In the two decades since the NIH, the surgeon general, and the National Academy of Sciences first declared that all Americans should consume low-fat diets, the research has also failed to support the most critical aspect of this recommendation: that such diets will lead to a longer and healthier life. On the contrary, it has consistently indicated that these diets may cause more harm than good. In 1986, the year before the National Cholesterol Education Program recommended cholesterol-lowering for every American with cholesterol over 200 mg/dl, the University of Minnesota epidemiologist David Jacobs visited Japan, where he learned that Japanese physicians were advising patients to raise their cholesterol, because low cholesterol levels were linked to hemorrhagic stroke. At the time, Japanese men were dying from stroke almost as frequently as American men were succumbing to heart disease. Jacobs looked for this inverse relationship between stroke and cholesterol in the MRFIT data and found it there, too. And the relationship transcended stroke: men with very low cholesterol seemed prone to premature death; below 160 mg/dl, the lower the cholesterol, the shorter the life.

In April 1987, the Framingham investigators provided more reason to worry when they finally published an analysis of the relationship between cholesterol and all mortality. After thirty years of observation, there was a significant association between high cholesterol and premature death for men under fifty. But for those over fifty, both men and women, life expectancy showed no association with cholesterol. This suggested, in turn, that if low cholesterol did prevent heart disease, then it must raise the risk of dying from other causes.

This was compounded by what may have been the single most striking result in the history of the cholesterol controversy, although it passed without comment by the authorities: those Framingham residents whose cholesterol declined over the first fourteen years of observation were more likely to die prematurely than those whose cholesterol remained the same or increased. They died of cardiovascular disease more frequently as well. The Framingham investigators rejected the possibility that the drop in cholesterol itself was diet-related—the result of individuals’ following AHA recommendations and eating low-fat diets. Instead, they described it as a “spontaneous fall,” and insisted that it must be caused by other diseases that eventually led to death, but they offered no evidence to support that claim.

The association between low cholesterol and higher mortality prompted administrators at the National Heart, Lung, and Blood Institute once again to host a workshop and discuss it. Researchers from nineteen studies around the world met in Bethesda, Maryland, in 1990 to report their results. The data were completely consistent (see charts on following page): when investigators tracked all deaths, not just heart-disease deaths, it was clear that men with cholesterol levels above 240 mg/dl tended to die prematurely because of their increased risk of heart disease. Those whose cholesterol was below 160 mg/dl tended to die prematurely with an increased risk of cancer, respiratory and digestive diseases, and trauma. As for women, if anything, the higher their cholesterol, the longer they lived.*25