Hold the Eggs and Butter

Cholesterol is proved deadly, and our diet may never be the same

This year began with the announcement by the Federal Government of the results of the broadest and most expensive research project in medical history. Its subject was cholesterol, the vital yet dangerous yellowish substance whose level in the bloodstream is directly affected by the richness of the diet. Anybody who takes the results seriously may never be able to look at an egg or a steak the same way again. For what the study found, after ten years of research costing $150 million, promises to have a profound impact on how Americans eat and watch their health. Among the conclusions:

> Heart disease is directly linked to the level of cholesterol in the blood.

> Lowering cholesterol levels markedly reduces the incidence of fatal heart attacks.

Basil Rifkind, project director of the study, believes that research “strongly indicates that the more you lower cholesterol and fat in your diet, the more you reduce your risk of heart disease.”

Everybody knows George Ford. Or somebody like George Ford. There he was, 52, the energetic president of a small Ohio electronics firm who “wouldn’t eat an egg unless it was fried in bacon grease” His lunches were executive size. He matched his business cronies drink for drink. He smoked “pretty heavily” and exercised with a knife and fork. In the winter of 1981 doctors informed Ford that his cholesterol levels were dangerously high; by April he required a quadruple coronary bypass operation. He emerged from the hospital determined to revise his ways radically. Today he does not smoke, he exercises four or five days a week, and he sticks scrupulously to a diet high in fiber and low in cholesterol and fat. “I haven’t had a slice of bacon in three years,” he says. He is proud and relieved that his cholesterol level is normal. “Maybe heart disease is God’s way of telling us we’re living too damn high on the hog,” Ford says. “It’s hard to practice moderation in this country. We’re a nation of excess.”

Sadly, George Ford is right. By the time the average American puts down his fork for the day, he has consumed the equivalent of a full stick of butter in fat and cholesterol. This is despite more than 25 years of warnings from doctors and the American Heart Association about the dangers of such oleaginous indulgence. All their good advice, plus the urgings of the health-and-fitness movement, has, it seems, succeeded only in making us feel guiltier as we plow our way through the eggs Benedict. Although intake of animal fats has been declining, American men continue to consume an average of about 500 mg of cholesterol a day, and women 350 mg, in both cases about 60% more than the Heart Association recommends. About 40% of our daily calories are taken in as fat; this is about 30% more than Americans ate 60 years ago, and nearly three times the amount consumed by the Japanese and some African and Latin American populations.

More to the point, the U.S. continues to have one of the highest rates of heart disease in the world. Last year more than a million Americans suffered heart attacks; more than half of them died as a result. Because most of the victims are in their prime productive years, mainly men in their 40s and 50s, the economic and social toll is huge, leaving aside the tragic personal waste. According to the National Heart, Lung and Blood Institute, deaths from heart attacks cost an estimated $60 billion in medical bills, lost wages and productivity, or more than last year’s total Medicare budget.

For decades, researchers have been trying to prove conclusively that cholesterol is a major villain in this epidemic. It has not been easy. Cholesterol is, after all, only one piece in a large puzzle that also includes obesity, high blood pressure, smoking, stress and lack of exercise. All of these play their part in heart disease “like members of an orchestra,” explains Pathologist Richard Minick of the New York Hospital-Cornell Medical Center.

To make matters more complicated, an individual’s susceptibility to these factors depends on inherited traits. Thus, while a fatty diet and smoking may mean early death for one man, another can puff away, gorge on steaks and banana splits and still live to a ripe old age.

Cholesterol has been perplexing researchers since 1769, when French Chemist Poulletier de la Salle first purified the soapy-looking yellow-white substance. Despite its bad reputation, cholesterol is essential to life: it is a building block of the outer membrane of cells, and it is a principal ingredient in the digestive juice bile, in the fatty sheath that insulates nerves, and in sex hormones such as estrogen and androgen. Although most of the cholesterol found in the body is produced in the liver, 20% to 30% generally comes from the food we eat.

Doctors first became suspicious about cholesterol, particularly the cholesterol in diet, when they looked inside the diseased arteries of heart attack victims. There, instead of smooth, supple vessels, they saw what looked like brittle, old pipes, clogged and hardened by deposits of cholesterol—the condition now known as atherosclerosis. In 1913, Russian Pathologist Nikolai Anitschkow showed that he could produce similar deposits, or plaques, in the arteries of rabbits just by feeding them a diet rich in cholesterol. Subsequent research further supported the connection between diet and cardio-vascular disease. Epidemiologist Ancel Keys conducted a landmark study in seven nations beginning in 1947. He discovered direct correlations between a country’s incidence of heart disease, the level of cholesterol in the blood and the amount of animal fat in the national diet. The Finns, with the fattiest diet, had the highest cholesterol levels and the highest rate of heart disease; the Americans, with a diet only slightly less rich, were a close second. But the Japanese, who eat a diet low in fat, had the lowest cholesterol levels and the least cardiovascular disease. Their rate of fatal heart attacks was one-fourth the American incidence. A later study showed that when Japanese emigrated to the U.S. and adopted a Western diet, their incidence of heart disease soared to ten times that of their countrymen in Japan.

The experts were still not quite able to pin the blame on cholesterol, however. Explains Fred Mattson, a leading researcher at the University of California at San Diego, “We were missing a key piece of evidence: no one had ever shown that reducing the level of cholesterol in the blood did any good.”

That was the reason for the N.H.L.B.I, study. The elaborate, ten-year program recruited 3,806 men between the ages of 35 and 59, all of whom had cholesterol levels above 265 mg per deciliter of blood (the average for U.S. adults is 215 to 220). Half the men were put on daily doses of cholestyramine, an unpleasant, cholesterol-lowering drug that was mixed with orange juice and taken six times a day. One participant likened taking it to swallowing “orange-flavored sand.” Among its side effects: constipation, bloating, nausea and gas. The other half received a similarly gritty placebo. Researchers had decided to use a drug rather than diet to lower cholesterol, because it would have been virtually impossible to control or measure the diet of so many men over so long a period. By the end of the study, the cholestyramine group had achieved an average cholesterol level 8.5% lower than that of the control group and had suffered 19% fewer heart attacks. Their cardiac death rate was a remarkable 24% lower than that of the placebo group.

The lesson is plain, says Dr. Charles Glueck, director of the University of Cincinnati Lipid Research Center, one of twelve centers that participated in the project: “For every 1% reduction in total cholesterol level, there is a 2% reduction of heart-disease risk.” This, says Project Director Basil Rifkind, is the evidence scientists have been waiting for. “It is a turning point in cholesterol-heart-disease research.”

Convincing though the study was, doctors disagree on its implications. There is no longer any doubt that lives can be saved by lowering cholesterol levels in the blood, but can this be achieved just by improving diet? If so, would healthier eating habits benefit all Americans? According to Columbia University Cardiologist Robert Levy, who directed the study, the answer is yes on both counts. Says Levy: “If we can get everyone to lower his cholesterol 10% to 15% by cutting down on fat and cholesterol in the diet, heart-attack deaths in this country will decrease by 20% to 30%.” Other doctors are not so sure, and urge a stricter interpretation of the study. Says Dr. Edward Ahrens, a veteran cholesterol researcher at Rockefeller University: “Since this was basically a drug study, we can conclude nothing about diet; such extrapolation is unwarranted, unscientific and wishful thinking.”

One point on which there is no argument is the importance of treating patients who, like the men in the study, have extremely high cholesterol levels. But doctors differ somewhat on when to sound the alarm. Some believe that anyone with a reading over 200 mg should cut back on fat and cholesterol: that would include more than half the U.S. population. A less extreme view is that only people with levels above 240 mg should receive serious attention. Says Rifkind: “People in this group represent only 20% of the population, but they suffer 40% of the heart attacks.”

Fred Shragai, 59, of Encino, Calif., is a good example. Fourteen years ago, the prosperous real estate developer had a cholesterol level above 300 mg. At the time, he smoked four packs of cigarettes a day, was overweight (202 lbs. on a 5-ft. 5-in. frame) and routinely put in five or six 14-hour, pressure-packed days a week at the office. Rich sauces and fatty meat were his standard fare for both lunch and dinner, and exercise meant reaching under the bed to grab from his stash of pretzels and potato chips. Shragai was a classic candidate for a heart attack, and at the age of 45, he had one. Nine years later he was hospitalized for an operation to bypass five seriously blocked coronary arteries. In desperation, Shragai enrolled himself in U.C.L.A.’s Center for Health Enhancement. By changing the way he lived, he was told, he could lower his cholesterol level and reduce his risk of another heart attack.

There was much to learn. Cholesterol, as Shragai found out, is packaged by the body in envelopes of protein, and only some of these packages are potentially harmful. The main culprit, LDL (for low-density lipoprotein), is the body’s oil truck, circulating in the blood, delivering fat and cholesterol to the cells. Studies have shown that the higher the level of LDL, the greater the risk of atherosclerosis. Another type of cholesterol package is called HDL (for high-density lipoprotein). It appears to play a salutary role, helping remove cholesterol from circulation and reducing the risk of heart disease. Shragai’s goal was to lower his level of LDL and raise his HDL.

Diet was a first step. To begin with, such cholesterol-rich foods as eggs and organ meats and most cheeses can directly add to the level of potentially harmful LDL. Fat has an even bigger impact, although the reasons are not well understood. Saturated fat tends to raise LDL levels. Butter, bacon, beef, whole milk, virtually any food of animal origin is high in saturated fat; so are two vegetable oils: coconut and palm. Polyunsaturated fats, which are typically of vegetable origin, have the opposite effect; thus corn, safflower, soybean and sesame oils tend to lower the level of potentially dangerous LDL. Fish oils do the same. In the middle are the mono-unsaturated fats such as olive and peanut oils. These may lower LDL slightly, but tend to be neutral.

The amount of fiber in the diet also seems to influence cholesterol levels. “LDL cholesterol can be reduced 20% in people with high levels just by consuming a cup of oat bran a day,” says Dr. Jon Story of Purdue University. However, Story adds, “that does not mean you can go and eat whatever else you want.”

For reasons that are still under study, cholesterol levels are influenced by a number of life-style factors. For instance, regular exercise can significantly raise the level of protective HDL. Alas, a couple of push-ups a day will not do the trick, says Dr. Josef Patsch of Houston’s Baylor College of Medicine: “You need sustained aerobic exercise for 20 minutes at least four times a week to really benefit.” A less strenuous way to raise HDL levels may be to have a daily shot or two of alcohol. “The evidence is indirect,” reports Epidemiologist Stephen Hulley of the University of California at San Francisco, “but social drinkers have HDL levels as much as 33% higher than those found in teetotalers.” On a more sober note, U.C.S.F.’s Dr. Richard Havel warns: “Anyone who recommends raising HDL by drinking is playing with fire.” Stress too has a detrimental effect. Studies have shown that the cholesterol levels of medical students peak at exam time, while accountants hit their high point around April 15.

By applying these lessons, says Shra-gai, “my life was totally changed.” Today the man who used to love steak says, “I won’t touch it.” At a restaurant, “if I choose fish, I ask the chef to skip the butter or please to sauté it in wine.” Every morning, regardless of weather, the man who once spurned exercise goes for an eightmile, two-hour hike through the wooded mountain trails near his home. He no longer smokes. His workdays average between eight and ten hours, but he insists, “I can absolutely stay away from the tension now. If I feel the pressure, I take off. Business associates get used to it; I set my own pace.” Shragai no longer lives in fear of a sudden heart attack: his blood pressure and pulse rate are down, and most remarkable, his cholesterol level has dropped to an exemplary 195.

More and more Americans are deciding to take such precautions before, not after, disaster strikes. Three years ago, officials at the San Diego County school system became alarmed by the growing number of workmen’s-compensation and health-insurance claims being filed by employees. “Most of the claims stemmed from poor health maintenance,” recalls Risk Management Analyst Florine Belanger. To counter the problem, Belanger organized a program that offered employees a complete physical examination, followed by counseling on diet, exercise and stress management. “We thought we’d try to get the employees of our schools interested in changing their life-style,” explains Belanger.

Janet Crowell, 42, a teacher’s aide for the handicapped, is one of 1,500 teachers and staff members in seven of the county’s 46 districts who have enrolled. After only four months, Crowell is jogging twelve miles a week, has lost 20 Ibs. and has reformed her diet. Says she: “I used to eat too many cheese and milk products and pasta with meat sauces.” Now she favors raw vegetables, yogurt and a lot of pasta but with less sauce. In the Escondido district, where one-third of the employees are in the program, workmen’s-compensation claims have dropped 34%, and health-insurance claims are down about 20%. Says Belanger: “We’ve caught the problems before they happen.”

The American Heart Association has been urging people for years to take this preventive approach. Specifically, A.H.A. experts recommend that American men limit themselves to 300 nag of cholesterol a day, and women to 225 mg, roughly the amount in a single egg. They insist that fat should make up no more than 30% (rather than its current 40%) of the diet, and no more than one-third of this should be saturated. “The diet is not a radical one,” says A.H.A. President Antonio Gotto. The organization urges a somewhat stricter regimen for people who already have elevated cholesterol levels or a family history of heart disease.

Because atherosclerosis develops slowly throughout life, Gotto believes that children should be started on a low-fat and low-cholesterol regimen at about the age of two. Children who begin eating a sensible diet early in life “are much more likely to follow it in the adult years,” he maintains. If everyone were to accept this advice, says Gotto, coronary bypass surgery, now the most common major operation in the U.S. (170,000 were performed last year), would become rare by the end of the century. “We could look forward to the time when atherosclerosis is conquered,” he says.

Many Americans have already heeded the A.H.A. gospel. Over the past 20 years, the nation’s consumption of butter has dropped 30%, egg consumption has declined 14%, and the average intake of animal fat has plummeted 60%. Over the same two decades, deaths from heart disease have declined 30%.

Even so, not everyone agrees with the A.H.A. on dietary reform. The drop in mortality, some scientists point out, is partly due to better treatment for heart disease and to a decline in smoking among middle-aged men. “I have an aversion to this cholesterolphobia,” scoffs Purdue Cardiologist Story. “Why treat everybody? We don’t give everybody insulin out of fear of diabetes.” According to Rockefeller University’s Ahrens, who has spent nearly 40 years studying cholesterol metabolism, individuals differ greatly in their response to dietary fat and cholesterol. “To deny everyone red meat could mean taking away the joy of life unnecessarily,” he says. “And as an inexpensive source of good nutrition, there is nothing more glorious than the egg.”

It comes as no surprise that the food industry agrees. “Most of us can eat one or two eggs a day without problems, provided we don’t eat a lot of saturated fats,” says Louis Raffel, president of the American Egg Board. M.F. Brink, president of the National Dairy Council, offers an even stauncher defense of milk, cream and cheese. “Without dairy foods,” he says, “people could experience deficiencies of calcium, riboflavin and in some cases vitamin D.”

The food manufacturers who oppose the Heart Association’s dietary recommendations have come in for widespread criticism. “Instead of making excuses, they ought to be adopting the long-range goal of making better products,” says Dr. John LaRosa, an internist at George Washington University Medical School. Many doctors believe that the labels on processed food should spell out the amounts of cholesterol, saturated fat and polyunsaturated fat the food contains. “How else is the shopper to know that something as innocent as a soda cracker contains 4 gm of saturated fat?” asks Cincinnati’s Dr. Glueck. Saturated fat, usually in the form of coconut oil, lurks in most commercially baked breads and cakes, in nondairy creamers, on the oiled surface of frozen French fries, and even in wholesome granola. At Washington’s Center for Science in the Public Interest, Nutritionist Bonnie Liebman has investigated the chic new frozen foods and found that some are surprisingly heavy in fat. Among them: Armour’s Dinner Classics, Swanson’s Le Menu and Pepperidge Farm’s frozen vegetables in pastry. Of the 200 calories in each of Pepperidge Farm’s croissants, she says, 118 are in the form of butter.

Pepperidge Farm defends its product: “Anybody’s croissant is made up of about one-fourth butter,” says Product Standards Manager Carol Johnson. In general, industry officials claim that they offer Americans a broad selection of foods, including lowfat, low-cholesterol varieties for those who want them. Kraft, Inc., Spokesman David Roycroft points out that the dairy industry has taken pains to increase the number of products from which the butterfat has been removed. Kraft’s Golden Image imitation cheeses and Light n’ Lively yogurt and cottage cheese were, he says, “developed in response to a perceived demand by consumers for such products.” The meat industry has also responded to this demand, by offering 95%-fat-free ham and pork luncheon meats. Over the past decade the amount of fat in pork has been cut 30% and the amount in beef reduced 6% to 7%. The American Meat Institute is seeking changes in U.S.D.A. fat requirements to allow further reductions.

Officially, the Federal Government has neither rejected nor endorsed the A.H.A. dietary recommendations, nor has it taken a position on whether foodmakers should adopt more candid labeling. Since 1980, the U.S. Departments of Agriculture and Health and Human Services have published a brochure offering Americans the following general recommendation: “Avoid too much fat, saturated fat and cholesterol.” Throughout this year, officials of both departments are meeting with scientists to discuss whether or not this recommendation should be made more stringent and specific, in light of the N.H.L.B.I. findings. “The time has come for the Federal Government to make some pronouncement on cholesterol,” says George Washington University’s LaRosa. But some nutritionists fear that opposition from the food industry will prevent the Government from taking a firmer stand.

Lowering cholesterol levels by eliminating eggs and fat is not the whole story, of course. Cholesterol levels are influenced by a number of factors, from age to genes, some of which cannot be controlled at all. The first is simply being an adult. Almost everybody has very low levels of cholesterol at birth, with LDL measuring around 50 mg per deciliter of blood. But by the time most people reach adulthood, they have at least twice that amount. “One of our problems as a species,” says Virgil Brown, a cardiologist at New York City’s Mount Sinai Medical Center, “is that we don’t remove LDL as fast as other animals.”

Gender also has an effect. Males and females start out with the same cholesterol levels, but around puberty boys experience a 20% to 25% drop in protective HDL and an ominous rise in LDL. This difference, researchers believe, is probably the reason why there are 60% fewer deaths from heart attacks in women than in men in the U.S. Race seems to play a part in how well the body handles cholesterol. Dr. Gerald Berenson, director of a long-term study in Bogalusa, La., has found that the changes in boys at puberty are more drastic in whites than in blacks. Says he: “It is as if white males are genetically programmed for early coronary disease.”

In some cases, high cholesterol levels are caused by genetic defects. Molecular Geneticists Michael Brown and Joseph Goldstein, of the University of Texas Health Sciences Center in Dallas, have discovered a tiny structure—a single molecule—that sits on the surface of cells and removes potentially harmful LDL cholesterol from circulation. About one in 500 Americans is genetically deficient in these structures, called LDL receptors, and, as a result, develops astronomically high levels of LDL cholesterol. People with this condition, called familial hypercholesterolemia (FH), have 25 times the normal risk of heart disease.

Such is the case for four out of five members of the Arnold Melman family of Ardsley, N.Y. The Melmans keep a chart tracing their rising and falling cholesterol and levels. Melman, a urologist, is the only member of his family who is free from such worries. His wife Lois and all three children have FH and must follow a strict lowfat, low-cholesterol diet. Lois and the two older children also take 30 gm a day of cholestid, a cholesterol-lowering drug similar to the cholestyramine used in the N.H.L.B.I. trial. Such drugs are expensive as well as unpleasant: as much as $200 for a month’s supply. But, together with diet, they have helped the Melmans “make ourselves normal,” as Lois puts it. Doctors hope that the results of the N.H.L.B.I. trial will convince pharmaceutical companies that there is a need and a market for less expensive, more palatable drugs.

At the opposite extreme from the Melmans are people who seem to be genetically programmed to escape the problem. The Pima Indians of Arizona have the world’s highest known rate of diabetes and one of the highest rates of obesity, both of which should increase their risk of heart disease. To make matters worse, they subsist on a diet heavy in foods fried in lard. Despite all this, Pimas have moderately low levels of LDL and only about one-fourth the heart-attack rate of the American public. Scientists believe that what makes the Pimas different from the more vulnerable masses is not that their bodies produce less cholesterol, but rather that they are more efficient at removing it from the bloodstream. Says Barbara Howard, a researcher for the National Institutes of Health: “The Pimas may have more LDL receptors or else more efficient ones than most people.”

The same may be true for the 1% to 2% of Americans who, according to Rockefeller University Geneticist Jan Breslow, “have a genetic composition that makes them immune to atherosclerosis.” Breslow calls this advantage “the Winston Churchill factor.” Says he: “These people break all the rules; they eat eggs, bacon and meat, and they smoke. And they live to be 95.”

For the 98% of Americans who are neither Winston Churchills nor Pimas, playing by the rules is important. It is a rare doctor, however, who will recommend dietary reform to a patient unless his cholesterol level is already quite high or he has suffered a heart attack. “Most physicians are used to treating acute illnesses; they are less comfortable with preventive medicine for healthy-looking patients,” says Dr. Eugene Passamani, associate director for cardiology at the National Institutes of Health. As a result, individuals must usually make up their own minds about a change in diet. The trends of the past two decades give cause for optimism. Medical researchers generally believe that Americans will become increasingly willing to change to a healthier diet and a more sensible lifestyle. By the year 2000, they say, heart disease could cease to be the leading cause of death in America. Twenty years ago, says Dr. William Friedewald of the N.H.L.B.I., “the public attitude was fatalistic: ‘You may get a heart attack or you may not.’ Today Americans are beginning to realize their health is in their own hands.” —By Claudia Wallis. Reported by Cheryl Crooks/Los Angeles, Patricia Delaney/ Washington and Sheila Gribben/Chicago, with other bureaus