Interview With Jerry Stamler, MD

Long before it was fashionable to talk about or consider various risk factors for cardiovascular disease, Dr. Jerry Stamler was pounding the pavement looking for converts to this concept. Early in his career he noted that when animals were fed a high cholesterol diet, atherosclerosis developed. Early in his career he had become convinced that a high salt intake resulted in elevated blood pressure (BP). He began to evaluate large numbers of people in Chicago to determine which factors in their lives contributed to cardiovascular disease. Therefore, it was not surprising to him when the Framingham Heart Study (FHS) and other large-scale epidemiologic studies confirmed his inferences that there were definite environmental factors that contributed to the early onset of coronary heart disease and other vascular diseases. Dr. Stamler was one of those epidemiologists who was not content with merely generating information. He became an activist in advancing risk factor information worldwide. For more than 40 years he has traveled widely informing individuals, populations, and governments about lifestyle changes to reduce coronary heart disease. He has been a strong, untiring voice in the ongoing effort to improve habits and has participated in most of the large-scale hypertension and lipid-lowering treatment trials. Those of us who have been involved in programs or studies with Dr. Stamler have marveled at his enthusiasm, his firm judgments, and his “take no prisoner” attitude when advancing a point. His evidence has been accepted by almost everyone worldwide. He has truly been a champion of a cause that has helped to enlighten people to the importance of hypertension,dyslipidemia, obesity, and smoking in the cardiovascular epidemic. He has made a difference. Certainly Dr. Stamler, no longer a basic scientist, qualifies as an icon in the world of hypertension based on his steady and unrelenting efforts to prevent heart and vascular disease. DR. MOSER: Jerry, you have certainly had a long and distinguished career in preventive medicine and especially in the field of cardiovascular risk factors. How did you get started? DR. STAMLER: After I graduated from Columbia College and Downstate Medical School and did a 9-month (wartime) internship, I decided to spend a year in research. I was interested in “hard” arteries and causative factors, not yet called risk factors. My first fellowship, with Louis N. Katz, began in 1948 shortly after I got out of the Army. My stipend was $200 a month. I thought that was great. I was at the Michael Reese Hospital in Chicago and mainly in the animal laboratory working with chickens, giving them extra salt and a high cholesterol diet. I became more and more convinced that elevated BP and elevated serum cholesterol is a bad combination. We then began to study humans. DR. MOSER: Jerry, you were overpaid. In 1948, I was working with William Dock for $25 a month. DR. STAMLER: Dock was a remarkable person. Exposure to him before leaving New York reinforced my research goals. In 1950 we embarked on my first relatively naive clinical trial on the use of estrogens as secondary prevention of heart disease. Subsequently, I became more interested in population studies and in 1957 began work with the Peoples Gas Company to track various possible heart disease risk factors. After that, as you know,I became involved in other prospective population studies and in major clinical trials: the Coronary Drug Project, the Hypertension Detection and Follow-up Program, the National Diet-Heart Study, the Multiple Risk Factor Intervention Trial (MRFIT), the Systolic Hypertension in the Elderly Program, etc. DR. MOSER: Yes, you certainly were involved in almost all of the major clinical hypertension trials. DR. STAMLER: Later on we inherited the Western Electric Study and surveyed almost 40,000 people at their places of work in Chicago. We are still following those people as well as the Gas Company and Western Electric cohorts. They total about 45,000 people, follow-up now is 30+ years. I have also been involved in the follow-up of the primary screenees in the MRFIT involving 361,662 men. We now have 25-year data. DR. MOSER: What was your base of operations for the Peoples Gas and Western Electric studies? DR. STAMLER: After about a decade at Michael Reese in Chicago, I became the first Heart Disease Control Officer in a city health department anywhere. This was after the American Heart Association convinced Mayor Daley that the Health Department should have a heart disease prevention and control arm. So I worked for 10 years as chief of that operation, first on heart disease, then on all chronic diseases, heart, cancer, diabetes, etc. Then in 1971 I went full-time at Northwestern after years as a volunteer. In 1971 I became the first chair of a new Department of Preventive Medicine. I'm now Emeritus, still there working full-time. DR. MOSER: You can summarize these experiences as your efforts to clarify the issues of causation, epidemiology, natural history, prevention, and control of major adult cardiovascular diseases. It's been a wonderful journey. I can remember our week-long lecture tour up and down Portugal spreading the message about potential problems with too much salt and fat in the diet. You were to be honored at a bullfight, but the matador was unable to bring the bull down and had to apologize. Memories of salted codfish and salty bread. DR. STAMLER: That week together in Portugal was great. The Portuguese people had Europe's highest salt intake and highest rates of hypertension and stroke. DR. MOSER: Jerry, there were other studies underway before you settled in at Northwestern. DR. STAMLER: Yes, the FHS started before 1950. The Heart Institute—sponsor of the FHS—was established in 1948, the year I started at Michael Reese, and in that year the American Heart Association became a voluntary health agency. Not long after, I became interested in epidemiology and its promotion, and primary prevention based on population findings as well as clinical and animal experimental findings. DR. MOSER: That's when Ancel Keys was studying different cultures around the world. DR. STAMLER: He's now 100 years old. Last month I participated in the First Keys International Symposium on Nutrition at the University of Minnesota. The role of high cholesterol, high BP, and obesity as major risk factors was already indicated by the first report from the FHS way back in the late 1950s. The facts had been clear from animal experiments. For example, you feed chickens cholesterol, they get dyslipidemia and atherosclerosis. You simultaneously give them salt and raise their BP. So they have three of what we now call risk factors—adverse diet plus resultant adverse blood lipid and BP levels. Atherosclerosis develops, aggravated and intensified. That was clear not only in chickens and rabbits, but later in monkeys and other primates. It was also clear from the clinical work of Paul White and others who studied the traits of people who had coronaries going back to the 1920s. The extensive epidemiologic studies clarified all this. By the late 1950s, the role of cigarette smoking as a risk factor also became clear. The question arose, why did so many people have high cholesterol or high BP? Was this just a human genetic propensity or predilection or something to do with the way we live? In the late 1960s, a tremendous amount of work was done defining what influenced blood cholesterol levels; dietary cholesterol and saturated fat clearly raise blood cholesterol. On an American diet, caloric imbalance with weight gain elevates it, high fiber lowers it, as does dietary polyunsaturated fat. These things were all delineated by the 1960s—the trans-fat adverse effect was shown later. Based on all the data, recommendations for healthier eating were made to the public from the early 1960s on. As to why all the high BP, very little research was done on it until the 1990s. It's a historical anomaly not easily explained. All of us who were interested in this—Keys, myself, others—focused on the blood cholesterol question and what influenced it, but did very little research about causes of high BP. I got more and more conscious of that. In the 1990s we began to focus, along with others, on what were the factors that result in elevated BP. Calorie imbalance was already known, salt was already known, also heavy drinking. We dotted the “I”s and crossed the “T”s on those. And we began to look at other things—various macro- and micronutrients—e.g., potassium, total protein, vegetable protein, magnesium, fiber—possibly protective against high BP and the usual BP rise during adulthood. That has been an interesting development culminating in the Dietary Approaches to Stop Hypertension (DASH) combination diet, plus reduced salt—highly effective in lowering BP of both prehypertensive and hypertensive adults, even under isocaloric circumstances in overweight people. The DASH combination diet—rich in fruits, vegetables, whole grains, legumes, protein from vegetables and low-fat dairy products; reduced in red meats, fats, saturated fats, cholesterol, sweets—was found to be effective in reducing BP especially if it was accompanied by a low-salt intake. There was prior information on vegetarians, etc. suggesting this, but no hard data. The hard data came along in the 1990s and in the early part of this century from population studies including our International Study of Sodium, Potassium, and Blood Pressure (INTERSALT) and International Population Study on Macronutrients and Blood Pressure (INTERMAP). There was a significant clear-cut relationship of diet to elevated BP. Multiple improvements in eating pattern lowered BP. DR. MOSER: Why does the public so readily accept very low-carb or Atkins diets when data suggest that that may not be the best way to lose weight and reduce the risk of heart disease? DR. STAMLER: An essential fact about diet is: If you reduce calories, you reduce weight. So it is with Atkins-type diets that reduce carb intake. But long-term success, taking weight off and keeping it off? And long-term health effects? Unknown—likely adverse. No population in the world of any size, under any more or less ordinary circumstances (leaving out special limited and peculiar circumstances, e.g., small Inuit groups above the Arctic Circle) has ever subsisted for any length of time on a nutritional pattern such as recommended by Atkins originally or recently—under pressure from criticisms—with modifications. It is not possible to regard this diet as optimal in caloric density, ratio of nutrients to calories, or in key essential nutrients (minerals, vitamins, antioxidants, fiber) that—as we learn more and more—are protective. This diet also tends to be, unless you pick your fats very carefully and knowledgeably, excessive in saturated fats and cholesterol—dietary items that we have known for years are harmful. It's a bill of goods sold to the public without decent long-term scientific assessment. DR. MOSER: Jerry, this is an important message. DR. STAMLER: Populations in the world have not experienced the culinary exposures and adverse lifestyle trends—the automobile/TV/fast food culture—that we have experienced in the United States, or have done so at a lower level. In the Mediterranean countries, where some people still eat something like the “classical” Mediterranean Diet, and in China and Japan very few are eating anything resembling what Atkins and company have been talking about. They are eating a diet modest in total fat, about 20% of calories from total fat, 25% at the most, low in saturated fat (less than 10%), low in cholesterol, not a lot of egg yolks, not a lot of meat, not a lot of dairy fat, not a lot of saturated spreads. The best longevity in the world is still Japan. DR. MOSER: Bottom line is: Reduce your calories, however you do it. This is difficult to do with foods high in fat. DR. STAMLER: It's indeed hard to reduce your calories and keep them down long term if you're eating 40%–50% of your calories from fat, not to mention that it's hard to get an optimal intake levels of essential nutrients or to really enjoy the pleasures of eating (unless you have an unusual idea of the pleasures of eating). DR. MOSER: Where do you think we should place our emphasis on changing habits? DR. STAMLER: We now have the basic information we need concerning lifestyles, particularly nutritional improvements, enhanced activity, and of course nonsmoking. The DASH eating pattern is the epitome of a good nutritional approach—akin to “classical” Mediterranean and East Asian fare (great cuisine), but low (not high) in salt, and moderate (not high) in alcohol (if desired). It prevents and controls both dyslipidemia and adverse BP and the rise in these major risk factors with age. The shift from an average BP at age 20 of about 120/75 mm Hg to levels by age 35, 40 and 45 of about 130/85 mm Hg with a high percent of the population frankly hypertensive can be avoided by most people by improving lifestyles. Much of the prehypertension (Bps 120–139/80–89 mm Hg according to the Joint National Committee on Prevention, Detection, Evaluation, and the Treatment of High Blood Pressure classification) can also be prevented. The rise from age 25 to age 55 of about 16 mm Hg systolic and 9 mm Hg diastolic on average can be reduced. This rise is now preventable for most people by sensible nutrition involving maintaining caloric balance, avoiding overweight, avoiding salt, and eating the kind of diet that's epitomized in the DASH combination diet, which is fully compatible with the pleasures of eating. I emphasize that because I love to eat. Let me state that in lectures to professionals and the public about this subject, I often start out by asking: Who here does not like to eat? An occasional hand is raised and my concern is about that person having anorexia nervosa. Most people like to eat. What we're talking about is completely compatible with even enhanced enjoyment of eating, one of the joys of the modern world. A public health lifestyle preventive solution is a more satisfactory approach than belated polypill treatment. Let's do it more the way we got rid of scurvy and smallpox. This approach involves reaching for the jugular and improving lifestyles to get rid of adverse eating/drinking/inactivity/smoking habits that were unprecedented on a mass scale for the human species until the mid 20th century. The public is very interested in health, and not resistant to healthier lifestyles. I learned about this long ago from practical experience, and from Reader's Digest: If you want to sell magazines, put two health articles in every issue and advertise them on the cover. That's why the news media have doctors to transmit health news, why The New York Times puts cholesterol on the front page every other week. The public has responded—will respond—to sustained, effective transmission of information, more so when the food industry and the supermarkets have better products available (70%–80% of the salt most of us eat comes from food processing). DR. MOSER: Again, the bottom line is that we probably have enough good, well documented information now to launch a more extensive campaign to the public and counteract some of the myths and misinformation that people are exposed to on a regular basis. Everyone is so health conscious that they frequently are misled by great sounding programs to lose weight, get stronger, or look better. DR. STAMLER: What our friends in Geneva at the World Health Organization emphasized starting some years ago was primordial prevention of disease by getting at the root of a problem. Start early to address risk factors to prevent disease, i.e., adverse eating and drinking habits, sedentary lifestyle, smoking, etc., from preconception on. I used to say from weaning on, from birth on. Now there's evidence that what goes on nutritionally, metabolically in utero influences the risk of diabetes, hypertension, dyslipidemia in middle age, and the risk of atherosclerotic and related diseases in middle age. Hence, we're concerned from conception on. We must do more to intervene as early as possible to prevent all major risk factors and increase the proportion of the population at low risk—from its present low level (<10%) to a great majority—so we can end the Coronary Heart Disease/Cardiovascular Disease epidemic. DR. MOSER: Your strong convictions suggest that the scientists have done the work needed and now it's up to the public, the media, and society to help get the message out. DR. STAMLER: When the main thrust of our efforts becomes a pill for obesity, for BP, for cholesterol, or a polypill or macropill with multiple pills within it, it is not good medicine. We are not helping all the people who need help, nor are we moving to end the epidemic, when we continue to advocate treatment and neglect prevention of disease. Many of these diseases now being treated in an expensive and complex manner with multiple medications can be prevented. DR. MOSER: Nice to hear that you are still the strong advocate of sounder public policy and public education. Good luck.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.