Dietary Fat and Its Relation to Heart Attacks and Strokes
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Dietary Fat and Its Relation to Heart Attacks and Strokes
REPORT BY THE CENTRAL COMMITTEE FOR MEDICAL AND COMMUNITY
PROGRAM OF THE AMERICAN HEART ASsoCIATION*
CURRENT available knowledge is sufficient fat consumed, the amount of cholesterol in the
to warrant a general statement regarding blood and the reported incidence of coronary
the relation of diet to the possible prevention artery disease.
of atherosclerosis (Appendix I). Study of diets in the United States indi-
A heart attack, also called coronary throm- cates that they usually contain large amounts
bosis or myocardial infarction, or just plain of fat which account for approximately 40-
"coronary, " is almost always caused by 45 per cent of the calories. In contrast, many
atheroselerosis (arteriosclerosis or hardening populations in other parts of the world-for
of the arteries). Stroke, or apoplexy, is often example, large groups in Asia, Africa and
caused by the same condition. The problem Latin America-eat food containing barely a
of preventing or retarding these diseases is, third as much fat. The concentrations of
then, one of preventing or retarding athero- cholesterol in the blood of such groups are
sclerosis. much less than in those consuming the excess
calorie and high-fat diets, and some reports
How Does Atherosclerosis Develop? indicate that heart attacks are corresponding-
Atherosclerosis is a complex disease of the ly fewer. There are other differences in these
arteries. It is known that a number of factors diets that may also be of importance, such as
influence or are related to its development. the amount and type of protein and carbo-
Among these factors are a high content in hydrate.
the blood of a type of fat called cholesterol. These and other research studies have given
elevation of blood pressure above normal, clues to the prevention of atherosclerosis by
presence of diabetes, obesity, and a habit of dietary means. A reduction in blood choles-
excessive cigarette smoking. Age, sex and terol by dietary means, which also emphasizes
heredity are also important. weight control, may lessen the development
What Types of Research Relate Diet to or extension of atheroselerosis and hence the
Atherosclerosis? risk of heart attacks or strokes. It must be
Many years ago a scientist fed cholesterol emphasized that there is as yet no final proof
and other types of fat to rabbits. The blood that heart attacks or strokes will be prevented
cholesterol content increased and the rabbits by such measures.
developed atherosclerosis; that is, cholesterol What Measures Reduce the Amount of
and other fatty substances were deposited in Cholesterol in Blood?
the walls of the arteries. Many other animal Several ways of reducing blood cholesterol
species have been found to behave similarly. concentration are being studied at the present
These animal experiments indicate that diet time. This discussion is limited to the modifi-
may be an important cause of atherosclerosis. cation of diet.
Global studies have shown that dietary The amount of cholesterol in blood usually
habits of human populations differ. Evidence reflects the concentration of other fatty sub-
gathered from many couiitries suggests a re- stances in the blood as well. If cholesterol is
lationship between the amount and type of reduced, other fats in the blood usually de-
crease.
*The Central Commiinittee for Medical and Communi-
ty Program is the senior medical body of the Ameri-
Several methods designed to reduce the
can Heart Association and is chaired by A. Carnton amount of cholesterol in the blood have been
Ernstene, 'M.D., of Cleveland, Ohio. suggested.
Circulation, Volume XXIII, January 1961 133
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First, it would seem that the simplest way more or less intermediate ill saturation and
to reduce cholesterol in the blood is to eat have no strong effect one way or the other
less foods containinog cholesterol. The problem on the blood cholesterol.
is much more complex. If the amount of cho- These measures make it. possible to attempt
lesterol in the diet is markedly decreased, but a considerable alteration in the cholesterol
the caloric intake kept constant, the body may level in the blood with the use of acceptable
make more cholesterol from other substances, diets.
chiefly from other types of fat, sometimes
nearly enough to make up for that which has Who in Particular Should Modify the Fat
Content of His Diet?
been removed from the diet.
Second, reduction of the total calorie intake, A) Mlost persons in the United States who
by decreasing the amount of ordinary fat in are overweight will find it profitable to re-
the diet, usually causes reduction of the blood duce their total caloric intake. Reducing the
cholesterol concentration. Avoidance of ex- amount of fat in the diet is one way to do
cess fat in the diet also helps avoid obesity this. In addition to the possibility that athero-
because one gramn of fat provides 9 Calories, sclerosis will be prevented, obesity will cer-
while one gram of protein or carbohydrate tainly be controlled. Regular, moderate exer-
provides only 4 Calories. This does not mean cise, exeml)hified by walking, is also desirable.
that unlimited amounts of carbohydrate and B) Men with a strong family history of
protein should be eaten, for these, ill excess. atherosclerotie heart or blood vessel disease,
also lead to obesity and may also increase the who have elevated blood cholesterol levels, an
level of cholesterol in the blood. increase in blood pressure, are overweight
Third, the blood cholesterol concentration and/or who lead sedentary lives of relentless
may also be reduced by controlling the amount frustration should consider modifying their
and type of fat in the diet without altering diets. A diet moderate in calories and fat
calorie intake. Not all fats in the diet have (about 23-35 per cent of total calories from
the same effect on the amount of cholesterol fat) mayr be helpful for these coronary-prone
ill the blood. In the usual diet eaten ill the personls. Substitution of poly-ulisaturated for
United States, a large part of the fat is of a substantial part of the saturated fat in the
the saturated type (Appendix II). Too much diet mnay also be a valuable addition to this
of this type of fat tends to increase the cho- program.
lesterol ill the blood. Considerable amounts C) Those people who have had one or more
of saturated fat are present in whole milk, atheros(clerotic heart attacks or strokes nmay
cream, butter, cheese and ineat. Coconut oil r'educe the possibility of recurrences by such
and the fat in chocolate also have a high con- a change in diet.
tent of fats of the saturated type. AMost It should be borne in mind that mod-
shortenings and mar(rarines have less than erate amounts of fat, particularly
half as much saturated fat, and the common those containing anl appreciable quan-
vegetable oils have still less. When the intake tity of the poly-ulnsaturated type, are
of saturated fats is reduced, blood cholesterol necessary for good health. Fat is an
levels usually decrease. economical, and in limited amounts,
Ill contrast to the above food fats, many a wholesome food. Food faddism of
matural vegetable oils, such as corn, Cottoln anxv sort should be avoided and sig-
and soya, as well as the fat of fish, are rela- nificant chamiges in diet should not be
tively low ill saturated fats and high in fats n(le.ltakeii without medical advice.
of the poly-unsaturated type (Appeimdix II).
In Conclusion
When these fats are substituted for a sub-
stantial paet of the saturated fats without ill- 1Phe reductioni or cotIrol of fat (olisinllll)tii
creasilng calories, blood cholesterol decreases. ulLlder medical supervisioni, with reasommable
Finally, some food fats, such as olive oil, are snbstitution of poly-umisaturated for saturated
Circulation, Volume XXIII, January 1961
Downloaded from http://circ.ahajournals.org/ by guest on September 24, 2015DIETARY FAT, HEART ATTACKS AND STROKES 135
fats, is recommended as a possible means of Ad Hoc Committee on Dietary Fat
preventing atherosclerosis and decreasing the and Atherosclerosis:*
risk of heart attacks and strokes. This recom- Irvine H. Page, M.D., Chairman,
mendation is based on the best scientific in- Cleveland, Ohio
formation available at the present time. Edgar V. Allen, M.D.,
More complete information must be ob- Rochester, Minnesota
tained before final conclusions can be reached. Francis L. Chamberlain, M.D.,
San Francisco, California
Such information can be obtained only Ancel Keys, Ph.D.,
through intensified research into the causes Minneapolis, Minnesota
and prevention of atherosclerosis-a program Jeremiah Stamler, M.D.,
to which the American Heart Association is Chicago, Illinois
fully dedicated. Fredrick J. Stare, M.D.,
Boston, Massachusetts
*The Ad Hoc Committee on Dietary Fat and Atherosclerosis reported to the Central Committee for Medical
and Community Program of the Association.
Appendix I
List of Recent Scientific References on Dietary Fat and Atherosclerosis
1. AHRENS, E. H., JR., INSULL, W., JR., BLOM- without vascular disease. Diabetes 8: 179,
STRAND, R., HIRSCH, J., TSALTAS, T. T., AND 1959.
PETERSON, M. L.: Influence of dietary fats on 10. MCCANN, M. B., TRULSON, M. F., WADDELL,
serum-lipid levels in man. Lancet 1: 943, 1957. W. R., DALRYMPLE, W., AND STARE, F. J.:
2. BROWN, H. B., AND PAGE, I. H.: Lowering blood Effects of various vegetable oils on serum
lipid levels by changing food patterns. J.A.M.A. lipids of adult American males. Am. J. Clin.
168: 1989, 1958. Nutrition 7: 35, 1959.
3. BUECHLEY, R. W., DRAKE, R. M., AND BRESLOW, 11. Measuring the Risk of Coronary Heart Disease
L.: Relationship of amount of cigarette smok- in Adult Population Groups: A Symposium.
ing to coronary heart disease mortality rates Am. J. Pub. Health 47: No. 4, Pt. 2, 1957.
in man. Circulation 18: 1085, 1958. 12. PAGE, I. H.: Atherosclerosis-a commentary.
4. GERTLER, M. M., WOODBURY, M. A., GOTTSCH, Fed. Proc. 18: No. 2, Pt. II, 47, 1959.
L. G., WHITE, P. D., AND RuSK, H. A.: The 13. PAGE, I. H., ed.: Chemistry of Lipides as Re-
candidate for coronary heart disease: Discrimi- lated to Atherosclerosis: A Symposium. Spring-
nating power of biochemical, hereditary and field, Ill., Charles ( Thomas, 1958.
anthropometric measurements. J.A.M.A. 170: 14. PELL, S., AND D 'ALONZO, C. A.: Diabetes mellitus
149, 1959. in an employed population. J.A.M.A. 172:
5. JOLLIFFE, N., RINZLER, S. H., AND ARCHER, M.: 1000, 1960.
Anti-Coronary Club: including a discussion of 15. PILKINGTON, T. R. E., STAFFORD, J. L., HANKIN,
effects of a prudent diet on serum cholesterol V. S., SIMMrONDs, F. M., AND KOERSELMAN,
level of middle-aged men. Am. J. Clin. Nutri- H. B.: Practical diets for lowering serum
tion 7: 451, 1959. lipids: A long-term study on out-patients with
6. KATZ, L. N., STAMLER, J., AND PICK, R.: ischaemic heart disease. Brit. M. J. 1: 23, 1960.
Nutrition and Atherosclerosis. Philadelphia, 16. PINCUS, G., ed.: Hormones and Atherosclerosis:
Lea and Febiger, 1958. Proceedings of a Conference. New York, Aca-
7. KEYS, A.: Epidemiologic aspects of coronary demic Press, 1959.
artery disease. J. Chron. Dis. 6: 552, 1957. 17. POLLACK, H., CONSOLAZIO, C. F., AND ISAAC,
8. KEYS, A., ANDERSON, J. T., AND GRANDE, F.: G. J.: Metabolic demands as a factor in
"'Essential'" fatty acids, degree of unsatura- weight control. J.A.M.A. 167: 216, 1958.
tion and effect of corn (maize) oil on serum- 18. PORTMAN, 0. W., AND STARE, F. J.: Dietary
cholesterol level in man. Lancet 1: 66, 1957. regulation of serum cholesterol levels. Physiol.
9. KINSELL, L. W., MICHAELS, G. D., WALKER, G.,
Rev. 39: 407, 1959.
WHEELER, P., SPLITTER, S., AND FLYNN, P.: 19. STAMLER, J.: Epidemiology of atherosclerotic
Dietary linoleic acid and linoleate: Effects in coronary heart disease. Postgrad. Med. 25:
diabetic and nondiabetic subjects with and 685, 1959.
Circulation, Volume XXIII, January 1961
Downloaded from http://circ.ahajournals.org/ by guest on September 24, 2015136 AMERICAN HEART ASSOCIATION CENTRAL COMMITTEE
20. STARE, F. J., VAN ITALLIE, T. B., MCCANN, Ml. B., 22. WELLS, 0. V.: Current food trends. Nutrition
AND PORTMAIN, I. W.: Nutritional studies re- Rev. 17: 161, 1959.
lating to serum lipids and1 nthetloseleirosis: 23. Wh"IIITE, P. D).: Atheroina allnd thrombosis: Major
threats to our health today. Lyman Duff
Therapeutic implications. J.A.M.A. 164: 1920,
Memorial Lecture, Council on Arteriosclerosis,
1957. American Heart Association, Ameriean Society
21. Symposium on Significance of Lowered Choles- for the Study of Arteriosclerosis, Nov. 8,
terol Levels. J.A.M.A. 170: 2198, 1959. 1959. Circulation 21: 1065, 1960.
Appendix 11
Different Kinds of Fat in the Diet
Food fats and oils are made up of sub- and margarines have less than half as much
stances called fatty acids which are chemically satllrated fat and the common vegetable oils
combined with glycerol. In general, there are have still less saturated fat. Mono-unsaturated
three different kinds of fats in our diet. These fat is present in appreciable amounts in most
are called saturated, mono-unsaturated, and dietary fat. Poly-unsaturated fat is highest
poly-unsaturated fats. All three types are in the nonhydrogenated liquid vegetable oils;
usually present in any single food fat though next in the lightly hydrogenated vegetable
in widely varying proportions. Thus, butter oils; then in margarines, shortenings, and
has about 55 per cent of saturated acids, 33 lard; and is lowest in beef and dairy fat.
per cent mono-unsaturated acids, and 4 per A considerable quantity of the fats and
cent poly-unsaturated acids. Corn, cotton- oils consumed in the UUnited States are of the
seed, or soya oils contain in the range of hldrogeiiated type. These fats and oils vary
10-25 per cent saturated, about 25 per cent (onsiderably in fatty acid composition de-
mono-unsaturated, and about 55 per cent poly- pendinlg on the extent of hydrogenation, a
unsaturated fatty acids. processing of the fat which retards the de-
Not all fats in the diet have the same effect velopment of rancidity and can be used to
on the amount of cholesterol in the blood. convert liquid fats to a semi-solid or solid
Those high in saturated fat tend to increase (olnsistenev. Hydrogenation also decreases the
the cholesterol in the blood, those high in amount of poly-unsaturated fats depending on
mono-unsaturated acids have little effect, and the extent of hydrogenation. Most of the solid
those high in poly-unsaturated fats may cause
margarines and shortenings inade in this
a decrease. With vegetable oils this decrease
country by the process of hydrogeniationi are
is thought to be due largely to a poly-un-
saturated fatty acid known as linoleic acid, moderate in their saturated fat content and
and with certain fish oils to a variety of other they are generally low in poly-unsaturated
poly-unsaturated fatty acids. fats (10-15 per cent) though not as low as
In the typical diet in the United States, beef and dairy fat (2-4 per cent). It might
a substantial part of the fat contains high be well for the manufacturers of fats and oils
levels of saturated fat-the fat in whole milk. to indicate for the consumer by label declara-
cream, butter, cheese and meat. Coconut oil tion the approximate fatty acid composition
and the fat in chocolate are also high in satu- of the final product in terms of the three main
rated acids. Most of these fats are also low types of food fats-saturated, mono-unisatu-
in poly-unsaturated fats. Most shortenings rated and poly-umsaturated.
Circulation, Volume XXIII, January 1961
Downloaded from http://circ.ahajournals.org/ by guest on September 24, 2015Dietary Fat and Its Relation to Heart Attacks and Strokes
Irvine H. Page, Edgar V. Allen, Francis L. Chamberlain, Ancel Keys, Jeremiah
Stamler and Fredrick J. Stare
THE CENTRAL COMMITTEE FOR MEDICAL AND COMMUNITY
PROGRAM OF THE AMERICAN HEART ASSOCIATIONAd Hoc Committee on
Dietary Fat and Atherosclerosis
Circulation. 1961;23:133-136
doi: 10.1161/01.CIR.23.1.133
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