Good Calories, Bad Calories

The evidence that Ahrens was looking for came first from Margaret Albrink, who was then a young physician working with John Peters, chief of the metabolic division in the Department of Medicine at Yale University. Once again, the available technology drove the research. Peters was renowned in the medical community for his measurements of the chemical constituents of body fluids. For this purpose he had a device called an analytical centrifuge, a less sophisticated version of Gofman’s ultracentrifuge, which could quantify the triglyceride concentration of the blood. Peters’s lab also analyzed blood samples for New Haven Hospital (now Yale–New Haven Hospital), so Peters suggested to Albrink that they use the analytical centrifuge to measure the triglycerides in those blood samples and test the hypothesis that high triglycerides are associated with an increased risk of heart disease. Peters was a “contrarian,” Albrink says; he didn’t believe the cholesterol hypothesis. Nor did Evelyn Man, Peters’s longtime collaborator. Albrink also worked with Wister Meigs, a Yale professor of preventive medicine who also served as company physician for the nearby American Steel and Wire Company. Meigs had been recording cholesterol levels in the plant employees, along with their family history of heart disease, diabetes, and other ailments. By 1960, Albrink, Man, and Meigs (Peters died in 1955) were comparing triglyceride and cholesterol levels of heart-disease patients from New Haven Hospital with the levels among the healthy employees of American Steel and Wire. Elevated triglyceride levels, they concluded, were far more common in coronary-heart-disease patients than high cholesterol: only 5 percent of healthy young men had elevated triglycerides, compared with 38 percent of healthy middle-aged men and 82 percent of coronary patients.

In May 1961, just a few months after the American Heart Association publicly embraced Keys’s hypothesis, both Ahrens and Albrink presented their research at a meeting of the Association of American Physicians in Atlantic City, New Jersey. Both reported that elevated triglycerides were associated with an increased risk of heart disease, and that low-fat, high-carbohydrate diets raised triglycerides. The New York Times covered Ahrens’s talk—“Rockefeller Institute Report Challenges Belief that Fat Is Major Factor”—in a story buried deep in the paper. Ahrens’s data suggested that “dietary carbohydrate, not fat, is the thing to watch in guarding against [atherosclerosis and heart disease],” the Times reported, and this “came as something of a surprise to many of the scientists and physicians attending the meeting.” Albrink’s talk did not make the newspaper, but she later told a similar story about her presentation. “It just about brought the house down,” she recalled. “People were so angry; they said they didn’t believe it.” This remained the case for much of the next decade. Albrink continued to work out the connection between carbohydrates, triglycerides, and heart disease and would present her results at conferences, where she would inevitably be attacked by proponents of Keys’s hypothesis.

By the early 1970s, Albrink’s interpretation of the evidence had been confirmed independently, first by Peter Kuo of the University of Pennsylvania, then by Lars Carlson of the Karolinska Institute in Stockholm, and by the future Nobel laureate Joseph Goldstein and his colleagues from the University of Washington. All three reported that high triglycerides were considerably more common in heart-disease victims than was high cholesterol. In 1967, Kuo reported in The Journal of the American Medical Association that he had studied 286 atherosclerosis patients, of whom 246 had been referred to him by physicians who thought their patients had the genetic form of high cholesterol. This turned out to be the case for fewer than 10 percent. The other 90 percent had carbohydrate-induced lipemia, and, for most of these patients, their sensitivity to carbohydrates had elevated both their triglyceride levels and their cholesterol. When Kuo put his patients on a sugar-free diet, he reported, with only five to six hundred calories of starches a day, both their triglyceride levels and their cholesterol lowered. Two months later, JAMA published an editorial in response to Kuo’s article, suggesting that the “almost embarrassingly high number of researchers [who had] boarded the ‘cholesterol bandwagon’” had done a disservice to the field. “This fervent embrace of cholesterol to the exclusion of other biochemical alterations resulted in a narrow scope of study,” the editorial said. “Fortunately, other fruitful approaches have been made possible in the past few years by identification of the fundamental role of such factors as triglycerides and carbohydrate metabolism in atherogenesis.”