William J. Zukel on the Early Nutrition Activities Under the National Heart Act of 1948
[ed. A letter of September 2010 to Henry Blackburn at Minnesota from William Zukel, retired Associate Director of NHLBI, summarizes the early initiatives of the National Heart Institute in nutrition, providing the information extracted, paraphrased, and commented on here by Henry Blackburn:]
Section 5.E of the National Heart Act under the heading “control grants,” and the follow-up circular issued by Surgeon General Scheele, provided the authority for establishing heart disease control programs in states, counties, and health districts. The Bureau of State Services was set up to administer the heart disease control grants and demonstrations in state services provided by the National Heart Act.
Under the sub-title, “Early nutrition activities, 1948-1960,” Zukel writes that Joseph Mountin, Assistant Surgeon General, had already in 1947 assigned Louis Robbins and the public health nurse Gertrude Anderson to the Massachusetts Department of Health to identify a community in which health department and the community leaders and physicians would cooperate, or would be willing to cooperate, in a heart disease prevention and control program. This resulted in the October, 1947 selection of the city of Newton. The Newton Heart Demonstration Program was formally established in May, 1948 as a 3-year study. It would be assigned public health staff to carry out recommendations of the program committee that would represent the Newton Health Department, the Newton Wellesley Hospital, and private physicians.
This committee appointed Egon Katwinkel, chief of medicine at the local hospital, as chairman. Ernest Morris, director of the local health department, provided space for Dr. Robbins and his staff. Nutritionist, Pearl Thoreson, MPH, joined the staff in January, 1948 and worked with the sub-committee on nutrition under Dr. Arthur Baldwin. They chose compliance to prescribed low-sodium diets as their intervention topic and found right away that the sodium restriction ordered by physicians and dietitians varied greatly from excessive to ineffective, along with much ambiguity about the assignment of calorie levels. The committee determined that its function would be to develop standardized, nutritionally-adequate, low-sodium diets. They achieved positive efforts including a widely circulated booklet, “Planning low-sodium meals,” by Pearl Thoreson. Some 13,000 copies were circulated in 32 states of the regimen that involved 3 levels of sodium restriction, 200, 400 and 800 milligrams of sodium daily, at 3 different calorie levels.
Other contributions of the control program was a 1950 cookbook for low-sodium diets by the Department of Nutrition at Harvard, the 1952 American Heart Association booklet, Food for your Heart, and a manual for patients and physicians, also from the Harvard School of Public Health.
The Heart Disease Control Branch of the Public Health Service from 1949-1969 was within the Division of Chronic Diseases of the Public Health Service. Its nutrition consultation services were an acceptable activity for use of grants-in-aid funds by the states and were used by New York, West Virginia and Arkansas. Six nutritionists became part of the professional staff of the Heart Disease Control Program, which, in turn, produced in 1953 a Heart Program Guide for state and local health departments, including segments on obesity control, low-sodium diets, and low-fat cholesterol diets, and ten segments on appropriate training for professional and patient education.
The advisory committee for the Heart Disease Control Branch in 1959, made aware of the need for physicians and nutritionists and other services in the states and in the Public Health Service, began to make such assignments of medical officers and nutritionists to various national projects. This was during the days of Viet Nam and a number of young physicians achieved exemption from military service by serving in the Heart Disease Control Program. The first assignment made was John McDonough to Curtis Hames’s project of the Evans County, Georgia Study, along with a nutritionist, Sarah Stulb.
The Heart Disease Control Program also developed a publication “Methods of dietary assessment in current epidemiologic studies of cardiovascular disease,” written by Marjorie Cantoni, Ralph Paffenbarger and Dean Krueger, all Public Health Service staff. Other studies involving nutritionist participation supported by NHLBI were the Framingham Study using the Bertha Burke method of 30-day food recalls and the North Dakota study in 1957 of coronary patients and matched controls that made an assessment of food intake over a one-month period.
The Heart Institute and James Watt contributed by developing the Methods Conferences in the 1950s, at Arden House and Princeton to deal with diet and lipid issues. The pioneer presentation of the NIH-sponsored cardiovascular cohort studies was made at the 4th annual meeting of the APHA, November 15, 1956 on “Measuring the risk of coronary heart disease in adult population groups.” This resulted in a publication the following year of a supplement to the American Journal of Public Health, the first major report on CVD risk factors with specific reports from Framingham, Albany, Los Angeles, and San Francisco that launched the importance of risk factors of high blood pressure, overweight, hypercholesterolemia, and smoking.
Zukel and Nevin Scrimshaw point out how remarkably homogeneous was the diet in the U.S. population compared to most rural populations. Both of them acknowledged the contribution of Ancel Keys to emphasizing the importance of studying different modes of life. The general consensus was that public health recommendations could not yet be made, but that the opportunities were rich for research to produce such answers within a short time.
Zukel describes the sub-committee on methodology for diet appraisal established for a Boston conference, chaired by Martha Trulson from Harvard and the professional nutritionists that served in that conference and issued a 10-page report on dietary surveys. One outcome of that conference was the formation and work of the Committee on Epidemiological Studies of the American Heart Association which dealt in data collection in nutrition.
In 1960, James WattJames Watt created a new program at NHI designated Biometry and Epidemiology under administrative associate director, Dr. Zukel, with combined activities with the Biometrics Research Branch, the Framingham Heart Study, an epidemiological research section, international laboratories, and the Geographical Disease Section. At this time, Jean Tillotson, dietician with a masters in nutrition, transferred from the clinical center to that division to consult with the epidemiological studies, including the Honolulu Heart Study and the Puerto Rico Study. She coordinated the use of 24-hour dietary recall between Framingham, Honolulu and Puerto Rico and analyzed results after 4-6 years follow-up in those studies indicating the lower rate of coronary disease at the same level of risk factors in Honolulu compared to Framingham. The relative weight predictive of coronary heart disease of total calorie intake and alcohol intake, negatively associated with coronary disease, was presumed to reflect greater activity.
LDL, HDL ratio were studied in detail in the Albany, Framingham, Evans County, Honolulu and San Francisco population studies reported in Circulation, vol 55, May 1977, pages 767-772 under the title “Serum cholesterol and other lipids in coronary heart disease. The cooperative lipoprotein phenotyping study,” lead author, William Castelli. He describes the Institute-supported collaborative studies funded by counterpart currencies brought to the U.S. by foreign countries, including the PL480 Project Israel as reported by Kahn, Medalie, and Lilienfeld, and the PL480 Project Yugoslavia as reported by Harold Dorn and Kozaravic, (American Journal of Epidemiology 1976) after 7 years follow-up. These collaborative studies sponsored by NIH, and their strong and consistent findings supported by basic research on mechanisms, provide the rationale for the clinical trials supported by NHLBI.
In the deliberations associated with Diet-Heart Feasibility Trial and the Coronary Drug Project Zukel gave credit to Ralph Knutti for supporting these activities and not supporting the Diet-Heart Trial and described Don Fredrickson’s appointments in 1968 of the Diet-Heart Study Review Panel that concluded “the sample size of 219,000 randomized participants followed for five years was not feasible and was prohibitively expensive.”
Zukel credits Theodore Cooper with convening the Institute’s 1970 Task Force on Arteriosclerosis, charged to develop a long-range plan to combat arteriosclerosis. This reported out in ’71, including its Ad Hoc Panel chaired by Oglesby Paul, and did not recommend a national diet-heart trial but did recommend extension of the Lipid Research Clinics and a Multiple Risk Factor Intervention Trial. (William Zukel, ed. Henry Blackburn)