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Healthy Habits
Dr. Philip Ades and Team’s Cardiac Rehab Approach Saves Lives and Lifestyles

by Kevin Foley

Dr. Philip Ades walks out into the narrow gym, glances quickly at the chattering bicycles and whirring treadmills jammed against the gray cinderblock walls, and smiles.

There is no spandex here, no loud music. An old woman, hair gray and sparse, chugs away determinedly on a treadmill, as a nurse in bright scrubs urges her on. Two paunchy men in their seventies trade stories and alternate sets on a leg-press machine.

This gym, tucked away in a remote corner of Patrick Gym, is the breathing, sweating center of the University of Vermont’s nationally renowned cardiac rehabilitation program. The small space is Ades’s laboratory, his classroom, his patients’ lifeline. This is the place where damaged hearts become strong, a place where patients rebuild their lives, one hesitant step at a time. It is also the proving ground for millions of dollars in research attempting to find the fastest and most effective ways to bring people back from serious heart problems — and make sure they never succumb again.

“For most people, heart disease is their first brush with death. It is the ultimate teachable moment,” Ades says. “If you’re ever going to change, it’s the ideal time.”

FROM PHYSIOLOGIST TO SOCIOLOGIST

Heart disease has a way of grabbing your attention. So does Phil Ades.

You live life long and well — perhaps, in retrospect, a bit too well — and then the fire starts. Time and genetics and hamburgers conspire. The arteries narrow. You feel weaker, or perhaps you don’t; you fail a stress test, possibly, or you might have a heart attack, a white-hot assault on the body’s most precious muscle. Then it’s a bypass, a stent, a balloon. Sometimes there isn’t a medical emergency, just a bad cholesterol test and a blunt take-down from Ades, his eyes slowly moving up from figures on a chart to lock in on your eyes: “Do you want to stop smoking before or after your heart attack?”

The doctor’s professional life is centered on convincing patients that a long life tastes better than steak, and then channeling that realization into a diet and exercise program for the rest of their lives. The tools are simple, treadmills and weights and the food pyramid, but the results are profound. Cardiac rehabilitation was found to reduce the risk of death in heart patients by 25 percent after three years in one large comparison of older studies. That’s a dramatic drop, especially when you consider that coronary heart disease is the leading cause of death in the United States. And a good rehabilitation improves the quality of life, not just its length. Participants enjoy less depression, less obesity, less incidence of disease, and a better quality of life on dozens of measures objective and subjective.

Ades and his UVM team try to help their patients do even better by driving clinical care with a burgeoning research program. The group recently received $1.5 million from the National Institutes of Health to conduct a long-term study testing Ades’s hunch that long, frequent walks might help heart patients lose weight more effectively than less frequent, shorter workouts. A smaller version of the trial was extremely encouraging, and Ades thinks the work may prove to be the group’s most important yet, providing clinicians with a simple but effective tool for combating America’s epidemic of obesity. Research like this, he says, is one of the most exciting aspects of the job.

“What really makes this interesting for me, the part of the job that I just truly love, is asking questions that could improve care and then going out and testing different ways of treating patients to help them do better,” Ades says.

In the mid-1980s, when Ades arrived to direct the program, his research focus was wonky. He was a measurement freak, conducting muscle biopsies and monitoring enzymes, and charting progress on dozens of obscure measures. His goal was to see which regimens most efficiently improved the capacity for exercise. But as he met more patients and talked with them about their lives and jobs and fears, his emphasis slowly shifted. The scientist became a sociologist, and he saw that the results under the microscope didn’t always translate into success at home. He began asking another question, powerful and simple: How can we help this person do better in the real world? How can we help them do better at home? Instead of just measuring the things that he found important, the enzymes and lipid indicators, he asked his patients to gauge their progress on measures they found important in their daily lives. The results were dramatic.

In a 1999 study, Ades put patients on a thrice-weekly exercise program and asked them to assess their daily functioning before and after the trial. They reported a 20 percent increase in their ability to get things done, a figure correlated with their improvement on physiological tests. The study also showed that the exercise program reduced depression significantly. The results were an encouraging validation that gains in rehab translated to gains in real life, but subsequent work has shown that the translation is not a given. Ades says that his team’s research shows that getting stronger in the gym doesn’t necessarily mean that patients do more.

Capacity, in other words, does not automatically translate into activity. That’s a bad thing, since doing more daily activity is crucial to leveraging the health gains earned in the gym. So Ades is working on a new study that will measure the effectiveness of combining rehabilitation with counseling. The aim is to get patients to the point where they can do more, then encourage them to actually do more, fighting the devastating “spiral of inactivity” that feeds upon itself and can leave older heart patients depressed, helpless, and in fragile health.

Ades’s goal is to save lives, of course, but he also wants to save lifestyles. This is not the hottest area of cardiology, but it suits him just fine.

“Let’s face it: It is far, far more exciting to place a $3,000 stent coated with drugs inside someone’s heart than prescribe and carry out strength training for an 80-year-old woman,” he says. “But that strength training is going to allow her to stay active at home rather than go to an assisted living facility. I don’t know, I find that exciting.”

THE ART OF THE COMEBACK

Doris Maeck ’34, a heart attack survivor and participant in the cardiac rehabilitation program, rubs her eyes after a lively half-hour of chat in her Shelburne home and begins telling a story that is typical of the program’s most successful participants. She’s been laughing and telling tales of trips all over the world and her unlikely discovery of pumping iron at age 88. The conversation turns to her heart attack now, and her voice gets quiet. “Needing a wheelchair, being chained to an oxygen tank, that’s death for me,” she says, a tremor creeping into her normally strong voice. “I couldn’t bear it.”

When she woke up in a San Antonio hotel feeling queasy with a dull ache in her chest, Maeck instantly knew what was wrong: her dinnertime martini. Her diagnostic skills, sadly, do not equal her abilities as a raconteur. The ache was a heart attack. In the blur of visits and consultations and decisions that followed, Maeck faced the stark choices of an elderly person confronted with a jam in the heart’s complex choreography. There was either surgery, difficult and invasive, or a life diminished. A life, perhaps, without travel, work, snowshoes.

For Maeck, that wasn’t a choice. “I asked them to give me the bypass yesterday,” she says.

Part of Ades’s job is helping his patients make changes, showing them how and why they should adopt better diet and exercise habits. Another part of the job, connected inextricably with the first, is helping people like Doris Maeck keep things exactly the same as they were before heart disease. His work keeps the elderly widower at home with his garden, rather than shunting him off to assisted living. It keeps the machinist on the job to protect his benefits, or lets the retired bon vivant with a bad heart valve keep racking up those frequent flier miles.

His most powerful tool to maintain lifestyle is lifestyle. Walks on a treadmill — or better yet, on the green grass of a Vermont June — build stamina and force the heart and lungs to get stronger. Lifting weights, so odd and unnatural for many older people, is key to carrying your own groceries up the stairs, or hefting a laundry basket. Or, in the case of 84-year-old Littleton “Tiny” Long, who spent 36 years as a University of Vermont English professor, to nimbly mounting the trusty Farmall tractor he uses to mow his South Burlington orchard
.
“Driving the tractor, that’s the easy part,” Long says.

The hard part was getting out of bed after entering the hospital with chest pains and leaving twenty-one days later with a quadruple bypass. Long couldn’t even get up to walk for the first ten days; even after returning home, he spent a month sleeping in his living room to keep movement to a minimum. But as he healed and got stronger, he began visiting Patrick Gym for rehabilitation sessions, starting with a few minutes on the treadmill. The nurses stayed close at first, watching his pulse and blood pressure. As he got stronger, they edged away. Now Long visits the rehab gym three times a week to exercise, check in with medical staff and visit with his fellow patients. He says he’s surprised that he looks forward to the appointments. And he’s delighted that he can once again tend his trees, dragging 150 feet of rubber hose through the orchard so he can spray antique trees laden with spitzenberg and northern spy apples.

“I am grateful that I can still fulfill my duty to the land. We bought the land, we have taken care of the land for fifty years, and there is pleasure in watching the trees flourish,” Long says.

HABITS OF THE HEART
Ades finds similar enjoyment in watching his patients progress. His role as a clinician and researcher is to be a coach, catalyst, authority, and a safeguard. But the strength to change long-held habits, replacing harmful routines with healthier ones, comes from within. The patients do the work; Ades offers expertise, and a very personal example.

“If I didn’t run five days a week, I’d be overweight,” he says. “I live the way my patients should.”

If Ades leaves his running shoes in the closet for more than two consecutive days, he feels an itch that becomes unbearable. Doing the right thing for his heart, his body, is easier in many senses than sitting around, he says, a rare thing in a contemporary culture characterized more by effort-sparing innovations like the Segway scooter than sweat. Habits are powerful and work for good as well as ill. So Ades might ask a patient to take walks four times a week at noon, trying to create a pattern, an association.

Cardiac rehab participants say that their regular visits to the facility also help establish exercise as a habit. The fellowship of exercising week after week at the same time with the same small group of people has rewards, says Bill Daniels, a retired UVM history professor, that go beyond health.

“We used to joke that you never left this program alive,” says Daniels, who has been in the program since his triple-bypass in 1995. “That’s a much better thing than it sounds like after you’ve had a gummed-up heart and should be dead.”

Most participants don’t, and can’t, spend as much time in Patrick Gym as Daniels. But most agree that the support they receive from other patients is as valuable as the counseling they receive from medical staff. The center, like the town, is a small and convivial space; the gray cinderblock walls only look drab. The room is alive with the sounds of movement, and conversation. “It’s exercise, and also social occasion. It’s a support group,” Daniels says.

Maeck agrees. “It was such a scary time after the surgery, and it was important to know I was not alone,” she says.

She takes that sense of fellowship home with her when she leaves the gym. Sitting on her sofa, just back from playing bridge with friends, Maeck muses on how lifting weights and walking on a treadmill, so unfamiliar before, are now a crucial part of letting her live life where she wants, in the way she wants, with travel, walks, and volunteer work.

“Every morning when I get up, I think, I made it,” she says. “I look out the window, and I can see the mountains. But even if it is cloudy, it’s still a fine day. I’m up, I’m moving. Life is good.”

The alarm on the dryer blares, interrupting her. The 88-year-old jumps up to check the load. She smoothly hefts the pile into a basket, completing another chore, getting another thing done for herself on a cold, gray, exquisitely beautiful day.

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