From the evidence summarized here, there is every reason to conclude, based on all seven criteria set forth, that the epidemiologic associations among dietary lipid (cholesterol and saturated fat), serum cholesterol, and CHD [coronary heart disease] incidence represent etiologically significant relationships. In the multifactorial causation of this disease, at least four major factors are operative-diet high in cholesterol and saturated fat, hypercholesterolemia, hypertension, and cigarette smoking. However, since the data from both animal and human studies indicate that high blood pressure and cigarette smoking are minimally significant in the absence of the nutritional-metabolic prerequisites for atherogenesis, it is further reasonable and sound to designate rich diet as a primary, essential, necessary cause of the current epidemic of premature atherosclerotic disease raging in the Western industrialized countries. Cigarette smoking and hypertension are then secondary or complementary causes. (This designation, of both practical and theoretical importance, in no way detracts from their relevance in terms of medical care and public-health approaches to the prevention and control of the epidemic.)

-Jeremiah Stamler, "Population Studies," in Nutrition, Lipids and Coronary Heart Disease, ed. R Levy, et al.

1. Overview

In reviewing the eating and dying patterns of different societies, we find two basic patterns. The poor nations of the world cannot afford the high-fat "refined" foods characteristic of the wealthier nations and, thus, eat a diet that tends to be high in starch (complex carbohydrates) and fiber and low in fat and cholesterol. Heart disease, diabetes, and various forms of cancer (colon-rectal, breast, ovarian, and others) are very rare in these societies. Individuals in such societies also cannot afford medical care and proper food storage. The primary causes of death are, therefore, infectious diseases. If salt and pickling are commonly used to preserve foods, then stomach cancer may also be high. These are the diseases of poverty

In contrast, the wealthier nations typically eat diets that are high in fat and cholesterol and low in fiber. In these societies, most of the deaths are caused by heart disease, thrombotic and embolic stroke (stroke caused by atherosclerosis), and cancers of the colon, breast, lung, and reproductive organs. These are the diseases of affluence.

Several questions come to mind. First, might the low rates of heart disease, colon cancer, breast cancer, and the other degenerative diseases in the undeveloped nations be due to the fact that these people succumb at an earlier age to infectious diseases and, thus, do not live long enough to get the degenerative diseases, which tend to develop in middle age and beyond? The answer is that death from infectious diseases occurs at different ages. Those who do survive into old age still have extremely low rates of heart disease and the other diseases typical of advanced societies. Furthermore, the elderly in these societies lead more productive lives. For example, in the regions of Japan that consume a traditional diet there is a significantly higher percentage of people over 70 who lead active, productive lives, when compared with regions of Japan, such as Tokyo, where people now eat a diet higher in fat.¹

Second, can we attribute these patterns to genetics? There are two responses here. It would be quite a coincidence, given the consistency of this pattern across the world. Furthermore, extensive studies of population migration show that people who move from one society to another adopt the disease patterns of the society they move to. The crucial and dominant role of nutrition as a primary causative factor in the development of heart disease, stroke, and the most prevalent forms of cancer is also supported by a vast literature of both animal and human studies, including recent human intervention studies.

Among the low-fat societies, we see two basic patterns. Japan is typical of the first pattern, a society that eats relatively little fat but an extremely high level of sodium (salt). The people have, as a result, very low rates of heart disease and breast and colon cancer, but the high level of salt causes a very high rate of hypertension. In the United States and other high-fat societies, hypertension is a risk factor for heart disease. But hypertension is a secondary, not a primary, factor. A high-fat, high-cholesterol diet is the primary factor and, thus, heart disease remains low in Japan despite the high level of hypertension (as well as the high rate of smoking). Still, the hypertension does cause a high level of intracerebral hemorrhage, a form of stroke caused by excessive pressure on the cerebral arteries. The other primary forms of stroke, thrombotic and embolic strokes, which are caused by atherosclerosis, remain at a low level in Japan, but are the primary forms of stroke in the United States. The extensive use of salt as a preservative and an affinity for blackened, charbroiled food also causes a high rate of stomach cancer. With the increasing affluence and resulting Westernization of Japan, the eating patterns and resulting disease patterns are moving gradually (though slowly) toward American and European patterns. Beef has become a symbol of luxury in Japan, and the consumption of meat and other fatty foods has been rising along with the rate of heart disease since World War II. The percentage of calories from fat, as well as the rates of heart disease and other "affluent" diseases, still remain, however, far below Western levels. There has also been a trend toward healthier methods of food preservation, and the rate of stomach cancer has also been falling. One interesting finding from studying Japanese patterns is the very low rate of lung cancer despite the very high rate of smoking. Smoking causes initiation of the cancer, but the growth phase of the cancer requires a diet high in fat.

Some parts of China are similar to Japan in having a low-fat but high-sodium diet, and the disease patterns are similar to Japan. Other parts of China are typical of the second pattern of diet in low-fat societies, where people eat a low-fat and low-sodium diet. Here we see very low rates of heart disease and other degenerative diseases as well as low lifetime blood pressure and very low rates of all forms of stroke. We do see high rates of infectious diseases in many of these societies due to the absence of medical care and the high level of pathogens in the food supply. There are also sections of China that eat a relatively high-fat diet (for China), and here we see higher rates of heart disease and other diseases typical of Western countries. China is, therefore, an ideal laboratory for assessing the impact of nutrition on disease because of its homogeneous genetic composition and diverse nutritional patterns. The massive study conducted at Cornell University discussed earlier has shown clearly the dramatic link of nutrition to disease.

Among Western societies, we also see two basic patterns. The worst pattern is that found in the United States and the northern European countries. High levels of saturated and polyunsaturated fats and cholesterol cause very high rates of heart disease, colon, breast, ovarian, and lung cancer, along with high rates of obesity and type II diabetes. In southern European countries, we see some amelioration of this pattern. Here, the primary form of oil is virgin (first pressed) olive oil, which is low in both saturated and polyunsaturated fat. The fat is primarily monounsaturated. This has led many people to comment that the monounsaturated fat in olive oil is "good" for you and lowers blood cholesterol levels. Actually, it is simply "less bad," and death rates from heart disease, while substantially lower than American and northern European levels, are still much higher here than in the Asian nations that eat very low levels of all forms of fat. France, despite its reputation for rich cream sauces and desserts, actually eats a day-to-day diet not too dissimilar in many regards to the southern Europeans' and its disease patterns are also similar.

The link of prosperity to high-fat diets and in turn to atherosclerotic diseases goes back to antiquity. Egyptian mummies of the nobility and priesthood contain bits of arteries with gross atherosclerosis. There are also many reports of angina pain and sudden death among the Roman aristocracy.²

In summary, we have the opportunity for the best of all worlds. We can enjoy a diverse and appealing diet that avoids both the diseases of affluence and the diseases of poverty.

2. A Comment on the Title to Part One

With regard to the reference to the "civilized" diet, it is certainly not my intention to imply that Asian diets are in some way "uncivilized." Clearly, it is the Western "civilized" diets that are the most objectionable. However, we do find a very strong worldwide link between the industrialization that is associated with civilization and the adoption of an unhealthy diet. As Japan has grown in wealth since World War II, its fat consumption has grown from around 10 percent to more than 20 percent, and heart disease rates have correspondingly increased. In China, we find the wealthier counties eating substantially higher levels of fat and cholesterol (as compared to the less-wealthy counties) and, not surprisingly, experiencing much higher rates of heart disease, cancer, and other diseases of affluence.

3. The United States

Of all countries, the United States has close to the worst profile in terms of eating patterns and the resulting degenerative diseases of affluence. Percentage of calories from fat is still around 37 percent, down somewhat from the mid-40s about ten years ago. Since the 1960s, there has been about a 40 percent reduction in saturated fat consumption, which has resulted in about a 35 percent reduction in heart disease. Along with the decrease in saturated fat, there has been, up until recently, a corresponding increase in other types of fat, notably polyunsaturated fat, which has caused an increase in cancer rates.

The change in Native Americans' health represents a good example of the impact of a Western diet on an indigenous population. Prior to the twentieth century, the diet of American Indians was high in grains, corn, and other high-fiber foods. Obesity and diabetes were unknown, and rates of coronary heart disease were extremely low. In those U.S. tribes that are still relatively isolated from the rest of American society, such as the Alaskan Athapaskans, the people's situation remains the same in terms of diet and patterns of disease. Prior to 1940, tribes in Oklahoma continued to eat a low-fat, high-fiber diet and had very low rates of heart disease, diabetes, and gallbladder disease. Since 1940, the diet and disease patterns for most tribes of American Indians have changed dramatically to those of the rest of American society. With the increased level of fat and decreased fiber, the rates of obesity, diabetes, heart disease, and the other characteristic conditions associated with a "civilized" diet have become very high. Liver cancer is also very high, due to high rates of alcoholism.³

UNITED STATES

HOW TO SAVE 1,138,200 AMERICAN LIVES A YEAR

1. Data from WHO, 1988.

2. All numbers rounded to the nearest hundred.

3. Data based on Korea, Guatemala, Thailand, and the Philippines. WHO, 1982, 1987, 1989.

4. If everyone followed the recommendations of the 10% solution, people who otherwise would have died of degenerative diseases would grow older and subsequently succumb to other causes, thus eventually increasing the figures for these other diseases. The charts in this section do not reflect this effect, but rather demonstrate the impact of life-style on current patterns of disease.

5. Including atherosclerosis.

6. Including bronchitis, asthma, emphysema.

The table above represents the leading causes of death in the United States and what can be done to avoid these diseases. The 10% solution represents all of the dietary and life-style recommendations detailed in chapter 12, "The Ten-Minute Guide to the 10% Solution," and discussed extensively throughout this book. The number of deaths that can be avoided through adoption of the 10% solution has been calculated based on corresponding rates of these diseases in the countries that follow these guidelines. Obviously, if everyone followed the recommendations of the 10% solution, people who otherwise would have died of degenerative diseases would grow older and subsequently succumb to other causes, thus eventually increasing the figures for these other diseases. The charts in this section do not reflect this effect, but rather demonstrate the impact of life-style on current patterns of disease.

4. Europe

As noted, the northern European countries have eating and disease patterns similar to those of the United States. With the campaign in the United States to cut down on saturated fat to some extent, rates of heart disease in some northern and eastern European countries (such as Finland, Poland, Hungary, Ireland, and the United Kingdom) are even higher than in the United States. Cancer rates are also very high.

In southern European countries, such as Italy and Greece, the extensive use of olive oil, with its high monounsaturated fat content as a primary oil for cooking and salad dressing, has resulted in a rate of death from coronary heart disease in between that of the low-fat Asian countries and the high-saturated-fat northern European countries and the United States. Consumption of fruits and vegetables and low-fat breads are also high in these southern European countries. On the other hand, rates of cancer of the breast, colon, and lung remain relatively high in these countries due to the high overall level of fat in the diet.

France is interesting in that it fits into the southern European model despite its reputation for cream sauces and rich desserts. Actually, the rich French cuisine is not typical of everyday eating and is reserved for special occasions. The French eat a lot of low-fat French bread and are avid consumers of fresh fruits and vegetables. The French typically do not overeat and obesity is rare. Also, much of the fat in their diet is in the form of cheese. While cheese is high in saturated fat, it is also high in calcium. Studies have shown that the high calcium content of cheese may provide some protection from its fat

Content. Apparently, the calcium may limit the absorption of the fat and cause a substantial fraction of it to be excreted. Other dairy products that are lower in calcium do not have this protective effect. Also, the consumption of wine may have a protective effect on heart disease (but not cancer).⁴

SEVERAL NORTHERN EUROPEAN COUNTRIES (FINLAND, GERMANY, IRELAND, AND THE U.K.)

HOW TO SAVE 216,200 LIVES A YEAR IN FINLAND, GERMANY, IRELAND, AND THE UNITED KINGDOM

1. Data from WHO, 1988, 1989.

2. All numbers rounded to nearest hundred.

3. Data based on Korea. Guatemala, Thailand, and the Philippines. WHO, 1982, 1987, 1989.

4. If everyone followed the recommendations of the 10% solution, people who otherwise would have died of degenerative diseases would grow older and subsequently succumb to other causes, thus eventually increasing the figures for these other diseases. The charts in this section do not reflect this effect, but rather demonstrate the impact of life-style on current patterns of disease.

5. Including atherosclerosis.

6. Including bronchitis, asthma, emphysema.

SEVERAL SOUTHERN EUROPEAN COUNTRIES (GREECE, ITALY, PORTUGAL, AND SPAIN)

HOW TO SAVE 138,700 LIVES A YEAR IN GREECE, ITALY, PORTUGAL, AND SPAIN

1. Data from WHO, 1988.

2. All numbers rounded to nearest hundred.

3. Data based on Korea, Guatemala, Thailand, and the Philippines. WHO, 1982, 1987, 1989.

4. If everyone followed the recommendations of the 10% solution, people who otherwise would have died of degenerative diseases would grow older and subsequently succumb to other causes, thus eventually increasing the figures for these other diseases. The charts in this section do not reflect this effect, but rather demonstrate the impact of life-style on current patterns of disease.

5. Including atherosclerosis.

6. Including bronchitis, asthma, emphysema.

5. Japan

In comparison to other highly industrialized countries, Japan offers a sharp contrast in its low rates of heart disease. The traditional Japanese diet is very low in fat and cholesterol, and correspondingly in areas that eat the traditional diet, there are extremely low rates of

atherosclerosis and the diseases produced by atherosclerosis, including coronary heart disease, thrombotic and embolic stroke, claudication, and others. The Japanese diet is also extremely high in sodium, which causes a high rate of hypertension. As a result, the form of stroke caused by a burst blood vessel (intracerebral hemorrhage)is one of the leading causes of death in Japan. There is also a high rate of stomach cancer, which has been linked to the high intake of salted, smoked, and pickled foods, particularly salted, dried fish, as well as the extensive use of charbroiling and blackening in food preparation, which produces a potent carcinogen.

The Japanese diet has been changing gradually since World War II with the influence of Western society. There has been a 650 percent increase in the consumption of meat, poultry, and eggs, a 1,400 percent increase in the consumption of milk, a 97 percent decrease in the consumption of barley, a 50 percent decrease in the consumption of potatoes, and a 30 percent decrease in the consumption of rice. Fat levels are still substantially lower than in the United States and Europe, although they have doubled since 1950. This trend toward a Western style diet is mostly restricted to the wealthy non-farmers and urban dwellers. Farmers, rural dwellers, and other less-wealthy people have largely retained the traditional diet. Also, older Japanese people tend to eat a more traditional diet. Along with the gradual change in diet has been a corresponding increase in heart disease, although still running at only 30 percent of American levels. Rates of diabetes have also increased. For example, the mortality rate from type II diabetes increased by 133 percent from 1950 to 1984. With a decrease in salt consumption, pickling as a food-preservation method, and charbroiling, there has been a gradual decrease in intracerebral hemorrhage and stomach cancer. Along with the change in disease patterns, the change in diet has caused the Japanese to become taller and heavier, as well as caused the onset of menstruation in Japanese girls to start earlier by three to six years. With the earlier sexual development of Japanese girls has been a parallel increase in the mortality rates of the cancers of the reproductive organs and breast, which were traditionally uncommon among the Japanese. However, Japanese rates of these diseases are still substantially lower than the rates in other industrialized nations.⁵

JAPAN

HOW TO SAVE 344,800 JAPANESE LIVES A YEAR

1. Data from WHO, 1988.

2. All numbers rounded to nearest hundred.

3. Data based on Korea. Guatemala, Thailand, and the Philippines. WHO, 1982, 1987, 1989.

4. If everyone followed the recommendations of the 10% solution, people who otherwise would have died of degenerative diseases would grow older and subsequently succumb to other causes, thus eventually increasing the figures for these other diseases. The charts in this section do not reflect this effect, but rather demonstrate the impact of life-style on current patterns of disease.

5. Including atherosclerosis.

6. Including bronchitis, asthma, emphysema.

6. China

As detailed earlier (see chapter 1), a massive study conducted at Cornell University tracking 6,500 Chinese, comprising 100 people from each of China's 65 counties, has confirmed the link of total fat and saturated fat in the diet to the incidence of heart disease and cancers of the colon, breast, prostate, and ovaries. One important aspect of the Cornell Study is that the subjects vary in their diet, but are relatively homogeneous genetically. We also find all three primary dietary patterns: high-fat, high-salt; low-fat, high-salt; and low-fat, low-salt.

In general, the Chinese eat a very low fat diet, consuming about one-third of the fat that Americans consume. Only 7 percent of the protein in the average Chinese diet comes from animal products, compared to 70 percent in the average American diet. In those regions that eat very low fat diets (which account for most of the population), heart disease, diabetes, and the above forms of cancer are very rare. In rural counties with very low fat consumption, rates of heart disease are 155 times lower than in the United States. In those regions that have more fat in the diet, mostly in the form of meat and oils, these diseases are correspondingly higher.

As in Japan, there is a link between certain methods of food preservation, most notably salt, fermentation, and pickling, and rates of stomach cancer. There is also a link between the ingestion of moldy food and rates of both stomach and esophageal cancer. A study in Shandong, China(in the eastern part of the country), found that risks of stomach cancer were increased by 50 percent by heavy (one or more packs a day) cigarette smoking in men, by 40 percent among those who ate large amounts of salt, and by 50 percent among families with moldy grain supplies. Conversely, decreased risk was associated with the consumption of fresh fruits and vegetables.

There are regions of China that have high rates of liver cancer, which have been linked to high rates of hepatitis B infection and high levels of aflatoxins (a potent carcinogen excreted by the fungus Aspergillus flavus, which often grows on potatoes, corn, and peanuts) in the food supply, although some recent studies have not found the link to aflatoxins.⁷

As in Japan, there is a strong link between salt intake and blood pressure. Studies have shown a significant intrapopulation correlation between systolic blood pressure and salt intake. In those regions where salt intake is high, usually because of its use as a food preservative, hypertension and intracerebral hemorrhage are very common. In those regions where salt is not added to the food, people have lifelong low blood pressure. No exceptions to this generalization appear to have been traced anywhere in the world.

7. East Africa

Historically, east African communities have relied on grains, vegetables, and fruits. For example, the Kikuyu diet in Kenya in 1930 was typical of that eaten by other east African agricultural peasants and consisted primarily of maize, millet, sweet potatoes, beans, and plantains, with very small amounts of meat on occasion and almost no milk. Calories derived from fat were under 10 percent. These communities had life long low blood pressure and no or very low incidence of coronary heart disease, cerebrovascular disease (stroke), obesity, and diabetes.

Beginning in the 1940s, Kenya, Uganda, and other east African communities underwent rapid Westernization, particularly in the urban regions. And beginning in the 1940s, the above-mentioned diseases began to show a large and progressive increase in east Africa. Today, obesity, diabetes, and heart disease are common in the urban areas where the Westernization has been most pronounced.⁸

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