"A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it." Max Planck
Planck remarked the above about the sociology of all sciences in general, but in the case of nutrition science, the situation is ever more dire. The story of how the myths about low-fat diets, and saturated fat became and managed to stay on as accepted common knowledge for so long is a fascinating case study of the failure of the scientific method.
“..how did the world’s top nutrition scientists get it so wrong for so long?”,
the subheading from a 2016 Guardian article on the same reads. [1]
This is a story of how the scientific method fails to stand up against our primal instincts of tribalism and herd mentality, of social hierarchy and rallying behind confidence. Accounts from the colleagues of Ancel Keys, the primary guy behind the diet-heart hypothesis, tell us how he was a very dominant guy and how he and his aides gained control over America's top nutrition authorities and controlled the public narrative.
Above all else though, this is a story of how money and politics distort science. Medical science is rife with such stories, of course. But this one is considered a classic.
Investigative health journalist and author of the groundbreaking book, The Big Fat Surprise, which has had a big impact on upending the old paradigm, Nina Teicholz tells us:
"In writing my book, I first thought I was writing about science. I quickly learned that, really, the actual evidence base in science has little to do with our actual nutrition policy and our understanding about nutrition and that it was ninety percent politics. We should all just study political science in order to understand nutrition policy.”
Nutrition science has been referred to as the most unscientific field of science. World-renowned health journalist and author Gary Taubes is a physicist by background. "In physics," he says, "You look for the anomalous result. Then you have something to explain. In nutrition, the game is to confirm what you and your predecessors have always believed."
The problems facing nutrition science are twofold really. Firstly, research on the effect of nutrition on health and chronic disease is uniquely challenging to conduct because you ideally need to control people's diets in a clinical setting over a long period in order to see meaningful results. While long-term clinical trials do exist, they are few. Most of the literature consists of shorter duration clinical trials and epidemiological data.
Secondly, the influence of industrial interests is particularly strong in this field. Both Big Food and Big Pharma have vested interests here.
What happens is both these problems work in conjunction to make matters worse- since the data is ambiguous and easy to manipulate, industrial lobbies take full advantage of it.
This, in a nutshell, is why the old paradigm still manages to stick around today. In part one of this multi-part blog series, we covered the diet-heart hypothesis- what it is and its validity based on the research around it. In this part, we are going to cover the history, surrounding politics, and the cultural impact of it
From part 1, to recap:
"Starting out, we would like to point out the absurdity of the hypothesis right at its inception. The hypothesis was formulated in the mid-1900s as a response to the rate of heart attacks that started rising very significantly that century. People were confused and looking for answers. And what finally came to be accepted is this theory that basically proposed that the foods Americans had been eating for hundreds of years had suddenly started to kill them for some reason. Red meat, eggs, and animal fats like butter, lard, and tallow were the staple food over there for hundreds of years until then. After the establishment of this hypothesis, they started to get replaced by unsaturated industrial fats in a major shift."
"If the impact of pushing this hypothesis just meant replacing saturated fats with some of the natural traditional unsaturated fats like olive oil, then there wouldn't be as much of an issue. But what transpired was the widespread adoption of industrially refined seed oils high in omega-6. This has been a huge public health catastrophe.
In this next article, we will be talking about the history of the diet-heart hypothesis, how the existing paradigm has managed to stay on despite so much evidence to the contrary, the vested interests behind it, and the impact it has had on our culture and health both globally as well as in India. "
We need to dive into the history of medical and nutrition science in America for a minute here.
Why America has such a big influence on scientific policy and culture around the world is a whole separate discussion in geopolitics. But in this particular case, it is definitely very evident- the USDA(U.S. Department of Agriculture) dietary guidelines practically dictate nutrition policy around the world.
Industrial interests
Up until 1911, the primary fats consumed by Americans were animal fats- tallow, lard, butter, etc. And in this time, people were consuming a lot more fat too (that was until the 1960s when low-fat dietary recommendations started being rolled out).
Meanwhile, whale oil, which was used as an industrial lubricant, started to run short as whales were hunted to near-extinction. This is when vegetable and seed oils, particularly cottonseed oil, were introduced as an alternative to serve as industrial lubricant.
These oils were never used for human consumption initially (even though adulteration in butter and other animal fats with these oils was happening to some extent). This changed in 1911 with the introduction of Crisco, a solid fat product that aimed to serve as an alternative to butter and other solid animal fats. It was introduced by Proctor and Gamble or P&G (the same company that sells you Pantene, Head & Shoulders, Olay, and Pampers, among other brands today). At the time, they only manufactured candles and soaps. Since these oils were inexpensive to manufacture, the profit margin was high. This is what propelled the massive seed oil industry we see today.
Modern chemical engineering to sell seed oils
Hydrogenation
So how did Crisco make a solid fat out of liquid cottonseed oil? The process used is called hydrogenation. Unsaturated fats (monounsaturated fatty acids or MUFAs and polyunsaturated fatty acids or PUFAs) are liquid because one or more links in their carbon chains have missing hydrogen atoms and thus form double bonds- this results in an unsaturated chemical structure (see picture below), creating a liquid physical state.
"Hydrogenation” involves a chemical process that pumps hydrogen atoms into the missing links, thus creating a saturated chemical structure and a solid physical state.
Different levels of hydrogenation allow for different textures with varying levels of solidity in the end product. This served as a big advantage to the food industry which was able to utilize this to make all kinds of products like whipped creams, sandwich spreads, coffee creamers, etc.
Making seed oils palatable
Even just extracting the oils from their natural sources and transforming them into a palatable oil form requires extensive industrial processing. The processing includes very high heat for extraction and deodourising and bleaching the oils to make them palatable. While a few seed oils like sesame and mustard can be obtained via just traditional cold pressing ("kachhi ghani") and have been traditionally consumed this way, others like soybean and canola can not be and are only the result of the aforementioned industrial processing, making them much worse.
We will discuss the catastrophic effects the introduction of these oils into our diets has had later. For now, let us continue with the history.
The marketing campaign launched by P&G to market Crisco is a lesson in marketing. How to spin up narratives that connect with the public. They played on the sentiments of immigrant American housewives who wanted to fit in with the new.
From their ad:
"Crisco may be a shock to the older generation born in an age less progressive than our own..a modern woman is glad to give up butter and lard just as her grandmother was happy to forego the fatiguing spinning wheel"
This is very similar to what happens in India with families migrating to urban areas and adopting unhealthy urban products and practices in place of their traditional ones to try to be modern and fit in.
P&G also tried to market how Crisco was made in clean lab settings versus butter, lard, and tallow that were made in slaughterhouses and farm settings which was supposedly unhygienic.
Later, after the diet-heart hypothesis started being rolled out as dietary guidelines, the key marketing point became that these oils were heart-healthy alternatives to traditional fats.
Dalda- Crisco's Indian counterpart
The name "Crisco" became synonymous with hydrogenated vegetable fat in the west. In the same way, the Indian counterpart is "Dalda.”
In the early 1900s, Kassim Dada, a businessman, was importing hydrogenated vegetable fat from the Dutch and selling it in India as a cheaper alternative to desi ghee which was very expensive at the time. The Hindustan Vanaspati Manufacturing Company (which is now Hindustan Unilever Limited) was incorporated in 1931 to manufacture hydrogenated vegetable fat locally in India. They partnered with Kassim Dada, who was selling his product as "Dada Vanaspati" at the time. The Hindustan Vanaspati Manufacturing Company was acquired by the British company Lever Brothers, and the latter insisted on inserting the "L” from their name into the product and that is how the name "Dalda” came to be.
In terms of marketing, you may think the Indian company could probably not match up to what Crisco did. But believe it or not, they actually outdid Crisco in many ways. When we said that the Crisco marketing campaign is a lesson in marketing, we said it for effect. But with Dalda, this is literally the case- their marketing campaign is considered a landmark in the history of marketing in India and is well documented as such.
Harvey Duncan, who handled Dalda's account at the ad agency Lintas, launched India's first multi-media marketing campaign. This included a short video ad, a marketing van in the shape of Dalda's signature tin can, print ads, pop-up shops for sampling, and leaflets for distribution. Dalda was one of the first products to successfully set up a strong brand identity in India.
The low cost was their biggest selling point as opposed to ghee, especially with India being a poor country. They tried to advertise how, unlike ghee, this wouldn't "feel heavy either on the pocket or on the palate".
It is reassuring to learn that even at the time, there was a lot of public backlash against the product. People understood that the product was essentially a factory-made artificial substitute for ghee and thus was bad for health. They were only using common sense and they were right.
Eventually, it led the then prime minister Jawaharlal Nehru to conduct a nationwide poll on the matter. The result was inconclusive, and nothing came of it in the end.
Dalda enjoyed a strong monopoly in the market for forty-plus years until the 1980s when other brands like Saffola and Sundrop emerged.
1961- First public messaging about low fat and cholesterol nutrition advise
We discussed how the diet-heart hypothesis emerged in an environment of crisis and the need for urgent solutions. Heart attacks had risen sharply in the 20th century without any known explanation. President Eisenhower's heart attack in 1955 further drove panic. A number of different ideas were floated before the diet-heart hypothesis came to be adopted. Three ideas that gained significant popularity were- vitamin deficiency, automobile exhaust, and excessive stress.
Many members of the American Heart Association were not convinced by Keys’ ideas and voiced their disapproval publicly. This is where we see the politics and Keys’ networking tactics play out. Within a year he was able to get himself appointed to the committee and turn the committee around to support his theory.
In 1961, The American Heart Association put out the first public advice telling people to cut back on saturated fat and cholesterol-containing foods like red meat, full-fat dairy, and egg yolks as their best strategy to avoid heart disease.
The Seven Countries study
So what was the evidence present at the time to propose this advice? Of course, at the time, there weren't all these studies that we have now. Besides the mechanistic explanation of cholesterol depositing on our arteries to cause blockage, the only major evidence to support it was this single world-scale epidemiological study called the Seven Countries Study that was headed by Keys. It enlisted 13,000 men from 7 different countries to study the correlation between saturated fat and cholesterol intake and heart disease. The included cohorts were from USA, Finland, Netherlands, Italy, Yugoslavia, Croatia, and Serbia.
The study claimed to find what Keys wanted to find- that diets higher in saturated fats are associated with a higher incidence of heart disease. This study has been the subject of enormous debate and dispute since its inception and still continues to be.
Critics have pointed out how Keys conveniently excluded countries that would not support his hypothesis- he included Italy and Greece which had a low consumption of saturated fats and a low incidence of heart disease, but excluded France, Germany, and Switzerland, which had a high consumption of saturated fats but low incidence of heart disease as well.
There are reports of how a lot of the survey data was discarded, and only a minority of the data that supported the hypothesis was included.
All issues aside, this study is still an epidemiological study which is very unreliable. And the data was acquired through survey questionnaires making it further unreliable.
The American Heart Association (AHA) rose to power on P&G money
The AHA was founded in 1924 when the rate of heart attacks started rising in America. They did not achieve much significance initially. This was until 1948 when P&G pumped 1740k USD (a very big sum at the time) into the organisation, kickstarting their growth. Within a few years, they were able to open multiple chapters across the country.
They continued to receive support from P&G and other food corporations. By 1960 they had 300 chapters across the country, becoming the nation’s premier heart health organisation and the biggest non-profit (at least officially) organisation.
Your Heart Has Nine Lives was a book that was distributed free of cost to doctors across America in the late 1960s. It was entirely funded by multiple vegetable oil companies and encouraged doctors to recommend vegetable oils as healthier alternatives to saturated fats.
Role of the media
We keep talking about what the scientific data shows versus what government guidelines say. But neither of these determines what actually sets the public opinion. What really determines public opinion is what the public is told. This was a time before the internet, and the influence of the mainstream media was all the more strong.
Unfortunately, all mainstream outlets wholeheartedly put their support behind Keys' hypothesis at this time. We don't know how much of a role industrial influences played here, but we can see how the media was entirely taken up by this new idea that traditional foods like dairy, eggs, and steak were the cause of heart disease and must now be avoided. It definitely made for appealing headlines, and skepticism towards the idea obviously didn't (And now, 50 years later, the idea is so well established that the exact opposite is true).
It changed the health food culture as low-fat diets and recipes started to popularise.
"Not only did Keys have a talent for publicity, but his fiery language and definitive-sounding solution were clearly more appealing to reporters than the dispatches from scientists such as Rockefeller's Pete Ahrens, who cautioned soberly about the lack of adequate scientific evidence" Teicholz explains.
They say people rally behind confidence in times of crisis, which is precisely what Keys represented in that time of panic and mystery over rising heart attacks.
If you want to fathom the extent of Keys' popularity at the time, you should know that Keys, a nutrition scientist, was put by Time magazine on their cover. They called him “Mr. Cholesterol” and upheld all his ideas. The New York Times, in particular, was also very taken up by his ideas. They continue to be a mouthpiece for scientism to date.
Naturally, these ideas started spilling over to the rest of the world too.
Testing the Diet-heart hypothesis
Once Keys' hypothesis was adopted as the norm, there was obviously a big drive among scientists across the globe to test it. As discussed in the previous article, many studies were conducted over the following decades to test the hypothesis. And they all drastically failed to verify the key point of the hypothesis- that saturated fats cause heart disease and increased mortality.
The level of politics and corruption was at a peak at this time. Keys and his camp had already taken charge of the AHA. They controlled the allocation of research grants, ran the studies conducted by these grants and the peer-review process was also muddled as they reviewed each other's studies. They sat on the editorial boards of medical journals.
A powerful herd mentality took hold. More and more scientists got on the "cholesterol bandwagon", as a JAMA editorial called it- that is, this obsession with the cholesterol and heart disease link, with complete ignorance of all other risk factors and possible causes.
Study after study failed to find any link between saturated fat intake and heart disease. Some of the most prominent studies conducted were the Framingham study, the Minnesota State Hospital trial, the LA Veterans Clinical trial, the Puerto Rico Heart Health Study, and the Honolulu Heart Program.
As shared in the previous article too, a recent 2020 review published by some of the most well-known scientists in cardiology, in the Journal of American College of Cardiology, considered one of the most prestigious journals for cardiology, reviewed all of the data on saturated fat and heart disease association. The paper estimates that 75,000 people have been tested in different clinical trials lasting between 1 and 8 years. [2]
It concluded that saturated fat intake has no effect on heart disease but instead has protective effects against stroke.
Autopsy reports of vegetarian individuals show the same level of atherosclerosis as that of non-vegetarian ones despite the former having a much lower intake of saturated fats and cholesterol and a lower serum LDL cholesterol as well.
In the International Atherosclerosis Project, a group of researchers analysed over thirty-one thousand autopsies from 15 different countries and found zero correlation between atherosclerosis, serum cholesterol levels, and saturated fat intake.
"Side effect" of death from cancer
While the studies showed a decrease in LDL cholesterol of roughly 10-15 percent in the vegetable oil cohorts, there was no difference in cardiovascular adverse events. However, a pressing issue was the significant number of cancer cases in the vegetable oil cohorts. Apart from cancer, case numbers for gallstones and liver cirrhosis were also significant. But the cancer issue was so significant that the NIH (National Institute of Health) was compelled to host a series of meetings on it in the early 1980s. No action points came out of the meetings though. They just concluded that the risk of heart disease from saturated fats was greater than any other risks from replacing them with PUFAs.
Fraud and malpractice
"The idea that saturated fats are bad for health was allowed to live on because any data to the contrary was simply not published or not spoken about."
-Teicholz
This is not uncommon in medical science. Big journals control the narrative by refusing to publish studies that contradict certain ideas. Often the editorials contradict the very studies published in the issue to continue to push a certain narrative.
Some of the incidences of malpractice in this particular story have been especially blatant:
The Minnesota State Hospital Trial was one of the largest clinical trials to test the Diet-heart hypothesis. Commencing in 1968, It was an NIH-funded trial that ran in six different mental hospitals for four and a half years and tested 9000 people. It was headed by Keys and was very meticulously designed- it was a double-blinded trial with foods specially designed for the study such that they had either saturated fats or PUFAs but looked identical on the outside.
The results drastically failed to prove Keys' hypothesis. The study was not published for 16 years(remember, this was a study funded by public tax dollars). It was finally published in an obscure journal called ATVB, and Keys name was removed. When Gary Taubes interviewed the co-author Ivan Francis and asked him why the study wasn't published for 16 years, he actually admitted that there was no issue with the study, but they were just so disappointed with the results that didn't publish it.
Christopher Ramsden, an NIH researcher who was investigating the issue, went down to the aforementioned co-author’s residence and was allowed to search his basement, where he found the magnetic tapes that contained the original raw data from the study. He found critical parts of the data omitted from the published paper. These particular parts revealed that the more the men in the study lowered their cholesterol, the more likely they were to die from a heart attack.
Ramsden re-published all the data from the study, including the missing data, in a 2014 re-evaluation paper [3]
From the paper's conclusion:
"replacement of saturated fat in the diet with linoleic acid
lowers the serum cholesterol but does not support the hypothesis that this translates to a lower risk of death from coronary heart disease or all-cause. Findings from the Minnesota coronary experiment add to growing evidence
that incomplete publication has contributed to overestimation of the
benefits of replacing saturated fat with vegetable oils rich in linoleic acid"
Ramsden also published a re-evaluation of the Sydney Diet Heart Study. This study is reported to have been stopped midway because the cohort on vegetable oil was experiencing cardiovascular events at a much higher rate.
From the re-evaluation paper's conclusion:
"In this cohort, substituting dietary linoleic acid in place of saturated fats increased the rates of death from all causes, coronary heart disease and cardiovascular disease. An updated meta-analysis of linoleic acid intervention trials showed no evidence of cardiovascular benefit. These findings could have important implications for worldwide dietary advice to substitute omega 6 linoleic acid, or polyunsaturated fats in general, for saturated fats."[4]
The Framingham Study was another large-scale study that happened very early on starting in the 1960s. The initial results in the first six years showed an association between total cholesterol and heart disease. These results were trumpeted everywhere as confirmation of the Diet-Heart hypothesis, and this study was highly popularised. But 30 years later, when all of the data up till then was analysed, it showed contradictory results. It found no association between total cholesterol and heart disease. And for the older age group(48 to 57), it actually found higher cholesterol had a protective effect.
Yet these later results of the study are seldom discussed in review papers.
From the 30-year later review paper:
"For each 1% mg/dL drop of cholesterol, there was an 11% increase in coronary and total mortality. "
George Mann, who conducted the part of the Framingham study on dietary patterns, concluded there was no association between saturated fat intake and cholesterol. "That went over like a wet blanket with my superiors at NIH," Mann said in an interview, "because it was contrary to what they wanted us to find."
"They(the NIH) wouldn't allow us to publish that data." The data lay in an NIH basement for nearly a decade until it was finally published, and even then, it wasn’t published properly.
Mann was a successful scientist until he started opposing Keys’ theories, which he says ruined his career. About Keys, he had to say, “You have to understand what a forceful and persuasive person Keys was. He could talk to you for an hour and you would utterly believe everything he said."
John Yudkin, of Queen Elizabeth College, London, was another prominent nutrition scientist who met the same fate. He is the author of the infamous book- Pure, White and Deadly. This book was the first published piece of work in 1972, warning the public about the deleterious effects of sugar and how it was sugar and not saturated fat that was behind the rising rates of heart disease and obesity. His ideas obviously did not sit well with Keys' camp, and he faced very harsh criticism from Keys publicly. Yudkin, in fact, was the scientist whose career was so devastatingly ruined that other scientists didn't dare to venture in his direction thereafter. He was relegated from his post at the institute's nutrition department, which he had himself founded, by someone who supported Keys’ hypothesis. Yudkin was shifted to a small office in a separate building.
Yudkin's book has seen a huge resurgence in the last decade only after a video of a lecture by endocrinologist Robert Lustig on the health effects of sugar, which featured Yudkin's work, went viral online.
This is just one example of the single-handed role of the internet and open-access media in modern times to democratise information and thus overcome long-standing institutional propaganda.
“The nutritional establishment has proved itself, over the years, skilled at ad hominem takedowns, but it is harder for them to do to Robert Lustig or Nina Teicholz what they once did to John Yudkin", Ian Leslie writes for the Guadian in the aforementioned article.
Another prominent example similar to that of Yudkin is Dr Robert Atkins. We've all heard about the Atkins diet- it essentially recommends a low-carbohydrate model. Dr Atkins' book was also published in 1972, but the diet only started gaining popularity in the 2000s.
Robert Knopp, a lipid specialist scientist from the University of Washington, ran a large study on the effect of varying dietary fat intakes. The study found very conclusive results showing that the more you lowered your fat intake, the more your heart disease risk increased. Knopp reported being shocked and disappointed by the scientific community's lack of response to the study's very significant findings.[5]
We're going to wrap up this article here. In the next part of the series, we will look at a little more of the history, its comparison to the current scenario, and the impact these health guidelines have had on public health so far, both in the West and in India.
REFERENCES :
- https://www.theguardian.com/society/2016/apr/07/the-sugar-conspiracy-robert-lustig-john-yudkin
- https://www.sciencedirect.com/science/article/pii/S0735109720356874
- https://pubmed.ncbi.nlm.nih.gov/27071971/
- https://pubmed.ncbi.nlm.nih.gov/23386268/
- https://pubmed.ncbi.nlm.nih.gov/11082213/
Other:
- https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(57)90614-1/fulltext
- https://www.sciencedirect.com/topics/immunology-and-microbiology/hydrogenation
- https://www.business-standard.com/article/management/40-years-ago-and-now-how-dalda-built-and-lost-its-monopoly-115030501153_1.html
- https://books.google.co.in/books/about/The_Big_Fat_Surprise.html?id=BTJvAAAAQBAJ&redir_esc=y
- https://www.tandfonline.com/doi/full/10.1080/17512433.2018.1519391
- https://www.pitara.com/science-for-kids/5ws-and-h/how-did-advertising-start-in-india/?story=104&page=2
