The 10% Solution For A Healthy Life, Chapter 1: Aside from That, Mrs. Lincoln, How Did You Enjoy the Play?

March 6, 2002

Atherosclerosis

From this printout, all of your tests appear to be normal. Your levels of serum cholesterol, triglycerides, and other lipids are normal. Other blood tests, such as thyroid function, are all normal.

That’s great. I do try to take care of myself, but it’s always good to hear that I’m in good health.

Yes, except for your fatal illness, you’re just fine.

Excuse me??

Oh, didn’t I mention that to you?

Mention what??

I’m talking about atherosclerosis. It’s almost certain that you have it. But aside from that one fatal disease, your health appears fine.

Fatal disease? How much time do I have?

Well, it won’t kill you right away. It is a fairly slow fatal disease with no symptoms for many years, kind of like AIDS, at least in that one regard.

Oh my God, I had no idea. I have to sit down. How does one catch this?

Actually, you don’t catch it. It’s a direct result of your life-style.

Now wait a minute. There’s nothing wrong with my life-style. I’m not all that overweight. I exercise fairly frequently. I watch what I eat, don’t go overboard on desserts, and all that.

Yes, by American standards, your life-style-that is, your eating habits and exercise-are perfectly normal, probably better than normal.

What do you mean by American standards? You’re American, aren’t you?

Yes, I am. But American eating habits-and this is true of much of the civilized world, particularly the Western civilized world-are a disaster. They are so far afield from what we were evolved to eat that most of the diseases we see are linked to what people eat and other aspects of their life-style.

So just what’s wrong with what I eat?

Well, the fat level, for one thing.

I hardly eat any fat at all. I’m very careful to cut the fat off my steaks. I can’t remember the last time I ate any fat.

That’s a good idea, to cut the fat off of your meat. Because the fat on meat is indeed 100 percent fat. But the “lean” meat of a typical steak can be 40 to 50 percent fat-that is, more than 40 percent of the calories are from fat.

You mean there’s actually fat in the steak itself?

Yes. Fat is one of the basic constituents of food. The calories from food are made up principally of fat protein, and simple and complex carbohydrates. Meat gets its calories from its protein and fat content. Vegetables and fruits are primarily carbohydrates, although they also contain protein and even a little fat. The calories in an apple are 6 percent fat.

Is that a lot?

No, not at all. You need some level of fat in your diet. You couldn’t live without obtaining certain essential fatty acids that the body is unable to produce itself. But if you are getting a sufficient level of calories, then it is almost impossible to have an insufficient level of fat, at least for adults. The problem is with the excessively high level of fat in the diet. The typical American diet gets 35 to 40 percent of its calories from fat. Beyond the fat that is naturally in foods, we add more. The American food rule is, “drench everything in fat”: vegetables, add a butter sauce; fruit, top them with whipped cream; salad, add an oil based dressing; bread, cover it with butter or margarine. Even milk is about 50 percent fat.

Oh, I use that 2 percent low-fat milk.

That’s about 37 percent of calories from fat.

Wait a minute, it says 98 percent fat-free-how can it be 37 percent fat?

Most of it is water, which has no caloric content. It’s 98 percent fat free by weight, but 37 percent of its calories are fat calories(5 grams of fat per cup, which is equivalent to 45 calories from fat out of a total of 120 calories).

I see, so fat is pretty pervasive.

Yes, in our society it certainly is.

But what’s so bad about fat? I’m not very overweight.

Fat certainly contributes to the obesity problem we have in this society. Each fat gram has more than twice the calories of a gram of protein or carbohydrates.1 Beyond that, studies have shown that even calorie for calorie, fat contributes to weight gain more than the other components of food.2 But that’s not the worst aspect of fat. Diets high in fat and cholesterol produce high levels of blood cholesterol.3

Oh, I avoid cholesterol as much as I can. I eat a lot of foods that are “low in cholesterol” or even “no cholesterol.”

The fact that you eat some foods low in cholesterol doesn’t mean that your diet is low in cholesterol overall. A single egg has more than 200 milligrams of cholesterol, which is more than you should have in two days. But perhaps more important, the amount of cholesterol you eat is only one factor affecting the level of cholesterol in your blood, and not the most important one at that.

I thought the cholesterol in my blood came from the cholesterol I ate.

That’s one of the big misconceptions. Some of the cholesterol in your blood (called serum cholesterol) does come directly from the cholesterol in your food (known as dietary cholesterol), and it is, therefore, important to avoid cholesterol in food. But the majority of the serum cholesterol in your blood is produced in your body, with most of that manufactured by your liver. You could eat no cholesterol at all and still have a very high serum cholesterol level if you eat a diet high in fat.4

Well, then, what’s the point of avoiding cholesterol in my food?

If you eat an excessive amount of dietary cholesterol, it will contribute significantly to an unhealthy cholesterol level in your blood. But the most important factor is the amount of fat you eat.5 Eating a diet high in fat causes a lipid (i.e., fat) metabolism that affects the liver’s production and distribution of cholesterol. The more fat you eat, the more cholesterol is produced by the liver (specifically two factions of cholesterol, called low-density lipoprotein, or LDL, and very low density lipoprotein, or VLDL).6 The cholesterol produced, particularly the LDL, travels in the bloodstream and is the primary cause of atherosclerosis.7

But what makes you think that I have atherosclerosis?

It’s a reasonable assumption, since 90 percent of all Americans do.8 Given that your lipid levels (blood levels of cholesterol) are “normal” (i.e., average), the probability that you have atherosclerosis is extremely high. Your levels need to be dramatically better than the American average not to have atherosclerosis.

Well, that puts a different light on things. How serious can it be?

Serious enough to cause a million and a half heart attacks a year and to kill about half a million Americans each year, which is about a third of all deaths. In addition, atherosclerosis is the primary factor in another 400,000 deaths per year from other cardiovascular diseases, such as stroke. It was a national tragedy when we lost 60,000 American lives in the Vietnam War over a 14-year period. We lose that many from heart and cardiovascular disease in just four weeks.

So what is atherosclerosis?

It is a progressive disease of the arteries, a gradual buildup of a rigid, plaquelike material in the walls of the arteries that over time narrows the passageways. It also weakens the walls of the arteries, which become increasingly hard, eventually becoming calcified and bonelike. The arteries, themselves, become diseased and are ultimately distorted by the plaque. This makes the arteries brittle and inflexible. But more important, the vessels have less and less room for blood to flow. We call this type of blockage an occlusion. Once the occlusion reaches about 70 percent of the diameter of an artery, there is great danger of a blood clot forming on or getting stuck in the damaged surface of an artery, leading to complete blockage by the atherosclerotic plaque, thus stopping blood flow altogether. If this happens in one of the coronary arteries, which are pencil-thin arteries feeding oxygenated blood to the heart itself, we call this a coronary thrombosis, or heart attack. Being deprived of oxygen, portions of the heart muscle die. Note that we are not talking about the large arteries, such as the aorta, that supply blood to the body, but rather the small coronary arteries that feed the heart itself. About a third of all heart attacks are fatal within a few minutes or hours. Most heart attacks cause permanent damage to the heart muscle and weaken heart function.

If a blood clot forms around the atherosclerotic plaque in one of the arteries feeding the brain, we call that a thrombotic stroke. If a circulating blood clot gets stuck in the atherosclerotic plaque in a cerebral artery, we call that an embolic stroke. These are the most common forms of stroke in the United States and typically cause massive death of brain cells, paralysis, and possibly death. There are many other conditions caused by atherosclerosis. In men, blockage of one of the arteries feeding the penis can cause impotence.9 Blockage of one of the arteries feeding the legs can cause claudication, a painful and dangerous condition in which blood does not reach the muscles and tissues of the legs.10 Plaque damage of the aorta can result in a potentially fatal aneurysm.

Where does the word atherosclerosis come from?

“Athero” in Greek means “grease” or “fat,” and “sclerosis” means “hardening,” so the word “atherosclerosis” literally means a fatty invasion and hardening of the arteries. But it is important to note that an analogy of atherosclerosis to built-up grease in a pipe is not entirely accurate. The grease in a pipe, while somewhat hard, is a lot softer than the pipe, so a strong cleaning agent and scouring device can scoop it out without damaging the pipe. In atherosclerosis, the plaque is very hard, while the pipe or vessel wall is soft. And it is not simply a matter of the plaque being embedded in an otherwise healthy vessel. The vessel is diseased as well.

It is not possible to simply clean out the accumulated plaque. There are medical procedures which attempt to widen the narrowed passage caused by the plaque. One procedure called balloon angioplasty involves inserting an inflatable device into the artery through a catheter (a long tube) and then inflating the device to compact the plaque and widen the passageway. While these procedures may have some medical merit they do not cure or even slow down the underlying atherosclerosis process. They also involve significant risk. Even the popular bypass surgery does nothing to alleviate the underlying plaque-formation process, and it is very common for “successful” bypass surgery patients to have their newly grafted coronary arteries clog up rather quickly after surgery.11

While bypass surgery can relieve angina pain, studies have failed to prove that they actually extend the patient’s life. For example, the Coronary Artery Surgery Study presented at the 1990 annual scientific meeting of the American Heart Association followed 780 people who had chest pain caused by angina and severely clogged arteries diagnosed 10 years earlier. Half of the group was randomly assigned to receive bypass surgery and the other half received dietary and drug treatment The study found no improvement in survival rates for the bypass group as compared to the nonsurgery group after 5 years, or after 10 years.12

It seems that one should do something about this disease before you get to that 70 percent level of artery blockage at which a heart attack is possible.

Unfortunately, the disease of atherosclerosis is symptom-free. For many individuals, the first symptom is sudden death. Sixty percent of all people who die from a sudden heart attack have never had angina pain, although they may have had, in retrospect, some poorly identified distress that may have been heart related.13

I thought you said that my heart was fine.

Fat and Cholesterol

It is. The disease underlying the vast majority of heart disease is not a condition of the heart structure at all, but a disease of its arteries. By the time the heart muscle is affected, it is often too late to take remedial action. Since this disease, atherosclerosis, is primarily related to the excessive level of cholesterol handled by the liver, you might actually consider the underlying condition to be a dysfunction of the liver. And to the extent that the liver is being influenced by your eating patterns, the underlying condition is really an eating disorder.

So you mean that eating all this hidden fat in food is tricking my liver into producing an excessive level of cholesterol, which in turn is clogging up my arteries.

That’s a reasonable way of putting it.

I thought you said the level of my cholesterol was normal.

Yes, it is. Your total serum cholesterol level is 190, a perfectly “normal” level. Also, your level of what we call high-density lipoprotein, or HDL, which is the “good” cholesterol, is also a “normal” 42.

Good cholesterol? I thought cholesterol was bad.

Actually circulating cholesterol is a fat-soluble, waxy substance (specifically the crystalline steroid alcohol C27H45OH) made up of primarily three factions: LDL, VLDL, and HDL. The cholesterol in these different factions is actually identical. The lipoproteins, which act as vessels carrying the cholesterol in the bloodstream, differ from one another in terms of what they do with the cholesterol they carry. LDL, which transports cholesterol from the liver to the body’s tissues, has been strongly implicated as a primary agent for the buildup of atherosclerotic plaque by transporting cholesterol to the body’s cells. VLDL is also involved, although its role appears to be less direct. VLDL level is closely linked to the level of triglycerides, which is the level of free-floating fat in the bloodstream. A study in the January 1992 issue of Circulation, published by the American Heart Association, has identified elevated triglyceride levels as another risk factor for heart disease, particularly in combination with elevated cholesterol levels.14

HDL apparently plays a constructive role, carrying cholesterol away from the arteries and back to the liver to be discarded.15 Major studies have shown that the total level of cholesterol, as well as the ratio of cholesterol to HDL, are primary risk factors for the development of heart disease.16 Your total serum cholesterol is a “normal” 190 and your cholesterol-to-HDL ratio is a “normal” 4.5.

So why, then, do you say I have atherosclerosis?

Because it is normal for Americans to have atherosclerosis. The “normal” ratio of 4.5 translates into a 75 percent chance of having a heart attack in your lifetime.l7 Most of the 25 percent who will not have a heart attack still have atherosclerosis. It’s just that something else will get them before they have a heart attack-something like cancer, which is also strongly linked to high levels of fat consumption. A “normal” ratio of 4.5 means, therefore, that the probability of atherosclerosis is well in excess of 90 percent. So “normal” in this instance does not equate with healthy.

I see, I think.

The medical community’s standards with regard to what is a healthy level of serum cholesterol have been progressively changing for the past 20 years. Originally 300 was the threshold for concern. Ten years ago, a cholesterol level of 260 was considered okay. Then it became 240, then 220, and now it’s 200. But 200 is generally not healthy. Most people with a level of 200 have atherosclerosis. If their HDL is below 45, then it can add up to be a rather high rate of atherosclerosis. And the rate of atherosclerosis is important The faster the rate, the faster your arteries get clogged, and the sooner you will develop conditions like a heart attack, stroke, claudication, aneurysm, angina, and many other dangerous, painful, and potentially fatal complications. The higher your cholesterol level, the more likely it is that you have a high rate of atherosclerosis. There are other risk factors that also affect the rate at which your arteries will clog up: smoking cigarettes, having high blood pressure, being overweight, having diabetes, and leading a sedentary life-style, to name a few.18

One further note on the role of HDL is in order. HDL appears to have some protective role if total serum cholesterol is elevated. However, if your total cholesterol is low enough-150 milligrams per deciliter(mg/dl) or less-then it does not seem to matter what the level of HDL is. For example, the Tarahumaras (Indians who live in the Sierra Madre region of northwestern Mexico) have an average serum cholesterol level of 125 mg/dl but a very low average HDL level of 25 mg/dl. Despite their very low HDL and very high total cholesterol-to-HDL ratio (over 5), they have virtually no heart disease or atherosclerosis.l9 Other studies have also found that nonindustrial societies consuming a low-fat diet have low rates of coronary heart disease despite low-HDL levels, suggesting that low HDL is most notably a risk factor only for populations with high-fat diets.20

So how much can I really do about this? I mean, aren’t my genes the primary controlling factor here?

Yes and no. One’s genetic inheritance is certainly very important. It is particularly important if you eat a high level of fat and cholesterol. And since that accounts for virtually all Americans, it would be reasonable to say that it is a crucial factor. In other words, if you eat a high-fat and -cholesterol diet, some people will develop artery disease quickly, others more slowly, and some-a relative few actually-not at all. It is also important to note that the level of fat in our diet is so high, that even people who think that their diet is reasonably low in fat are in most cases still eating an excessive level of fat. But virtually everyone, regardless of their genes, can dramatically reduce the likelihood of heart disease through the right life-style, primarily by focusing on diet and exercise. In other words, with the right diet and exercise, almost everyone can stop the process of atherosclerosis. So genetics is a critical factor only if you are eating a high-fat diet, which almost everyone in the United States does.

There is now convincing evidence that in many cases, atherosclerosis can actually be reversed through controlling these life-style factors. Reversal of disease was, until recently, a controversial proposition. We have known for along time that atherosclerosis could be reversed in animals such as rhesus monkeys and swine, but for some reason people were skeptical that this could be achieved in humans.21

How much healthier are the people in countries that eat low-fat diets compared to Americans?

If we look at societies that eat a very low fat diet-and low fat generally implies low cholesterol-we indeed find extremely low rates of heart disease. For example, an autopsy study of 22-year-old American soldiers from the Korean War, published in the Journal of the American Medical Association, found that 77 percent of the Americans had significant levels of atherosclerosis. The researchers contrasted this with the virtually nonexistent level of atherosclerosis in Asian males of the same age.22

In China, the diet consists primarily of vegetables and grains. Most Chinese are not wealthy enough to afford the luxury of our high-fat foods. Cholesterol levels are typically 100 to 150, with an average level around 127. A level of 180, which we consider low, is considered very high in China. And heart disease is very rare.23

The same results have been noted for many populations eating low-fat diets, including the Bantus of Africa and the indigenous peoples of Brazil and New Guinea.24 For New Guinea natives, cholesterol levels, which tend to run about 100, do not vary with age.25 Interestingly, blood pressure is also constant, and low to normal, throughout their lives.26 Studies of 25 other societies eating low-fat, low cholesterol, and low-sodium diets have shown the same results.27

In those nonindustrialized countries where the fat level in the diet is very low, serum cholesterol tends to be low, generally under 150, and there is a virtual absence of coronary heart disease.28 Even in the United States, the more than 40-year-long Framingham Study (an extensive research project that has been tracing approximately 5,000 individuals since 1948 to determine the risk factors for coronary heart disease) found that people who ate a very low fat diet tended to have serum cholesterol levels below 160 mg/dl. It also found essentially no deaths from heart disease when serum cholesterol levels were below 160. According to Dr. William Castelli, director of the Framingham Study, researchers have not seen a single heart attack in subjects whose cholesterol level was below 150 in the 40 years that the study has been in effect.29 The study found that in general, the higher the serum cholesterol level, the higher the incidence of heart disease. For example, in the 20-to-39-year-old age group, persons with a cholesterol level of 260 or above had four times the number of cardiovascular events as those with a level below 200.30

Heart disease is epidemic only in those countries where the typical diet is high in fat and cholesterol. In these same countries, serum cholesterol typically exceeds 200 mg/dl. Only a handful of countries have higher rates of heart disease than the United States. These northern European countries have diets that are even higher than ours in animal and dairy fat as well as cholesterol, and they also have correspondingly higher serum cholesterol levels (see chapter 15, “Ranking the Killers: How to Save a Million American lives a Year”).

A major study called the International Atherosclerosis Project, completed in 1965, involved more than twenty-two thousand autopsies in fourteen countries over a five-year period. All were conducted by the same group of pathologists. The findings were that the artery surface area damaged by plaque and the overall plaque damage was directly proportional to both the serum cholesterol level and the dietary intake of fat and cholesterol. Race, vocation, climate, and nationality did not affect the results.31

How do we know that this apparent link of fat in the diet to heart disease isn’t a coincidence? How do we know it isn’t just genetic?

Good question. Consider this. Japanese men and women who eat a traditional low-fat Japanese diet have very low rates of heart disease. Yet when these same Japanese people come to the United States and adopt an American diet, they also end up adopting American levels of serum cholesterol and American rates of heart disease. A major study of Japanese who migrated to Hawaii and California documented a threefold increase in coronary heart disease rates within a generation for those who migrated to the West Coast and a twofold increase in Japanese who migrated to Hawaii.32 So Japanese genes don’t protect Japanese people from the American diet.

In Hawaii, the level of fat in the diet is about 30 percent, which is between the 10 percent level of the traditional-pre-World War II- Japanese diet and the 40 percent level of the “traditional” American diet. Interestingly, those Japanese who move to Hawaii increase their rate of heart disease exactly to the Hawaiian level, which, not surprisingly, is between that of Japan and the continental United States.33 In parts of Japan, such as Tokyo, the diets have been affected by Western influences and are gradually becoming higher in meat, high-fat dairy products, and the like, and heart disease rates have been increasing since World War II.34

Fat consumption in Japan (now 20 to 25 percent of calories) is still only about half of that in the United States, and their rate of death from heart disease is about a third of the American rate. Forty years ago, when Japanese fat consumption was closer to 10 percent of calories, heart disease was almost nonexistent.

Isn’t stress a big factor?

Stress is an important issue and can accelerate an existing condition. Well talk more about that in chapter 8, “The Mind-Body Connection.” To obtain some insight into the relative importance of diet and stress, it’s worthwhile to examine the experience of European countries (England, Finland, Sweden, Holland, Norway, and others) under food rationing during World War II. Despite the enormous stress of those years, the death rate from heart disease in countries where rationing was imposed dropped dramatically to about one-fourth of prewar levels. In countries without food rationing, such as the United States, there was no drop in heart disease rates. And when the war was over and rationing ended, the heart disease rates in the rationing countries rose quickly again to “normal” levels. So the “hardships” of rationing-being forced to do without butter, cheese, eggs, and milk; substantially reducing the intake of meat and subsisting instead on such staples as potatoes and rice-resulted in a dramatic and relatively quick drop in heart disease. This drop occurred despite the fact that these people had been eating high-fat diets all their lives up to the period of rationing. The rationing, notably, was not completely meat free, but was simply a reduction in high-fat foods.35

An even more dramatic finding from World War II had to do with the survivors of the concentration camps. Those who had been in the camps for the full four years, many of whom had been diagnosed earlier with heart disease, were found to be completely free of this disease after their release from the camps. The dietary restrictions in these camps were more severe than the rationing found in many European countries, but the diet was nonetheless sufficient for these individuals to survive. Their atherosclerosis had stopped and, in fact, had reversed. Interestingly, they were also found to be free of hypertension and, in most cases, diabetes.

Similar results were found in autopsy studies in central Europe during the post-World War I period. Actual regression of atherosclerosis was noted during this period, in which the most notable characteristic of the people’s diet was a severe shortage of eggs, milk, butter, and meat.36

The case for a diet very low in fat and cholesterol does not rest on any single study or even a single type of study, but rather a rich mosaic of evidence, drawing together many human population studies (i.e., studies comparing different populations), human longitudinal studies (studies conducted on a population over a long period of time), human intervention studies (studies of the effect on a group of persons of prescribed changes in diet, life-style, or medication), and animal intervention studies.

The point is that if you eat an unhealthy diet, you had better hope that you have benevolent genes. You may survive an unhealthy diet but you are playing a particularly deadly form of Russian roulette. On the other hand, the vast majority of the population can overcome atherosclerosis through a very low fat, low cholesterol diet. In the parts of Japan where people eat the traditional low fat Japanese diet, as well as in the regions of China and other societies of Asia where people eat this way, heart disease is virtually unheard of. This simply cannot be attributed to good genes, because when these same people move to Western societies and adopt our eating habits, they develop our high rates of this disease.

So I have to adopt a concentration camp diet to avoid heart disease?

No, not at all. What a healthy diet and a concentration camp diet have in common is that they are both low in fat, cholesterol, and sodium. However, concentration camp victims were not given a sufficient number of calories and that caused malnutrition in many cases, which can be immediately health threatening. But your healthy diet can be satisfying, diverse, and appealing.

Okay, so how low in fat do I need to go? If I cut out some of my more fattening desserts, is that enough?

The Public-Health Recommendations

I’m afraid that’s not going to do it. The dietary changes you need to make to make a real difference are significant. The diet can be very interesting and enjoyable, but it requires a major change in eating patterns. Dropping a few high-fat items, adding a high-fiber cereal, and other little changes won’t make much of a difference.

The American Heart Association recommends a diet that is 30 percent of calories from fat, as opposed to the usual 40 percent.37 In advanced cases of heart disease, they recommend 20 percent. But these recommendations do not go nearly far enough. The 30 percent recommendation in particular is, in my view, the moral (and health) equivalent of telling a two-pack-a-day smoker to cut down to only a pack and a half a day. That’s a change in the right direction and does make a difference, but is clearly not the right answer.

Many studies have shown that a diet of 30 percent of calories from fat does indeed result in better cholesterol levels and lower levels of heart disease than a diet of 35-40 percent calories from fat, but a 20 percent diet is better still, and a 10 percent diet best of all. The reduction in risk of heart disease resulting from a diet that is 10 percent calories from fat is dramatically greater than the reduction resulting from a diet that is 30 percent calories from fat. At 10 percent, which is the level of a traditional Japanese or Asian low-fat diet, atherosclerosis and the resulting heart disease virtually do not exist.

Are there studies that show the plaque from atherosclerosis actually being reduced?

A particularly interesting study that showed regression of atherosclerotic plaque was reported at the 1988, 1989, and 1990 annual meetings of the American Heart Association by Dr. Dean Ornish, a professor of medicine at the University of California at San Francisco.38 He compared two groups of patients who had been randomly assigned from a pool of subjects, all of whom had experienced angina pain caused by proven partial blockage of the coronary arteries. The control group followed the standard medical recommendations of cutting down to 30 percent calories from fat and ceasing cigarette smoking. They also received standard advice for hypertension and performed aerobic exercise approximately one and a haft hours per week. The experimental group followed a program very similar to the 10% solution described in this book, including a diet of less than 10 percent calories from fat, exercise of at least three hours per week, and stress management. After a year, the average total cholesterol for the control group decreased from 251 to 230 mg/dl, a still very dangerous level despite their having followed all of the standard public health recommendations for high serum cholesterol levels and heart disease. More significantly, the average blockage of their coronary arteries, as measured by an advanced technique called quantitative coronary angiography (a computer analysis of angiogram X rays), got worse!

In contrast, the total cholesterol of the experimental group fell to 135 mg/dl, a very healthy level. Only one subject (out of 22) in the experimental group did not follow the advice, and his arteries got worse. The other subjects in the experimental group followed the program and none of them had an increase in blockage of their coronary arteries. Eighty-five percent had a decrease in blockage. Encouragingly the greatest decreases in blockage were found in the arteries with the greatest blockage. Ornish also measured their actual coronary flow reserve, a measure of the flow of blood to the heart, using a sophisticated imaging technology called positron emission tomography. Here again, the coronary flow got worse for those following the standard medical recommendations, including 30 percent calories from fat, but improved for the group following the recommendations of 10-percent-calories-from-fat diet, exercise, and stress management Other studies have shown similar regression of atherosclerotic plaque, given sufficient reduction of serum cholesterol levels, confirming many years of animal studies and human population studies.

With regard to population studies, most of the studies you’ve mentioned compare populations that differ in diet but also differ genetically.

Perhaps the most exciting population study of a genetically homogeneous population is a vast and comprehensive study of 6,500 Chinese, comprised of 100 people from 65 Chinese counties, conducted by a team of Chinese and American researchers and published in 1990.39 The study, which has been called the Grand Prix of epidemiology, tracked in considerable detail the eating habits and health of each of these individuals.40 The study was conducted in China for several reasons. First of all, the Chinese represent a very large population that generally eats a diet that is very low in fat and cholesterol. Most important, the population is genetically similar, so the difference in habits that do exist between counties can be examined without the confounding factor of genetic differences. Third, the very low cost of labor in China allowed the collection of a vast set of data that would be virtually impossible in American society.

The overall difference between Chinese eating habits and health patterns and those of Americans is dramatic. The average percentage of calories from fat in the Chinese population is less than 15 percent compared with about 39 percent for Americans. Their average cholesterol level is 127, compared with 212 for Americans. And there is virtually no heart disease, colon cancer, breast cancer, prostate cancer, and ovarian cancer among the Chinese, compared with very high rates of these diseases in American society. What little heart disease and cancer that do exist in Chinese society are seen in those counties that eat the highest levels of fat and cholesterol. The rate of heart disease, for example, in the rural counties of China is 26 per 100,000 adults, compared with 4,036 per 100,000 adults in the United States. In other words, the American rate of heart disease is 155 times higher than the rate in rural China. According to Dr. T. Colin Campbell, nutritional biochemist at Cornell University and one of the study’s researchers, the Chinese data provides a very clear picture in a genetically similar population that eating l0 to 15 percent calories from fat provides a very high level of protection from heart disease and cancer, whereas the level of 30 percent, recommended by public-health authorities in the United States, is completely inadequate to provide optimal protection from these diseases.41

So what do the Chinese die of?

In those few regions that are affluent and therefore eat relatively high levels of fat and cholesterol, the primary causes of death are similar to those in American society: heart disease, cancer, and diabetes. In those regions that are poor and therefore cannot afford animal sources of protein, these diseases virtually do not exist. Because of limited refrigeration and health care, infectious diseases are the leading causes of death in these regions. In some counties, a high level of salt is used to preserve food, and this combined with a high level of sodium in the food itself causes a high rate of hypertension and stroke caused by hypertension, similar to Japanese society. In those counties that eat low levels of fat as well as low levels of salt, there are low levels of blood pressure and correspondingly little stroke.

This extensive study has provided other intriguing results. Despite the fact that the Chinese eat only half of the calcium of Americans, there is virtually no osteoporosis. Adjusted for height, the Chinese actually eat 20 percent more calories than Americans, yet Americans are 25 percent fatter.

The overall message of the study is this: While eating 30 percent calories from fat is a bit better in terms of health and weight than eating 40 percent calories from fat, going down to about 10 percent calories from fat is necessary to virtually eliminate the risk of heart disease and most cancers and to readily control weight. Given the wealth of American society, we have the opportunity to avoid the diseases of poverty (i.e., infectious diseases) as well as the diseases of affluence (heart disease, cancer, and the other degenerative diseases).

So why the recommendation of 30 percent?

That is a very good question and the source of some considerable and complex controversy. I have talked with doctors involved in setting these guidelines. Many of these doctors are aware that the recommendations represent a significant compromise. They find it difficult to make recommendations for the general population that are so at variance with the deeply ingrained eating patterns of the entire population. They feel it might set the entire economy into a tailspin. Frankly, I think they overestimate the impact such recommendations would have, at least economically (they would have dramatic health benefits, however). After all, about 50 million Americans still smoke, despite the very clear-cut and uncompromising recommendations from the medical community that have been aggressively delivered through many channels.42

The most common argument for these watered-down recommendations on the ideal fat level is the theory of maximum compliance. The 30-percent-of-calories-from-fat recommendation is supposedly easy to follow. Just make a few minor adjustments, remove a few items from your diet, add a little fiber, and so on. The effect of the 30-percent-calories-from-fat diet is a reduction in heart disease risk of about 30 percent compared to a diet of 40 percent calories from fat. The 10% percent-calories-from-fat diet, on the other hand, if sustained over a period of several years, results in a reduction of risk of at least 90 percent. In my own case, the reduction of risk, as indicated by my cholesterol, HDL, and other measurements, was more than 97 percent according to the statistics of the Framingham Study.43 The likelihood of my having a heart attack during my lifetime fell from more than 90 percent (with a high likelihood of it occuring during middle age) to just a few percent. Personally, I would rather make a significant change in my eating habits for a 97 percent reduction in the risk of contracting heart disease, as well as comparable reductions in the risk of major cancers and other diseases, than make a moderate change for a 30 percent improvement in risk. Also, although it sounds counterintuitive, the major change is, I believe, easier to make and to stick to. I’ll explain more about that later in this book (see chapter 3, “The Benefits”). But the maximum compliance argument is that more lives will be saved by having relatively large compliance with a 30 percent reduction in risk than by having fewer people comply with stricter guidelines, even if the individuals following the stricter guidelines achieve virtual elimination of their risk.

Isn’t there some logic to that?

The logic is there, but I believe the recommendations are nonetheless misleading and ultimately not in the public interest. First, they are certainly not in your own private interest, in that you can achieve virtual elimination of the risk of heart disease and most cancers. That fact is not generally communicated.

My second objection is that they are precompromised. They are presented as the ideal recommendations based on what we know, and that is clearly not the case.

Third, a lot of people compromise these recommendations on their own anyway. Either they don’t fully understand and follow them or they think that the public-health recommendations must represent perfection and it is not their intention to achieve such perfection.

Thus, a typical person who takes these recommendations at all seriously figures, if perfection is 30 percent calories from fat, then it must be good enough to be at 35 percent. Often through ignorance or inattention, they end up even higher than that. Then the reduction in risk is almost nonexistent.

This leads to a fourth objection to the 30-percent-calories-from-fat recommendation, which is that it is subject to criticism of its effectiveness. Studies have shown that it is effective, but the effects are not overwhelming. Some critics have said, “Why bother? It’s not worth the trouble.” Recently there has been publicity about this debate between the cholesterol interventionists and their critics. But the two sides in this so-called debate are really on the same side, with neither side calling for meaningful changes. One side calls for very minor changes, although they certainly don’t refer to them that way. The other side says that the results from these changes are not worth the effort. Studies show that reducing fat consumption to 30 percent of calories does slow down atherosclerosis to some extent, but doesn’t stop it, let alone reverse it. The risks for heart disease are diminished, but by only a modest 30 percent or so. It’s as if there were a debate between those advocating that two-pack-a-day smokers cut down to a pack and a half a day versus those who said that cutting down by a half pack a day is too difficult and not worth it. Overlooked in this debate is the case for truly meaningful changes. Human population studies as well as human intervention studies have clearly demonstrated the dramatic benefits of a dramatic reduction of fat intake. Cholesterol levels do drop significantly, and actual measurements of the plaque development show that not only is atherosclerosis completely halted in most individuals but can be reversed. Thus the results for greater restrictions on fat intake do show results that can withstand the objections.

Finally, those individuals who take these guidelines very seriously (I know people who have actually written to obtain the guidelines in great detail and attempt to follow them very carefully) would be willing to follow stricter guidelines, but they are not being informed of their alternatives.

What initiated this controversy?

An article, “The Cholesterol Myth,” written by Thomas J. Moore (a condensation of Moore’s book Heart Failure), published in The Atlantic, attempts to makes the case that it is not worth the trouble to reduce your blood cholesterol.44 A great deal of his argument is based on a discussion of the MR FIT (Multiple Risk Factor Intervention Trial) study, which he claims “failed completely.” For seven years, MR FIT followed two groups totaling fifteen thousand men who were at high risk for heart disease. One group was given instructions to quit smoking, alter their diet (to the usual 30-percent-calories-from-fat recommendation), and control their blood pressure. For ethical reasons, those in the other group were also told of their high-risk situation and referred to their own physicians for treatment. In the end, the two groups did not differ significantly from each other in mortality or number of cardiac events, which led to Moore’s charge that the recommendations were ineffective.45 As it turns out the so called control group went to their physicians as instructed and, not surprisingly, received the same recommendations, since the MR FIT recommendations were identical to standard medical practice. Being in the study alerted both groups to their precarious situation, and both groups apparently took the recommendations equally seriously. Thus both groups changed their diet and life-styles to the same degree. And both groups benefited to the same limited extent. The number of coronary deaths and events was 30 to 40 percent lower in both groups, compared with statistics for other men at the same ages and with the same risk factors. Critics of MR FIT have pointed out several other serious design flaws. The study does show, however, the modest improvement that can be obtained by following the standard health recommendations. Neither Moore nor the MR FIT researchers examined the benefits of a more extensive diet and life-style change.

Moore also points out the side effects and dangers of some of the cholesterol-lowering medications, and here his criticisms have some validity.

So why don’t they put out multiple recommendations? They could put out the 30-percent-calories-from-fat guideline which gives you some benefit, and a 10-percent-calories-from-fat guideline for those who really want to do everything they can to eliminate their risk.

That’s not an unreasonable suggestion. There is something along these lines in that the so-called phase 3 American Heart Association guideline for adults with hyperlipidemia (elevated cholesterol levels) is 20 percent calories from fat.46 But this doesn’t go far enough either and is limited to people with advanced disease. Ten percent calories from fat is the ideal level for most any adult, specifically to avoid getting to the point of having advanced disease.

The objection I have heard against multiple recommendations is that they would be confusing. People want recommendations that are straightforward and want to believe that they reflect the ultimate wisdom on the subject. The policymakers are concerned that people would reject the 10 percent guideline as too radical and then also reject the 30 percent guideline because there would be no point in following it since it would be clear that it is a compromise.

So what should the guidelines reflect?

I believe that the guidelines should reflect everything that is known. Let people judge for themselves what they want to do. Those who wish to follow such guidelines carefully will have the opportunity for a dramatic improvement in their health. The compromisers will at least be departing from a position that is not already severely compromised to begin with. And the great unwashed majority who ignore such counsel regardless of its merit will be no worse off.

The saddest thing to me are people who desperately need such information, people who have passed the 70 percent occlusion level, have angina pain, or have had a heart attack or bypass surgery (or have had a bypass operation recommended), and are not informed that there is a way to reverse years of atherosclerotic neglect. Many would be willing to go to the ends of the earth to regain their health, but they’re not pointed in the right direction. Then there are others who, even after becoming ill, don’t take any advice they get seriously. But these individuals are probably hopeless anyway. In many cases, though, people ignore the advice they get because the advice is not presented in a convincing or effective way. The enormous impact of diet and life-style on health is often presented in a low-key, ineffectual way, which invites people not to take it seriously.

You know, pain has value. Discomfort can make us aware of a situation and cause us to take remedial action. I’ve always thought it tragic that atherosclerosis is painless.

I understand that women don’t get heart disease very often. So this stuff is mainly of concern to men, isn’t that right?

It is true that women have some protection from heart disease prior to menopause. High levels of estrogen prior to menopause are linked to relatively high levels of HDL (the “good” cholesterol) and this reduces the rate of atherosclerosis.47 Also, menstruation reduces the level of iron in the blood. Iron facilitates the oxidation of LDL (the “bad” cholesterol), which is an early step in the process of atherosclerosis. Thus reducing iron levels may slow atherosclerosis. But most pro-menopausal women still have atherosclerosis. The lower rate of plaque buildup prior to menopause (compared to men) results in a much lower rate of coronary heart disease during that period, but it also means that once menopause is reached, a woman’s arteries have already made substantial progress toward reaching the level at which a heart attack will occur. Women catch up quickly to men after menopause, and heart disease is the leading cause of death in women during these later years. There are other dangers that result from any rate of atherosclerosis, which we will discuss a little later.

Perhaps the most important reason that women should take this “stuff” very seriously is cancer. The rate of breast and other cancers is rising dramatically. I believe that a major reason for this may be the current preoccupation with so-called “heart-healthy oils” that are high in polyunsaturated fats, which accelerate the progression of cancer. As we will discuss in some detail, eating a diet that is very low in fat reduces the risk of most major cancers by 90 percent or more.

Hypertension, stroke, type II diabetes, and many other health concerns are equally important to both sexes, and the risk of all of these is dramatically reduced by this program. Also of interest to both sexes are the immediate benefits, including delaying the aging process, having smoother skin, and avoiding excess weight.