“If It Isn’t Fun.” – The Laboratory of Physiological Hygiene and the Division of Epidemiology, School of Public Health, University of Minnesota
The segment to follow goes well beyond the time of the story I am trying to tell here, but it may help to put in context both Volumes I and II of this personal medical memoir. At any rate, those familiar with The Lab and The Minnesota Story would do well to skip over this formal section.
A Short History
The Laboratory of Physiological Hygiene (LPH) was founded by Ancel Keys in 1937 and housed from 1940 until 1992 under the south stands of Memorial Stadium, entered through Gate 27. It was a bizarre maze, a cozy, lived-in space of central offices and laboratories from which we operated numerous satellites and field surveys in the United States and abroad. It was drafty in winter, held heat for days in summer, and offered shelter to transients and rodents as well as to its eager bunch of investigators. For devoted research fellows on Saturday afternoons, the noise of the football crowd following a Minnesota touchdown was remote, like distant thunder.
The new Division of Epidemiology was formed in 1983 by merger of the LPH, headed by Ancel Keys from 1937 to 1972, and by me thereafter, with the old Division of Epidemiology, led by Leonard Schuman until 1983 and the merged units by me until 1990. Russell Luepker has directed the division since 1991. Stadium Gate 27, our home, mailing address, and identity for 50 years, was razed in 1992 and replaced by suites at the West Bank Office Building, 1300 S. Second St., Minneapolis, where most of the faculty, staff, and graduate students are now housed.
Ancel Keys and the Laboratory of Physiological Hygiene (LPH) gained national recognition during World War II. Keys assembled a multidisciplinary team of physiologists, physicians, biologists, psychologists, and chemists who carried out diet and stress studies in the laboratories of the stadium South Tower. The LPH organizers were veterans of classical training in physiology and biochemistry. After years of research on body composition and function, Keys and his colleagues were prepared to address the urgent questions raised by World War II, such as the chronic effects of heat, cold, and semi-starvation. They developed a practical field ration for fighting troops, later called the K ration (K for Keys), which became the official survival ration of the armed forces.
Then, forecasting that famine and malnutrition would be the most serious problem at the end of the war, the staff began research on the longer term physiological effects of starvation. A group of conscientious objectors and army volunteers housed in the stadium were assigned to months of calorie-deficient diets and to varied activities and tests. That study, published by the University of Minnesota Press as The Biology of Human Starvation, is now a recognized classic. The research on wartime privations led to a series of fundamental explorations of the effect of systematic changes in physical activity and diet on human physiology.
After World War II, the LPH became a part of the School of Public Health and began studies on the rapidly emerging peacetime health problem of heart and blood vessel diseases. The Minnesota Business and Professional Men’s Study, conceived and initiated in the late 1940s, followed men for more than 30 years, examining the aging process and the causes of coronary heart disease. From this and other classic studies made at Framingham, Massachusetts, Albany, New York, Chicago, and elsewhere, the risk factor concept for cardiovascular disease prevention emerged.
At the same time, LPH researchers found that study of many questions was being held up by inadequate methods. They developed a number of basic measures to characterize human structure and function, along with objective measurements of disease for use in population studies. This greatly forwarded the new field of cardiovascular disease epidemiology and prevention. Early Minnesota contributions to new methods include:
• indirect measurement of body fat by underwater weighing and skinfold thickness measurements;
• quantitative assessment of maximal work capacity by oxygen consumption and heart rate during work;
• standardized methods for measuring blood lipids and their fractions;
• objective measurement and classification of the electrocardiographic manifestations of heart disease (The Minnesota Code);
• standardization of cardiovascular disease survey methods (for the World Health Organization), blood pressure measurement, and methods of population sampling and recruitment; and
• a practical tool for predicting the effects on blood cholesterol of a specific change in dietary fat or cholesterol (the Keys equation).
These methods were applied to the study of diet, physical activity, and heart disease risk beginning in the 1950s, when the laboratory began long-term projects that were international in scope. The role of diet and occupational activity was studied in U.S. railworkers by a team led by physiologist Henry L. Taylor, operating on the rails in a fully equipped Pullman car laboratory. The Seven Countries Study, led by Ancel Keys, clearly established that populations differ vastly in their rates of coronary heart disease, and that these differences are importantly related to the nature of the habitual diet and its effects on average serum cholesterol levels. Locally trained teams supervised by me and Alessandro Menotti conducted field surveys of heart disease and risk factors in Japanese, Italian, Yugoslavian, and Dutch villages, in the Finnish forests, and on the Greek islands.
The LPH experiments and population observations, taken together, produced firm evidence of the powerful influence of lifestyle on population risk and disease rates. The time had come to test experimentally the effects of making lifestyle changes.
The first such test was the collaborative pilot Diet-Heart Study in the 1960s, which demonstrated that blood cholesterol levels could be predictably changed in large numbers of people by modifying their diets, either by preparing the food or prescribing the food they purchased and ate. When a government panel decided in the late 1960s that “the definitive diet-heart experiment” was not feasible, the LPH then helped plan and carry out tests of broader public health strategies. A generation of national preventive trials followed.
The Hypertension Detection and Follow-up Program demonstrated that a systematic, community-based approach to identification and treatment of hypertension markedly reduced cardiovascular disease risk. The Multiple Risk Factor Intervention Trial (MRFIT) showed that systematic strategies can lower risk factors of middle-aged, high-risk men. The Coronary Drug Project showed that risk of death could be reduced following a heart attack.
The more recent of these trials, the Minnesota Heart Health Program (MHHP), demonstrated that entire communities could organize themselves effectively to promote health through lifestyle change. This project promoted a “heart-healthy lifestyle” in three Minnesota cities through a variety of local organizations, events, and programs. The community models developed and tested by MHHP, Stanford, and Brown University are being used widely throughout the United States. Their educational and promotional strategies are now applied not only to cardiovascular disease prevention but to other major public health issues as well. The Minnesota efforts particularly opened new strategies now widely used for health promotion in schools, work sites, community organizations, and government.
With the spread of health promotion, the rapid changes in social mores, and the greater value given to health, the risk and the rates of disease of the U.S. population changed for the better. Our major surveillance project, the Minnesota Heart Survey, found that deaths declined as much as 50 percent for heart attacks and 60 percent for strokes since the 1960s, due to improved lifestyle and to better cardiac care. Recently, however, this study has demonstrated that the benefits of preventive strategies are leveling off, requiring new efforts at education and health promotion focused on vulnerable groups of youth, women, and the disadvantaged.
In the 1990s the division turned to new challenges in health promotion along several lines, following the proposition that direct education, and mass media education combined with community organization are more effective than a single strategy. Division investigators are applying what they have learned in cardiovascular disease prevention to helping communities organize preventive approaches to cancer, injury, smoking, obesity, and adolescent substance abuse, among other lifestyle issues.
The Lab’s tradition bridges biology to public health through epidemiology and behavioral science. The tradition continues in Minnesota program developments such as a Cancer Prevention Research Unit, Alcohol-Substance Abuse Group, and sections of Infectious Disease, Nutrition, Maternal and Child Health, and Genetic Epidemiology.
Five decades of Minnesota studies have firmly established that populations and individuals differ greatly in risk of chronic diseases, and that these differences are strongly related to lifestyle, which, in turn, is importantly determined by culture. These findings, and this thesis, have become the core of much epidemiological research on the prevention of chronic diseases and the promotion of health; they now provide a sound basis for public health policy and preventive practice.
I’ve gotten well ahead of the story. Let us return now to early days in “The Lab.”