groups and women and…other more modest elevations of cholesterol levels.” As Rifkind told Time magazine, “It is now indisputable that lowering cholesterol with diet and drugs can actually cut the risk of developing heart disease and having a heart attack.”
Pete Ahrens called this extrapolation from a drug study to a diet “unwarranted, unscientific and wishful thinking.” Thomas Chalmers, an expert on clinical trials who would later become president of the Mt. Sinai School of Medicine in New York, described it to Science as an “unconscionable exaggeration of all the data.” In fact, the LRC investigators acknowledged in their JAMA article that their attempt to ascertain a benefit from diet alone had failed.
Rifkind later explained the exaggerated claims. For twenty years, he said, those who believed in Keys’s hypothesis had argued that lowering cholesterol would prevent heart attacks. They had spent hundreds of millions of dollars trying to prove it, in the face of extreme skepticism. Now they had demonstrated that lowering cholesterol had reduced heart-disease risk and maybe even saved lives. They could never prove that cholesterol-lowering diets would do the same—that would be too expensive, and MRFIT, which might have implied such a conclusion, had failed—but now they had established a fundamental link in the causal chain from lower cholesterol to cardiovascular health. With that, they could take the leap of faith from cholesterol-lowering drugs to cholesterol-lowering diets. “It’s an imperfect world,” Rifkind said. “The data that would be definitive is ungettable, so you do your best with what is available.”
With publication of the LRC results, the National Heart, Lung, and Blood Institute launched what Robert Levy called “a massive health campaign” to convince the public of the benefits of lowering cholesterol, whether by diet or drug, and the media went along. Time reported the LRC findings in a story headlined “Sorry, It’s True. Cholesterol Really Is a Killer.” The article about a drug trial began, “No whole milk. No butter. No fatty meats. Fewer eggs…” In March, Time ran a follow-up cover story quoting Rifkind as saying that the LRC results “strongly indicate that the more you lower cholesterol and fat in your diet, the more you reduce your risk of heart disease.” Anthony Gotto, president of the American Heart Association, told Time that if everyone went along with a cholesterol-lowering program, “we will have [atherosclerosis] conquered” by the year 2000.
The following December, the National Institutes of Health hosted a “consensus conference” and effectively put an end to thirty years of debate. Ideally, in a consensus conference an unbiased expert panel listens to testimony and arrives at conclusions on which everyone agrees. In this case, Rifkind chaired the planning committee, of which Steinberg was a member. Steinberg was then chosen to head the expert panel that would draft the consensus. The twenty speakers did include three skeptics—Ahrens, Robert Olson, and Michael Oliver, a cardiologist with the Medical Research Council in London—who argued that the wisdom of a cholesterol-lowering diet could not be established on the strength of a drug experiment, let alone one with such borderline results. A month after the conference, the NHLBI epidemiologist Salim Yusuf described the controversy to Science as remaining as polarized as ever: “Many people have already made up their minds that cholesterol-lowering helps, and they don’t need any evidence. Many others have decided that cholesterol-lowering is not helpful, and they don’t need any evidence either.”
March 1984: the results of a drug trial are translated into the message that fatty foods will cause heart disease. (Time magazine © 1984 Time Inc. Reprinted by permission.)
But this was not the message of Steinberg’s “consensus” panel, which was composed exclusively of lay experts and clinical investigators who “were selected to include only [those] who would, predictably, say that all levels of blood cholesterol in the United States are too high and should be lowered,” as Oliver wrote in a Lancet editorial following the conference. “And, of course, this is exactly what was said.” Indeed, the consensus conference report, written by Steinberg and his panel, revealed no evidence of any discord or dissent. There was “no doubt,” it concluded, that low-fat diets “will afford significant protection against coronary heart disease” to every American over the age of two. The NIH Consensus Conference officially gave the appearance of unanimity where no unanimity existed. After all, if there had been a true consensus, as Steinberg himself later explained, “you wouldn’t have had to have a consensus conference.”
Chapter Four
THE GREATER GOOD
In reality, those who repudiate a theory that they had once proposed, or a theory that they had accepted enthusiastically and with which they had identified themselves, are very rare. The great majority of them shut their ears so as not to hear the crying facts, and shut their eyes so as not to see the glaring facts, in order to remain faithful to their theories in spite of all and everything.
MAURICE ARTHUS, Philosophy of Scientific Investigation, 1921
ONCE THE NATIONAL INSTITUTES OF HEALTH had declared the existence of a consensus, the controversy over dietary fat appeared to be over. A series of official government reports and guidelines that followed served to confirm it. In 1986, the NIH established the National Cholesterol Education Program (NCEP), which released its first guidelines for cholesterol reduction in October 1987. “The edict has been handed down,” as the Washington Post reported: “total blood cholesterol should be below 200…. If it’s above that threshold physicians must put their patients on cholesterol-lowering diets or use some of the new cholesterol-combating drugs to bring down the levels.” Surgeon General C. Everett Koop’s seven-hundred-page Report on Nutrition and Health, released in July 1988, “exhorts Americans to cut out the fat,” Time reported. The “disproportionate consumption of food high in fats,” according to the Report on Nutrition and Health, could be held responsible for two-thirds of the 2.1 million deaths in the United States in 1988. “The depth of the science base…is even more impressive than that for tobacco and health in 1964,” explained Koop in the introduction, which was certainly not the case. In March 1989, the National Academy of Sciences released its version of the surgeon general’s report, thirteen hundred pages long, entitled Diet and Health: Implications for Reducing Chronic Disease Risk. “Highest priority is given to reducing fat intake,” the NAS report stated, “because the scientific evidence concerning dietary fats and other lipids and human health is strongest and the likely impact on public health the greatest.”
These authoritative reports implied without foundation that yet more independent expert committees had weighed the evidence and agreed that dietary fat was a killer. But the surgeon general’s report had been overseen by J. Michael McGinnis, who had been Mark Hegsted’s liaison at the Surgeon General’s Office when the first USDA Dietary Guidelines had been drafted a decade earlier. The chapter linking dietary fat to heart disease had been contracted out to the same administrators at the National Heart, Lung, and Blood Institute who had organized the NIH Consensus Conference and founded the National Cholesterol Education Program. In Diet and Health, the chapter assessing the hazards of fat had been drafted by three old hands in the dietary-fat controversy: Henry Blackburn, a protege of Ancel Keys at Minnesota; Richard Shekelle, who had co-authored more than forty papers with Jeremiah Stamler; and DeWitt Goodman, who had chaired the National Cholesterol Education Program panel that had drafted the 1987 guidelines.*18
In the media coverage that followed, those investigators skeptical of the underlying science seemed to have vanished from the public debate. New on the scene were public-interest groups—most notably, the Center for Science in the Public Interest and its director, Michael Jacobson—arguing that neither the NAS nor the surgeon
