In the late 1950s, Keys supported his fat hypothesis with the disparity in fat consumption, cholesterol levels, and heart-disease mortality he found among Japanese men living in Japan, Hawaii, and Los Angeles. This association was then confirmed, more or less, in his Seven Countries Study, in which the Japanese villagers still had remarkably little fat in their diets, low cholesterol levels, and fewer heart-disease deaths over ten years than any other population with the exceptions of those of the islands of Crete and Corfu and the village of Velika Krsna in what is now Serbia. By the mid-1990s, however, the Japanese contingent of the Seven Countries Study, led by Yoshinori Koga, reported that fat intake in Japan had increased from the 6 percent of calories they had measured in the farming village of Tanushimaru thirty-five years earlier, to 22 percent of calories. “There have been progressive increases in consumption of meats, fish and shellfish and milk,” they reported. Mean cholesterol levels rose in the community from 150 mg/dl to nearly 190 mg/dl, which is only 6 percent lower than the average American values (202 mg/dl as of 2004). Yet this change went along with a “remarkable reduction” in the incidence of strokes and no change in the incidence of heart disease. In fact, the chance that a Japanese man of any particular age would die of heart disease had steadily diminished since 1970. “It is suggested that dietary changes in Tanushimaru in the last thirty years have contributed to the prevention of cardiovascular disease,” Koga and his colleagues concluded.

In the late 1950s, Keys had dismissed the possibility that misdiagnosis might have contributed to the extremely low heart-disease death rates in Japan they had observed initially. In 1984, Keys reversed himself, saying that the Japanese cardiologists who had worked with his Seven Countries Study “might have been misled by the local physicians who signed the death certificates and provided details.”

Three years later, Keys acknowledged to the New York Times that he had re-evaluated his hypothesis. “I’ve come to think that cholesterol is not as important as we used to think it was,” he said, “Let’s reduce cholesterol by reasonable means, but let’s not get too excited about it.”

As in Japan, increases in fat consumption with coincident decreases in heart disease have occurred recently in Spain and Italy, which has prompted the observation that the French paradox—a nation that eats a high-fat diet and has little heart disease—has evolved into the French-Italian-Spanish paradox.*24 Through the mid-1990s, according to John Powles, an epidemiologist with the British Institute of Public Health, France and Italy both showed declines in death rates from stroke and heart disease that were greater than those in most European countries, while the decline in mortality in Spain lagged only slightly behind. And studies of Mediterranean immigrants to Australia suggest that the low heart-disease rates of these immigrants fall even lower in Australia, despite a considerable increase in their meat consumption.