Winning the War on Cholesterol Interview with NHLBI director Claude Lenfant, M.D. Reprinted from Food Insight March/April 1991 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

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