December 04, 2019

The Framingham Heart Study

By Conor McKechnie and Dodi Axelson

The Framingham Heart Study

During a lively lunch chat about the popularity of wearable fitness trackers, the curious question came up: where would healthcare be now if we’d been able to generate all this data 50 to 70 years ago? Dodi directly thought of the world’s longest running human study, the Framingham Heart Study, which is still ongoing after 70 years.

DODI: Conor, do you wear a fitness tracker?

CONOR: Yes. I know my heart rate, the steps I’ve taken and what I had for breakfast. I almost know what I'm thinking about at all times.

DODI: And do you keep track of what you eat?

CONOR: No, that’s a bit much. Beyond porridge for breakfast, nothing else.

DODI: Well, I used to keep track. But for me, it was just way too much accountability. I couldn't take it. I just like to sneak food too much, I don't want to admit how much I'm eating. But for people who are better than me, all of this knowledge is making us live better lives. And the truth of that old saying “those who dine together die together” is proven every day. How we got to this point can actually be traced back into one amazing long-running study that looks at connections between what we eat, our environment, and how all of that influences our health.

CONOR: So, I'm guessing you're going to tell me that that's what matters in this episode.

DODI: Yep, it's the Framingham Heart Study on this edition of Discovery Matters.

[Intro music]

DODI: The Framingham study is named after Framingham, Massachusetts, near our Marlborough office actually. It's a pretty special place. Way back in the 40s scientists already cottoned onto how interesting it was.

VASAN RAMACHANDRAN: It was average middle-class American town, that reflected the demographics of the country at large. Most of the people they worked in a couple of places in the town of Framingham. One of them was called the Dennison factory. And they went to a single hospital called the Cushing hospital, near the Dennison factory, not where the Cushing hospital is anymore. With this is a stable middle-class American town and people who worked in a place, lived over there without a lot of out migration. And that is an epidemiologist’s dream. When you can measure things in people, follow them up over time, and then see who develops disease and who does not.

CONOR: So, who's that?

DODI: That's Vasan Ramachandran.

VR: I’m a professor of medicine and epidemiology at Boston University School of Medicine.

DODI: He’s also a director of the Framingham heart study.

VR: Ten years into the study, following up 5200 people every two years, making measurements on them in terms of their blood pressure, their lifestyle habits, like smoking, and measuring the blood cholesterol and taking the ECGs. Ten years into the study Bill Kannel published a paper, a landmark paper, where he described what he referred to as factors of risk. He reported that having high blood pressure, having high blood cholesterol, and having increased voltages in your ECG, and smoking resulted in heart attacks. This was at a time when people thought that as people age your blood pressure increases, the link between smoking and heart attacks was less scary.

CONOR: So back in Framingham, in a community of motivated people this started out as a 20-year study with 5200 people. So how long does it last in the end?

DODI: Believe it or not, it is 70 years old now. And it's still going. The reason for that, well, it all comes down to families.

VR: Twenty years into it that, the National Heart Institute decided that we discovered the risk factors for heart disease and that the study could be closed. It was just about this time that Dr. Kannel, Dr. Dawber, all the scientists were prolific publishers of scientific input and they began to publish and show, look at other forms besides heart attacks. That high blood pressure causes heart failure, that high blood sugar causes heart failure. And irregular beating of the heart causes stroke and this was the time when Dr. Kannel began to understand that heart disease runs in families. He used to say that “men and women who dine together, they die together” in part because the shared environment but also that the children of people who have heart attacks seem to be predisposed to developing heart attacks.

CONOR: There, he said it!

DODI: Exactly! And here's how the study became a family affair.

VR: So, in 1971 Bill Kannel and his group were funded start the Framingham Offspring Study. These were 5200 additional people who are the children of the original cohort and the spouses of those children. The familial basis of heart attacks and strokes and the familial clustering was identified by the Framingham Heart Study 30 years before the Human Genome Project was completed.

CONOR: The Human Genome Project, which of course we talked about a few episodes back.

DODI: We sure did in the protein Atlas episode, but back to Framingham. Fast forward 30 years later the Human Genome Project has been completed and Framingham was funded to recruit a third generation.

VR: The children of the offspring cohort, who are the grandchildren of the original cohort to further harness the power of the Human Genome Project and other scientific development to really understand how does heart disease track across generations. What the combination of environmental factors, lifestyle, genetic factors. How do they interact with each other, to play into this risk of developing heart attacks, strokes, and different forms of heart disease?

DODI: I sat down with one of the first participants in this offspring study, Tom Gracia.

TOM GRACIA: I’m a complete failure at being a retired corporate attorney and been a participant for more than 40 years with this study.

CONOR: So, how did Tom get involved in the study?

TG: Well, they actually got in touch with me. My father-in-law was a participant and then we started the second generation and spouses. And I was a spouse, given it was a father-in-law. At that point I only knew that there was such a study, but they invited us. And I raised my hand and here I am.

CONOR: So, what exactly is required if you are a participant in a study like this?

TG: You come in for a series of, a major examination that has components. They poke and probe and take samples and look at things and occasionally scan. And then provide you with a wealth of information about what they are seeing and finding. Heart study has done two things for me, individually. So the first is the joy that comes from the participation because you're making a contribution. Of course, I didn't know that when I signed up. But as I learned what the heart study was doing, and it has expanded over and over again in terms of what it does. I became very acutely aware of the contribution that you were making to this world of health science. I’m very proud of it. And I think, my guess is that most participants have figured that out and feel that way. And the second piece is that it has given to me an awful lot of personal information about myself. Its own studies and then because we are an essentially controlled group these studies that are either sponsored here or from an outside source. So, I’ve had all sorts of things that I've learned about myself and most of them, most of the time when I leave an examination I get a good report, which adds a lot of buoyancy to my life. So in and of itself, being a participant makes you feel better about yourself, if you are fortunate enough to be healthy.

DODI: So, there's that. Just like you and your fitness tracker, Tom is healthier because he knows more.

CONOR: And is that the only benefit that he's enjoyed?

TG: It was the hearth study that pointed out to me that I had a thinning bone density, and I might never had known that if it was not for some of the testing that has gone. So I have responded to it and you know I take the, I am looking at vitamin D supplements and some calcium and a little sunshine. And I have had a very good result once learning about that particular deficiency. So, two really good areas, one is the contribution and the other is learning as much as you do about personal health.

DODI: So, you and Tom you're both such good people. Others are simply weak mortals like me. I said earlier that knowing more makes me uncomfortable and doesn't really improve my behavior. So, I asked Dr. Ramachandran if the cohorts in Framingham are more like me or more virtuous like you and Tom.

VR: I think it's been well described in epidemiology as what's called as the healthy cohort effect. When people are observed, they tend to behave better. And that's no surprise, we are humans. It's very well-known. So the Framingham heart study cohort on an average in healthier than an average American group of people. I think we understand that it's a healthier cohort the internal validity of the findings still remains. The generalizability of the findings need to be taken in the context that is a slightly healthier cohort than an average American group of people. But that’s true of all epidemiological cohort studies that are fairly long lasting. When you follow people for sustained amounts of time they do change their behavior because they are being observed.

DODI: So back to Tom, he sees this is such a civic duty. And I wonder does he recruit participants, perhaps his own kids, or how much is he out there sharing his experience of being a cohort. We're back to dining together, but this time not necessarily dying together. Tom said the study often becomes a topic of conversation around the dinner table.

TG: Well, I think you get invited. So they may or may not have been on the list. There's a certain number that we’re limited to. But if I had the opportunity, I certainly would do that with people who have been invited. And I will tell you that I've travelled pretty widely the world and while it doesn't come up on every trip or every dinner I have, the Framingham heart study does come up. And when they find out that you're actually a participant in the study, the conversation can change. Especially if you are talking with people in science with medical sciences especially. They know about it. They’re curious about it and I delight in talking about it because I very much believe in the way it's done. And of course, it's done anonymously too. So we're not, you know, unless we do something like this, we’re not people the anyone knows other than our families and so forth that we participate. But that contribution is really significant, and it does make you feel good that you're doing something that is uniquely human. Not, you know, the other entities that live on the planet don’t do this kind of things. So, it’s just, it really, it’s terrific.

CONOR: So, in the end we've learned a lot about what those involved have to say about the study. But what does the study itself have to say? What are the results?

TG: There’s real education going on here. I often say when I see someone smoke, didn’t they read the newspaper or article or the magazine article? And, you know, don’t they know about this? Don’t they know about that. And some people are just, they don't care or aren’t interested. But anyone who thinks about the quality of their life from a health stand point, the heart study is really putting out that information, they can have it, they can learn about it, and they can improve their circumstances.

DODI: And Dr. Ramachandran says that it is far from over.

VR: The beat goes on. Sometimes people ask, you know, how long will the study go on and I tell them that this is what we’ve achieved so far is the end of the beginning. There’s a long march ahead. So we hope that our mission continues, thanks to people like Tom and the third generation, perhaps a fourth generation. And we continue to contribute to public health in this country and worldwide.

CONOR: So, the world's longest running human study should really just keep on going?

VR: That's our goal and that’s our dream and we are working hard to see how far we can go.

[Outro music]

DODI: And that's it for today's episode. Conor want to go grab something to eat?

CONOR: Only if it means dining together and not dying together, I’m happily doing that.

DODI: Amen to that. Stay heart healthy everyone and we'll see you next time.

CONOR: Bye bye.

DODI: Bye.

DODI: Our executive producer is Andrea Kilin. Discovery Matters is produced in collaboration with Soundtelling. Production and music by Thomas Henley.