J Leonard Dixon

Composite of Figure 1, Age-adjusted secular trend of coronary heart disease in Anglo-Celtic countries and Europe 1950–2000, and Figure 2, Age-adjusted secular trend of coronary heart disease in North America, from: M Mirzaei, A S Truswell, R Taylor, and S R Leeder. Coronary heart disease epidemics: not all the same. Heart 2009;95:740–746.

Numbers on the graph refer to these historical occurrences in the “War Against Coronary Heart Disease”:

1 – 1952 – Initial visit to Naples, Italy by Dr. Ancel Keys and Margaret Keys

2- 1958 – Seven Countries Study officially began

3 – 1959 – Eat Well and Stay Well, by Ancel and Margaret Keys, published by Doubleday, and serialized in newspapers

4 – 1965 – Four articles on the fat and cholesterol feeding studies carried out in the Keys lab were published in Metabolism

5 – 1975 – How to Eat Well and Stay Well the Mediterranean Way, by Ancel and Margaret Keys, published by Doubleday

6 – 1977 – Landmark report: Gordon T. and colleagues. High density lipoprotein as a protective factor against coronary heart disease. The Framingham Study. Am J Med. 162(5):707-14.

7 – 1977 – Congressional Select Committee (McGovern committee) issued the “Dietary Goals for the United States.”

8 – 1980 – Seven Countries, by Ancel Keys and colleagues, published by Harvard University Press

9 – 1984 – National Heart, Lung, and Blood Institute’s Lipid Research Clinics Coronary Primary Prevention Trial was published

10 – 1987 – First statin, Mevacor, approved by FDA

11 – 1990 – Landmark report: Mensink R, Katan M. (1990) Effect of Dietary Trans Fatty Acids on High-Density and Low-Density Lipoprotein Cholesterol in Healthy Subjects. N Eng J Med. 323: 439-445. http://www.nejm.org/doi/full/10.1056/NEJM199008163230703

12 – 1996 – Pietinen P, Vartiainen E, Seppänen R, Aro A, Puska P. (1996) Changes in diet in Finland from 1972 to 1992: impact on coronary heart disease risk. Preventive Medicine 25(3): 243-250. http://www.sciencedirect.com/science/article/pii/S0091743596900535

Why was Ancel Keys Correct?

If you read Seven Countries (Harvard University Press) carefully, it is evident that Ancel Keys and his colleagues gave a balanced view of the hypothesis that diet was an important reason for the high rates of Coronary Heart Disease (CHD) in the U.S. in the 1950s and 1960s. In many places in the book Dr. Keys addressed other possible causes for the higher incidence of CHD in the U.S. But in the end, he concluded that age, sex, and blood cholesterol concentration were the three significant risk factors for CHD, and that diet was a major factor in determining blood cholesterol concentration. The other two risk factors were more difficult to change. At the time this hypothesis was raised by Dr. Keys, it was difficult to comprehend the underlying biology behind it, and Dr. Keys took wide criticism from other scientists and from agricultural commodity groups. In Genius and Partnership, I added a significant additional factor to be considered, in that I posited that the increase in the use of margarine, with its high content of trans fatty acids, in the U.S. in the period 1940s to early 1960s increased the rates of CHD to higher than what they were in northern European countries during the same period, except in the case of East Finland, which had the highest rates of CHD in the entire world.

The Seven Countries study that was officially started in 1958 by Dr. Keys was a huge undertaking that followed 13,000 men in 16 regions of seven countries. The study was carefully performed and the differences in the blood cholesterol concentrations and in the rates of CHD between certain populations were fairly large. But the criticisms by certain scientists that Seven Countries was an ecological epidemiology study and involved populations with different and possibly unique genetic backgrounds cast some doubt at the time concerning the results observed by Dr. Keys and his colleagues.

However, in the 25 year period after the Seven Countries study started, the decreases in CHD that occurred in East Finland (not really shown above as the data in the graph is from Finland as a whole; but reviewed in Genius and Partnership) from 1965 to 1990 following significant efforts to change the Finnish diet, is the strongest evidence to date that diet can affect the blood cholesterol concentration and influence the rates of CHD.

Now the analysis of the changes in the rates of CHD across many countries throughout the world during the past 40 to 50 years provides strong support that the results and conclusions reached by Ancel Keys were absolutely correct. Rates of CHD have decreased in many countries where dietary intervention was implemented and stressed. The graph above is a compilation of two graphs that were in the excellent article by M Mirzaei, A S Truswell, R Taylor, and S R Leeder. Coronary heart disease epidemics: not all the same. Heart 2009;95:740–746.  http://heart.bmj.com/content/95/9/740.long

In this graph it can be easily seen that the “War on Coronary Heart Disease” (essentially comprised of the following: a) the awareness and education campaigns that were fostered by Ancel Keys and his colleagues, b) the research supported by the National Institutes of Health, c) the myriad of efforts performed by the American Heart Association, plus d) the improved treatment of patients by clinicians, and later on, e) the development of more powerful LDL cholesterol lowering drugs) brought the rates of deaths due to CHD by the year 2000 down to levels that approached those observed in Mediterranean countries.

No matter what the “nutrition media experts” say to try to convince the general public that dietary saturated fat is not a factor in the development of CHD, the sum total of all the research that has been performed in the past 60 years proves the “nutrition media experts” wrong. The data in this graph shows convincingly that the efforts to lower total dietary fat, and especially to lower dietary saturated fat, were indeed successful in reversing the epidemic of deaths due to CHD that were observed by Ancel Keys and other scientists in the time after World War II.