In just seven years since the
National Institute of Health consensus
development conference on "Lowering
Blood Cholesterol to Prevent Heart
Disease," many of the panel's
recommendations have become realities.
The National Cholesterol Education
Program is in full swing. The Food and
Drug Administration is reforming food
labeling regulations. and a wide
variety of reduced-fat foods are
becoming available. The panel suggested
professional education programs an
additional means for implementing
dietary recommendations in the general
population. While the National Heart,
Lung and Blood Institute has sponsored
national conferences on cholesterol and
high blood pressure separately, a joint
conference is being held this spring
for the first time to examine both of
these risk factors in the development
of heart disease. In conjunction with
the National Conference on Cholesterol
and High Blood Pressure Control,
Food Insight interviewed Claude
Lenfant, M.D. director of NHLBI since
1982, about the aggressive and
sometimes controversial public health
programs that have been implemented
under his leadership.
How well have Americans complied with recommendations of the 1984 conference on lowering cholesterol?
On the whole I think NHBLI's
programs have been extraordinarily
successful in educating the public. The
American people are much more aware of
the issues of heart disease than they
were before. Our surveys over the years
show continuos trend in the right
direction.
Physicians also are much more aware
of heart disease and we are beginning
to see them prescribe preventative
treatments, from which they make little
or no money. That's a good sign.
Perhaps the most significant sign is in
the consumption of commodities. The
movement toward lower-fat dairy
products and meats, and the increase of
fish consumption are all moves in the
right direction. From a medical
viewpoint, we are witnessing a decrease
in the death rate that's not being
counteracted by the aging population.
So I think we have good reasons to be
fairly optimistic.
How do you respond to criticism that a diet of no more than 30 percent calories from fat, and 10 percent from saturated fat, does not go far enough?
Some people want to use the
sledge-hammer approach to dietary
change and hit people as forcefully as
they can. I happen not to agree with
this approach, This is why a two-step
approach was developed for dietary
treatment. If step one with 30 percent
fat calories is not good enough, then
you go to step two, which is more
restrictive. And if that's not good
enough, you reevaluate. But these are
judgments that must be made for each
individual, not for the general
population.
If the original dietary recommendations apply to the general population over the age of two, why was a separate report on children issued?
The dietary recommendation in the
children's report are not drastically
different. The value of this report is
to reinforce the fact that these
recommendations do apply to children.
This is important because heart disease
begins in childhood. The public
perception is that nothing happens
between birth and the age of 30, but
that's not the case. The report should
help to correct public misperception.
Will future technology detect whether some people are more sensitive to saturated fat than others, as with sodium and hypertension?
Yes, there is no question that some
people are reacting to these things
more than others. There's a theory very
much in fashion these days called the
"French paradox". A recent article
pointed out that the French and other
Europeans eat food with terrible
nutritional profiles, yet they do not
die from heart attacks at the rate that
Americans do. It certainly explains
that there are factors other than food,
and that some individuals are more
sensitive to diet than others. In the
ideal situation, we would be able to
tell that someone is sensitive to
certain substances and recommend a
modified diet. But the next person is
not sensitive, so leave that person
alone. I can foresee this in 20 to 40
years, but it's not there now.
Therefore, it is very important to help
the people who are sensitive by
providing recommendations to the
population as a whole.
Is it appropriate to apply the 30 percent fat standard to individual food rather than to the diet over time?
I think it may be appropriate for
some people but not for the whole
population. My personal view is very
much in line with the "10 Tips to
Healthy Eating" brochure (published by
the International Food Information
Council and the American Dietetic
Association) which is balanced and
moderate.
If dietary intervention is to work
it must not be a punishment. But
perceptions of punishment vary
according to individuals. One person
might be very unhappy to eliminate red
meat completely while another may not
mind. So rather than advocate sweeping
generalizations, I advocate moderation
and balance, not punishment.
How do we teach people to apply the 30 percent fat standard over time rather than to individual foods?
I think by providing a number of
recipes and advice on meals and daily
intake. We are beginning to do that on
our own publications. We provide
examples of meals for a whole day
rather than advice on the elimination
or exclusion of individual foods. This
is a more global approach and it helps
people develop diets that meet dietary
recommendations.
Are we losing sight of other factors that affect heart disease, such as obesity, smoking and exercise?
Yes, and we must not if we are to
control heart disease. We need to work
on all of them--the control of blood
pressure, smoking. blood cholesterol,
obesity and physical activity. All are
very important. Today, one of the most
significant problems we have in the
United States is obesity. But it is
very difficult to change because some
components of our society equate
obesity with beauty and status.
Personally, I'm not so sure we should
try to change these people, because
we'll end up with people who are skinny
but miserable. It's a very complex
issue and we must remember that we are
dealing with human beings.
Are Food and Drug Administration proposed revisions of food labeling regulations consistent with the panel's recommendations?
Yes, I think that FDA is doing a
very effective job. The focus over the
past few years has been mainly on
cholesterol, yet the impact of dietary
cholesterol on blood cholesterol is a
very controversial issue. Some people
are strongly affected by dietary
cholesterol, but the majority of the
population is not--at least not to the
extent that messages and information
were focused on it. In this case,
saturated fat is more of a culprit and
I think it is a good idea to emphasize
food labels. But we will need to alter
our messages a bit to shift the focus
to saturated fat.
Should the public be concerned about trans fatty acid content of foods?
No, its too early. The trans fatty
acid study that came out last summer
needs to be confirmed. The
recommendations on saturated fat and
cholesterol are the result of 30 years
of sound science. We shouldn't debate
our strategy and recommendations based
on the results of a single study.
The consensus development panel encouraged the food industry to develop foods with less fat and cholesterol. How is industry responding?
The industry had done very well in
many respects. They now have a much
larger array of products to offer the
public and this is a good approach.
People need choices. It would be simple
to eliminate all products rich in
saturated fat, but it also would be
stupid. Industry has been very
responsive by offering reduced-fat
products in addition to traditional
products. Industry and commodity
groups, like meat and dairy, have
worked very hard to reduce the
saturated fat content of products. This
is progress in the right direction.
Do you predict any major scientific breakthroughs in the area of heart disease in the next 10 years?
Yes, without question. We began by
focusing on cholesterol, then it became
HDL and LDL. Now we are talking about
subfractions of lipoproteins. It is
very clear that serum cholesterol
levels probably are genetically
determined and determination of genetic
predisposition is in he future. We
might be able to get the genetic
fingerprints of people relative to
heart disease, which would be a
tremendous advance. Right now we're
doing very well by controlling acquired
risk factors, but we still have 500,000
deaths a year. And that probably is
because we still can't control the
genetic risk factors.
What is the most satisfying part of your position as NHLBI director?
I am most pleased by the tremendous
progress we have made in the area of
prevention. There is no question in my
mind that NHLBI is recognized as a
leader in preventive intervention. This
was begun by my predecessor, but I have
certainly reinforced it and made it
much more evident. We view our
activities as spanning all the way from
gene to bedside. In fact, I might say
from the gene on out to the streets. We
have a very significant purpose in what
we do in the street and at the bedside,
and I think we can be very successful.
It's a very exciting job.
Reprinted from the International
Food Information Council Foundation,
1991
