By Reimert T. Ravenholt, MD MPH

GROWING UP on a dairy farm in West Denmark/Luck, Wisconsin, I learned to love rich milk, ice cream, and other dairy products; then considered among the most healthful of all foods.

But in 1949, while I was a medical student at the University of Minnesota a physiology professor there, Dr Ancel Keys, reported an association between countries consuming high levels of fat in their diets and those with high mortality rates from coronary heart disease. This report triggered additional studies of dietary and atherosclerotic cardiovascular disease patterns, the findings of which during some years seemed supportive of Keys' hypothesis. And so was launched "The Great Cholesterol Scare," which has greatly altered the American diet and medical practices.

But the studies implicating dietary fat and cholesterol as causes of coronary heart disease, generally neglected the key fact that the populations eating considerable animal products and therefore fats and cholesterol were also foremost smokers of cigarettes—now known to be the main cause of pandemic atherosclerotic cardiovascular disease during this century: killing more than 5 million Americans. (Am. J. of Preventive Medicine, vol. I, 1985)

Indeed, the decision by General Pershing and the USG during WWI to include free cigarettes in soldiers' rations quickly doubled U.S. cigarette consumption—resulting in several million cigarette-addicted war veterans who subsequently communicated their addiction to millions of their families and associates, while the ever-rapacious tobacco purveyors employed radio and film stars to assure the gullible that there was "Not a cough in a carload," and "More doctors smoke Camels than any other cigarette."

Within a few years deaths from coronary heart disease—a rare event before WWI—became epidemic among young and middle-aged men addicted to cigarettes. And as cigarette consumption rapidly increased during the '20s, `30s, and '40s, coronary heart disease became the foremost cause of death in the United States; first of men, and a little later also of smoking women.

But lacking a clear concept of how smoking caused coronary heart disease, and themselves heavily addicted to smoking, the medical profession was slow to accept the emerging evidence that smoking was not only the foremost cause of cancer, but also the foremost cause of coronary heart disease and other atherosclerotic vascular diseases.

Atherosclerotic cardiovascular disease and cancer are ordinarily viewed as two distinctly different diseases—because one originates within blood vessels and the other originates in almost all tissues except blood vessels—but they can both be considered as manifestations of the same fundamental disease process: Malignant Cellular Evolution (Lancet, March 5, 1966). When viewed from this unified perspective the critical trigger role of mutagens in the pathogenesis of both "malignant" atheromas within blood vessels and malignant neoplasms (cancers) in other tissues can be more fully appreciated.

How does inhalation of tobacco smoke cause atherosclerosis and cancer of non-respiratory tissues? By the pathogenic mechanism of absorption of chemical and radioisotopic mutagens through the pulmonary circulation and their circulation throughout the vascular system to every tissue and cell, causing mutation of cellular genetic structures, acceleration of malignant cellular evolution (aging), and greatly increased morbidity and mortality from cardiovascular disease and cancer of many tissues.

Although there is evidence that elevated blood cholesterol is associated with increased occurrence of atherosclerotic cardiovascular disease, it has not been reliably demonstrated that the former causes the latter, nor that by avoidance of dietary fat and cholesterol one can somehow protect vascular endothelium from the ravages of circulating mutagens from inhaled smoke. In fact, I believe it makes better sense to view cholesterol—an essential component of all body cells and mainly manufactured in the liver—not as an enemy but as a friend: helping to repair and maintain failing vascular structures. Hence, increased blood levels of cholesterol accompany aging, smoking, high blood pressure, and other vascular diseases; and the increased levels of cholesterol should be viewed not as itself a hazard but indicative of increased body need for cholesterol—analogous to the increased levels of white blood cells when the body is battling infections.

Participation in a recent (26 September 1989) press conference by the American Council on Science and Health in New York City on "The Facts and Myths About Coronary Heart Disease" brought additionally to view the dismal extent to which the "Medical Industrial Complex" of tobacco interests, drug companies, medical laboratories, enthusiastic clinicians, food faddists, and purveyors of low fat, low cholesterol foods has greatly stretched inconclusive and often specious research findings to generate widespread fear of cholesterol while misleading an apprehensive public away from the preponderant scientific evidence: that the massive 20^th century pandemic of cardiovascular disease and cancer, in which we are still immersed, is caused not by eating fats and cholesterol, but mainly by the inhalation of cigarette smoke.

From three years experience as Chief, Epidemiology Branch, U.S. Food and Drug Administration, I can assure readers that despite the barrage of publicity urging reduction of blood cholesterol levels by dietary restrictions and use of cholesterol-lowering drugs, there is until the present time no substantial evidence of death prevention by these means. Furthermore, recent studies have consistently demonstrated that those persons with the lowest cholesterol levels (under 180 mg per deciliter) have increased death rates from cancer and other diseases.

Hence, my advice to family, friends and readers seeking long healthy lives: avoid tobacco entirely, use alcohol only moderately, maintain normal blood pressure, eat moderate quantities of a considerable variety of foods—including whatever dairy products they enjoy—and get regular exercise and sleep. Then, with reasonable heredity and good fortune, they will live at least 80 years and perhaps 100.