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49
which, coronary disease in women before the age of 45 years is
uncommon. The menopause brings a change in the hormone
pattern and her immunity wanes until, in old age, she is as prone
to coronary troubles as the male. Epidemiologically it has been
noted not only here but in Japan and the United States that the
average death rate for middle-aged men is substantially higher in
areas where the drinking water is soft than in others where it
is hard.
As a group, the middle-aged man is enjoying unprecedented
prosperity and affluence but not the standard of health of prewar
days. Heart disability, with particular emphasis on coronary
disease, is the main cause of death in these men and the
persistently rising death rate of this group and the consequent loss
to the nation of such potential is cause for great concern.
My previous reports have given information relating to
aetiological factors which, in the light of present day knowledge,
are thought to be implicated, namely, excess of animal fat in the
diet producing a rise in serum cholesterol—the association of
smoking with heart disease—the lack of physical activity with a
consequent rise in weight—coronary disease and its hypothetical
connection with "stress and strain" and diabetes and genetic factors.
If all or most of these circumstances are present then a patient
possesses the right credentials for entry to the "coronary club".
Dietary fat is considered to be a cause of coronary atheroma
for two very good reasons: —
1. In communities where the habitual diet is low in
animal fat, coronary disease has a low incidence rate.
For example, in Southern Italy where the peasants' diet
consists mainly of pasta, fish, fruit and vegetables, and where
the intake of fat is predominantly vegetable in origin (olive
oil), coronary disease is rare.
Again, this disease was not common in poor, undernourished
Arab-Jews arriving in Israel during 1948, whose
diet until then had been low in animal fat. Within ten
years of living on a westernised regimen this disease began
to make its appearance.
To emphasise this point, it is a fact that rats on a starvation
diet live twice as long as those which are well fed.
2. In the affected arteries, fat-like substances are found
in the atheromatous areas.
The lipids in these atheromatous patches are in fact
normal constituents of the blood, and cholesterol is the fat
present in greatest quantity. Blood cholesterol varies not
only from person to person but also from time to time in
the same person, even in health. Nevertheless, coronary