There are certain (dietary!) truths that Americans hold to be self-evident . . . bedrock beliefs that have been part of the nutritional landscape for as long as most can remember . . . truths that have been publicized far and wide over much of the last century . . . truths that have been endorsed by leading health organizations, national government bodies and the most respected nutritional experts.
These are the basic truths.
Among them, the rock-solid knowledge that low-fat foods pave the road to heart health, weight control and overall well-being, while foods high in saturated fats (think juicy red steaks and creamy rich sauces) are artery-clogging, cholesterol-raising poisons that lead to heart attacks and shortened life spans.
Generations of Americans have staked their health—and their lives—on these truths. They’ve followed official government advice and reduced their consumption of red meats, dairy, animal fats and tropical oils, replacing them with leaner meats, vegetable oils, grains and a slew of carbohydrates.
And, of course, the evidence for such truths is, well, rock solid . . . right?
Well, not quite. Not by a long shot.
As it turns out, an astounding narrative of health-shattering proportions is revealing itself—a tale of egos, politics, power, fortunes and incompetence that stretches back to the early-to-mid 1900s, when heart disease (once a rarity!) skyrocketed inexplicably, outpacing every other killer . . . a tale of long-buried evidence and long-silenced voices that have been ignored, ridiculed and even hidden from the American public.
In her New York Times bestseller, The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet, author Nina Teicholz lays out the evidence uncovered during her “all consuming, nine-year obsession” to get to the root of America’s long-held views on fat and how they’ve shaped the nation’s nutritional tenets.
It’s a story rooted in a simple, never proven (and many would argue, disproven!) hypothesis: Saturated fat leads to (dangerously!) high cholesterol, and high cholesterol leads to heart disease.
Teicholz approached her challenge with a tenacious appetite for the truth: She “read thousands of scientific papers, attended conferences, learned the intricacies of nutrition science, and interviewed pretty much every single living nutrition expert in the United States, some several times, plus scores more overseas” and “dozens of food company executives,” as well.
In the end, she describes the results as “startling.”
The book, itself, reads like a nutritional thriller, tracing the rise of anti-fat dogma in the United States, and how it’s impacted the dietary habits of generations of Americans (whose health, despite such advice, has become “strikingly worse”) and led to a billion dollar industry for cholesterol-lowering drugs.
It’s a personality-riddled tale that winds through the world of nutritional research and into the world of government politics and policies. It’s a story of how a nation removed or drastically reduced key elements of its traditional diet, filling the void with non-traditional—even fabricated—ingredients and higher proportions of other dietary elements.
It’s a tale of emotional attachments and a stubbornness to see beyond assumed facts, and an epidemic rise of obesity, diabetes and other ills in a population that still counts heart disease as its Number 1 killer.
One Man’s Story
In many ways, it’s a story of one man. His name is Ancel Keys.
Keys, a biologist and pathologist at the University of Minnesota, was no ordinary man. He was a “forceful” and “persuasive” personality with an “indomitable will” who would argue an idea “to the death.” Described as “arrogant” and “ruthless” by various colleagues, he would “aggressively” and “relentlessly” disparage those who opposed him. He had a “quick, bright intelligence” and a talent for cultivating key relationships among the day’s most powerful and influential people. He had a level of ambition capable of changing the course of history . . . and blinding himself . . . and others . . . to the truth.
According to Teicholz, Keys falls under the “Great Man” theory of history—the belief that “strong personalities steer events using their own personal charisma, intelligence, wisdom or wits”—and in the world of nutrition, she counts Keys as “by far the Greatest Man.”
So what, exactly, did Keys do?
In short . . . He hypothesized . . . and refused to let go.
In other words, Keys came up with an idea, and loved it so much—or perhaps the power and prestige it brought—that he protected it at all costs. His tenacity, paired with an immense talent for promotion, transformed his (never-proven!) hypothesis into national nutritional policy—and made him an “unparalleled” influence in the dietary world.
Most, if not all, of how we’ve been told to eat for the last half-century-plus, as well as our national obsession with cholesterol, rests on his shoulders.
Keys almost single-handedly turned America against dietary fat—especially the saturated kind—and in doing so, created a tremendous nutritional void which Americans obligingly filled . . . with carbohydrates and vegetable oils.
Carbohydrates (one of the three macronutrients, along with fats and proteins), became the top energy source, fueling a nation . . . as well as an industry. Indeed. Food manufacturers, sensing an emerging market, stepped up their game, creating a seemingly endless supply of everything from cereals and crackers to breakfast foods and snacks—all delivered with little or no fat . . . just good ‘ole carbs.
The American Heart Association—for a “hefty fee”—even joined in, offering its “Heart Healthy” checkmark on “approved” products. What could be better for the heart than a serving of Kellogg’s Frosted Flakes, Fruity Marshmallow Krispies, Low-Fat Pop-Tarts or Honey Nut Cheerios?
Carbohydrates, although the darling of the anti-fat movement, have, of course, been shown to send blood sugar skyrocketing. No wonder obesity and diabetes have reached epidemic proportions!
Vegetable oils—particularly the polyunsaturated kind—also earned a prominent spot in Keys’s nutritional world—partly because they were shown to lower cholesterol, but also because fat was a tremendous culinary workhorse that had to be replaced.
Indeed. When the powers that be threw their muscle behind the vilification of fat, the traditional methods of cooking with suet, lard, tallow and even butter, as well as coconut and palm oils (aka saturated fats), were no longer acceptable . . . at least not in sophisticated circles.
In the scramble to replace these ancient ingredients, health experts recommended a switch to vegetable oils (once considered suitable only for soaps, candles, waxes and the like); as well as their “hydrogenated” counterparts, which included vegetable shortenings like Crisco.
Crisco, introduced in 1911 by Procter & Gamble—and originally called Krispo!— was the country’s first hydrogenated food product, ushering in the era of trans fatty acids. P & G, which had secured U.S. patents for the hydrogenation process a few years prior, originally planned to manufacture soap, but found that the new product so resembled lard that they might as well sell it as such.
They billed it as a “new” and “better” fat that was easier than butter or lard to digest; and set out to convince the American housewife that the “modern woman” was “glad” to “give up butter and lard just as her ‘Grandmother’ was happy to forgo the ‘fatiguing spinning wheel.’”
In 1913, P & G published The Story of Crisco, the first of several “Crisco” cookbooks, in which it noted that the product was produced in “sparkling bright rooms” where “white enamel covers metal surfaces.” Not a dirty animal in sight!
American women listened, and sales of Crisco quadrupled within four years of its introduction.
Hydrogenation, the process by which P & G turned cottonseed oil into Crisco’s semi-solid state, would become a lifesaver for the food industry, which would need a way to replace traditional animal fats, as public opinion turned against them.
The new process was extremely versatile, allowing oil chemists to create varying degrees of hardness, depending on the need. While less hydrogenation could produce a soft chocolate suitable for drizzling over a donut, more hydrogenation could be used to produce a harder version of the same topping, suitable for chocolate-covered caramels.
In 1961, the AHA—with Keys on its nutrition committee—officially recommended a diet low in saturated fats and high in polyunsaturated fats (aka vegetable oils), and Americans were advised to “replace butter with margarine or Crisco and always to choose vegetable fats over animal fats.”
This was the “first official statement by a national group anywhere in the world recommending that a diet low in saturated fats be employed to prevent heart disease,” says Teicholz. “It was Keys’s hypothesis in a nutshell” and it “would be influential not only in the United States, but also around the world.”
After the AHA’s endorsement, one trade publication noted that “the rush to get aboard the polyunsaturated bandwagon has become a stampede,” with new products containing “higher and higher amounts of polyunsaturated oils” flooding the market.
And the government was just getting started. In the following years, more and more agencies would join the chorus, with the recommendations on fat becoming increasingly restrictive, while those promoting polyunsaturated vegetable oils would broaden.
What the public didn’t know, however, was that vegetable oils—in both liquid and hydrogenated forms—weren’t the cure-alls they were made out to be.
In fact, there have long been warnings of their sinister effects on health. In their liquid form, vegetable oils are toxic when heated to higher temperatures and have been linked to cancer, tumor growth and significantly shortened life spans in lab animals; and one of their side effects—lowered cholesterol—has been linked to gallstones, strokes and overall mortality. In their hydrogenated form, they contain trans fatty acids, a substance considered so harmful that the U.S. Food and Drug Administration has given the food industry until 2018 to eliminate it from their products.
So much for replacing saturated fats!
But, of course, little of this was known—or at least, made known to the American public—in the early years, when Americans were encouraged to jump on the anti-fat bandwagon.
Indeed. Vegetable oils were fairly new on the dietary horizon. It was only in the 1930s that mechanization enabled the widespread—and economical—hulling and pressing of seeds. As it turned out, making vegetable oils was far cheaper than raising and slaughtering animals. Yippee!
Such oils went from being “completely unknown” before 1910 to comprising around 7-to-8 percent of “all calories consumed by Americans by 1999,” according to estimates,” says Teicholz, who points out that soybean oil—mostly in its hydrogenated form—is consumed a thousand times more in the United States today than it was in 1909.
“That Americans came to see vegetable oil as the healthiest possible kind of fat was one of the more astonishing changes in our attitudes about diet in the 20th Century,” she says.
In the meantime, saturated fats—strong, stable fats capable of withstanding high heat without breaking down—actually raise good cholesterol, satiate hunger and keep blood sugar levels stable.
Interestingly, a number of well-documented anthropological studies—well-known in Keys’s era—pointed strongly to the health aspects and sustainability of diets high in saturated animal fats. Such studies, however, went against what Keys called his diet-heart hypothesis, and thus tended to be dismissed.
In one population study, the “most favored and precious food” was fat, while the “leaner parts, including the tenderloin, were fed to the dogs,” says Teicholz.
Such diets, she points out, mimic the way “large, meat-eating mammals” eat—first consuming the blood and viscera, all high in saturated fat, and leaving the muscle meat (highly valued by Keys) for the vultures.
“Meat consumed without fat was commonly understood to lead to weakness,” she adds.
But there are other studies that seemingly support Keys’s hypothesis. Teicholz calls them the “various trials that ‘experts’ rattle off in supporting their position.” Like a detective, she identifies the top ones and then goes where few have gone before: She skips past the all-too-convenient summary papers and studies the original work.
In other words, she looks beneath the nice, tidy hood to see what’s happening underneath. What she finds is far from pretty.
One bedrock study, launched in 1957, monitored 1,100 men who avoided saturated fats and consumed two tablespoons of polyunsaturated vegetable oil a day. Five years into the study, the men had lower “cholesterol and blood pressure” and a loss of weight—an outcome that prompted the New York Times to link the diet to reduced heart attacks.
All was seemingly well—until investigators began to see “somewhat unusual” results a decade into the trial: Twenty-six of the men on the special diet had died, compared to only six in the control group.
The study report—which lacked commentary by the lead researcher, a doctor who had himself died of a heart attack (despite his wholehearted embrace of Keys’s hypothesis)—emphasized the improvement in assumed risk factors, such as lowered cholesterol, but conveniently disregarded the overall number of deaths.
“Even though their cholesterol inevitably goes down, their risk of death does not,” says Teicholz. “It is an unpleasant result that has plagued the field . . . and the result has been confirmed by other studies—whose authors have also, on the whole, decided that this is a detail best ignored.”
After all, if Keys’s hypothesis is right—and that has been the assumption!—then surely, such details must be wrong!
In another study, 850 elderly men who were fed a diet that replaced saturated fats with polyunsaturated vegetable oils saw their cholesterol drop by almost 13 percent compared to a control group; and their risk of heart attacks reduced—48 compared to 70 in the control group.
And while this would “appear to be extremely good news,” Teicholz points out that overall mortality for both groups remained the same.
Somewhat worrisome, however, was the fact that 31 of the men on the vegetable oil diet died of cancer compared to only 17 in the control group.
And the list goes on. Teicholz delves into many of the most oft-quoted studies, revealing foundations built on weak statistics and riddled with faulty assumptions and contradictory information.
Women and Children
And, there’s another somewhat troubling fact: While most of the studies have been conducted on middle-aged men, the belief in the diet-heart hypothesis has been so strong that the powers that be have wholeheartedly assumed and embraced its application for women . . . and children.
Even though researchers as early as the 1950s had warned that women “responded differently to fat and cholesterol” than men and “needed to be studied separately,” most studies have focused on middle-aged men.
In the Framingham Heart Study, one of the few early studies to include women, it was shown that women older than 50 showed “no significant correlation between total serum cholesterol and coronary mortality.”
And in 1992, an expert panel appointed by the National Heart, Lung and Blood Institute to review all the heart disease data on women found “total mortality” to be “higher for women with low cholesterol than it was for women with high cholesterol, regardless of age,” says Teicholz, adding that such results “were also ignored.”
In one large, government-funded study of 700 female employees of Boeing in Seattle who were put on a very strict, low-fat diet, the head researcher was “alarmed” at “how much worse the diet looked for women, but . . . found that no one wanted to discuss or even acknowledge his study findings when they came out in 2000,” says Teicholz.
He was left to conclude in a 2005 review paper that “the low-fat diet could not really be recommended for women . . . maybe women need a diet lower in carbohydrates and higher in fat.”
His study showed that while the diet did reduce cholesterol—including the LDL kind—its main impact was a dramatic decrease in HDL-cholesterol (7-to-17 percent!), thus increasing the risk of heart attack.
The view of cholesterol as a health-stealing villain grew to such stature that it was only a matter of time before its reach encompassed children.
Indeed. Although the NHLBI, as early as late 1960s, had been recommending that “at-risk” children as young as 4-years-old be put on cholesterol-lowering diets and given a cholesterol-lowering drug, it wasn’t until the 1980s that things really heated up.
Considered the height of the low-fat craze, the mid-1980s ushered in a tremendous debate on the importance of including all children in the low-fat regime.
After all, watching one’s cholesterol couldn’t start too early!
But not everyone agreed.
“There is absolutely no evidence that it’s safe for children to be on a cholesterol-lowering diet,” exclaimed Thomas C. Chalmers, former president of the Mount Sinai Medical Center in a Science article, citing an “unconscionable exaggeration of all the data.”
For years, the most vocal and vociferous voice crying out for children to be excluded from such diets were those entrusted with their very well-being: the pediatricians.
The American Academy of Pediatrics fought a long, hard battle, decrying “the differences in the nutritional needs of growing children, especially during the growth spurt of adolescence, compared to those of middle-aged men with high cholesterol,” as stated in a 1986 editorial published in its Pediatrics journal
Foods like meat, dairy and eggs—long considered to promote growth—should not be abandoned, stated one expert . . . especially since they had been producing Americans who were “healthy and tall.”
But eventually, even without government intervention, the inevitable happened: Parents, long indoctrinated on the evils of saturated fat, simply began altering their children’s diets. Concessions like the replacement of whole milk (once a stalwart of a child’s diet), with low-fat milk, were increasingly made.
In a 1995 survey, 88 percent of a thousand mothers surveyed said they believed that a low-fat diet was “important” or “very important” for their infants; and 83 percent said they “sometimes or always avoided giving fatty foods to their children.”
Unfortunately, the science supporting such beliefs was merely speculative, says Teicholz.
Indeed. In a 1988 article in the New York Times, Lloyd Filer, a professor of pediatrics at the University of Iowa, said that young children placed on low-fat milk had been turning up in hospitals showing “failure to thrive” and only “gained weight and began to grow” when fed higher-fat diets.
A year later, Fima Lifshitz, a professor of pediatrics at Cornell University, noted a worrisome trend among children in families where a parent’s heart-disease diagnosis had prompted a dietary overhaul in the household: A strict adherence to low-fat, low-cholesterol diets was causing “nutritional dwarfing,” as well as disrupted weight gain, delayed puberty and vitamin deficiencies.
Just a year later, in 1990, a proposal by the NHLBI for widespread cord blood screening at “no more than” five dollars per baby was given serious consideration.
As the years passed, the voices calling for lowering saturated fat and cholesterol became louder, drowning out those calling for caution. And so it was, that in 1998—helped in part by the influx of a new generation of pediatricians long schooled in the diet-heart hypothesis—the AAP officially recommended that children over the age of 2 be fed a diet derived of only 10 percent saturated fat and 20-to-30 percent overall fat.
Today, the government continues to push the low-fat, low-cholesterol agenda. Many school districts have banned whole milk, serving only low-fat versions; and its special supplemental nutrition program for women, infants and children (WIC) contains no meat, few animal products and only low-fat milk for those above the age of 2.
Cholesterol-Lowering Drugs (aka Statins)
But dieting isn’t the only way to affect one’s cholesterol.
The pharmaceutical industry, ever on the march, discovered statins in the 1970s—and the beginnings of what would be a billion dollar industry was born.
Statins—which include drugs like Simvastatin, Atorvastatin and Lovastatin—earned $956 billion in worldwide sales in 2011, thanks to their ability to lower LDL-cholesterol.
But that ability also betrays one of their limitations. Teicholz points that one of the “big surprises” of the Framingham Heart Study was the discovery that HDL-cholesterol—not LDL!—had the greatest risk impact for both men and women 40-to-90 years of age.
“People with low HDL-cholesterol levels (below 35 mg/dL) had an eight times higher rate of heart attacks than did people with high HDL-cholesterol levels (65 mg/dL or above),” says Teicholz, adding that the study authors found the correlation “striking” and the “most important finding” from all their cholesterol data.
Interestingly, the government felt otherwise. By 2002, the National Cholesterol Education Program—created in 1985 to advise doctors and educate Americans—was calling high LDL-cholesterol “the primary target” for therapy. Other agencies in the tight-knit group agreed.
Teicholz calls this a “strange turn of events” in light of the “compelling” case for HDL-cholesterol, and offers a handful of somewhat flimsy explanations, before mentioning the obvious: Drug companies, long-time supporters of researchers on various NCEP panels, had yet to find a drug that raised HDL-cholesterol. The continued targeting of LDL-cholesterol was, therefore, crucial to their bottom line.
Meanwhile, saturated fats—Keys’s villain of villains—are the “only foods known to raise HDL-cholesterol,” says Teicholz.
The drug companies’ ties with the NCEP may also explain why “cholesterol targets” have been “ratcheted ever lower” over the years, “thereby bringing greater and greater numbers of Americans” into the “statin” category, she says.
As the patient pool expands, so do the profits.
How It Happened
So what’s the story?
If cholesterol isn’t the evil beast it’s been made out to be, and saturated fat isn’t its evil twin, then why have we for so long thought otherwise?
As Teicholz points out, every story has a beginning.
This one starts simply enough. Keys, our main player, simply wanted to address his era’s most pressing health threat—heart disease, a condition that had exploded inexplicably onto the American scene.
The disease—which had skyrocketed from a “mere handful” of cases in 1900 to becoming the “leading cause of death” by 1950—had rattled the American public, who sensed an epidemic. “Tense and fearful,” they were “thirsting for answers” . . . and a confident, charismatic Keys was just the person to provide them.
It’s easy to see how Keys locked his laser-like focus onto cholesterol. After all, the substance had been found in atherosclerotic plaque, which, itself, was believed to cause heart attacks by reducing arterial blood flow. Many of the day’s scientists suspected cholesterol was a culprit in heart disease.
Keys, however, believed cholesterol was the culprit behind heart disease. Guilt by association seemed good enough for him!
Of course, at the time, neither he, nor his contemporaries, knew of cholesterol’s greater complexities. There was, for example, little, if any, understanding of its various subsets, such as HDL, LDL and VLDL. Keys was interested in just one number, and that, alone, was measured. Who knew there was more to the story?
And so it was that Keys, confident in the “knowledge” that cholesterol led to heart disease, set out to determine what raised cholesterol. He was pretty sure he knew the answer: dietary fat.
Starting in the early 1950s, Keys, along with his wife, Margaret, began traveling the world—visiting countries like South Africa, Sweden, Spain and Italy—measuring the cholesterol levels and dietary fat contents of various populations; and convincing local researchers to act on his behalf, doing the same.
As province would have it, the evidence seemed to support his belief that high-fat and high cholesterol went “hand-in-hand.” In 1952, armed with his newly gathered data, Keys officially unveiled what he called his “diet-heart hypothesis” before a gathering of scientists and journalists at New York’s Mt. Sinai Hospital. It was a presentation that would later garner “enormous attention.”
The centerpiece of his presentation was a graph showing a “close correlation between fat intake and death rates from heart disease in six countries.” Presented as a “perfect upward curve, like a child’s growth chart” it suggested that the “risk of heart disease would nearly disappear” if one simply stopped eating fat.
Calling it “the acorn that grew into the giant oak tree” of today’s war on fat, Teicholz says that “all the ailments” blamed on fat over the years—heart disease, obesity, cancer and diabetes, to name a few—can be traced to this very hypothesis and Keys’s commitment to “promoting it.”
Keys’s presentation was clear and simple, leaving little, if any, room for doubt. After all, the scientific research was impeccable . . . or was it?
Teicholz points out that even as Keys continued his travels to build an ever-stronger case, there were problems: The samplings were “minuscule” and the strength of his argument rested mostly on his ability to “deftly knit together . . . skimpy data from far and wide” into a “picture that looked convincing.”
Such was one of the great hallmarks of Keys’s career: The ability to identify supporting evidence, disparage or bury conflicting data and present seemingly solid findings with clarity and confidence. People were looking for answers, and he was happy to provide them.
“Keys confidently drew a direct line of causation from fat in the diet to serum cholesterol in the blood to heart disease,” says Teicholz. By the mid-1950s, he had fine-tuned his hypothesis even more, focusing on saturated fat as the real culprit.
In September 1955, Keys’s ideas were “thrust into the national spotlight” when Dwight D. Eisenhower, the nation’s 34th president, suffered the first in a series of heart attacks. Eisenhower’s physician, a man of great influence, was Paul Dudley White, a cardiologist and Harvard professor who had helped establish the National Heart Institute several years earlier.
As it turns out, Keys had been cultivating a relationship with White, who had accompanied him and Margaret on fact-finding trips to Hawaii, Japan, Russia and Italy. It was during such trips that Keys had most likely swayed White to his way of thinking—and it was all about to pay off . . . in a big way.
The day after Eisenhower’s heart attack, White held a press conference to address the president’s health—and a media relationship was born. Over the ensuing months, White became a central figure in a national script. He kept the American people up-to-date on the presidential prognosis . . . and told them how to avoid such health threats themselves.
During the first press conference, White provided a “clear and authoritative lecture on heart disease as well as the preventive steps that could be taken to avoid it”—among them, “cut(ting) down on saturated fat and cholesterol.”
The following month, White wrote a guest article for the New York Times, which was given front-page billing. In it, there was only one dietary theory that he “quoted at length” and only one researcher that he mentioned by name, describing that man’s work as “brilliant.” The theory pointed to fat as the culprit, and the man, of course, was Ancel Keys.
But not everyone so generously agreed with Keys. In a presentation he made at the World Health Organization conference in Geneva that same year, there was at least one scientist, Jacob Yerushalmy, who thought Keys’s data “seemed a little fishy.”
Yerushalmy, the founder of the Biostatics Department at the University of California, Berkeley, pointed out that, “Right there in Geneva, for instance, the local population consumed a great deal of fat—animal fat—but did not die from heart disease very often.”
And Geneva wasn’t the only supposed “paradox.” When all 22 countries for which national data were available were plotted, “such paradoxes” also existed for West Germany, Sweden, Norway, and Denmark.”
Yerushalmy believed that Keys had cherry-picked countries that supported his hypothesis, and in 1957 he listed other factors that could “equally well explain” heart disease trends, including the sale of cars, as well as cigarettes, and the consumption of protein, as well as sugar.
As for fat, when the data was plotted for all 22 countries—instead of Keys’s chosen six—the theory was greatly weakened, with a graph showing a “more random Jackson Pollock-like splatter of data points,” says Teicholz.
Keys was amassing a number of critics among well-respected scientists—a problem that would dog him throughout much of his career—but the criticism leveled against him seemed to only ignite his anger and steel his resolve. After all, who doesn’t want to win an argument?
The Seven Countries Study
Henry Blackburn, one of Keys’s closest colleagues, remembers the fall-out from Keys’s 1955 presentation as representing “the pivotal moment in Keys’s life.”
He “got up from being knocked around and said, ‘I’ll show you guys’ . . . and he designed the Seven Countries study,” says Blackburn.
The Seven Countries study, funded by a $200,000 annual grant from the U.S. Public Health Service—an enormous sum for such a project at the time—became one of the most famous studies in nutritional history. It’s considered the keystone of the diet-heart hypothesis.
The project sought to follow 12,700 “middle-aged men in mostly rural populations in Italy, Greece, Yugoslavia, Finland, the Netherlands, Japan and the United States.”
Critics have since noted that Keys’s choice of countries was far from random. Rather, they seemed to be countries that would support his hypothesis. Switzerland and France need not apply!
And there were other problems in the study. One was the timeframe—1958-to-1964—in which it was conducted. It was a “time of transition in the Mediterranean region” with countries still emerging from the “extreme poverty and near starvation” of World War II, and Italy emerging from 25 years of “suffering under a fascist government,” says Teicholz.
“The people . . . were in a moment of deprivation,” she adds. “They would have eaten a richer diet in childhood before the war, as would have their mothers during pregnancy.”
Indeed. Before Keys arrived in Greece, the Rockefeller Foundation of New York had sent epidemiologist Leland G. Allbaugh to study “underdevelopment” in Crete. Allbaugh found that although the Cretan diet consisted mostly of vegetables, cereals and fruit, with little meat, fish and eggs, the Cretans considered themselves “hungry most of the time” and longed for meat, which had been more prevalent in their pre-war diets.
There were other problems as well—although most did not surface until well after the study had ended and its results had (conveniently!) supported Keys’s hypothesis.
One of the “most stunning and troubling errors” occurred in Crete, where one of the three surveys conducted fell during the strict, 48-day fasting period of Lent, a time when the Greek Orthodox abstained “from all foods of animal origin, including fish, cheese, eggs and butter,” according to one observer.
“Since the foods avoided during Lent are the principal sources of saturated fat, a sampling of the diet during this holiday would obviously undercut that nutrient,” notes Teicholz, adding that a 2000 and 2001 study on Crete “showed that saturated fat halved during Lent.”
Although Keys mentioned the problem in his monograph, he “immediately excused it, saying that ‘strict adherence (to Lent) did not seem to be common.’” Thank heavens!
Keys was similarly dismissive of data—quite a bit—that didn’t seem to add up. As a method of checks and balances, Keys collected food samples from small subsets of the men whose responses were being recorded in written questionnaires.
In one case, Keys felt that the two pools of information did not line up as expected and could not be reconciled. Keys assumed that the men—655 of them on Corfu and Crete—had given inaccurate responses to the questionnaires, so . . . he simply discarded their data.
Teicholz calls this action “astonishing” and says you have to “read carefully between the lines of (Keys’s) papers to figure it out.”
The end result, says Teicholz, is that the only source of dietary data left was that collected from 30 to 33 men on Crete and 34 on Corfu. And although the meals were gathered on three separate occasions, one set was thrown out because some of the fats were “destroyed in processing,” while others were “absorbed” into the carrying containers.
The problem with secretly flawed studies is that they often have far-reaching consequences. Such has been the case with Keys’s Seven Countries Study, which, according to one estimate, had been referenced close to a million times by 2004.
Even the Mediterranean diet, which was developed in the mid-1980s, was based at least partly on the “pattern of eating” reported in Keys’s work, prompting Teicholz to call the handful of Crete and Corfu men whose samples were used, the “founding men of the Mediterranean diet, whose meals over the course of a few weeks fifty years ago have influenced the entire course of nutrition history in the Western Hemisphere.”
In order for Keys to have satisfied the statistical requirements for a population of 8.375 million Greeks or the 438,000 Cretan in 1961, he would have needed a far greater data pool. Of course, he had one, before he discarded his data.
Not easily deterred, Keys’s early writings left the “overwhelming impression” that his conclusions were based on all the men involved—a misrepresentation that has been passed down through the years, says Teicholz.
Another vexing problem concerned the gathering of food samples which were sent for lab analysis.
A careful reading shows that, “of the 12,770 participants, the food they ate was evaluated for only 499 of them, or 3.9 percent” and there was a lack of consistency among how the data was gathered among nations—a one-day sample here, a seven-day sample there, some foods cooked, some foods not, and some a mixture of both.
Then there were paradoxes, like the Eastern Finns, who “died of heart disease at rates more than three times higher than the Western Finns,” despite “virtually identical” “lifestyles and diets,” and the Corfu islanders, who ate “less saturated fat than did their countrymen on Crete,” yet experienced higher rates of heart disease.
In 1984, years after the study’s end, Keys followed up on it and found even more “paradoxical” results. “By then,” says Teicholz, “the consumption of saturated fat could no longer explain differences in heart disease rates at all.”
The data showed that although a diet low in saturated fat “appeared to be associated with fewer deaths from heart disease (within those countries, at least), that advantage did not extend to total mortality,” says Teichoz. “People eating diets low in saturated fat had just as high a risk of dying as their fat-gorging counterparts.”
But despite such glaring problems—many of which remained buried for years—Keys’s influence and prestige continued to increase on the nutritional scene.
Around the time the Seven Countries Study was starting, Keys published his famous Keys Equation, in which he claimed that the “exact amount of serum cholesterol could be calculated to rise or fall in a population, depending on the amount of saturated fat, polyunsaturated fat and cholesterol” consumed.
The equation “gained enormous influence . . . probably because it was a relief for people looking for answers to have a just-so formula for the mass of humanity,” says Teicholz, adding that Keys reduced the “enormous complexity of human biology” to a “sure and confident explanation.”
Keys Goes Big
Even still, Keys was just getting started. The year 1961 proved to be a pivotal one for him—and the American public.
The year started out with Keys featured on the cover of Time magazine’s January 13 issue, along with an article that dubbed him “Mr. Cholesterol.” In the article, Keys advised Americans to slash their overall fat intake from 40 percent of total calories to a “draconian” 15 percent—and saturated fat in particular, from 17 percent to 4 percent.
Keys assured the public that such measures were the “only sure way” to avoid high cholesterol, which—of course!—led to heart disease. The article barely mentioned that Keys’s ideas were “still questioned” by “some researchers.”
And Time magazine wasn’t the only publication celebrating Keys. The media in general had jumped aboard the Keys’s bandwagon early on, swayed, perhaps, by the “fiery language” and charismatic personality of a confident expert with a “definitive sounding solution.”
Keys presented the media with an answer that was “clearly more appealing” than that of the sober-toned scientists who cautioned about the “lack of adequate scientific evidence,” says Teicholz.
The media was further emboldened in its support of Keys when, later that year, the AHA condoned the diet-heart hypothesis by officially endorsing a diet low in saturated fats and high in polyunsaturated fats (aka vegetable oils) for preventing heart disease.
It was a stunning reversal from a few years prior, when the AHA had pointed out that the evidence couldn’t “reliably say whether high cholesterol . . . would predictably lead to a heart attack” and had taken diet-heart supporters to task for their “uncompromising stands based on evidence that does not stand up under critical examination.”
But by 1961, Keys, along with one of his closest colleagues, had “maneuvered” himself onto the AHA’s nutrition committee and did what he did best: change minds. Even though the evidence had not changed, the AHA now condoned Keys’s hypothesis. It did, however, embrace a more moderate approach, calling for the “reasonable substitution” of saturated fats with polyunsaturated fats, based on the “best scientific evidence available at the present time.”
Although Keys considered such modest recommendations “undue pussy-footing,” it would take another nine years before the AHA would stress the reduction of total fat.
Even still, the AHA’s endorsement of Keys’s hypothesis was a stunning coup.
“Keys’s ability to insert his own hypothesis into these guidelines was like splicing DNA into the group: It programmed the AHA’s growth, and as it grew, the group . . . served as both rudder and engine” for the “diet-heart ship” says Teicholz.
Shortly thereafter, the New York Times declared that the “highest scientific body” now condoned “reducing or altering” dietary fat to “help prevent heart disease.”
Another stunning coup was delivered that same year when the Framingham Heart Study published six-year results that seemed to support Keys’s hypothesis. Although the data was later found to have been misinterpreted, the damage was done. It had been announced that “high cholesterol was a reliable predictor of heart disease.”
The announcement, says Teicholz, “seemed to erase any lingering doubts that researchers might have had about the diet-heart hypothesis.”
The Ancel Keys ship was sailing in.
All Together Now
Over the years, more and more government agencies embraced Keys’s diet-heart hypothesis, gradually tightening their recommendations on dietary fat, while downplaying concerns or questions that might be presented.
In the late 1960s, for example, the AHA was concerned that reducing fat would lead to increased carbohydrate consumption, especially refined carbohydrates, and “counseled against the ‘excessive use of sugar, including candy, soft drinks and other sweets.’”
By 1970, however, such warnings were lost, and from 1970 to 1995, AHA pamphlets actually advised Americans to “control their fat intake by increasing refined carbohydrate consumption.” Snacks such as low-fat cookies, low-fat crackers, unsalted pretzels hard candy, gum drops, sugar, syrup, honey, jam, jelly and marmalade were all preferable to fat, the AHA advised. Pass the sugar! Hold the fat!
By that same year, the AHA—which was now telling Americans to reduce total fat—boldly called for a “vast overhaul of the country’s food production systems” by developing “new strains of leaner livestock,” as well as introducing new low-fat products, promoting margarine over butter, virtually eliminating egg yolks and “revising school lunches and food stamps,” as well as the “meals for both the armed forces and veterans’s facilities.”
In the late 1970s, the U.S. Congress, itself, got involved, convening committees to decide what “Americans ought to eat” and to study the connection between diet and “killer diseases.” The latter, although an amazingly broad topic, was wrapped up after just two days of hearings. Imagine that!
Understandably, such hearings left much to be desired.
In one such hearing, Gio Gori, the director of the National Cancer Institute, presented a graph showing a corresponding rise in fat consumption and cancer among the nation’s Japanese emigrants, emphasizing that the correlation did not prove causation, but warranted further research.
Rather than taking his advice, the Senate committee simply implied in its written report that “a low-fat diet could help reduce cancer risk.”
That, along with a few additional bits of data, was enough to get the fat-cancer hypothesis “adopted and incorporated into reports” by the National Cancer Institute, the National Academy of Sciences and the American Cancer Society from 1979 to 1984; and into the Surgeon General’s Report on Nutrition and Health in 1988. They all recommended a low-fat diet to avoid this disease. Who says the government drags its feet?
Breast cancer was a popular target of those who supported the fat-cancer hypothesis, and by the 1980s, women were being advised to “reduce their consumption of fat in order to prevent breast cancer.”
Teicholz points out that many individuals who played key roles in such far-reaching policy changes weren’t experts schooled in nutrition science.
In the Senate’s two-day committee on killer diseases, Teicholz notes that the staff was comprised of “lawyers and former journalists who knew little more than interested laymen on the subject of fat and cholesterol and nearly nothing about the scientific controversy that had been simmering on this topic for years.”
The staffer who wrote the report, a young man by the name of Nick Mottern, was a former labor reporter (and future vegetarian restaurant owner!) with no background in nutrition or health, who “believed the meat industry to be totally corrupt.”
He relied almost exclusively on the views of a die-hard, diet-heart stalwart and, in the end, wrote a report that lined up with AHA recommendations, with “overall fat reduced from 40 to 30 percent of calories, saturated fat capped at 10 percent of calories and an increase in carbohydrates in between 55 percent and 60 percent of calories.”
Although Mottern preferred to advise against fat altogether, others disagreed, and compromises were made—namely the recommendation that Americans eat more poultry and fish and less red meat, butterfat, eggs and whole milk.
When the committee’s report, called Dietary Goals, was presented at a 1977 press conference, Senator George McGovern, the committee’s head, expressed concern that the country’s diet had “changed radically” over the past 50 years with “great and harmful effects” on health.
Americans were criticized for diets that were “excessively ‘rich in meat’ and other sources of saturated fat and cholesterol, which were ‘linked to heart disease, certain forms of cancer, diabetes and obesity,’ and called upon to return to the healthier, plant-based diet, which they once ate,” says Teicholz.
Few Americans knew that the data cited as proof that early Americans lived on a plant-based diet were highly suspect. Teicholz delves into the nitty gritty of the data, points out the holes in the argument and then cites historical accounts that paint a picture of a land overflowing with an “extraordinary abundance” of much-valued—and enjoyed!—game.
But in 1977, it was all about the Dietary Goals, which would become “arguably the most influential document in the history of diet and disease,” she says.
Amazingly, the report acknowledged that the science behind its recommendations wasn’t airtight, but warned that “We cannot afford to await the ultimate proof before correcting trends we believe to be detrimental.” In other words, decades after its introduction, the diet-heart hypothesis was still . . . an hypothesis!
In addition, after decades of Americans being schooled in the evils of saturated fat and being encouraged to switch it out for vegetable oils and carbohydrates, the nation’s health was still seen as dire!
The headline, “Benefits Would Be Shared by All” was indicative of the report’s far-reaching recommendations: Women and children, not just middle-aged men, were advised to jump on the anti-fat bandwagon.
“No studies had been done on whether a low-fat diet was better or even safe for infants, children, adolescents, pregnant or lactating women, or the elderly,” says Teicholz. “Yet, the diet-heart hypothesis had taken hold to such a degree in the expert community that it was just considered a commonsense measure of prevention against heart disease for everyone at any stage of life over the age of 2 to start on this regime.”
Congress designated the U.S. Department of Agriculture to implement the recommendations set forth in its Dietary Goals report, and in February 1980, the USDA did just that by publishing its Dietary Guidelines for Americans—which would later become the basis for the “Food Pyramid,” which would later morph into “My Plate.”
These are the “most broadly recognized food guidelines in the United States,” says Teicholz, “familiar to all schoolchildren and highly influential in determining school lunches and nutrition education across the country.”
But what about those who disagreed?
Unfortunately, theirs was not always an easy road.
Throughout her book, Teicholz interweaves personal stories of great scientific minds who looked at the evidence presented, and lifted their voices in dissent. Some disagreed entirely with the assumptions being made, while others called for caution, lest the scientific world jump to (misdrawn!) conclusions. Imagine that!
They included highly respected researchers such as E.H. “Pete” Ahrens Jr. of Rockefeller University in New York City, a leading lipid researcher who correctly identified carbohydrates (not fat!) and triglycerides (not cholesterol!) as main players in the heart disease field; and Fred A. Kummerow, a professor of biochemistry at the University of Illinois in Urbana-Champaign and a one-time “big wheel” who sacrificed influence and prestige for calling attention to the “worrisome” discoveries he was making about America’s darling hydrogenated oils.
For many such scientists, grants were lost, professional prestige was sacrificed and speaking engagements came to an end. In some cases, Keys and his colleagues waged aggressive campaigns to disparage, ridicule and intimidate those who dared to dissent.
“(T)he aggressive style adopted by Keys . . . was beyond the norm,” says Teicholz. “Few men could match (he and his colleagues), and as time went on and the diet-heart hypothesis gained followers as well as institutional legitimacy, fewer and fewer tried.”
Even the country’s government agencies met with harsh consequences for questioning the diet-heart hypothesis. Such was the case for the highly respected Food and Nutrition Board of the National Academy of Sciences, which was asked by the USDA to review its first set of Dietary Guidelines.
Despite the invite, the contract was never signed—supposedly because the USDA “caught wind” of the academy’s lack of support for the new low-fat diet—which, in turn, prompted the academy to fund its own review, in which it called the “evidence” supporting the diet-heart hypothesis as “generally unimpressive.”
The media, according to Teicholz, “had a heyday” because the “government and the academy were at odds”—although coverage was generally in favor of the government. After all, everyone knew low-fat was better!
In the summer of 1980, each house of Congress “held hearings on the report and the academy’s reputation was raked over the coals,” says Teicholz, noting that critics called the review “conspiratorial,” “slipshod” and an outgrowth of lobbyists.
That same summer, the New York Times ran a front-page story stating that one of the academy board members had consulted for the egg and dairy industries, while another had consulted for the meat industry—connections that supposedly proved their “ulterior motives” and morally compromised positions. Never mind that “two other board members were food company employees.”
Although scientists in many countries followed America’s lead, those in other countries, like England, seemed incredulous at America’s obsession with the diet-heart hypothesis.
“There was a very big emotional component,” said one influential British cardiologist. “It was quite extraordinary to me. I could never understand the huge emotion towards lowering cholesterol.”
Another stated that people like Ancel Keys “raised the blood pressure of British cardiologists to a level which was not believable. It was something strange; it was not rational, it was not scientific.”
Editors of England’s Lancet medical journal, who sometimes “mocked the American obsession,” also cautioned that “The cure could be worse than the disease.”
But for America, once Keys’s diet-heart hypothesis made its way through the world of nutritional research and into the world of national government policy, there was little that could stop it. The train was barreling down the tracks.
In 1984, the NHLBI held a 2 ½ day conference in which it sought to “grapple with and debate the entire massive stack of scientific literature on diet and disease” and come up with a clear-cut “consensus” on the recommended cholesterol targets for the American public.
It was a seemingly daunting task that attracted more than 600 doctors and researchers—most of whom agreed with the diet-heart hypothesis and presented as such. Many believe it was a meeting with a pre-drawn conclusion.
At the end, it was announced that there was “no doubt” 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 2.
The “consensus conference” effectively silenced the remaining critics of the diet-heart hypothesis. It drew a line in the sand that effectively said that the issue had been settled. Dissenters, once allowed some token of debate, were forced to “fold their case,” says Teicholz.
So chilling was the effect, that during the next 15 years, only a few dozen “among the tens of thousands of researchers in the worlds of medicine and nutrition” would “publish research even gingerly challenging the diet-heart hypothesis, and even then, they worried about putting their careers on the line,” she adds.
But, if not fat?
But if saturated fat wasn’t behind the epidemic rise of heart disease in the early 1900s, than what was?
Although Teicholz doesn’t claim to know the answer, she does point out a great irony: “(M)eat eating went down before coronary disease took off.”
Indeed. The 1906 publication of Upton Sinclair’s book, The Jungle—which painted a highly negative, albeit fictionalized, picture of the meatpacking industry—greatly impacted the American public, which began turning against meat, causing sales to drop by half that same year . . . and they didn’t “revive for another 20 years.”
And although fat consumption rose during the years 1909 to 1961—just when heart attacks were surging—the increase was not due to animal fat consumption, but rather, that of vegetable oils, which had been recently invented, says Teicholz.
While Teicholz’s book is a true eye-opener, peeling back the layers of history and revealing how generations of Americans have been told to eat and why, it is not the end of the story. As she notes, in light of the government’s recent decision to ban trans fats—those dangerous substances found in hydrogenated vegetable oils—the question arises: What will replace them?
Teicholz notes that the food industry is already working on the next generation of fat replacers, and is focusing more and more on using vegetable oils in their liquid form—which, although they do not contain trans fats, do turn highly toxic at higher temperatures.
Unfortunately, Teicholz warns that the “new” fat substitutes may be worse than the last and laments that, if only America had stuck to its use of traditional fats, such as lard and suet.
Despite a loss of prestige among his early contemporaries, he went on to labor almost single-handedly in the trans-fat field for decades to come, publishing more than 70 papers on the subject—more than any other scientist in the world.
Today, Kummerow, who turned 100 in June 2015 and still works as a researcher, continues to avoid trans fats and has lived to celebrate something he fought hard to gain: the government’s decision to ban them.
It’s been said that he enjoys an egg—cooked in butter—every morning for breakfast.
Perhaps we should all do the same!
Note: Unless otherwise noted, most, if not all, of the unattributed quotes used throughout this article are from Nina Teicholz’s book “The Big Fat Surprise: Why Butter, Meat & Cheese Belong in a Healthy Diet.” Copyright 2014.
Copyright 2015-2016 Jonna Crispens. All rights reserved.