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tinue to be honest professional disagreement concerning the best path for treatment and for prevention.

One must balance the presumed benefit of any form of therapy with the risks involved. As far as diet is concerned, there may be some risk of gall stones in a diet with a higher ratio of polyunsaturated fat, but the risk of following a diet of lower cholesterol and tryglycerides and maintaining ideal body weight must be very low in comparison with the risk of dying of an early heart attack in our society.

Dr. Hegsted and others have referred to at least 18 different authoritative groups which, by deliberative procedure, have recommended dietary changes by way of lowering plasma cholesterol for the general population. These include the Royal College of Physicians of London, the British Cardiac Society, and the Intersociety Commission on Heart Disease.

I support this position and I believe it to be one of moderation and one which could save thousands of premature deaths from coronary artery disease.

Thank you. Mr. RICHMOND. Thank you, Dr. Gotto. Without objection, the prepared statement submitted by Dr. Gotto will be included in full in the record.

[The prepared statement of Dr. Gotto may be found on p. 128.]

Mr. RICHMOND. Dr. Wynder, it is good to have you back before this panel.

Dr. WYNDER. I would like to call on my colleague, Dr. Arnold, to give the

view and I will give some comments. Mr. RICHMOND. We have reserved 10 minutes for both you and Dr. Arnold to make your presentations before we start questioning, so whatever you would like is fine with us.



Dr. ARNOLD. Thank you very much, Mr. Chairman. I will be brief.

In reviewing this question, we believe that the public health issue involved in the recommendations by the Board carry with it the central issue for us. The question could be phrased as follows: To what extent do we now possess information regarding coronary heart disease and nutrition such that a reasonable person would conclude that the public's health would benefit from the nutritional recommendation at this time?

The question, as Dr. Gotto has said, is not of course whether or not we possess all the information for action at this time—that is, enough to satisfy our intellects. Public health history is replete with examples of diseases which have been prevented before all scientific evidence was available. Here, I refer to issues such as Jenner's work on the prevention of smallpox in 1798, years before laboratory evidence was available; scurvy's prevention with citrus fruits more than 100 years ago; and more recently the evidence for lung cancer and tobacco before we had exact biological evidence as to how the mechanism operated.

We think that, with respect to the question involved here—that is, the nutritional factors in coronary heart disease—the evidence from animal experiments, clinical research, and epidemiologic studies tell us that the public's health would be served by modifying the risk factors for coronary heart disease.

Important in looking at the existing evidence, which has been referred to earlier and which we cite in extensive references in a written statement we have submitted to you, is the consistency of these findings within each field and among the fields which show that serum cholesterol, high blood pressure, and, in the United States, cigarette smoking interact very strongly to produce the disease we know as and call coronary heart disease.

Therefore, we wish to draw attention to the fact that at the moment cholesterol levels in the United States are approximately 220 milligrams percent for the adult population. At a conference of the American Health Association held a year ago, this past spring, on the optimum levels, we concluded that the optimum level for total serum cholesterol should be eloser to 160 milligrams percent.

This was arrived at after a review by scientists in animal experiment work, clinical studies, and epidemiology. Further, it was concluded that an achievable cholesterol level of approximately 190 was possible in this country at the time with appropriate changes in the diet.

These would be, as has been discussed before, reducing the saturated fat content of the diet with particular attention to moderating the quantity of meat and dairy products consumed; decreasing dietary cholesterol; and decreasing saturated fats.

To summarize, the public health issue asks: How can we assure the Nation's health will be preserved by acting on evidence such as this? We believe that attention to the extensive research represented by the kinds of panels which Dr. Hegsted referred to before creates a body of knowledge and the opinion necessary for public health action in the country at this time.

Mr. RICHMOND. Thank you, Dr. Arnold.

Without objection, your complete statement will be included in the record.

[The prepared statement of Dr. Arnold may be found on p. 135.] STATEMENT OF DR. ERNST L. WYNDER, PRESIDENT, AMERICAN


Dr. WYNDER. So much has been said, so I would just like to make some general comments.

I belong to the peculiar breed that you call epidemiologists. If there is one thing I have learned by being for 30 years in this field it is that cardiovascular disease and most types of cancers are the inevitable consequences of aging, so they are part of our lifestyle.

Another thing I have learned is that common diseases must have common causes. If half of us die from a disease, that means all of us are affected.

Another thing I have learned is that the hallmark of good science is the consistency of the data and strengths of the associations and, may I add, the biological reasonableness of the data. It seems eminently

logical to me that cholesterol and saturated fats, relating to plaques in our coronary vessels, can relate to coronary disease and to heart attack.

At times I think we need to reflect upon the anthropology of nutrition. There was a time when we suffered from what we call today the malnutrition of the poor. Today we have the malnutrition of the affluent, and it seems to us that we do not have the evolutionary capacity to deal with this kind of metabolic overload that we have in terms of cholesterol, saturated fats, and, as Dr. Hegsted mentioned, a number of other dietary components.

A very important element to recognize is that coronary artery disease really has its beginnings in childhood. In a recent study on some 17,000 children in many countries throughout the world we have shown that the serum cholesterol levels in children can allow us to predict the death rate from coronary disease in the adult population.

For instance, the country with the highest rate of coronary disease in Europe is Finland, and children ages 10 to 13 have already average serum cholesterol levels of 200 milligrams percent. Whereas, children in Italy, known to have a much lower rate of coronary disease, have average levels around 145. I would like to suggest to all of you, whoever have been in southern Italy in particular, that the Italians certainly know how to eat.

The question, it seems to me, is: What is really an optimal diet for a relatively sedentary population?

We have and the report only generally deals with this—substantial evidence that the same type of

dietary fat that relates to coronary disease and atherosclerosis also relates to cancer of the colon, cancer of the breast, cancer of the prostate, and other types of human malignancy.

One of the best pieces of evidence of this in epidemiology is what happens to migrants. There was a time when breast cancer and coronary disease were quite uncommon in Japan. As the Japanese migrated to the United States—California and Hawaii—their rates 'went significantly up.

Most recently, when I was in Japan with my colleagues of the National Cancer Institute, I saw data that not only have heart attacks become more common in Japan but so have certain types of human cancers that we have found to be related to high dietary fat intake.

Unfortunately, therefore, we as people are an experimental group from which we can prove, in due time, what these different risk factors in the environment do to our health.

Finally, I would like to make a comment about recommendations. A long time ago it was suggested that the American people ought to eat more prudently. We should consume, as Dr. Hegsted indicated, less fat, less cholesterol, fewer calories, less refined sugar, less salt, and probably more dietary fiber.

The American people have already adjusted to that. We do consume less cholesterol and certainly less saturated fats. Perhaps the fact that heart attacks have gone down can be attributed to a change in the American diet. Of course, anyone who works with risk factors takes credit for this reduction.

The blood pressure people take credit for treating blood pressure better. The tobacco people take credit for lower nicotine in their cigarettes, and I think the nutrition industry can take some credit.

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The suggestion that I would like to make to the food industry is as follows and is similar to the suggestions that I have made to the tobacco industry. There are three areas in which we can do something. Make sure that our children eat better and do not smoke; that our adult people eat better and give up smoking; and that the industry—just as in the tobacco area where, when I first began some 30 years ago, and I recall testifying before a congressional committee many years ago, the tar yield of an American cigarette was 40 milligrams or more. The nicotine content was 2.2 milligrams or more. Today it has less than half.

It is possible to reengineer the American cigarette. It is possible to practice what I call managerial preventative medicine. We emphasize it because individual preventative medicine is rather difficult because all of us, whether you are in Congress or whether you sit on this side of the aisle, suffer from the illusion of immortality and we believe it cannot happen to us.

I am suggesting to the American food industry that they do have the capacity to reduce the fat and cholesterol content of the American diet. We can have a lower fat content than we presently have and have meat with a lower fat content than we presently have in many of our meats.

I even believe that we can reduce the cholesterol content of our eggs. Rather than debating here what is right or what is wrong, as Dr. Hegsted said, we have so much evidence that we need to act—I suggest that the American food industry has the capacity to make an optimal American diet which Americans like, which is better for sedentary man than the kind of diet that we eat today.

Oftentimes in medicine, as in politics, we have to consider the alternatives. By doing nothing I can assure you that we will meet 20 years from now and will have the high rates of coronary disease, atherosclerosis and its sequelae, as we have them today.

By doing something we can surely reduce a major killer in our society, a killer that saps the very energy of our Nation.

Mr. RICHMOND. Thank you, Dr. Wynder, Dr. Arnold, and Dr. Gotto.

Without objection, Dr. Wynder, your full testimony will be included in the record.

[The prepared statement of Dr. Wynder may be found on p. 151.]

Mr. RICHMOND. Dr. Gotto, there are three major risk factors, it appears, in cardiovascular disease_high blood pressure, smoking, and high blood cholesterol levels. Would it be a fair question to ask you which of these three major risk factors you consider the most serious ?

Dr. GOTTO. The three are interrelated. As I said, coronary artery disease is multifactorial in our society. If one looks at parts of the world where the diet is quite different and where the level of serum cholesterol is under 160 milligrams percent, there is virtually no atherosclerosis and no coronory artery disease. They do have hypertension and cerebrovascular disease. They do practice cigarette smoking, and if the level of cholesterol could be decreased to that amount then we would probably see the elimination of coronary disease.

I think, at the present time, this is not a practical achievement within our society. I think that all three of the risk factors are important and should be concentrated upon.

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Mr. RICHMOND. Dr. Gotto, what do we actually know is the most significant factor that would affect high blood cholesterol levels? We all use the phrase high blood cholesterol level. To the consumer what does that really mean?

Dr. GOTTO. A high blood cholesterol level really means different things to different people. If one gets to a clinical laboratory and has a cholesterol measure, the doctor may

that the cholesterol is normal or he may tell you that it is high. He may be referring to a so-called statistically normal cholesterol which would define the upper 5 or 10 percent of the population.

The average cholesterol value in our society for adults, as has been said, is about 210 milligrams percent. Looking at our society all together, this is probably higher than a desirable level.

Dr. Hegsted mentioned a figure of 180. I would agree that 180 would be a more desirable level for our population than 210, which is the current level.

Mr. RICHMOND. What actually affects high blood cholesterol levels!

Dr. Gotto. Cholesteral is affected by metabolism, by genetics. The body makes a certain amount. There is a certain genetic susceptibility to having a given level of cholesterol. It is, second, affected by diet, by the amount of saturated fat in the diet, by the amount of polyunsaturated fat, and by the amount of cholesteral in the diet.

Mr. RICHMOND. The Food and Nutrition Board report seems to say that heart conditions have very little to do with nutrition. Would you agree with that? Dr. Gotto. No; I do not agree with it.

Mr. RICHMOND. Would you agree that that is what they indicated in their report, that one could eat whatever one wished as long as one kept one's weight within reasonable bounds food would have very little to do with a heart condition ?

Dr. Gotto. The report is actually contradictory. Part of the report has been read. One part of the report says that healthy Americans, whatever that means, need not worry about cholesterol intake or fat intake in their diets, which is a rather sweeping recommendation.

On the other hand, on page 12 of the report, they recommend that anyone with a positive family history of heart disease and other risk factors, which probably includes half of the population—those with obestity, hypertension, and diabetes—should consult a physician and have blood lipids measured. If they are found to be elevated those people should be placed under treatment.

The report itself is contradictory.
Mr. RICHMOND. Thank you, Dr. Gotto.

Dr. Wynder, you said something absolutely fascinating in your short statement. You indicated that cholesterol and saturated fats not only could lead to cardiovascular problems, but you indicated that there is a body of evidence that indicates that they can also cause cancer. Would you like to expand on that for a moment ?

Dr. WYNDER. The epidemiologic and experimental evidence in oncology suggests that fat, not specifically cholesterol, effects the risk of cancer of the colon and breast, as examples.

We and others have shown that fats increase and act principally as tumor promoters to cancer of the colon in animals, and we have demon

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