Daan Kromhout

Quotes

Another development in the Netherlands was that in internal medicine a lot of people were interested in cholesterol and biochemistry and Snapper was, of course, also a famous example of that. And one of his well-known pupils wasGroen. And Groen did already kind of metabolic studies before the Second World War in Snapper’s department. S. became at a very young age a professor of internal medicine at the age of 29 in Amsterdam and he was not so much older than Groen, but he was the tutor of Groen and he educated him along that line. And in his department already interventions were done on diet and to see how you can manipulate the cholesterol level, in 1935-1936 around that time. And they were, of course, not controlled studies. It was just having a couple of patients and then they intervened at the diet and saw that the cholesterol level went down when they went to a more vegetable diet. So if I have to summarize the Dutch situation, then the internists were playing a very important role because De Langen and Snapper and Groen were all internists and they started from the clinical perspective. De Langen because he went to Batavia caught also a cross-cultural perspective on the problem. So in the Netherlands internal medicine has played an important role from that point of view. (5)

Another important point for the Dutch situation to mention is that the Netherlands Heart Foundation had this year its 40th Anniversary so it started in 1964 and it really became powerful in the 1970s through the work of Dr. Bart Decker, who was very influential. And what he did he also asked Olli Miettinen from Harvard to come to the Netherlands to lecture about methodology and also biostatistical aspects of epidemiology, but also of trials. What Dr. Decker did is that all the people who got a grant from the Heart Foundation had to go one a year to [review] . . the way they had designed their studies and the mistakes that they made. And because of that critique the quality of the work in the Netherlands improved enormously. So, to my opinion, Bart Decker was one of the persons in the Netherlands who has been extremely influential in developing epidemiology. And he was a pupil of Groen, so you see, everything comes together in that way. (8)

“Snapper was also a very critical type. In the biography of Groen they had some examples of it and one of the nice stories of him was when Groen defended his thesis – in the Netherlands that is a big event and you have a big party after that – Snapper had to give a speech after Groen defended his PhD thesis… and you may recall that Groen was a very small fellow. I think he was only 1 meter and 58 centimeters or something like that and then Snapper said in his after-dinner speech, “Groen, you came in as the smallest man in my department, but you have become the tallest.” That was really fantastic.” (16)

Role of MONICA

What I personally find a pity is that after the MONICA project there was not a real big project on which people could be brought together for new work [throughout Europe]. There is a genetic component in the MONICA Study that is led by Alun Evans and uses several of the MONICA cohorts that collected blood samples with its own, let’s say, smaller scale than the whole MONICA enterprise was. To my opinion to use all the diversity in Europe for epidemiologists is, of course, a fantastic source and it’s a pity that MONICA is not continuing one or another way.

At the moment I am working on a paper together with Hugo Kesteloot and Susanna Sans where we show in former Eastern European countries like Poland, Hungary, Lithuania that you see enormous decreases in mortality from coronary heart disease in the second part of the 1990s. So even their rates are coming down there. And there is some evidence that the composition of the diet changed very much – animal fat went down and vegetable fat went up and also the consumption of fruit went up. So it is, of course, not causality that you can imply directly, but it shows the dynamics of the disease in a European context and I think that we are not using that in a way that we could have done to study the [mass] causes of the disease. (21)

On Genetics: “In relation to the future, in Europe in general nowadays, if you are not doing genetic work it is very hard to get any money and that’s a big problem. In my own field there are people who are talking already about a personalized diet. Personally, I don’t believe in it at all . . . I am personally convinced that if you look at cardiovascular disease, that for 80-90%, and also for diabetes, it’s environmental in its origin and why talk about personalized diets in that context when you know that lifestyle is so important. Personally, I find it very important to counteract that idea and to show that the diet, lifestyle, environmental factors are very important. Of course, there are gene/nutrient interactions and gene/environment interactions that play a role and that are very important in understanding the etiology of the disease [in the individual]. But when you look to those diseases as mass phenomena you have to come to diet and lifestyle as important determinants. And if I look to the future I think it can take quite some time before we will come into a new situation and we will realize that genetics is not bringing all the happiness that people are believing it will.

HB: It’s just impossible to find powerful relationships. I think there is a political-conceptual difference between the geneticists and the epidemiologists and it’s encapsulated in a statement that the head of the Diet-Health Report in the National Academy made that I worked on a few years ago. Arno Motulsky – a distinguished geneticist from Seattle. He said: “Soon we will be able to determine those people who need to go on a diet and then we won’t have to bludgeon the whole population to change.” That’s the attitude, without realizing that even in those cases there are families and communities that have to be involved in individual change! (22)

When Asked About Community Trials

I think you need them, especially in relation to the problem of obesity. I think one of the mistakes we have many times made in the Netherlands and probably also in other countries is that we go to the community with certain measures without adequate evaluation… In my opinion, also if you go into the community you should start with very small pilot studies to see whether your intervention will work or not. Yesterday at the Keys Symposium someone said that in relation to advertisements that we say, ok we’d like to ban advertisements for kids, but we have first to show that it will really work or not and just to go into the community and say we have to do all those things without knowing what the effects are that would also not be a good development. So my idea is that a lot of things need to be more evidence-based and we have to take the steps there that are necessary to become more believable from that point of view. (24)

Foods vs Nutriceuticals

Another point you are mentioning now is vitamin A. In relation to the antioxidants I think we have been wrong in taking such a high dose. My personal opinion about antioxidants is that…[The balance in real foods is much better than popping pills.]

Yeah. And also if you look to different antioxidants the balance between the water soluble and the fat soluble is extremely important and if you go higher than say one or two times the recommended dietary allowance you are destroying the balance and that has been forgotten in a lot of trials where they took 10 times the recommended dietary allowance.

And that is one of the things that, I hope, that we will readdress in the years to come. I think in relation to the antioxidant hypothesis I’m not sure what we’ve thought about is correct, but I’m sure the doses that we were using were completely wrong. (25)