Book Review

Coronary Heart Disease: The Dietary Sense and Nonsense -- An Evaluation by Scientists

N Engl J Med 1994; 330:943-944March 31, 1994

Article

Coronary Heart Disease: The Dietary Sense and Nonsense -- An Evaluation by Scientists
Edited by George V. Mann. 149 pp., illustrated. London, Janus, 1993. $17.95. ISBN: 1-85756-072-8 (Distributed in the U.S. by Paul and Company, Concord, Mass).

This is clearly a book with a point of view, and it must be read as such. It contains the views of members of the Veritas Society, who met in November 1991 to voice their objections to the diet-heart hypothesis (linking diet to heart disease), which they believe is “based upon fragile and selected data.” The society was apparently formed to focus these specific objections with a “call for a return to scientific and informational honesty.” Dr. George Mann writes in the preface that “the regulatory agencies have been derelict in their duties, allowing fraudulent health claims to continue in food and drug advertising.” In the first chapter, he summarizes his view of the past five decades of heart research in this area and rails against the National Heart, Lung, and Blood Institute; the American Heart Association; and many distinguished leaders in medicine, but particularly Dr. Ancel Keys and Dr. Jeremiah Stamler. Other chapters are written by investigators who point out what they believe are fallacies in the chain of evidence linking diet to coronary heart disease. Each chapter is followed by a brief discussion so that the views of the participants in the meeting can be heard.

As might be expected, this book suffers greatly from the two-year lag in publication. The chapter on atherosclerosis does not discuss the role of oxidized low-density lipoprotein and focuses primarily on hemodynamic effects, which are stated to be inconsistent with the diet-heart hypothesis.

The first paragraph of the chapter on diet, serum cholesterol, and coronary heart disease contains the following quotation: “The diet-blood cholesterol-CHD [coronary heart disease] literature has seldom been reviewed critically and never thoroughly.” The 12th footnote in the chapter attributes the statement to the Diet and Health Report of the National Research Council. Would that the author of the chapter had read the report more carefully: it is truly a critical and comprehensive review of this issue. (The Surgeon General's Report on Nutrition and Health from 1988 [Washington, D.C.: Department of Health and Human Services, Public Health Service] is likewise very thorough.) The chapter does present a detailed discussion of the effect of trans fatty acids in the diet and their putative role in promoting coronary heart disease in this country over the past century. The tone of the chapter, however, suggests that this is an issue that mainstream medicine has shunned; in fact, articles and editorials dealing with this important subject continue to be published in leading medical journals. Although the role of trans fatty acids is being clarified, the authors fail to consider that cholesterol values and rates of coronary heart disease have been falling in the U.S. population, even as the intake of vegetable fat has been increasing.

The chapter on clinical trials summarizes the objections that have been made to some of the clinical-trial data. In fact, the objections have been addressed in the literature, in particular, in the above-mentioned Diet and Health Report. Critical analysis, however, gives way to sweeping statements such as “our disagreement with Keys and Stamler and their sycophants is in management. They claim that dietary manipulation of fat and cholesterol will reduce hypercholesteremia and thereby diminish [coronary heart disease]. They have not shown that to be true, and more importantly, they have not shown that any dietary or drug treatment or any combination of them is safe.” Omitted from the discussion is any mention of one of the best clinical diet trials: the Oslo Study Diet and AntiSmoking Trial, which showed the importance of a cholesterol-lowering diet low in saturated fat in reducing both morbidity and total mortality from coronary heart disease. Omissions such as this make the book's treatment of this issue less than comprehensive.

Regrettably, most of the data from regression trials using angiographic findings as an end point were not available when this book was written. One wonders how the authors would have dealt with the clinical-trial data now at hand showing that treatment of hyperlipidemia by diet as well as by diet and medication retards the progression of symptomatic atherosclerosis in femoral and coronary arteries.

The debate on the many facets of diet and coronary heart disease remains an active one. Even so, the degree of anger present throughout this book is both distracting and, in my opinion, unjustified. For those searching for the truth, peer-reviewed journals (such as this one) and the scientific sessions of many of the national societies such as the American Heart Association seem more current, less inflammatory, and more helpful forums for discussion than books such as this.

Neil J. Stone, M.D.
Northwestern University School of Medicine, Chicago, IL 60611

Citing Articles (1)

Citing Articles

1. 1

   (1994) More on Coronary Heart Disease: The Dietary Sense and Nonsense. New England Journal of Medicine 331:9, 614-616
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