Early informal cross-cultural studies

In a Rome meeting of Food and Agriculture Organization nutritionists in late 1951, where the subject of interest among European leaders was the under-nutrition and malnutrition still prevalent throughout post-war Europe, Ancel Keys expressed his enthusiasm about the “new” diseases of over-nutrition and diet-heart theories of their origins. This “American idea” was either ignored or considered an annoyance by the serious-minded professionals preoccupied with deficiency diseases still prevalent in post-war Europe. For example, Gino Bergami, nutritionist-physiologist of Naples, remarked to Keys that there were few coronaries in his part of the world. When Keys expressed skeptical interest, Bergami invited him to come see for himself.

Thus, in spring 1952, Keys drove his wife Margaret across France and Italy to Naples where Bergami set them up with a laboratory and assigned them a young nutritionist assistant, Flaminio Fidanza. Margaret prepared for serum cholesterol determinations, Flaminio for the dietary survey. They proceeded to make a crude comparison of Italian laborers, university staff, and Neapolitan banker friends of Bergami, recruited in sufficient numbers to demonstrate statistical significance for serum cholesterol differences on the order of 10 percent between groups that differed in habitual eating pattern. Thus, Keys’s uncommon common sense led him early to the sine qua non of epidemiological design, to look first among apparent contrasts, to seek out variations, rather than among homogeneous groups.

The Naples results were promising. Laborers and peasants who ate a typical poor man’s Mediterranean diet of pasta, olive oil, legumes, vegetables and wine, had lower values of serum cholesterol than the bankers who ate “high on the hog.” A quick side trip to meet colleagues in Spain and make similar comparisons was confirmatory. Then this modern-times Marco Polo was off, for travel and adventure afar, back home in Minneapolis, in Sardinia, South Africa, Finland, Honolulu, and Japan. Marco Keys returned from each new adventure with ever-engaging booty: confirmatory data and fresh ideas.

By the mid-1950s, Keys and his now expanding team of participating investigators worldwide had demonstrated social class differences in serum cholesterol level within cultures as well as remarkable cross-cultural differences in blood lipid levels and in eating patterns, accompanied by apparent differences in hospital-ascertained prevalence of coronary heart disease. He had rounded out that picture showing the graded differences among Japanese on the mainland and Japanese migrants to Honolulu and Los Angeles, thereby, he believed, “holding genes constant” (ante-dating NIHONSAN by a decade).

The intellectual traveling circus of Keys and White secured entry of these population concepts into the mainstream of international cardiology. They arranged for the first symposium on cardiovascular disease epidemiology before a plenary session of the World Congress of Cardiology in fall 1954 in Washington, DC. Participants in a panel were Ancel Keys, Paul Dudley White, Jeremy Morris of London, Gunnar Bjork of Sweden, Noboru Kimura of Japan, and John Higginson of the UK, experts embracing clinical, laboratory, and the new population research strategies. There in Washington, the population evidence was aired for the first time en extenso before the world community of cardiological leaders. A few were excited. Most were indifferent. (Henry Blackburn)