KANSAS CITY, Mo. — When a man is attacking a monster pork sandwich at Arthur Bryant’s, the most famed of this city’s famous barbecue joints, it is, perhaps, impolite to raise the subject of

heart disease. But Don Breckon doesn’t mind. “Heart attack?” he asks, and cheerfully holds out his plate, overflowing with BBQ pork and thick-cut french fries, a few wilted pickles on the

side. The very air in this stifling brick box of a restaurant seems slick enough to clog your arteries. And Breckon, 61, knows from sad experience that if you take your leftovers home,

you’ll find them coated with congealed grease by morning. Still, he loves the place, and the food, all the same. Let short-order cook Quincy Echols explain: “Everything here is high fat,

region’s cardiac disease rate sky high. The state with the highest mortality rate for coronary heart disease is New York. But nine of the next 10 states on the list are clustered in the

Midwest and the upper South. A Kentucky cardiologist has dubbed the region the “Coronary Valley,” and this fall the American College of Cardiologists will focus its annual conference on how

to overcome cultural inertia and spread heart-healthy habits. After several years of study, physicians and epidemiologists are now convinced that it’s lifestyle--not some quirky toxin of the

Mississippi River--that accounts for the Coronary Valley phenomenon. Health Habits ‘Among the Poorest’ “It’s not the water,” said Dr. Thomas F. Whayne Jr., a professor at the University of

Kentucky’s Gill Heart Institute. “It’s not any chemical company belching out bad humors. It’s the health habits.” Those habits, agreed Dr. Thomas Kottke, a Mayo Clinic cardiologist, “are

among the poorest in the country.” And they are deeply ingrained, though their toll has only recently been quantified as scientists learn more about the causes of heart disease. Take, for

instance, diet. Meat is emphasized in the Midwest as nowhere else in the country. As Matt Bucknell, a native of Oregon, observed after a few days on business in Kansas City, “there’s no tofu

on the menu here.” In part, it’s economics: Midwesterners have an interest in promoting beef and pork since so much of the farm economy depends on meat prices. (Drive through big cattle

states like Kansas and South Dakota and you may well see roadside billboards urging, “Eat Beef.”) It’s also, by now, become cultural tradition. To many, a meal doesn’t feel right without

meat. “We would have no friends if we had barbecue with salmon,” said Steve Bode, 35, of Lincoln, Neb. “They would not come over no matter how much free beer there was.” Most physicians

agree that red meat is fine in moderation, maybe 12 ounces a week. But the diet in the Coronary Valley is heavy on all kinds of artery-clogging fat and cholesterol, not just marbled steak.

In St. Louis, for instance, the trademark foods are deep-fried beef ravioli wrapped in bread crumbs and frozen custard so thick you can hold your cup upside down without losing a drop. In

small towns across the Coronary Valley, meanwhile, many cafes feature salad bars packed not with veggies but with macaroni and cheese, potatoes doused in mayonnaise and jello concoctions

made with whipped cream. “It’s a rich, ridiculously heavy-on-the-fat diet,” Whayne said. “It’s appalling what they serve at Millie’s Diner.” Regional grocery habits tell much of the story.

While consumers in the West purchase way more fruit juice and olives (and Mexican food) than the rest of the country, Midwest shoppers stock up disproportionately on such goodies as pie

filling, baking chocolate and potato chips. The South goes heavy on sausage and shortening, according to an economic study by researchers from the U.S. Department of Agriculture and Purdue

University. Shoppers in the Midwest and South actually spend slightly less on beef than consumers in the rest of the country, perhaps because they buy cheaper cuts, the study found. Yet they

also spend dramatically less on heart-healthy fruits, vegetables and fish, according to a federal Consumer Expenditure Survey. Poor diet is not the region’s only risk factor. Valley Home to

5 Big Smoking States Five of the top six smoking states are in the Coronary Valley, led by Kentucky, where nearly 1 in 3 adults smokes. (Nevada ranks second, followed by West Virginia,

Arkansas, Missouri, Ohio and Indiana.) In Missouri’s Ozark Mountains, health care volunteers report that children as young as second-graders smoke regularly. And even nonsmokers are often

exposed to tobacco’s toxins, as the hubs of small-town life--the local diner, the VFW post, the gas station quick-mart--tend to be thick with cigarette smoke. And if smoking is a cultural

norm in much of the Coronary Valley, exercise is not. In generations past, the effects of a high-fat diet may have been cushioned somewhat by all the hard physical labor that farm families

did; exercise is an excellent promoter of heart health. But now, machinery--and hired help--have eased the way for those still living off the land. Then too, the fitness craze never really

swept the heartland, and what with blizzards in winter, floods in spring and fog-the-eyeglasses humidity in summer, there are plenty of excuses to postpone a jog. Americans in general have

been getting fatter and less fit for at least a decade, according to the federal Centers for Disease Control and Prevention. So some experts believe the Coronary Valley is not an odd pocket

of cardiac distress but a model of what the United States will look like a generation down the road. “They’re just leading the pack,” Kottke said. “The lifestyle is infectious.” It’s an

infection that public health experts are working hard to stop. In Kentucky, Whayne is testing 2,000 residents of an Appalachian county for blood pressure, blood sugar and cholesterol levels.

Those at high risk of heart disease are referred to their physician for lifestyle counseling. “We want to show whether all this attention brought to bear on one county will make any

difference.” In Missouri, St. Louis University has trained volunteers in a dozen rural counties to educate their neighbors through health fairs and nutrition classes. When residents

complained they had no place to exercise--no fitness clubs and few sidewalks--the volunteers rounded up donations and built 21 walking trails. In Illinois, a recent survey of women across

the state made clear that poor health habits, rather than poor health care, were responsible for much of the most devastating disease--and prompted a new public health strategy. “In the past

we have put more emphasis on access, things like building facilities, getting doctors out there, getting people insurance. Now we’re trying to look at education,” said Paul McNamara, a

health economist at the University of Illinois. Mayo Clinic Lends a Helping Hand And just outside the Coronary Valley, the Mayo Clinic in Rochester, Minn., rewards residents who maintain

heart-healthy diets and restaurant owners who ban smoking or put low-fat dishes on the menu. Over the Christmas holidays, about 1,200 Rochester residents submitted to voluntary weigh-ins as

an incentive to lay off the egg nog. Philadelphia Mayor John Street has launched a similar program in his city, challenging residents to lose a collective 76 tons. Advocates of such programs

hope that with enough education, people will go for tofu instead of steaks, stairs instead of elevators and chewing gum instead of cigarettes. But back at Arthur Bryant’s, where the smell

of barbecued pork could tempt the staunchest vegetarian, customers shoveling in the high-fat fare say they’re aware of the risks--and don’t care. “We’ve grown up on meat and potatoes. There

was always a meat and a starch at every meal, and it just carries on to how we eat today,” explained Greg Reeder, 34, a salesman who drove 3 1/2 hours from Nebraska for a beef-and-pork

combo. Sweating as he piled towers of meat onto white bread, barbecue cook Echols said he’s eaten his creations every day since he was hired seven years ago. He plans to keep right on doing

it too, fat and cholesterol be darned. “Two, three, four meals a day here,” he said with a satisfied grin. “I haven’t gotten tired of it yet.” (BEGIN TEXT OF INFOBOX / INFOGRAPHIC) Heart

Attack Central Physcians have dubbed the Midwest and upper South “Coronary Valley” because of the high mortality rate for coronary heart disease there. Here’s a look at heart attack death

rates: * Death rates per 100,000 197.6 to 253.1 174.7 to 192.2 154.2 to 168.2 110.7 to 152.0 The 10 states with the highest death rates from heart dease: 1. New York 2. Missouri 3. Oklahoma

4. Tennessee 5. West Virginia 6. Arkansas 7. Ohio 8. Kentucky 9. Rhode Island 10. Indiana Source: American Heart Assn., 2001 Heart and Stroke Update MORE TO READ