May 6, 2012

Researchers strive for decades to solve mysteries of Total Health

Isidore Snapper, MD, (1889 – 1973) discovered benefits of a diet low in harmful cholesterols and rich in polyunsaturated fats. Photo courtesy of the Mount Sinai Hospital Archives.

Contributed by Lincoln Cushing, Archivist and Historian

President Dwight D. Eisenhower had a heart attack in 1954 and lived to urge all Americans to change their diets and exercise habits to avoid heart disease and other chronic disease. In the early 1960s, John F. Kennedy called us “soft” and in danger of losing our physical and intellectual edge. He referred to Americans’ documented lack of muscle tone as a trend that had to be reversed. For a time, we took his message seriously and began to exercise, some of us furiously.

But despite the heavily publicized advice of these powerful men — and God knows the urgings of our doctors — we find ourselves in 2012 with a startlingly high rate of obesity, overweight and resultant chronic illness, including heart disease and diabetes.

Understanding the connection between healthy living and good health didn’t come easy. Over the last 100 years, physicians and researchers have been studying chronic disease and looking for ways of saving and lengthening lives. They’ve made a lot of progress.

This “History of Total Health” series spotlights the milestones in the journey of scientists and physicians, including Kaiser Permanente practitioners, to help patients achieve Total Health, a concept Kaiser Permanente has embraced since World War II in the Kaiser Shipyards. 

— Ginny McPartland

Childhood artery changes may signal heart disease in later life

In 1965, Martin Reisman, MD, a Kaiser Permanente pediatric cardiologist and clinical professor at UCLA School of Medicine, warned of the danger of a fatty diet in childhood leading to early onset of coronary heart disease. His supposition that this disease may begin in the young and that pediatric intervention is called for was not the prevailing view.

Kaiser Permanente pediatric cardiologist Martin Reisman, MD, published in the Journal of Pediatrics in 1965.

“The present standard American diet is a major contributing factor in the etiology of atherosclerosis [the fatty deposits of plaque that accumulate in arterial walls]. “The larger part of the ‘incubation period’ of this disease may very well be the first two decades of life, and a modest change in diet, instituted early and sustained through life, might be clinically significant.”

In the future, Reisman said, “our pediatric nutritionists will have to concern themselves . . . with the long term consequences of prevailing childhood diets.” Studies of the disease “should begin to appear in the table of contents of our pediatric journals and on the agenda of our meetings and conferences. It is time for us to join intellectually with our colleagues in adult medicine, and concern ourselves with a disease that is probably a mutual responsibility.”

The doctor confessed that his speculations though shared by a few pediatric cardiologists were a “personal groping in a yet incompletely charted field of possible pediatric responsibility.”1

Reisman’s warnings seem prescient today

If Reisman’s recommendations 50 years ago were “speculative,” they seem prescient today. The alarm sounds on the incontrovertible evidence that empty calories and sedentary lifestyles have dramatically increased the incidence of overweight and obesity, a known driver in heart disease. One third of the nation’s young, ages 2 to 19, and two-thirds of the adults 20 years and older are overweight or obese.

The impact of overweight or obesity on the quality of life for both the young and older is real. The afflicted often suffer from high blood pressure; higher rates of joint, kidney, and gall bladder disease; from issues in infertility; and higher rates of psychological depression. Worse, overweight and obesity factor into five of the 10 leading causes of death in this country, including coronary heart disease, Type 2 diabetes, cancer, stroke and kidney disease.

“Obesity has become one of the most serious threats to the health of the American people,” says Harvey Feinberg, MD, President of the Institute of Medicine. And Francis Collins, MD, director of the National Institutes of Health, has said that we must face this or “face, for the first time in our history, a situation where our children are going to live shorter lives than we do.”

Debate on nutritional intervention

In 1959, R.L. Holman, MD, titled his address to the Ninth International Congress of Pediatrics provocatively: “Atherosclerosis — A Pediatric Nutrition Problem?” He said any disease that is responsible for 54 percent of the deaths in the U.S. “is a pediatric problem, but whether it is a nutritional problem, I am not too certain.”

Citing autopsy studies, Holman traced the progress of the disease in a four-stage development starting in infancy with the presence of fatty streaks in the aorta; the development of fibrous plaque in the second decade of life; lesions and ulceration follow in the coronary arteries; then as early as the fourth decade of life, atherosclerosis and the onset of clinical manifestations like heart attack and stroke.

Absent in his concluding remarks are the words so familiar in today’s lexicon on coronary heart disease — mention of the preponderance of empty calories, and worrisome lipids and cholesterols in the blood. Holman concludes saying fatty streaks in the aorta occur in infancy, are universal the world over, appear to be independent of ethnicity, and accelerate down the path to aggravation and illness beginning in puberty. He offered no dietary recommendations in pediatric care.2

Snapper compared Eastern and Western diets

There were others at the time who joined the debate citing evidence of the role of diet in the progression of coronary heart disease, prominent among them the irrepressible Isadore Snapper, MD, Chief of Medicine at Mount Sinai Hospital in New York City. Snapper is remembered for throwing clinical light on the benefits of a diet low in harmful cholesterols and rich in polyunsaturated fats.

A physician of international reputation in service to royalty in his native Holland, Snapper was recruited by the Rockefeller Foundation in the 1930s to become chief of medicine at the University of Beijing where he did research and published on the causes of cardiovascular disease.

In popular work, Chinese Lessons to Western Medicine (1941), Snapper contrasted the rates of heart disease among Chinese and Westerners, their different levels of blood cholesterols and attributed the cardiovascular health in the Chinese population to diets rich in plant foods.

In 1963 Snapper weighed in on the debate on the prevention of the disease in children in the American Journal of Cardiology. If Holman were reticent on the effects of diet and nutrition in the onset of the disease, Snapper was anything but. He said the disease could only be prevented early if a diet high in a ratio of polyunsaturated to saturated fat (P/S ratio) is “introduced in early childhood immediately or soon after the child is weaned, as is the custom in the Orient.

“The difficulties of the implementation of this proposal may well be insurmountable. The myth that a daily intake of 800 cc of milk rich in saturated fats is mandatory for normal calcium metabolism can probably never be destroyed. This, despite the fact that most clinicians today recognize that it is dangerous to encourage children to stuff themselves with milkshakes, ice cream and other foods with unsatisfactory P/S ratios.” 3

Debate among pediatric cardiologists continued in the 1960s

The debate among experts in pediatric cardiology on the role of diet and nutrition continued through the 1960s, and discussions continued on the pediatrician’s responsibility in preventing heart disease.

The American Academy of Pediatrics’ Committee on Nutrition took up for consideration the newly released “Report of the Inter-Society Commission for Heart Disease Resources: Primary Prevention of the Atherosclerotic Diseases” (1970) and issued its recommendations on it in 1972.

In its report “Childhood Diet and Coronary Heart Disease,” the academy concluded that dietary intervention was experimental at the time and recommended against sweeping changes in children's diet.

“Unproven preventive measures should be tested first in a group at exceptionally high risk of disease,” the committee reported . Though children at excess risk should receive preventive therapies, “a nationwide alteration in diet may well impair the sense of well-being of the general public.”4

The academy’s caution surfaced a view within the pediatric community that early screening for heart disease risk may do more psychological harm than medical good.

Also in 1972, others were reporting research studies and looking up the road. “The technologic revolution has provided a surfeit of food at the same time that physical activity has been curtailed. Eating habits, indolence and sedentary living habits, propensity to obesity, and possibly the cigarette habit” require pediatric intervention, wrote the authors of one study.

With food choices conditioned in childhood, they argued, “It would seem reasonable for pediatricians to counsel mothers on the feeding of a diet emphasizing skim milk, cottage cheese . . . legumes, fruits, starches, lean meats, poultry and fish.”

Citing evidence that atherosclerosis has its origins in childhood, the authors concluded that the prevention of obesity, early screening for lipid abnormalities, nutrition and diet intervention, the promotion of exercise, and the discouragement of cigarette smoking should involve the intervention of the pediatrician.5

Bogalusa Heart Study confirms childhood diet and disease connection

Also in 1972, researchers at Tulane University School of Medicine launched what has become a definitive long-term study of the early natural history and development of coronary artery disease. The Bogalusa Heart Study (1972 – present) has tracked vital data on children’s heart health in Bogalusa, Louisiana, a Black/white rural community on the Louisiana/Mississippi border. More than sixteen thousand individuals have been tracked over three decades from infancy into adulthood. From the study emerges a clear picture of the beginnings of cardiovascular disease in the young.

Among the study’s key findings:

  • Heart disease may begin in childhood and there is a clear relationship between diet and cardiovascular health;
  • Autopsies of young participants who were killed in accidents provide clear evidence that fatty buildup forms in the aorta in the first decade of life with documented anatomic changes occurring by 5 to 8 years of age;
  • Cholesterol levels are predictors of arterial plaque;
  • Children who are overweight have a high risk of becoming overweight adults — excess weight tracks from childhood to adulthood;
  • Obesity in children and adolescents is related to elevated cholesterol and elevated blood pressure and these track from childhood to adulthood.6
Weight of the Nation - HBO series on obesity

The Bogalusa Heart Study confirmed pediatric responsibility in the prevention of coronary heart disease. Though atherosclerosis is “a silent disease” with clinical manifestations occurring later in life, the pediatrician, as Dr. Reisman understood, should intervene with clinical guidance in sound nutrition, the control of overweight and obesity and recommendations for regular physical activity.

The Bogalusa Heart Study is featured in “Consequences,” the first episode of “The Weight of the Nation,” a documentary series on the national obesity epidemic airing on Home Box Office (HBO). The series will air May 14 and 15.


1 Reisman M, Atherosclerosis and Pediatrics, Journal of Pediatrics, 66, no. 1, 1965.

2 Holman RL, Atherosclerosis — A Pediatric Nutrition Problem? American Journal of Clinical Nutrition, 9, 1961.

3 Snapper I, Diet and Atherosclerosis: Truth and Fiction, The American Journal of Cardiology, 11, no. 3, 1963. See also Snapper I, Chinese Lessons to Western Medicine, Grune & Stratton, New York and London , 1941 and 1965.

4 Childhood Diet and Coronary Heart Disease, Committee on Nutrition, American Academy of Pediatrics, 49, no. 2, 1972.

5 Kannel, WB, et al., Atherosclerosis as a Pediatric Problem, Journal of Pediatrics, 80, no. 4, 1972. See also Voller RD, Pediatric Aspects of Atherosclerosis, American Heart Journal, June 1981.

6 Berenson, GS, et al., Atherosclerosis: A Nutritional Disease of Childhood, American Journal of Cardiology, 82 (10B), 1998. See also Tulane University Center for Cardiovascular Health, “History of the Bogalusa Heart Study, 1972-2005."