If everyone felt that way

The role of saturated fat in the diet and cholesterol in the blood is in need of re-evaluation

On 13 March this year, the Secretary-General of the United Nations António Guterres wrote a piece titled ‘Covid-19: We will come through this together’ https://www.un.org/en/coronavirus/covid-19-we-will-come-through-together. I thought of Joseph Heller and Arthur Koestler.

Though separated in time and space, Heller and Koestler were close in two ways. First, in 1998 the Board of the Modern Library, a division of the publisher Random House, listed the 100 best English-language novels of the 20th Century, with numbers seven and eight Heller’s Catch-22 (1961) and Koestler’s Darkness at Noon (1941), respectively. Second, both authors had interesting observations on crowds.

In Catch-22, Captain John Yossarian is determined to avoid further dangerous missions. “But Yossarian,” asks Major Danby, “what if everyone felt that way?” Yossarian replies, “Then I’d certainly be a damned fool to feel any other way, wouldn’t I?” In his essay ‘The Urge to Self-Destruction’ (1969), Koestler cites one aspect of the human predicament as a need for identification “with a social group and/or system of beliefs which is indifferent to reason, indifferent to self-interest and even to the claims of self-preservation”. So, despite the Secretary-General’s well-intentioned adjuration, forgive me if I harbour a faint distrust of those who would predict how “we” might, or ought to, behave.

More refreshing are those exemplars whose independence of thought demonstrates that individuals can act for themselves. Thus, when the history of this coronavirus pandemic comes to be written, it must include Dr June Almeida (1930–2007), whose robustly creative approach to scientific challenges enabled her to not only become the first person to see a human coronavirus, but also to make several seminal contributions in diverse virological fields. Almeida was the first to see the fine structure of rubella virus; she demonstrated the morphological characteristics of human papillomaviruses; and showed that hepatitis B virus includes both a surface antigen and a core antigen, a finding which she regarded as perhaps her most important contribution.

Born June Hart in a Glasgow tenement — father a bus driver, mother a shop assistant — she received a high-quality Scottish education at Whitehill Senior Secondary School. With financial constraints thwarting hopes of a university education, Hart left school aged 16 to work as a junior histopathology technician at Glasgow Royal Infirmary. Fast-forwarding to marriage in 1954, by 1956 Almeida had secured a research assistant post at Toronto’s Ontario Cancer Institute. Two important points arise.

First, whereas UK laboratory recruitment favoured those with university degrees (Almeida later earned an M.Phil and D.Sc), her Oxford Dictionary of National Biography entry https://www.oxforddnb.com/view/10.1093/ref:odnb/9780198614128.001.0001/odnb-9780198614128-e-99332 states:

“On the other side of the Atlantic, there was less emphasis on formal training requirements and the necessity of having to overcome academic hurdles.” Such institutional reluctance to run with the academic herd is admirably instructive. Second, this afforded Almeida — without previous electron microscopy working experience — full intellectual expression in a flurry of research papers, the first of which was submitted a year after arriving in Canada.

One hopes the current Covid-19 pandemic might soon recede, and that when it does, lessons might be learned and applied. For example, Bornstein et al have investigated the ‘Endocrine and metabolic link to coronavirus infection’ in Nature Reviews: Endocrinology (2020, 16: 297–298), finding that “[t]ype 2 diabetes mellitus and hypertension are the most common comorbidities in patients with coronavirus infections.” This lends impetus to an urgent consideration of evidence-based ways of successfully addressing the global problem of insulin resistance, diabetes, and their connections with arterial disease. But is it possible to do this while cleaving to the dogma that a key driver of arterial disease is saturated fat in the diet and cholesterol in the blood?

Let us assume that the medical equivalent of Captain Yossarian is determined to avoid missions that deliver his patients dodgy dietary messages that derive from this doubtful dogma, and, moreover, that he adduces evidence supportive of his stance. He might, for example, note that when Ramsden et al evaluated complete data from the randomised, double-blind Minnesota Coronary Experiment (1968–73) in the BMJ (2016, 353: i1246), they reported: “Results of a systematic review and meta-analysis of randomised controlled trials do not provide support for the traditional diet heart hypothesis.” Or, ‘Dr’ Yossarian might highlight Astrup et al’s recent ‘Saturated Fats and Health: A Reassessment and Proposal for Food-based Recommendations: JACC State-of-the-Art Review’ in the Journal of the American College of Cardiology, which points out that “[m]ost recent meta-analyses of randomised trials and observational studies found no beneficial effects of reducing saturated fatty acid intake on cardiovascular disease and total mortality, and instead found protective effects against stroke.”

Faced with this, Yossarian’s ‘Prof’ Danby asks the inevitable: “But what if everyone felt that way?” The ineluctable logic of Yossarian’s reply — “Then I’d certainly be a damned fool to feel any other way, wouldn’t I?” — must surely give those who are not indifferent to reason, as Koestler puts it, pause for thought.

And it is not good enough for Prof Danby to merely repudiate Dr Yossarian’s assertions. Danby, and colleagues holding similar opinions, must instead refute them, using arguments that reflect independence of mind, not herd mentality.