The rationale for lowering the
Another striking aspect of the low-fat diet recommendations is how little any individual might benefit from lowering his cholesterol.*19 Keys and others had argued that heart disease had to be prevented because its first symptom was often a fatal heart attack. But in twenty-four years of observation, the Framingham Heart Study had detected no relationship between cholesterol and sudden cardiac death. The likelihood of suffering a fatal first heart attack was no less for those with a cholesterol level of 180 mg/dl than for those with 250. “The lack of association between serum cholesterol level and the incidence of sudden death suggests that factors other than the atherosclerotic process may be of major importance in this manifestation of coronary artery disease,” explained Thomas Dawber.
There is also little to gain from lowering cholesterol even in less catastrophic manifestations of the disease. This was made clear in 1986, when Stamler published a reanalysis of his MRFIT data in
Using the MRFIT data, however, it is possible to see how large or small that benefit might be (see chart, below). For every one thousand middle-aged men who had high cholesterol—between, say, 240 and 250 mg/dl—eight could expect to die of heart disease over any six-year period. For every thousand men with cholesterol between 210 and 220, roughly six could expect to die of heart disease. These numbers suggest that reducing cholesterol from, say, 250 to 220 would reduce the risk of dying from a heart attack in any six-year period from .8 percent (eight in a thousand) to .6 percent (six in a thousand). If we were to stick rigorously to a cholesterol-lowering diet for thirty years—say, from age forty to seventy, at which point high cholesterol is no longer associated with an increased risk of heart disease—we would reduce our risk of dying of a heart attack by 1 percent.
Whether we would actually live longer by lowering our cholesterol is, of course, a different question. People die from myriad causes. Though Stamler neglected to include total mortality data in his