Nonetheless, when small, dense LDL and metabolic syndrome officially entered the orthodox wisdom as risk factors for heart disease in 2002, the cognitive dissonance was clearly present. First the National Cholesterol Education Program published its revised guidelines for cholesterol testing and treatment. This was followed in 2004 by two conference reports: one describing the conclusions of a joint NIH-AHA meeting on scientific issues related to metabolic syndrome, and the other, in which the American Diabetes Association joined in as well, describing joint treatment guidelines. Scott Grundy of the University of Texas was the primary author of all three documents. When I interviewed Grundy in May 2004, he acknowledged that metabolic syndrome was the cause of most heart disease in America, and that this syndrome is probably caused by the excessive consumption of refined carbohydrates. Yet his three reports—representing the official NIH, AHA, and ADA positions—all remained firmly wedded to the fat-cholesterol dogma. They acknowledge metabolic syndrome as an emerging risk factor for heart disease, but identify LDL cholesterol as “the primary driving force for coronary atherogenesis.” Thus, heart disease in America, as the National Cholesterol Education Program report put it, was still officially caused by “mass elevations of serum LDL cholesterol result[ing] from the habitual diet in the United States, particularly diets high in saturated fats and cholesterol.”

There was no mention that carbohydrates might be responsible for causing or exacerbating either metabolic syndrome or the combination of low HDL, high triglycerides, and small, dense LDL, which is described as occurring “commonly in persons with premature [coronary heart disease].*53 In the now established version of the alternative hypothesis—that metabolic syndrome leads to heart disease—the carbohydrates that had always been considered the causative agent had been officially rendered harmless. They had been removed from the equation of nutrition and chronic disease, despite the decades of research and observations suggesting the critical causal role they played.

Chapter 11

Chapter Eleven

THE SIGNIFICANCE OF DIABETES

Does carbohydrate cause arteriosclerosis? Certainly it does if taken in such excess as to produce obesity, but except in this manner no one would attribute any such function to it…. Is a persistent [high blood sugar] a cause of arteriosclerosis in diabetes? It very likely is a cause because it is an abnormal condition and any abnormal state would tend to wear out the machine.

ELLIOTT JOSLIN, “Arteriosclerosis and Diabetes,” 1927

DESPITE NEARLY A CENTURY’S WORTH OF therapeutic innovations, the likelihood of a diabetic’s contracting coronary artery disease is no less today than it was in 1921, when insulin was first discovered. Type 2 diabetics can still expect to die five to ten years prematurely, with much of this difference due to atherosclerosis and what Joslin’s Diabetes Mellitus has called an “extraordinarily high incidence” of coronary disease.