The Great Cholesterol Myth: Part 1

Out on a Silent Hill

On the outskirts of the Field of Medicine there lies a wasteland. A land of banishment, where things deemed outmoded or dangerous go to live out their days. Pale and wasting Lead, glowing Lady Radium, and the dooming Leech creep amongst piles of rusting medical instruments, ashy forests of cigarettes, and empty bottles of opium. Knotted, wrinkly grey tumours, flocks of cancer cells that spread and retract like oil spills along the landscape, a burst appendix, infected tonsils. But, like any normal land of banishment, amongst the ruthless killers, thieves, and cons, there are often those with stories worth a second glance. Worth questioning. And in this necrotic landscape there is one who sits waiting for redemption.

You’ve probably heard of him. He’s not glamorous, but he has a rustic charm. His wardrobe is lumpy, and often a bit drab, but he’s hard working and of honest stock, and was the darling of both mother’s kitchen and the doctor’s prescription for most of history. His family name is Lipid, but everyone knows him as Fat. Animal Fat.

Since almost the dawn of time, patients suffering from epilepsy and diabetes were prescribed diets high in fat. Bone broths cooked from boiled marrow carried and moistened the food of peasants and kings alike.  Soap, candles, and beauty products were made from lard and tallow. Fatty cuts of meat were prized for their nutrition, and the skin of poultry and fish was enjoyed without restraint or repercussion. Fat was nothing special. No one paid him mind, except as an essential of everyday life for everyone who had ever lived and ever would. But then, one day, as often happens with villains, something snapped. He wasn’t the same. Underneath that wholesome face, a silent killer had been taking shape. He had gained the world and its trust, and now he was ready to strike.

Among Us

It’s the 10th of June, 1924. A sunny, late spring day in the Windy City. Six men have gathered at the newly opened and opulent haunt of America’s elite, the Drake hotel; a ten floor monument to leisure standing at the edge of Lake Michigan, panelled in wood and marble and furnished with tropical plants and notes from Herbie Kay’s trumpet. They convene as investigators on the trail of a rising and unidentified menace taking the lives of men and women across the nation. Unidentified because although they have put a name to the phenomenon, exactly what is causing it remains elusive. Headlines are starting to catch the flavour of obituaries as the words “dies of heart attack” make an appearance more and more frequently. Generals, doctors, congressmen, playwrights, bankers, railroad engineers. No one is safe.

All six of these men are cardiologists, each representing a different regional group studying heart disease, and each of them have come to the conclusion that this is too strong a villain to fight on their own. A national effort will have to be organised. Although unprepared and almost unbelievably ignorant (none of them had even heard the words “heart disease” in medical school) they valiantly decide that today is the day they will begin their war. Papers are passed and signed around the table, and with that, they found a professional society for doctors aimed at “facilitating research, disseminating information, increasing public awareness, and developing public health policy related to heart disease.” It comes to be known as the American Heart Association (AHA).

The legacies of these men outside of this moment will be mostly lost to time, except for one. Dr. Paul Dudley White, a compassionate man with blue eyes encircled by rimless glasses, and an upper lip dressed in a tidy moustache. A Harvard Medical School graduate and an avid cyclist, for White this will be just one step in hundreds that he will take over the course of his life to understand and protect the human heart. He’s already co-invented a method for measuring the clotting time of blood, and will go on to help found several organisations for the study of cardiology. A syndrome, an award, a society, and a section of the Charles River Bike Path will eventually be named after him. He’d even have his own 3¢ postage stamp. 

With the technicalities officially in place, the association gets down to business. The following year, around 200 physicians and a few laymen seat themselves nearly knees-to-rump in a conference room at the Haddon Hall Hotel in New Jersey. Manila programs with a heart and torch on the cover lay on their laps as presenters at the first Scientific Sessions meeting define their mission. By the end of the 1920s, the AHA has published its own medical journal, and set official criteria for detecting and diagnosing heart disease.

Seventeen years later, and a thousand miles away, a 44 year old zealous physiologist has just finished a study and is looking for something new. While starving 36 Minnesoten men and reconstituting them for science was interesting, no one really cared. The world had already been hungry for several years in the wake of war, and countries were starting to rebuild resources by the time the experiment had finished. As of now he has held six jobs, sports several degrees in disparate fields from Berkeley, Cambridge, and the University of Minnesota, discovered why eels can be happy in saltwater and freshwater, climbed a 20,000 ft. Andes mountain to study the oxygen content of his own blood, and, despite not being a nutritionist, developed the infamous K-ration for the U.S. Military. But physiologist Ancel Keys needs a new question to ask, and cardiology seems to be the place to look. He, too, is noticing the dooming headlines.  Since the war, 1 out of every 3 men have developed a form of heart disease before the age of 60, and the life expectancy for the average male has dropped to 45. Keys is only a year away from that himself.

Many of the men dying of atherosclerosis, more exactly coronary heart disease, are business executives and this specifically piques Keys’ interest. These are men who presumably have the means to care for and feed themselves well, so what’s the problem? Teaming up with fellow physiologist Henry Taylor, he decides to study the characteristics common among men who develop heart disease versus men who remain healthy. Funded by the U.S. Public Health Service and the budding AHA, they recrute 286 Minneapolis-St. Paul businessmen between the ages of 45 to 54 as test subjects and set up shop in the Laboratory of Physiological Hygiene, founded by Keys himself. It’s a crowded, concrete bunker of offices and laboratories tucked under the south facing Gate 57 of University of Minnesota’s Memorial Stadium. Kept company by the distant thunder and minor seismic activity of Saturday afternoon football games, measurements are taken of each subject’s blood pressure, reflexes, serum cholesterol count. They take electrocardiograms, and x-rays, and even conduct psychological examinations to see if there is a personality more prone to becoming a victim. The doctors regularly gather equipment for new experiments when possible.  When the tool they need doesn’t exist, they build it. Doctors had discovered that carrying extra weight ages the cardiovascular system, so the team also measures each man’s weight with an Archemedian contraption called a densitometer to calculate how much is fat and how much is muscle mass.

Two years later, Keys concludes that diet probably isn’t a factor. Refraining from fat and cholesterol in the diet “reduces the blood cholesterol in a few weeks, but the diet would scarcely  support life indefinitely, even if it could be tolerated — no meat, fish, eggs, milk, cheese, or anything made from these materials… We conclude that the control of cholesterol in the body must be generally sought in the body itself and not through dietary measures. The dietary damage from eliminating meats, eggs and dairy products may be a real hazard. The possibility of useful effect on arteriosclerosis of such a diet seemed to be remote indeed... If you are a vegetarian to hold down cholesterol you are vegetating in a field of delusion.”  In 1950, Keys and three other scientists publish a technical paper, The Relation in Man between Cholesterol Levels in the Diet and in the Blood, saying, “The general picture, then, is that the blood cholesterol level is independent of the intake over a wide range.”

Fat is safe. Science has spoken. The study will continue for the next thirteen years, but Keys and Taylor, in alignment with an earlier study conducted by biochemists Rittenberg and Schoenheimer, have come to the conclusion that refraining from fat was neither necessary nor helpful in the management of cardiovascular health, and that cholesterol isn’t “the whole story in the development of atherosclerosis”. Doctors are free to investigate other risk factors, and Fat continues his plot.

  

Back in Chicago, the AHA has grown only a little under the care of Dr. White and the others. During the 1930s they established specialty counsels and ran campaigns to wake the public to the danger they were in. The topic of Rheumatic Fever and its related heart disease is deeply important to Dr. Paul White; he had seen the “tremendous crippling of the young people” while studying the condition at the Massachusetts General Hospital, and it was a driving reason for his involvement in founding the AHA. The society launched a community program for Rheumatic Fever and Rheumatic Heart Disease. The project was funded by the American Legion, and other public donations were being made, but it wasn’t enough to sustain the association.

In 1948, however, things begin to change rapidly. It starts when the sponsor of the NBC radio show “Truth or Consequences” pledges the show’s proceeds to the group. The consumer goods company Procter & Gamble donates $1,740,000 dollars (or $23 million in today's money), allowing the society to reorganise into a national organisation. Seven chapters are opened across the U.S., and its first research grant is awarded to Nobel prize winner Dr. Albert Szent-Györgyi to pioneer research into heart muscle contractions.

By June 16, America is a little more awake. It has only been three years since she lost a president to a brain haemorrhage. The current president is secretly not doing any better. Perhaps this weighs on Harry Truman as he signs the National Heart Act, creating the National Heart Institute (NHI) and the National Advisory Heart Council, for which Dr. White serves as Executive Director. Within a year, a research program is established under the NHI in Framingham, Massachusetts “to study the expression of coronary artery disease (CAD) in a ‘normal’ or unselected population and to determine the factors predisposing to the development of the disease through clinical and laboratory exam and long-term follow-up.” The nationwide investigation the AHA founders had envisioned finally begins.

 

1.  “A century of progress against cardiovascular disease” American Heart Association, Jan. 8, 2024 www.heart.org/en/around-the-aha/a-century-of-progress-against-cardiovascular-disease

2.  Elkind M.S.V., Arnett D.K., Benjamin I.J., Eckel R.H., Grant A.O., Houser S.R., Jacobs A.K., Jones D.W., Robertson R.M., Sacco R.L., Smith S.C. Jr, Weisfeldt M.L., Wu J.C., Jessup M. (March 19, 2024) The American Heart Association at 100: A Century of Scientific Progress and the Future of Cardiovascular Science: A Presidential Advisory From the American Heart Association.  www.ahajournals.org/doi/10.1161/CIR.0000000000001213

3.  “100 Years of Impact”  American Heart Association, www.heart.org/en/bold-hearts-the-centennial/100-years-of-impact

4. Baker, D. B., & Keramidas, N. “The psychology of hunger.” American Psychological Association (2013, October 1) www.apa.org/monitor/2013/10/hunger

5.  Evans DH. (August 28, 2008) Teleost fish osmoregulation: what have we learned since August Krogh, Homer Smith, and Ancel Keys., pubmed.ncbi.nlm.nih.gov/18525009/

6.  Sparling, P.B., Legacy of Nutritionist Ancel Keys, Mayo Clinic Proceedings, Volume 95, Issue 3, 615 - 617

   www.mayoclinicproceedings.org/article/S0025-6196(19)31088-2/fulltext

7.  Keys A. Adventures of a medical scientist. Sixty years of research in 13 countries. Sarasota, Florida, Crown Printing, 1999.

8.  Blackburn, H. (January, 2001) If it Isn’t Fun…: A Memoir from a Different Sort of Medical Life, Volume 1 - The First 30 Years, 1942-72 www.epi.umn.edu/cvdepi/essay/if-it-isnt-fun-the-laboratory-of-physiological-hygiene-and-the-division-of-epidemiology-school-of-public-health-university-of-minnesota/

9.  “The Search: University of Minnesota Heart Disease Research (Young America Films, 1955)” YouTube, uploaded by National Library of Medicine, 13 July, 2022, www.youtube.com/watch?v=z8o0moaW7o0

10.  Ibid., 6

11.  Noakes, T. “It’s the Insulin Resistance, Stupid: Part 6” CrossFit, October 31, 2019  www.crossfit.com/essentials/its-the-insulin-resistance-stupid-part-6

12.  Keys A., Mickelsen O., Miller E.V., Chapman C.B., (July 21, 1950) The relation in man between cholesterol levels in the diet and in the blood.  pubmed.ncbi.nlm.nih.gov/15442234/

13.  Rittenberg D.,  Schoenheimer R., (August 3, 1937) “Deuterium as an Indicator in the Study of Intermediary Metabolism: Further Studies on the Biological Uptake of Deuterium into Organic Substances, with Special Reference to Fat and Cholesterol Formation” Journal of Biological Chemistry, Volume 121, Issue 1, pg. 235-253,  doi.org/10.1016/S0021-9258(18)74342-1

14.  Keys A. (1952) Human atherosclerosis and the diet.  www.ahajournals.org/doi/pdf/10.1161/01.cir.5.1.115

15.  Tan S.Y., Kwock E., (April, 2016) Paul Dudley White (1886–1973): Pioneer in modern cardiology, pmc.ncbi.nlm.nih.gov/articles/PMC4853490/

16.  Merschel, M., “How the war against rheumatic heart disease was – and wasn't – won” American Heart Association, August 23, 2014, www.heart.org/en/news/2024/08/23/how-the-war-against-rheumatic-heart-disease-was-and-wasnt-won#:~:text=An%20excerpt%20from%20the%201951,children%20suffered%20in%20many%20ways

17.  Marvin H.M., (1964) “Forty year war on heart disease,” archives.libraries.emory.edu/repositories/5/archival_objects/522804

18.  Ibid., 3

19.  Huget, J. “The Secret Heart of Harry Truman” The Washington Post, July 21, 2003,  www.washingtonpost.com/archive/lifestyle/wellness/2003/07/22/the-secret-heart-of-harry-truman/1aea4663-ab69-49d5-ae5b-ed60ae4195b3/