Medicine: The Fat of the Land

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The reading public, the theatergoing public, the skindiving public, the horseplaying public—all these and others fill substantial roles in U.S. life, but none is so varied, vast and vigilant as the eating public. The Department of Agriculture averaged out U.S. food consumption last year at 1,488 Ibs. per person, which, allowing for the 17 million Americans that John Kennedy said go to bed hungry every night, means that certain gluttons on the upper end must somehow down 8 Ibs. or more a day. That mother hen of the weight-height tables, the Metropolitan Life Insurance Co., clucks that 48 million Americans are overweight.

Through previous centuries, eating changed by nearly imperceptible degrees, and mostly toward just getting enough. Now big forces buffet food. For the first time in history, the U.S. has produced a society in which less than one-tenth of the people turn out so much food that the Government’s most embarrassing problem is how to dispose inconspicuously of 100 million tons of surplus farm produce. In this same society, the plain citizen can with an average of only one-fifth his income buy more calories than he can consume. Refrigeration, automated processing and packaging conspire to defy season and banish spoilage. And in the wake of the new affluence and the new techniques of processing comes a new American interest in how what people eat affects their health. To eat is human, the nation is learning to think, to survive divine.

Fads, Facts . . . Not all the concern for health is well directed. From the fusty panaceas of spinach, eggs and prunes, the U.S. has progressed to curds, concentrates and capsules. Each year, reports the American Medical Association, ten million Americans spend $900 million on vitamins, tonics and other food supplements. At juice bars in Los Angeles’ 35 “health” stores, a new sensation is a pink, high-protein cocktail, concocted of dried eggs, powdered milk and cherry-flavored No-Cal, which sells for 59¢ per 8-oz. glass. Grocery stores sell dozens of foods that boast of having almost no food value at all.

But a big part of the public wants to know facts about diet and health, and a big group of U.S. scientists wants to supply them. The man most firmly at grips with the problem is the University of Minnesota’s Physiologist Ancel Keys, 57, inventor of the wartime K (for Keys) ration and author of last year’s bestselling Eat Well and Stay Well. From his birch-paneled office in the Laboratory of Physiological Hygiene, under the university’s football stadium in Minneapolis (“We get a rumble on every touchdown”), blocky, grey-haired Dr. Keys directs an ambitious, $200,000-a-year experiment on diet, which spans three continents and seven nations and is still growing. Pursuing it, he has logged 500,000 miles, suffered indescribable digestive indignities, and meticulously collected physiological data on the health and eating habits of 10,000 individuals, from Bantu tribesmen to Italian contadini. He has measured the skinfolds (the fleshy areas under the shoulder blades) of Neapolitan firemen, studied the metabolism of Finnish woodcutters, analyzed the “mealie-meal” eaten by Capetown coloreds, and experimented on Minneapolis businessmen.

. . . And Fats. Keys’s findings, though far from complete, are likely to smash many an eating cliché. Vitamins, eggs and milk begin to look like foods to hold down on (though mothers’ milk is still the ticket). Readings of the number of milligrams of cholesterol in the blood, which seem to have value in predicting heart attacks, are becoming as routine as the electrocardiogram, which can show that the heart has suffered a symptomatic attack. Already many an American knows his count, and rejoices or worries depending on whether it is nearer 180 (safe) or 250 (dangerous).

Out of cholesterol come Keys’s main messages so far:

¶ Americans eat too much. The typical U.S. daily menu, says Dr. Keys, contains 3,000 calories, should contain 2,300. And extra weight increases the risk of cancer, diabetes, artery disease and heart attack.

¶ Americans eat too much fat. With meat, milk, butter and ice cream, the calorie-heavy U.S. diet is 40% fat, and most of that is saturated fat—the insidious kind, says Dr. Keys, that increases blood cholesterol, damages arteries, and leads to coronary disease.

Obesity: A Malnutrition. Throughout much of the world, food is still so scarce that half of the earth’s population has trouble getting the 1,600 calories a day necessary to sustain life. The deficiency diseases—scurvy, tropical sprue, pellagra —run rampant. In West Africa, for example, where meat is a luxury and babies must be weaned early to make room at the breast for later arrivals, a childhood menace is kwashiorkor, or “red Johnny,” a growth-stunting protein deficiency (signs: reddish hair, bloated belly) that kills more than half its victims, leaves the rest prey for parasites and lingering tropical disease.

In the well-fed U.S., deficiency diseases have virtually vanished in the past 20 years. Today, as Harrison’s Principles of Internal Medicine, a standard internist’s text, puts it, “The most common form of malnutrition is caloric excess or obesity.”

Puritan New England regarded obesity as a flagrant symbol of intemperance, and thus a sin. Says Keys: “Maybe if the idea got around again that obesity is immoral, the fat man would start to think.” Morals aside, the fat man has plenty to worry about—over and above the fact that no one any longer loves him. The simple mechanical strain of overweight, says New York’s Dr. Norman Jolliffe, can overburden and damage the heart “for much the same reason that a Chevrolet engine in a Cadillac body would wear out sooner than if it were in a body for which it was built.” The fat man has trouble buying life insurance or has to pay higher premiums. He has—for unclear reasons—a 25% higher death rate from cancer. He is particularly vulnerable to diabetes. He may find even moderate physical exertion uncomfortable, because excess body fat hampers his breathing and restricts his muscular movement.

Physiologically, people overeat because what Dr. Jolliffe calls the “appestat” is set too high. The appestat, which adjusts the appetite to keep weight constant, is located, says Jolliffe, in the hypothalamus —near the body’s temperature, sleep and water-balance controls. Physical exercise raises the appestat. So does cold weather.

In moderate doses, alcohol narcotizes the appestat and enhances appetite (the original reason for the cocktail); but because liquor has a high caloric value—100 calories per oz.—the heavy drinker is seldom hungry. In rare cases, diseases such as encephalitis or a pituitary tumor may damage the appestat permanently, destroying nearly all sense of satiety.

Food for Frustration. Far more frequently, overeating is the result of a psychological compulsion. It may be fostered by frustration, depression, insecurity—or, in children, simply by the desire to stop an anxious mother’s nagging. Some families place undue emphasis on food: conversations center on it, and rich delicacies are offered as rewards, withheld as punishment. The result says Jolliffe: “The child gains the feeling that food is the purpose of life.” Food may act as a sedative, giving temporary emotional solace, just as, for some people, alcohol does. Reports Dr. Keys: “A fairly common experience for us is the wife who finds her husband staying out more and more. He may be interested in another woman, or just like being with the boys. So she fishes around in the cupboard and hauls out a chocolate cake. It’s a matter of boredom, and the subconscious feeling that she is entitled to something, because she’s being deprived of something else.” For the army of compulsive eaters—from the nibblers and the gobblers to the downright gluttons—reducing is a war with the will that is rarely won. Physiologist Keys flatly dismisses such appetite depressants as the amphetamines (Benzedrine, Dexedrine) as dangerous “crutches for a weak will.” Keys has no such objections to Metrecal, Quaker Oats’s Quota and other 900-calorie milk formulas that are currently winning favor from dieters. “Metrecal is a pretty complete food,” he says. “It contains large amounts of protein, vitamins and minerals. In the quantity of 900 calories a day, anyone will lose weight on it—20, 30 or 40 Ibs.” But Keys worries that the Metrecal drinker will never make either the psychological or physiological adjustment to the idea of eating smaller portions of food.

That Remarkable Cholesterol. Despite his personal distaste for obesity (“disgusting”), Dr. Keys has only an incidental interest in how much Americans eat.

What concerns him much more is the relationship of diet to the nation’s No. 1 killer: coronary artery disease, which accounts for more than half of all heart fatalities and kills 500,000 Americans a year—twice the toll from all varieties of cancer, five times the deaths from automobile accidents.

Cholesterol, the cornerstone of Dr. Keys’s theory, is a mysterious yellowish, waxy substance, chemically a crystalline alcohol. Scientists assume that cholesterol (from the Greek chole, meaning bile, and stereos, meaning solid) is somehow necessary for the formation of brain cells, since it accounts for about 2% of the brain’s total solid weight. They know it is the chief ingredient in gallstones. They suspect it plays a role in the production of adrenal hormones, and they believe it is essential to the transport of fats throughout the circulatory system. But they cannot fully explain the process of its manufacture by the human liver. Although the fatty protein molecules, carried in the blood and partly composed of cholesterol, are water soluble, cholesterol itself is insoluble, and cannot be destroyed by the body. “A remarkable substance,” says Dr. Keys, “quite apart from its tendency to be deposited in the walls of arteries.”

When thus deposited, Keys says that cholesterol is mainly responsible for the arterial blockages that culminate in heart attacks. Explains Keys: As the fatty protein molecules travel in the bloodstream, they are deposited in the intima, or inner wall of a coronary artery. The proteins and fats are burned off, and the cholesterol is left behind. As cholesterol piles up, it narrows, irritates and damages the artery, encouraging formation of calcium deposits and slowing circulation. Eventually, says Keys, one of two things happens. A clot forms at the site, seals off the flow of blood to the heart and provokes a heart attack. Or (more commonly, thinks Keys) the deposits themselves get so big that they choke off the artery’s flow to the point that an infarct occurs: the heart muscle is suffocated, cells supplied by the artery die, and the heart is permanently, perhaps fatally injured.

Fats & Coronaries. Ordinarily, the human liver synthesizes only enough cholesterol to satisfy the body’s needs—for transportation of fats and for production of bile. Even eggs and other cholesterol-rich foods, eaten in normal amounts, says Dr. Keys, do not materially affect the amount of cholesterol in the blood. But fatty foods do.

During World War II, doctors in The Netherlands and Scandinavia noted a curious fact: despite the stresses of Nazi occupation, the death rate from coronary artery disease was slowly dropping. Not until long after the war—1950, in fact—did they get a hint of the reason. That year, Sweden’s Haqvin Malmros showed that the sinking death rate neatly coincided with increasingly severe restrictions on fatty foods. That same year the University of California’s Dr. Laurance Kinsell, timing oxidation rates of blood fats, stumbled onto the discovery that many vegetable fats cause blood cholesterol levels to drop radically, while animal fats cause them to rise. Here Keys and others, such as Dr. A. E. Ahrens of the Rockefeller Institute, took over to demonstrate the chemical difference between vegetable and animal fats—and even between different varieties of each.

All natural food fats fall into one of three categories—saturated, mono-unsaturated and polyunsaturated. The degree of saturation depends on the number of hydrogen atoms on the fat molecule. Saturated fats can accommodate no more hydrogens. Mono-unsaturated fats have room for two more hydrogens on each molecule, and the polyunsaturated fat molecule has room for at least four hydrogens.

The three fats have similar caloric values (about 265 calories per oz.), but each exerts a radically different influence on blood cholesterol. Saturated fats in meat and dairy products promote production of cholesterol in quantities too large for the body to excrete. Mono-unsaturated fats (predominant in olive oil, most margarines) have no apparent effect at all on blood cholesterol levels. Polyunsaturated fats, such as those in corn, cottonseed or fish oils, on the other hand, actually lower cholesterol by increasing the excretion of bile acids.

Marbled Meat. Thus, says Physiologist Keys, the big cut in reducing U.S. fat intake should come in the popular saturated fats which, although more expensive, have become a bigger and bigger part of the American diet. Restaurants take pride in heavily marbled meat. Most margarine manufacturers “convert liquid fats into partly saturated solids by “hydrogenating” them—that is, by forcing hydrogen atoms onto the liquid fat molecules. Dairy farmers are paid more for milk with high butterfat content. Keys is a milk drinker himself—but only of modified skim milk that contains a maximum of 2% butterfat.

Proof in Tests. Neither Keys nor anyone else claims to know the whole complex chemical-mechanical story of cholesterol deposition, but he regards the cause-and-effect relationship between cholesterol and heart disease as proved. In 1946, long before Keys suspected that this relationship existed, he and Dr. Henry Taylor persuaded 286 Minneapolis-St. Paul businessmen, then aged 45 to 54, to submit to painstaking, yearly physical examinations. The idea: to see if the onset of ailments in general could be accurately forecast by physiological measurements, i.e., weight, blood pressure, electrocardiogram, cholesterol count. So far, among other diseases, 27 of the businessmen have suffered heart attacks, 16 of them fatal. The common element in 18 of the cases was high (240-360) cholesterol levels. Moreover, it was the only significant common element. The electrocardiograph, says Keys, “doesn’t hurt anybody and looks impressive in a doctor’s office,” but it is a poor predictor of coronary disease.

Later, Keys studied the eating habits and coronary death rates of middle-aged Japanese—in Japan, Hawaii and California. The native Japanese, he reports, get only 13% of their calories from fats. They eat a high-carbohydrate diet of rice, fish and vegetables, have an average cholesterol count of 120. The Hawaiian Japanese, on the other hand, also eat fish, along with meat, eggs and dairy products; they get 32% of their calories from fats, have an average cholesterol count of 183. The Los Angeles Nisei’s diet is typically American; they get 45% of their calories from fatty foods, and their average cholesterol count is 213. For every one heart attack in Japan, Keys notes, the Hawaiian Japanese have four, the Los Angeles Nisei ten.

“I’ve Got 5,000 Cases.” Though Keys’s theory gained sanction from the American Heart Association last month (TIME, Dec. 26), it is still questioned by some other researchers with conflicting ideas of what causes coronary disease. The main difference is that they variously blame hypertension, stress, smoking and physical inactivity, while Keys gives these causes only minor roles. But the army of Keys supporters is growing. Some of them are converted skeptics, like Heart Specialist Irvine Page (TIME cover, Oct. 31, 1955), who, with Harvard Nutritionist Frederick Stare and others, drafted the A.H.A.’s position paper. Keys’s chief weapon has been the sheer weight of solid statistics. Says one Philadelphia physician: “Every time you question this man Keys, he says, ‘I’ve got 5,000 cases. How many do you have?’ ”

Keys gets his cases all over the world. A doggedly inquisitive scientist, he is as familiar a figure in the vineyards of Crete, the mountains of Dalmatia and the forests of Finland as he is on the University of Minnesota campus. Money to support his wide-ranging studies comes from the U.S. Public Health Service ($100,000 a year), the American Heart Association ($17,000), the International Society of Cardiology, six foreign governments and about a dozen other no-strings sources. One of his chief fund raisers is Dr. Paul Dudley White, President Eisenhower’s heart specialist, who, together with Mrs. White and Mrs. Keys, has traveled widely with Keys on foreign research missions. Keys used to get money also from the National Dairy Council and American Meat Institute. Shrugs Keys: “They didn’t like my findings.”

Three Breakfasts a Day. A man whose interest in food is sybaritical as well as clinical, Ancel Keys tends to regard his own life as one long experience of culinary concern. As a child in Berkeley, Calif., he satisfied his early (and still strong) yen for fresh fruits by stealing apples, apricots and cherries from neighborhood orchards. Meals at home were varied and imaginative—”Mother was reputed to be a great cook”—but Ancel was not home much. Bright but unbridled, he disliked school, at ten spent three days camping with two young friends on the slopes of nearby Grizzly Peak. “We didn’t see a solitary soul.” says Keys. “Just hiked and ate. Three breakfasts a day—Aunt Jemima pancakes, dried prunes and bacon. Not too bad a diet. You can eat anything for a few days.”

Already his present height (5 ft. 7½ in.) at 13, Ancel “sort of stopped growing.” But he did not step eating. ”I was always ready to eat,” he says. “Chinatown was wonderful: an egg roll and two bowls of chow fan for 40¢. A little concentrated on the calories, perhaps.” Precociously peripatetic at 15, Ancel spent the summer in a lumber camp, left school midway through the year to shovel bat manure in an Oatman, Ariz. cave. “Great fun,” says Keys. “I slept out in the desert with the other desert rats. I’d hate to think what we ate. Stews and sourdough bread, I guess.”

From a short hitch as assistant powder monkey in a Colorado gold mine. Keys came home with a new straw hat and $75 —and finally stayed long enough to finish high school. A budding chemist in his freshman year at the University of California at Berkeley, he loaded up with brain-crushing courses (chemistry, physics, calculus, German, Chinese, English), worked 30 hours a week in the university library, took his classmates for “$20 or $30 a month” playing bridge, and kept a big bag of dried apricots beside his dormitory bed. That spring, embittered by his failure to capture the chemistry department’s sole scholarship, Keys signed on as an oiler aboard the President Wilson, bound for China, and quickly dispensed with nutritional niceties. “The diet was mainly alcohol,” he says. “I don’t remember eating anything.” Back again at Cal, Keys switched to economics, graduated in two years, went to work for Woolworth, quit in boredom after eight months and returned to the university.

Although he had never before taken a college biology course, Student Keys entered the school of zoology, completed a major in six months.

Up, Down & Around. Three years and a Ph.D. later. Keys headed for Europe on a National Research Fellowship and began a seven-year odyssey that took him to Copenhagen to study under Nobel Prize-winning Biochemist August Krogh, to Cambridge University for another degree, to Harvard for human-fatigue experiments, and to an 18,000-ft. peak in the Chilean Andes for high-altitude studies of miners. Then he landed at the Mayo Clinic, where he found himself “in a real medical environment” for the first time. Dr. Keys also found his wife-to-be, Margaret Haney, when he interviewed—and hired—her for a medical technologist’s job at Mayo. By 1940 Keys had moved to the University of Minnesota to open and head its Laboratory of Physiological Hygiene. His broad franchise: “To try to find out why people got sick before they got sick.”

An early riser (6:45 in winter, 5:30 in summer), Dr. Keys eats a leisurely breakfast—half a grapefruit, dry cereal with skim milk, unbuttered toast, jam and coffee. Then, brown paper lunch bag on the seat beside him, he drives to work in a two-toned Karmann-Ghia. Although lunch is slim—a sardine sandwich, an olive, a cooky and a glass of skim milk—Keys eats with deliberate slowness. “I don’t like to insult food,” he says. Lunch done, he sits back, closes his eyes, and goes to sleep for exactly ten minutes in his office chair.

In the Keyses’ French provincial home on the shore of Lake Owasso in the St. Paul suburb of Shoreview, dinner is a neatly scripted ritual, played to soft Brahms and candlelight, that often lasts for two hours. At first, recalls Keys, Margaret was not much of a cook: “She fed me — but she was pretty inexperienced.” She learned; the walls of kitchen and den are lined with 254 cookbooks, not counting copies of Eat Well and Stay Well, for which Mrs. Keys supplied 200 tasty recipes. The Keyses do not eat “carving meat” — steaks, chops, roasts — more than three times a week, and a single entree normally is not repeated more than once every three weeks. For cocktails they have martinis or negronis (¼ gin, ¼ Campari bitters, ¼ sweet or dry vermouth, ¼ soda water, over ice in an old-fashioned glass). The typical Keys dinner contains 1,000 calories, only 20% of which come from fats of any kind, 5% from saturated fats. A sample menu: pasta al brodo (turkey broth with noodles), veal scallopine a la Marsala, fresh green beans, homemade Italian bread (no margarine or butter), cookies, a tossed salad (dressed with tarragon vinegar and corn oil), espresso coffee and fruit.

No-Cal & Nonsense. One of the paradoxes of this era of affluence is that such civilized dining ceremony is not every body’s lot. Prosperity and faddism, suggests the A.M.A.’s Dr. Philip White, go hand in hand. “People are able and willing to seek the easy way out. Today they have the money and leisure time to indulge themselves, and they have been conditioned by the dramatic progress of medicine in the past few decades to believe that almost any pill, capsule or tonic is a miracle drug. People are disease conscious, and their fears about disease set them up for exploitation by the pseudo-scientific huckster.”

Most fads are short-lived and harmless. Even the worst usually harms only a relatively few susceptible people. But fads encourage distrust of doctors and self-diagnosis. In such an atmosphere of skepticism, it is difficult for a physician to convince a patient who feels fine that he must give up something he likes, to preserve his health. Yet, says Dr. Keys, that is exactly what many Americans should do. The average blood cholesterol count among middle-aged (40-60) U.S. men, says Keys, is an uncomfortable 240. “People should know the facts,” he says. “Then if they want to eat themselves fo death, let them.”

Drugs? There is no effortless way to control cholesterol, warns Dr. Keys. Some drugstores peddle bottles of artificially flavored safflower seed oil emulsion (polyunsaturated fat), suggest drinking it by the spoonful to offset the effects of saturated fat in the diet. Says Keys: “Nonsense. All this does is to increase the total fat intake and breed obesity.” Although polyunsaturated fats are a healthful substitute for saturated fats, they make an ineffective antidote. It takes more than 2 oz. of polyunsaturated fat, says Keys, to reduce blood cholesterol by the same amount that 1 oz. of saturated fat increases it.

Widely touted preparations such as triparanol and nicotinic acid (one of the B vitamins, also called niacin) do lower blood cholesterol, but they have undesirable side effects. Triparanol interferes with the liver’s formation of cholesterol, forces it instead to produce a suspicious substance called desmosterol that is chemically related to cholesterol—and may even have the same damaging effect on arteries. Nicotinic acid, to be effective, must be administered in massive doses. The result: flushing, itching, nausea, headaches, changes in the blood.

The only sure way to control blood cholesterol effectively, says Keys, is to reduce fat calories in the average U.S. diet by more than one-third (from 40% to 15% of total calories), and take an even sterner cut (from 17% to 4% of total calories) in saturated fats. He also warns against confusing the blood cholesterol level with cholesterol actually deposited in the arteries. No known diet will remove deposited cholesterol, and the object of all diets is only to keep deposits from growing to the point that they cut off the heart’s blood supply.

His diet recommendations are fairly simple: “Eat less fat meat, fewer eggs and dairy products. Spend more time on fish, chicken, calves’ liver, Canadian bacon, Italian food, Chinese food, supplemented by fresh fruits, vegetables and casseroles.” Adds Keys: “Nobody wants to live on mush. But reasonably low-fat diets can provide infinite variety and aesthetic satisfaction for the most fastidious—if not the most gluttonous—among us.” On such fare, Gourmet Keys keeps his own weight at a moderate 155, his cholesterol count at a comfortable 209.