Diet-Heart Hypothesis

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Gina Kolata, then a reporter for Science magazine, wrote a skeptical piece about the quality of the evidence supporting the conference’s conclusions. The studies “do not show that lowering cholesterol makes a difference,” she wrote, and she quoted a broad range of critics who worried that the data were not nearly strong enough to recommend a low-fat diet for all men, women, and children. Steinberg attempted to dismiss the criticisms by calling her article a case of the media’s appetite for “dissent [which] is always more newsworthy than consensus,” but the Time cover story in support of Steinberg’s stated conclusions was clearly an example of the opposite, and on the whole, the media supported the new cholesterol guidelines.

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Steinberg:

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The most widely read general scientific journal, Science, covered the Conference but the published article was entitled "Heart Panel's Conclusions Questioned." It dwelt as much or more on the points of view of a handful of vocal dissenters as it did on the unanimous views of the expert panel and the supporting views expressed by the majority of the invited participants who spoke from the floor. Did the dissenters quoted in this Science pice have access to different data? No. Did they poke holes in the rationale by which the expert panel reached its conclusions? No. Did they actually represent a larger number of professionals in the field than did the expert panel? No. It is simply that dissent is always more newsworthy than consensus. This is especially true if the dissenters are highly vocal and even more so if they claim to be exposing flaws in the establishment position. If they can in addition imply malfeasance and conspiracy, so much the better. That's news."

The Consensus Conference

If a large portion of middle-aged American adults are now cutting back on meat and taking statin pills, it is due almost entirely to the step that the NHLBI took next. Dispensing drugs and dietary advice to the entire US population is a huge responsibility, and the NHLBI decided it needed to create a scientific consensus, or at least the appearance of one, before moving forward. Also, the agency needed to define the exact cholesterol thresholds above which it could tell doctors to prescribe a low-fat diet or a statin. So once again, in 1984, NHLBI convened an expert group in Washington, DC, with a public meeting component attended by more than six hundred doctors and researchers. Their job—in an unrealistic two-and-a-half days—was to grapple with and debate the entire, massive stack of scientific literature on diet and disease, and then to come to a consensus about the recommended cholesterol targets for men and women of all ages.

The conference was described by various attendees as having preordained results from the start, and it’s hard not to conclude otherwise. The sheer number of people testifying in favor of cholesterol lowering was larger than the number of spaces allotted to challengers, and powerful diet-heart supporters controlled all the key posts: Basil Rifkind chaired the planning committee, Daniel Steinberg chaired the conference itself, and both men testified.

The conference “consensus” statement, which Steinberg read out on the last morning of the event, was not a measured assessment of the complicated role that diet might play in a little-understood disease. Instead, there was “no doubt,” he stated, that reducing cholesterol through a low-fat, low-saturated-fat diet would “afford significant protection against coronary heart disease” for every American over the age of two. Heart disease would now be the most important factor driving dietary choices for the entire nation.

After the conference, in March 1984, Time magazine ran an illustration on its cover of a face on a dinner plate, comprised of two fried-egg eyes over a bacon-strip frown. “Hold the Eggs and Butter!” stated the headline, and the story began: “Cholesterol is proved deadly, and our diet may never be the same.”

As we’ve seen, LRC had nothing to say about diet, and even its conclusions on cholesterol were only weakly supported by the data, but Rifkind had already demonstrated that he believed this extrapolation was fair. He told Time that the results “strongly indicate that the more you lower cholesterol and fat in your diet, the more you reduce the risk of heart disease.”

The consensus conference spawned an entirely new administration at the NIH, called the National Cholesterol Education Program (NCEP), whose job it remains to advise doctors about how to define and treat their “at-risk” patients, as well as to educate Americans themselves about the apparent advantages of lowering their cholesterol. In the following years, the NCEP’s expert panels became infiltrated by researchers supported by pharmaceutical money, and cholesterol targets were ratcheted ever lower, thereby bringing greater and greater numbers of Americans into the category that qualified for statins. And the low-fat diet, even though it had never been properly tested in a clinical trial to ascertain whether it could prevent heart disease, became the standard, recommended diet of the land.

For longtime critics of the diet-heart hypothesis such as Pete Ahrens, the consensus conference was also significant because it marked the last time they could speak openly. After this conference, Ahrens and his colleagues were forced to fold their case. Although members of the nutrition elite had, over the previous two decades, been allowed to be part of the debate, in the years following the consensus conference, this was no longer true. To be a member of the elite now meant, ipso facto, supporting the low-fat diet. So effectively did the NHLBI-AHA alliance silence its antagonists, in fact, that among the tens of thousands of researchers in the worlds of medicine and nutrition over the next fifteen years, only a few dozen would publish research even gingerly challenging the diet-heart hypothesis. And even then, they worried about putting their careers on the line. They saw Ahrens, who had risen to the very top of his field and yet found himself having a hard time getting grants, because there was “a price to pay for going up against the establishment, and he was well aware of that,” as one of his former students told me.

No doubt this is why Ahrens, in looking back on the conference, which came to be his swan song, spoke with an uncharacteristic lack of reserve. “I think the public is being hosed by the NIH and the American Heart Association,” he declared. “They desire to do something good. They’re hoping to God that this is the right thing to do. But they are not acting on the basis of scientific evidence, but on the basis of a plausible but untested idea.” Plausible or even probable, however, that untested idea had now been launched.

In the January 4, 1985, issue of Science, Gina Kolata covered the 47th consensus panel report from the National Institutes of Health (NIH), published some three weeks earlier. Since 1961, the American Heart Association had asked Americans to reduce their intake of saturated fats and cholesterol and recommended its “prudent diet” emphasizing fruits, vegetables, and vegetable oils. The NIH had been hesitant to take a firm position on the diet-heart hypothesis, according to Kolata, because the scientific literature focusing on the connection between dietary cholesterol and saturated fatty acids (SFA) on the one hand, and heart disease on the other, did “not show that lowering cholesterol makes a difference” (Kolata 1985).