Dr. Oz on the Real Threat to the Sopranos

James Gandolfini's death is a reminder that everyone is vulnerable to heart disease

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Craig Blankenhorn / HBO / AP Photo

From left, James Gandolfini, Steven Van Zandt and Tony Sirico, cast members of the HBO television drama The Sopranos

When I heard of actor James Gandolfini’s untimely passing after a heart attack, I was reminded of a recurring theme in the television series he made so memorable. His tough mafia-don character valued family above all, but was incessantly anxious about his ability to protect them and keep them well. Tony Soprano did keep his family safe — in his decidedly unconventional fashion. And Gandolfini, a husband and a father of two, looked after his own as well — until he left them altogether, claimed by a heart attack at just 51.

When it comes to our health, we are all like the much missed Gandolfini. We will do anything for the people closest to us — anything, that is, except take the steps we need to maintain our health and allow us to spend as many years as possible loving and playing with the people we treasure most.

If even tough guys like Tony Soprano need to get checked out, the rest of us do too — whether we think we’re in good shape or not, and whether we’ve ever had chest pains or not, since plenty of people are pain-free until the very moment their heart gives in. Some have argued that Gandolfini’s past substance abuse contributed to his premature death. Perhaps it did. But we shouldn’t ignore the more obvious risk factor: at just over 6 ft. (1.8 m) tall and around 272 lb. (123 kg), he was an outsize personality in a dangerously outsize body. In a country that is simultaneously obsessed with bodily perfection, even as two-thirds of us are overweight or obese, weight has become an exceedingly fraught topic, and in the first hours after Gandolfini’s death, some commentators sought to sidestep the topic, wondering how a vigorous man with no known health complaints could have suddenly succumbed. But if we saw an anorexic teenager we wouldn’t pretend she wasn’t heading for serious health trouble, so why should we be so coy at the other end of the weight spectrum?

A key role in anyone’s weight gain may be stress — something that can be a defining feature of a celebrity’s day. Stress hormones like cortisol can hijack our normal appetite sensors, pushing us to eat even when we are not hungry. This is particularly dangerous when the excess fat that results from overeating is belly fat, which squeezes the kidneys. Since it’s the kidneys that, in turn, regulate blood pressure, it’s no surprise that overweight people are at such high risk of hypertension, the leading cause of heart attack and stroke. Belly fat also harms the liver, prompting it to release more cholesterol. In many people, those changes can block the ability of insulin to break down blood sugar, contributing to diabetes, which wears away at our major arteries and leads to atherosclerosis, a condition often discovered after lethal heart attacks. Half of all victims die during their first heart attack because they do not know their risk factors or do not recognize the subtle warning signs that make their hearts vulnerable.

This awareness can be a lifesaver, and two of Gandolfini’s own Sopranos castmates are living proof. Vincent Pastore and Frank Vincent both had heart-artery blockages that resembled the type that may have killed Gandolfini. They both noted increasing shortness of breath, and although they did not realize at the time they were at risk of heart disease, they were brave and wise enough to seek help for their symptoms; each had lifesaving surgery at my center during the run of The Sopranos. Shortness of breath is a telltale sign of cardiovascular trouble, since it results when the heart cannot even pump the blood out of the lungs, essentially meaning we are drowning from lack of oxygen. But most of us ignore this symptom and many people have no symptoms at all — until it’s too late. And that is why we suffer the loss of so many wonderful people like Gandolfini.

It wasn’t easy for Pastore and Vincent to shed their afraid-of-nothing mobster characters and visit the doctor. In fact, when Pastore first met my colleague Michael Argenziano, he introduced himself by his Sopranos nickname, Big Pussy. Dr. Argenziano had never seen the show and was caught off guard. Don’t worry, he assured Pastore, we’re all afraid in situations like these. But showing up for treatment in the first place was a profound act of courage — courage that is fortified by our deep desire to protect our families.

Pastore and Vincent both agreed to speak openly about their cases because they hope their stories will serve as an important example. For those willing to follow it, here is my gauntlet for the brave:

First, if your belly looks like Gandolfini’s, you need a checkup. I am specifically asking you to measure your waist size at the belly button and honestly report if this number is more than half your height. Forget using your current belt size as a tool, since most men slip it below the belly-fat pad.

Second, ensure that your baseline risk factors like hypertension, diabetes and cholesterol are under control. These are often corrected with lifestyle alone.

Third, shortness of breath from walking up two flights of stairs or any sudden change at all in your breath or stamina is worrisome. Think of it as the equivalent of having chest pain.

Fourth, what have you eaten in the past 24 hours? Fatty and fried foods cause spasms in blood vessels, which limit blood flow for six hours, at which point we often have another fatty meal. Most heart attacks occur on Monday mornings because of our dietary transgressions over the weekend and the stress of the upcoming workweek. What you eat and do today will affect the chance of a heart attack tomorrow.

We’ll never know what wonderful work Gandolfini would have done if he had a full measure of years. We’ll never know either the things he would have taught his young daughter, who will have her first birthday in October. We do know the steps that might have helped him live to have all those experiences, and they’re the same things that can help protect us — and our families — too.