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HEART ATTACK PREVENTION: SOME OPPOSING IDEAS
Some eminent doctors still regard the evidence as inadequate. Here we refer to some of their arguments. It is strange that most controversy concerns the reduction of blood-cholesterol levels by dietary changes. Yet while the evidence that heart-attack risk can be decreased by treating high blood pressure or obesity, by stopping smoking or by taking exercise is certainly encouraging, it is far less complete than that concerning cholesterol reduction.
1. One of the most widely heard criticisms is also the most trivial; it is that some heart-attack victims have low cholesterol levels. This certainly happens, and sometimes the observation is valid. Sometimes the cholesterol level falls temporarily after a heart attack. So blood cholesterol measured after a heart attack may not be representative of the previous state.
There is a more sophisticated comment. It is not really possible to define ‘normal’ – whether one is speaking of cholesterol, blood pressure or weight. Heart-attack risk is greater if the cholesterol level is 240 mg/100 ml than if it is 200, and greater still if it is 260 mg/100 ml. A level of 300-400 is sufficiently unusual to justify the word ‘high’. An international panel of experts met recently to try to define the desirable levels of blood cholesterol for adults; the range they agreed on was 100 to 220 mg/100 ml. This is similar to that found in young adults in Mediterranean countries.
The factors we have been discussing are, of course, risk factors for coronary heart disease due to atherosclerosis. There are other explanations for coronary obstruction, too, such as inflammation of the coronary arteries or mechanical blockage (embolism) from various causes. All these are rare compared with atherosclerosis. These conditions have nothing to do with atherosclerosis risk factors.
2. A more substantial criticism concerns groups of people who do not seem to fit the trend linking high fat diets with high cholesterol levels and high mortality rates from coronary disease. It has often been said that the Eskimos have a low risk of coronary heart disease, although they eat a high fat diet. Accurate statistics on the Eskimos are hard to come by. One group which has been carefully studied is the Eskimo population on the west coast of Greenland; they do have a remarkably low coronary-disease mortality rate. They also have strikingly low blood cholesterol and triglyceride, as Dr Dyerberg and his colleagues have shown. In general, Eskimos eat a high fat diet for only part of the year, in the sealing season; their fat intake is lower when fish is their major food. Both sources are rich in polyunsaturated fat. The Eskimos are no exception to the theory that a high intake of saturated fat increases heart-disease risk. We have mentioned how rarely heart attacks happen in the Masai people of East Africa; although they eat large amounts of saturated fat for part of the year they are extremely thin and very active physically, and seldom smoke cigarettes.
3. The third argument could be called the ‘You gotta die of something’ syndrome; it tends to be heard after the third round of drinks. There are two flaws in this case. One is to assume that death from coronary disease comes suddenly, at an advanced age, and without a long preceding illness. Unfortunately, heart attacks also strike the young (their peak contribution to deaths in British men is at about age fifty, when they account for 40 per cent of all deaths). And coronary disease can lead to years, even decades, of disability with many symptoms, including profound anxiety.
The other mistake is to assume that if one cause of death is removed another comes up to take its place. Earlier we compared death rates at ages fifty-five to sixty-four in two groups of countries, one with a high coronary-disease mortality, the other with a far lower death rate from heart attack. The striking point is that total deaths were also lower in the countries where heart attack was infrequent. In middle age, at least, other diseases do not replace heart attack, and expectation of life is correspondingly longer. Coronary disease is well worth preventing.
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