Early Prevention Message: ‘Your heart has nine lives. Nine steps toheart health.’ 1963. Pocket Books, New York.
“Dedicated to the thousands of men and women in research and medicine throughout the world whose skills and efforts are bringing control over the plague of heart disease.”
This booklet, historic for its impact in the early 1960s, was a major attempt to reach the wide American public with an early prevention message from a leading medical journalist, Alton Blakeslee, and a prominent medical researcher, Jeremiah Stamler. It was sponsored by a vegetable oil company and begins with the authors’ preface citing consensus-based advice in the detailed and prolix language for which Stamler became famous: To eat “less animal saturated fat; to increase the intake of unsaturated vegetable oils and other polyunsaturated fats, substituting for saturated fats wherever possible; to eat less food rich in cholesterol; if overweight, to reduce caloric intakes until the desirable weight is achieved and maintained; to apply these dietary recommendations early in life; to maintain the principles of good nutrition, which are important with any change in the diet; to adhere consistently to the broad dietary recommendations, so the decrease in concentration of blood fats may be both achieved and maintained; to make sound food habits a ‘family affair’ so that the benefits of proper nutritional practices – including the avoidance of high blood fat levels – may accrue to all members of the family. Other factors may increase the risk of developing coronary heart disease. These include hypertension, diabetes mellitus, cigarette smoking, lack of exercise, and others. As in the case of diet, these factors may be corrected or controlled by programs based upon advice from the family physician” (Blakeslee and Stamler 1963, v).
The authors acknowledge Paul Dudley White for his introduction to their book and pay tribute to the American Heart Association, the National Heart Institute, and the National Institutes of Health for “their enlightened research policies and wise allocations of research funds [that] have played a key role in making possible the sustained and many-sided investigative assault on the atherosclerosis problem that has yielded such rich results” (ibid., v). Then they provide paragraphs of personal acknowledgments to many leaders in cardiovascular disease prevention research, attack epidemic and the need for primary prevention starting in childhood: “It is the establishment of unhealthy habits of over-nutrition, physical lethargy, and excessive cigarette smoking in the twenties that sets the stage for the prevalent and crippling or fatal atherosclerotic diseases of heart and brain, legs and kidneys, which suddenly appear in middle-age” (ibid., xx)
The authors’ theme is that by personal action everyone can reduce any of the nine risk factors that “make a man more susceptible to a heart attack far too early in life” (ibid., 1). [ed. Ignoring the disease risk in women was a common omission in the early days of CVD prevention. And the admonition against “excessive” cigarette smoking, rather than “any” cigarette smoking is another familiar gesture of those days, a bow to the message of uncertainty sown by the tobacco industry.] The first chapter ends with the upbeat idea that individuals can recognize and act against each member of the “heart conspiracy” and that this need not hurt or require a Spartan existence.
Chapter 3 is provocatively titled “Hearts too good to die,” indicating that the heart muscle is often sound in disease of the coronary arteries. They tell the story of cholesterol and the Russian rabbit studies and define the problem of heart attacks as the problem of atherosclerosis, fatty arteries. They end the chapter with stories of epidemiologists roaming the world “comparing the mode of life of many different peoples including what they eat” (ibid., 39).
Chapter 6 continues the cultural comparisons of heart attack rates around the world and then brings up the idea that modern humans are poorly adapted by evolution to the onslaught of modern western diets. There is great emphasis throughout on diet: “Diet does appear to be a key and even necessary cause of widespread premature disease, abetted by other things in the way we are living…On this basis, the unhappy fact is that virtually all adult American men, and many women, are running avoidable risk” (ibid., 52).
The 9-item heart risk checklist also includes obesity, excessive eating, heredity, little exercise, cigarette smoking, and tension and then the book turns to a counter-attack to avoid risk. At this early stage of the prospective evidence they speculate that: “…a 15-20% reduction in cholesterol levels among middle-aged men could reduce heart attacks by 25-50%” (ibid., 67).
To the 1962 American Medical Association Council on Food and Nutrition’s labeling the cholesterol-diet question “a new food fad,” they retort: “The plea that we ought not to change it [the American way of eating] in any way is very hard to justify. The prime concern is to change it with good sense” (ibid., 74).
In Chapter 10 on choosing foods the authors advise not to add, rather to substitute polyunsaturated for saturated fats, de-emphasize high-fat dairy products, whole eggs, and high- fat meats, and emphasize poultry, fish, and seafood, fruits and vegetables. They make no plea for the health values of alcohol. And the term “Mediterranean Diet is found nowhere in the book.
On how to lose weight and expend calories, they attribute to nutritionist Jean Meyer the idea that metabolic regulation of food intake and energy output was ill adapted to highly mechanized American society; that even farmers have known for centuries the principle of penning up animals to fatten them. “Sensible activity and exercise in the largest amounts that you can handle are indeed part of the new approach to guarding your heart” (ibid.,120).
In Chapters 12 and 14 the authors discuss the early combined results on tobacco of Framingham and Albany prospective studies showing a 6-fold difference in fatal heart attacks and death from all causes among cigarette smokers compared with non-smokers. They also cite Doll and Hill’s classic paper on the excess of coronary disease in younger men, with evidence that stopping smoking reduces risk.
On the controversial issue of stress, they tip their hand by asking the question, “Is stress or certain types of stress significant only when linked with other elements such as diet, smoking, and high blood pressure?” (ibid.,132) After a thoroughgoing review they conclude that little solid information supports psychological and cultural stresses by themselves producing “enough of a large and lasting change in blood cholesterol or other mechanisms to hurry the development of the artery-clogging disease” (ibid., 140).
In Chapters 16 and 17 they give thorough attention to hypertension and diabetes, “the sweet menace,” and in Chapter 18 emphasize the ability to influence any heredity tendency toward high risk and be “master of one’s fate.”
In Chapter 19 they discuss a woman’s advantage and speculate that women are more resistant to atherosclerosis due to “biological superiority” under similar conditions and habits in the lives of men. Most of the remainder of the book involves how to manage recovery from heart attack and how to avoid atherosclerosis of other arteries.
A closing chapter on needed future research is a big endorsement for the Diet-Heart Study then in pilot phase. Eventually NIH did not approve that trial.
A missionary theme closes the text: “Your defense, at any age, is in your own hands. Your counter-attack is neither ‘radical’ nor difficult. The counter-measures are simple, and age-old habits can be modified. No one need become a hypochondriac, fearful of every shadow and statistic or every egg on his plate, every cigarette or cigar smoked, and every vague pain.”
The senior cardiovascular authority of the time, Irvine Page, adds: “Understand heart disease and you will not fear it” (ibid., 232).
An insert from the sponsor, Corn Products Company, expounds, with the usual commercial bias, on: “The role of corn oil in family nutrition.” (Henry Blackburn)
Blakeslee, A. and Stamler, J. 1963. Your heart has nine lives. Nine steps to heart health. Pocket Books, New York. Professional edition courtesy Corn Products Company.