, with the following commentary:  “Here are some recipes my roommate and I have been making.  Money’s tight, so these are not only healthy, but also cheap.  If I can get 3 pounds of onions for the same price as a bag of chips, its inevitable that we’re going to eat well.  Enjoy!  You’ll notice that almost everything we make starts with our trifecta of onions, garlic, and olive oil.  How could you go wrong from there?”  Indeed — I could not agree more!  Each one of these recipes is fabulous. 

I’ve known Molly since she was in middle school, and it is a pleasure to introduce her, and her cooking, to the readership of Your Health is on Your Plate.  Thank you, Molly, and feel free to send in more of your fabulous recipes whenever you’d like!

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Some time ago it came time for us to replace our 300-foot-long driveway, so we hired some able-bodied cement guys.  They put a date on the calendar for the following spring, and we waited patiently until the next May came around.  When it did, they showed up one day and ripped out the old driveway, fully intending, of course, to replace it in the days ahead.  Alas, as my grandmother used to say, “Menschen tracht und Gott lacht.” That means people plan and God laughs.

I could start a long explanation here about how the original driveway’s footprint veered unexpectedly close to a property line, but I would prefer not to go into it.  So let’s just say there were technical difficulties.

And that is how I found myself parking out on the street for the better part of three months, while we gathered the necessary information, and then waited through the dog days of summer, to allow the city to make the ruling that would allow us, finally, to replace, in August, our exceedingly long driveway.

Although I often find things amusing that other people might not, this was not one of them.  In retrospect, keeping the wheelbarrow parked by the street for groceries and the like now seems pretty funny.  But it did not feel very amusing at the time.

But here’s something that did interest me:  Within a couple of weeks, my pants were fitting a little more loosely.  Now as you’ve certainly already discerned, we have a very long driveway, at least in comparison to all the other homes on our suburban street.  But it’s not like we’re set back a mile or anything.  Even still, just being required to walk that extra 300 feet 2-4 times a day more than previously was obviously enough to make a difference in my physique.  [Not a word I usually use when speaking about myself.]  Believe you me, it wasn’t much more than that either, because I made it my business to be very efficient about the number of trips I had to make to get out to my car that summer!

I believe that I may have written on this theme before.  It goes by other names, such as “the excellent is the enemy of the good,” or “every little bit helps,” or “every little bit counts,” or “you don’t have to do everything right, just pick the first right thing,” or “whatever you do, please just stop drinking soda/pop,” or “can I talk you into eating a high-protein breakfast instead of that candy they call breakfast cereal?” or “what do we have to do to get kids walking or riding bikes to school again?,” and so on.  Just pick one thing — it’s a great way to start.

No one was more surprised than me to discover that just a few more steps a day made a real, measurable difference in how my clothing fit.  So if you’re not up to walking 10,000 steps a day, I can understand.  But try answering this:  how many steps can you take?  More importantly, how many steps can you add to your current usual daily number?  Can you add 300?  600?  That works for me.  And it will work for you.  Promise.

In each of the past three weeks, I have been delighted to find garlic
scapes in the weekly box of produce I receive from the CSA
(community-supported agriculture) I joined this year.  Because those firm,
green, curly-cues of flavor come only once a year, and then they’re
gone, this is the time to enjoy them!  As I’ve said before about
belonging to a CSA, I appreciate the zucchini, onions, and tomatoes, but
I adore the kohlrabi, Swiss chard, chamomile (jam it into a small mug
and pour boiling water over it) and the things whose names I learned
only recently.  Like garlic scapes.

You may be one of those people who is asking right now, “What exactly are garlic scapes?” Here is what I’ve learned:

Garlic and its Allium family relatives (leeks, chives, scallions,
onions) begin their underground lives as soft bulbs. As garlic bulbs
harden, a shoot rises up and curls above the ground.  This shoot,or
flower stalk, is called the scape, and I read that it appears only on
the finest hardneck varieties of garlic.  If left unattended, the scape
eventually straightens, hardens and turns the opaque white/beige color
of a garlic peel.  That’s the status of several garlic scapes in my
garden currently.  Oh well, better luck next year.  As the scape absorbs
its share of energy from the plant, it also prevents the garlic bulb
from growing large and fragrant.  So farmers harvest the scape in full
curl, before it straightens, when it is still tender and delicious.

Here are a few ideas for what to do with garlic scapes.  You can 1)
grill them like asparagus; 2) chop them up and add them to eggs,
vegetables, salad, rice, pasta or a stir-fry; 3) cut them to green bean
size, saute them in butter and salt for 6-8 minutes, and add a teaspoon
of balsamic vinegar the last minute of cooking; or 4) make garlic scape
pesto.  Toss pieces of 4-8 raw garlic scapes into a food processor.  Add
grated parmesan cheese and walnuts, toasted if you’d like.  Use pumpkin
seeds if you don’t eat nuts.  Pour in 1/4 cup olive oil, 2 tablespoons
lemon juice, some salt and pepper, and give it a spin —> voila,
garlic scape pesto!  Spread pesto on toast, add it to pasta, or place a
tablespoonful in a little ramekin with a raw egg (cracked open, no
shell).  Bake in the toaster oven at 350 for 10-12 minutes.  The flavor
of this simple recipe is so heavenly that if you make it for breakfast,
it will put a glow on the rest of your day.

Yesterday I fried a full bunch each of approximately 10 garlic scapes
and 10 scallions in some olive oil until they were starting to turn a
bit brown around the edges.  I added a bunch of kale [rinsed, leaves
sliced from the rib, and then sliced again into thin strips].  My co-cook
stirred it around a bit until all the leaves were bright green and
shiny.  We sprinkled in some hot curry powder for flavor, just two
shakes, plus a few generous shakes each of salt and pepper.  Then we
poured in 10 scrambled eggs, put the cover on the frying pan, and turned
down the heat.  The first time I checked, the eggs were still wet, but
when I checked it again in after about 15-18 total minutes of cooking, it looked perfect.  I
turned off the heat and left it to sit a few minutes to absorb the kale
liquid, and then served it in slices, straight from the pan.  Leftovers went into the refrigerator to be eaten later, cold.

I’m captivated by the mythical plant creation that Barbara Kingsolver
calls the “vegetannual.”  Kingsolver’s vegetannual is what a single
plant would look like if that single plant were a representation of the
entire cycle of germination, growth, and ripening through which a garden travels from early
spring to the end of the growing season.  It’s real life, producing
all food in its proper season, in its own time.  Like all gifts from
the garden, garlic scapes have their own season, so get some now if you
have the chance.