Fiscal prevention of ischaemic heart disease should be based on facts
Tom Marshall´s suggestion to treat ischaemic heart disease (IHD) by
fiscal measures1 is based on the assumption that diet determines
cholesterol concentrations which again determines the prevalence of IHD.
These assumptions have been iterated since decades. in spite of many
contradictory observations and experiments . Let it suffice to mention a
few of the most devastating facts concerning the alleged link between
dietary fats and IHD.2 More can be found elsewhere.3
Secular trends of national fat consumption and IHD mortality go
opposite each other almost as often as they coincide.
Among 21 cohort studies of IHD including 28 cohorts and more than
150,000 individuals, those who developed IHD ate significantly more
saturated fats than individuals without IHD in three cohorts and
significantly less in one cohort; in 22 cohorts no difference was found.
In three cohorts those who developed IHD had eaten more polyunsaturated
fats, in 24 cohorts no difference was recorded. ( In a few studies the
consumption of saturated or polyunsaturated fats were not recorded).
Three of four cohort studies analysed the correlation between the
consumption of saturated and polyunsaturated fats and degree of
atherosclerosis at autopsy; none of them found any. All four analysed the
total fat intake; in one it was correlated with degree of atherosclerosis,
in one no correlation was found; in two the correlation was inverse.
In six case-control studies of patients with IHD and sex and age-
matched controls, no significant differences were noted between their
intake of saturated or polyunsaturated fats.
In a meta-analysis of nine controlled, randomised, unifactorial,
dietary trials with reductions of saturated and additions of
polyunsaturated fats that were more radical than any of the official
recommendations, neither total (OR 0.99) or IHD mortality (OR 0.94,
confidence interval 0.80-1.10) was lowered; in fact the total number of
deaths in the treatment and control groups were identical.
In the only unifactorial, dietary trial that lowered fatal and non-
fatal IHD significantly, included in the mentioned meta-analysis, the
cholesterol concentrations in the diet and the control group were almost
No doubt the edible oil industry will applaud the idea about fiscal
medicine, but certainly not those of us who prefer evidence-based
Råbygatan 2, S-22361 Lund, Sweden
1. Marshall T. Exploring a fiscal food policy: the case of diet and
ischaemic heart disease. BMJ 2000; 320: 301-5.
2. Ravnskov U. The questionable role of saturated and polyunsaturated
fatty acids in cardiovascular disease. J Clin Epidemiol 1998; 51: 443-60.
3. Ravnskov U. The cholesterol myths.
4. de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N.
Mediterranean diet, traditional risk factors, and the rate of
cardiovascular complications after myocardial infarction. Final report of
the Lyon Diet Heart Study. Circulation 1999; 99: 779-85.
Competing interests: No competing interests