First national conference: Eleven years into my ca reer
as a surgeon, I became disillusioned with the treatment paradigm of US
medicine in cancer and heart disease. Little had changed in 100 years in
the management of cancer, and in neither heart disease nor cancer was
there a serious effort at prevention. I found the epidemiology of these
diseases provocative, however: Three-quarters of the humans on this planet
had no heart disease, a fact strongly associated with diet.
In 1985, I began a small research study focused
on controlling coronary disease with diet. By 1991, the results of that
study were encouraging enough to convene that first conference. There, I
challenged a panel of experts to answer the question, "What do you tell
the patient who says, 'I'll do anything, but I never want to have heart
disease,' or, 'I've had a heart attack, and I never want another?"'
One panelist replied, "Have him eat beans, beans, and
more beans." Another said that it was time for the public to embrace a
plant-based diet. Those opinions contrasted starkly with the 1989 National
Research Council guidelines in Diet and Health developed just 2
years before and led 10 of 13 faculty to agree on several concepts:
Present nutritional guidelines of government and
national health organizations do not provide a maximal opportunity either
to arrest or to prevent coronary artery disease.
The 1989 National Research Council guidelines
recommended a diet in which no more than 30% of the calories would come
from fat and that blood cholesterol levels should be <200 mg/dL,1 although
many scientists believed that greater health benefits would derive from a
diet considerably lower in fat. These levels were unacceptable to the
panel of experts that met in Tucson. Because we now know that 35%
of heart attacks occur in people with total cholesterol levels of 150--200
mg/dL,2 and a target level of only 200 mg/dL guarantees that millions of
US citizens will perish of coronary disease. Studies demonstrate that
persons following present guidelines will have faster rates of disease
progression than persons achieving lower serum lipid levels through diet
and/or lipid- lowering drugs. Why is there a reticence to provide the
public with guidelines that will spare them this disease or its
progression?
Speculation about the degree of public compliance
with a very low-fat diet must not alter the accuracy of the
recommendations.
The National Research Council position was that a
dietary fat recommendation lower than 30% would be too frustrating for
those attempting to achieve a significant reduction. Although it is
uncertain to what extent people will adopt the advice because of habit,
custom, and different tastes and textures of foods, it is nevertheless
scientifically and ethically imperative to inform the public what
constitutes an optimal diet. We must tell the public the truth about what
is best for their health and let them decide their degree of compliance.
The optimal diet consists of grains, legumes,
vegetables, and fruit, with <10% of its calories coming from fat.
A diet that would achieve superior results in de
creasing atherosclerosis is a 10--15%-fat diet provided largely by a
variety of grains, vegetables, fruits, and legumes. This diet minimizes
the likelihood of stroke, obesity, hypertension, type-2 diabetes, and
cancers of the breast, prostate, colon, rectum, uterus, and ovary.3 There
are no known adverse effects of such a diet when mineral and vitamin
contents are adequate.
These experts advocated a plant-based diet to achieve
optimal lipid levels without requiring the ma jority of the population to
consume cholesterol-reducing drugs. As long as Western society consumes
butter, eggs, cream, cheese, oils, ice cream, fish, poultry, and meat on a
daily basis, the common Western diseases will persist. No amount of
technology or mediation will prevent these illnesses. That is why the
faculty recommended the plant-based diet.
Children and adolescents require major attention to
develop early habits of optimal nutrition. Schools should assume a
significant leadership role in achieving this goal.
Because coronary disease begins in youth, primary
prevention must begin there also. Changing nutrition patterns in children
is much easier than trying to overhaul ingrained patterns in adults.
Second national conference: By 1997, the evidence had
mounted from epidemiologic studies, pathophysiologic discoveries,
lipid-lowering drug trials, and diet and lifestyle modification programs
that noninvasive therapies could arrest or reverse heart disease.
Before the first conference, the United States-- China
Study,4 a major epidemiologic study of diet and disease, had demonstrated
the link between dietary fat and heart disease, certain cancers, and other
"Western" diseases. Its second phase, completed since the first conference
and soon to be published, strengthens the evidence of that link. Data from
the Framingham Heart Study clearly confirmed that atherosclerosis is not a
concern when cholesterol levels are ~ 150 mg/ dL. In 1992, the Bogalusa
Heart Study5 demonstrated that diet contributes to coronary artery disease
risk starting in childhood.
Four major trials using 3-hydroxy-3-methylglu-taryl
coenzyme A (HMG-CoA) reductase inhibitors, or "statins," demonstrated the
benefits of lipid-lower ing medical therapy. In 1994, the Scandinavian
Simvastatin Survival Study (4S)6 showed that such treatment could decrease
the relative risk of death and coronary events in patients with
demonstrated heart disease without increasing the risk of death from other
causes. In 1995, the West of Scotland Coronary Prevention Study (WOSCOPSY
showed similar results in men with hypercholesterolemia and no history of
infarction. In 1996,. the Cholesterol and Recurrent Events (CARE) Trial8
demonstrated reductions in the relative risk of infarction and death in
patients with heart disease who had "average" total cholesterol 1evels (a
mean of 209 mgldL). And in 1997, the Post Coronary Artery Bypass
Graft (Post-CABG) Trial9 showed that aggressive lipid lowering with
medical therapy decreases the progression of atherosclerosis in bypass
grafts.
Basic research has revealed more about the patho
physiology of coronary artery plaque, showing that the lesions susceptible
to rupture and resulting in infarction are not the major stenotic ones we
see on angiography but smaller, hemodynaniically insignificant plaques
that can be affected by lipid-lowering therapy. Meanwhile, innovators had
developed creative and safe nutrition programs for schools and had
demonstrated that children and adults can accept and make major dietary
and lifestyle changes that decrease their coronary disease risk.
So with the "modest" goal of shifting the treatment
emphasis away from invasive interventions that treat symptoms toward
noninvasive therapies that treat the cause, the second conference brought
together the leaders of these studies--a rare nucleus of expertise-- with
physicians, nurses, nutritionists, and other health professionals. The
goal is modest because we now know that we can manipulate the. critical
factors that cause heart disease.
These expert clinicians, basic scientists, and
epidemiologists presented their findings in plenary sessions, discussed
the significance of their findings in panel discussions with the audience,
and conducted seminars with the registrants on implementing therapeutic
and dietary change. Even the meals served at the summit--which were
9.5--11% fat--demonstrated that a very-low-fat, plant-based diet can be
tasteful, varied, and attractive. As an added reinforcement to the
importance of lipid levels, registrants were given the opportunity to have
a free lipid profile taken by Florida Hospitals.
