HOME   HYGIENE LIBRARY CATALOG   CHAPTER 11

*Cardiovascular disease as it specifically affects the coronary arteries of the heart is sometimes called Coronary Heart Disease (CHD). It should be understood that heart disease is a condition developed over a long period, not to be confused with a heart attack which is an event, occurring usually as a result of severe CHD.

  

   While true that a man is "as old as his arteries", equally true is that his health is only as good as the health of his blood. The bloodstream is known as the "river of life", and it is the purity of this river which determines, almost entirely, the health--mental and physical--of the individual.

   If the condition of the blood declines, so will health decline--all the way from vague "indisposition" and head colds, to eventual heart disease and cancer.

   Blood is a complex fluid which performs many functions. Apart from nourishing and cleansing the billions of cells of which our bodies are made, and providing them with oxygen, it conveys hormones and other vital substances, transports protective white cells of the immune system, initiates the healing of wounds, cools active muscles and provides water for perspiration. Its composition constantly changes to meet the demands of the body.

   The word "cardio" relates of course to the heart, and "vascular" relates to blood vessels. The entire system is sometimes simply referred to as the "circulation".

   The heart is often referred to as "the pump". In fact it comprises two pumps, side by side, the chambers of which are rhythmically squeezed by muscle tissue surrounding them to provide the pumping action. The pressure chambers which propel the blood are called the ventricles.

   The left-hand pump is more powerful than the right and its job is to receive blood from the lungs, freshly charged with oxygen, and eject it into the main arteries for its journey to supply every part of the body with oxygen and nutrients.

   The heart muscle gets its supply of blood directly from the left ventricle via the aorta and the coronary arteries which surmount the heart from the top like a crown, thus deriving the name coronary.

   The artery system branches off to all parts of the body, splitting into smaller and smaller tributaries, into tiny arterioles, and finally into the minute capillaries, which are so fine (1/50,000 of an inch) and so numerous that their total length in an adult has been estimated at 60,000 miles.

   The walls of all these blood vessels incorporate muscle tissue which automatically contract or dilate the vessels to control the blood flow according to varying requirements in different parts of the body. As the blood passes through the capillaries it transfers oxygen and nutrients to the cells, and at the same time, picks up waste products for elimination, carbon dioxide to be eliminated by the lungs, and other wastes by the liver, the kidneys and the urine.

   When it leaves the heart the blood is bright red in color, but on its return it is rather a dark red as it is no longer as rich in oxygen. For protection, the arteries are located deep in the body tissue, but the veins which carry the returning blood at very low pressure lie near the surface and you can see them in your arms and hands. They took dark in color because venous blood is dark. The veins connect their branches and carry the "used" blood back to the heart again, this time to the smaller pump, which pumps it through the lungs where it unloads its carbon dioxide and picks up more oxygen. Then back it goes to the big pump again for another trip around the body.

   With every beat, a small portion of the entire blood supply is sent on its way and the entire ten pints or so keep constantly circulating. The arteries flex with the passage of each little "wave" and this can be felt in the neck or wrist as the "pulse". If the heartbeat is irregular, fast or slow, so then will be the pulse. The flexing of the arteries smooths out the flow of blood so that by the time it reaches the tiny vessels, the flow is constant and comparatively slow.

   On its way around the body, the blood picks up nutrients from the intestines and the liver, hormones from the glands, and drops off waste products for elimination as mentioned.

   The initial blood pressure is barely sufficient to propel the blood all the way around the circuit and back to the heart again, especially back from the lower limbs. The return of blood from the lower extremities is ensured by the veins themselves acting as pumps. The veins incorporate numerous tiny valves which allow the blood to flow only one way--upwards, back to the heart. Movement of adjacent muscles squeezes against the veins and propels the blood along. Similar squeezing occurs from adjacent arteries as they expand with each "pulse" of arterial blood. Sometimes guardsmen, standing motionless on parade, will faint when a large quantity of blood pools in their legs so that the heart is short of blood to supply the brain. Blood return from the lower body is further assisted by movement of the diaphragm which is in constant motion as you breathe. These additional pumping accessories are particularly important during vigorous exercise.

   Blood pressure is measured from an inflated pad wrapped around the upper arm because it is convenient and close to the heart. The pressure becomes less and less as the vessels become smaller. Pressure is maintained all the way around but is nearly zero by the time the blood returns to the heart. Blood pressure is measured in millimetres of mercury, and is expressed as two figures, eg 120/80 (a good reading). The higher figure (systolic) is the pressure attained as the heart pumps, the lower (diastolic) is the minimum pressure between beats. The reading should be made with the subject rested and relaxed because ordinary mild activity or eating will cause an increase and give a misleading impression.

   "Normal" standards allow for gradual increase as one gets older. It is commonly believed that an acceptable systolic pressure is "100 plus your age". This figure indeed is almost the general standard because, unfortunately, everybody on a typical Western diet, in blissful ignorance, has blood of high viscosity and slowly blocking arteries, and the heart must pump at a higher pressure to circulate the blood. Generally, a figure below 140/90 is accepted as normal. These figures are unrealistically high. A really physically fit person will maintain the optimum pressure throughout life.

   As the body's activity changes, so blood supply requirements of cells in the different parts of the body change. The muscular walls of tiny arteries, the arterioles, expand and contract as required, directed automatically by the nervous system. Not all are open at one time. Control of blood flow also accomplishes dissipation of excess heat generated by the muscles by directing flow through the skin.

The lymphatic system

   Not all of the blood returns from the capillaries by way of the veins. Blood plasma is the clear liquid portion of the blood and some of this leaves the blood through the capillary walls and circulates around the cells, transferring nutrients to them and receiving their wastes. This fluid is called lymph.

   The red blood cells which carry the oxygen do not leave the capillaries. Most of the lymph re-enters the capillaries and rejoins the bloodstream, but the remainder returns in a different network of vessels altogether. This network is called the lymphatic system and flows one way only. The lymph's function is to cleanse, and at intervals along the lymph vessels are lymph glands which produce white cells to destroy bacteria, abnormal cells or other foreign substances. The lymph glands or "nodes" also filter harmful substances from the lymph fluid and supply it with the protective white blood cells.

   As the lymph vessels are not directly connected with the main circulation, the only pressure available to propel the lymph in its flow is that provided by the pulsations of adjacent arteries and by various muscular movements which provide a squeezing action. The lymph vessels are just like veins and have the same system of valves which ensures the one-way flow of lymph back to the heart.

   The main lymphatic vessels connect to the main veins at the base of the neck and so the lymph re-enters the bloodstream to become part of the blood again before it re-enters the heart.

   The lymphatic system is involved with the digestion of fats and this is described in the chapter on nutrition, Chapter 15.

Cardiovascular disease

   Good health and a good life expectancy depend on an efficient cardiovascular system. The basic essentials are:

1. A strong healthy heart.
2. Clean, free-flowing blood.
3. Clean, flexible blood vessels.

   The heart: The heart has a nervous system of its own which co-ordinates the muscle contractions to provide the pumping action. Over-riding this systern is the body's central nervous system which directs not only the heart rate, but the depth of stroke as well. The depth of stroke means the quantity of blood ejected at each stroke. Thus the output is adjusted to provide the demands of the body. These vary widely from the requirements when asleep, to a maximum of extreme physical exertion. just to digest a meal requires a substantial blood supply to the digestive organs. Mental effort or stress calls for more blood.

   The constant work of the heart is no strain upon it, it remains strong and works uncomplainingly as long as its arteries continue to supply it sufficiently with blood.

   The condition of the blood: The second factor determining the efficiency of the cardiovascular system is the condition of the blood. Toxemia is a condition of the blood when it contains undesirable amounts of toxic substances, and when toxemia is accompanied by high levels of fat and cholesterol, the condition is called lipotoxemia. (Lipids are fats.)

   Viscosity means the degree of stickiness of a liquid. The viscosity of healthy blood is low, permitting it to flow freely.

   The condition of the blood is affected by the following factors:

1. Excess cholesterol and fat, together with various waste products due mainly to wrong diet, circulate in the bloodstream like sludge and gradually deposit in the artery walls. Fat causes the red cells to aggregate or clump together, seriously reducing their oxygen-carrying capacity. Tiny particles called platelets whose function is to clot the blood in the event of injury, also stick together. The effect of this clumping is to increase the blood viscosity, it becomes thick and sluggish and cannot flow freely, particularly in constricted vessels. This often causes drowsiness after heavy meals or perhaps angina or heart attack. Angina pain is frequently mistaken for indigestion. When red cells bunch together and block capillary vessels, clear fluid of the blood is forced out of the capillary walls and causes the tissues to swell. This condition is called "edema".
2. Toxins produced in the colon from putrefying food residues when constipation exists enter the bloodstream from the bile circulation, the condition being known as "auto-intoxication".
3. Alcohol also causes red corpuscles to clump together, and immobilizes certain enzymes preventing oxygen exchange to cells. After eight hours' sleep following a "binge", not only is the heart pounding, but the rate is elevated by 20 beats a minute or more. Alcohol elevates blood triglycerides, destroys valuable nutrients, and immobilizes enzymes.
4. Hypoglycemia--low blood sugar. This is caused mainly by eating excess protein and refined carbohydrates such as sugar, sweets, soft drinks etc. and results in chronic fatigue. Hypoglycemia is described in Chapter 21.
5. Smoking. Apart from the adverse effect on the lungs and nervous system, the worst harm from smoking is due to carbon monoxide, a poisonous gas, which is picked up by the red corpuscles, displacing oxygen in the bloodstream. Dr Eliot of Florida reported that smoking can reduce the blood's oxygen-carrying capacity by up to 20%. It also destroys Vitamin C which is important in oxygen transport. Nicotine affects the nervous system causing free fatty acids to be released into the blood. At the same time it causes arteries to constrict and the heart rate steps up. Thus nicotine has a similar effect to stress. More red blood cells enter the blood from the body's reserves to compensate for the ones that are poisoned and this further increases the blood viscosity.
6. Stress. A reasonable degree of stress is normal in day-to-day activities. It has the effect of increasing blood pressure and the levels of certain hormones and fatty acids in the blood to provide for the anticipated activity associated in nature with stress. If the bloodstream is already thick and turbid, the viscosity will further increase, in which case this perfectly normal process can be dangerous.
7. Thyroid deficiency. An underactive thyroid due perhaps to a deficiency of iodine or Vitamin B1 (sugar can deplete this vitamin) reduces the metabolism of fat, thus increasing blood fat levels and also increasing blood cholesterol. Excess protein in the diet can also deplete the body of thyroxine.
8. Physical fitness. Although subject to the foregoing adverse factors of an incorrect lifestyle, the blood of a fit person does not suffer the degree of toxemia as that of an unfit person, because of the better metabolism of a physically fit body. Blood viscosity is always measurably less in athletes, regardless of diet.
9. Sunlight. Direct exposure to sunlight has an effect similar to that of physical exercise; blood fats and cholesterol reduce, blood viscosity lessens and oxygen levels increase, in addition to which hormone production improves and general metabolism becomes more efficient.

   Considering these factors, it does not take much imagination to realize how vital they are to a person with arteries almost closed with atherosclerosis.

   The condition of the arteries: Whereas the condition of the blood can vary from day to day, and if bad, can be rapidly rectified, the degeneration of the vascular system is a long process usually commencing in early childhood and continuing at a rate determined by living habits, primarily diet.

   The disease affects vessels throughout the body, and the early symptoms, which are plain to see, cause no great distress and indeed are considered normal. These may be in the form of "mildly" elevated blood pressure, gradual loss of high frequency hearing, or the requirement to wear reading glasses. When the arteries of the heart are affected specifically, the condition is called heart disease or coronary heart disease.

   Hardening of the arteries was once the most common form of cardiovascular disease, and is called arteriosclerosis. The hardening is caused by deposits of calcium and other insoluble minerals absorbed into the artery walls so that elasticity is lost and the artery gradually blocks, closing off the flow of blood. This condition can eventuate from a diet containing little or no cholesterol but excessive amounts of vegetable protein, mineral salts and fat, contained in cereals and nuts.

   To a lesser extent, arteriosclerosis can he caused by changes in blood composition brought about by excessive adrenal secretions. Such excessive secretions are caused by stress and the stress effects of nicotine, alcohol and sugar.

   The most common form of artery disease today is different. Instead of the long-term hardening process once synonymous with old age, a more rapid process called atherosclerosis occurs, affecting people much earlier in life. The name derives from the word atheroma, the Greek word for porridge, which describes the build-up of fat, cholesterol and fibrin in the artery lining which occurs with or without calcium and other minerals.

   Thyroid deficiency, as mentioned, can adversely affect fat metabolism and lead to artery degeneration. Dr Broda Barnes, MD, PhD, author of Solved: The Riddle of Heart Attacks (Robinson Press, Fort Collins, Colorado, 1976), contends that thyroid deficiency is the prime cause of atherosclerosis. He points out that removal of the thyroid gland in animals or humans soon leads to atherosclerosis and that administration of thyroid hormone will retard or prevent this process. Dr Barnes contends also that thyroid deficiency is far more common than is suspected and to a large extent is due to the demands placed upon the body by a high protein diet.

   The fact remains that one way or another, artery disease as we know it today is caused by our high protein, high cholesterol, high fat Western diet.

   The arteries become diseased more often where there is a bend or a branch, and there are a number of such points in particular where blockages commonly occur (see Fig. 10.1). As the disease progresses, the body degenerates further and more serious symptoms such as kidney failure, strokes, angina or heart attack may occur.

   The disease process is gradual and insidious, beginning at first as creamy streaks on the artery walls as cholesterol and fat begin to be deposited in the cells. The arteries' inner lining and the muscle layer next to it have no capillaries of their own and rely on oxygen transferred directly from the main bloodstream through the lining. With continuing high levels of dietary fat and cholesterol in the blood, more and more are absorbed into the artery walls.

   The process originates more frequently in places where deterioration has occurred in the artery walls, and research has indicated that such deterioration may be caused by a deficiency of Vitamin C resulting in lessened integrity of the collagen binding the artery's cells together. Smoking, by destroying Vitamin C, is not only deleterious to the blood but also to the condition of the arteries. The cells eventually become engorged and begin to burst. As the body attempts to heal the damaged area, new cell growth occurs, and together with fibrous tissue, a plaque is formed in the artery wall. With further deposits, the artery gradually closes, restricting the blood flow. The blood pressure increases in order to keep up an adequate flow of blood.

   As the condition worsens, the artery may lose elasticity, further increasing resistance to the blood flow. Sometimes calcium forms part of the deposits and the artery hardens like a clay pipe. This effect can result from excess protein in the diet which causes leaching of calcium from the bones. It also results from smoking.

   The plaques, like little abscesses, protrude from the artery walls interfering further with the blood flow. They may be isolated or numerous, affecting the artery in varying degrees.

   When the heart's own coronary arteries become badly blocked, perhaps 90-95% closed, severe coronary insufficiency occurs. In this precarious condition, relatively minor factors affecting blood viscosity can easily trigger a heart attack. Some heart attacks are caused by a piece of plaque becoming detached causing a blockage downstream from the diseased area.

   The fantastic ability of the body to adapt and protect itself enables tiny new vessels to grow around the obstructions in the artery and keep a limited blood flow going. This is called collateral circulation and has enabled people to survive even with their three coronary arteries totally blocked. A surgical means to alleviate distress caused by blocked arteries is to take a vein from another part of the body and graft it to each side of a blocked section to form what is called a by-pass.* Some people have a "triple by-pass" which means one on each of the main coronary arteries, and so the supply to the heart is restored. Unfortunately, about 8% of patients die within 30 days, and on an unchanged diet the new vessels acquire atherosclerosis much faster than natural arteries. Twenty per cent close in 12 months. With the by-pass working, the main artery closes completely and so does its collateral circulation at that point. Although initial relief is gained, unless strict dietary corrections are adopted survival rates are not much better. Another means of alleviating a blocked section of an artery has recently been demonstrated by Dr Andrea Gruentzig of Zurich University. A tiny plastic device is inserted into the artery and positioned where the plaque is blocking it, stretching the artery wider to permit the blood to flow.

*Collateral circulation assists trouble spots other than the heart and so too do surgical bypasses.

   Heart transplants have also been done in an attempt to rescue people with severe heart disease. Dr Phillip Blaiberg, at one time the longest surviving heart transplant patient, died after 19 months. He did not die because of tissue rejection as was at first thought, he died of a heart attack. The doctor who assisted Dr Christian Barnard, the surgeon, examined Blaiberg's second heart after death and found his arteries choked with atherosclerosis. The same doctor had examined it before the transplant when the arteries were healthy and clean. The diet that destroyed his first heart had destroyed his second heart. His cholesterol level had been over 300 mg% (7.7 mm/l) constantly, an extremely dangerous level for anybody.

   Smoking, by its effect on the nervous system, tends to constrict vessels. Long periods of inactivity cause the automatic operation of the capillaries to become sluggish in some parts of the body, resulting in circulation impairment and increased blood pressure. Alcohol immobilizes enzymes in tissues for long periods, preventing release of oxygen to the cells.

   Obesity: Excess body tissue in overweight people depletes the efficiency of the cardiovascular system for the following reasons:

1. Useless tissue must be supplied with blood, adding to the heart's workload.
2. "Deadweight" equivalent to carrying a load of bricks everywhere adds further to the heart's workload and discourages physical exercise which is vitally important.
3. Excess fat is readily released into the bloodstream.
4. Sagging of vital organs hinders circulation and impairs the function of the lungs.

General signs of advancing cardiovascular disease

   Premature aging, blotchy skin.
   Florid face.
   Arcus senilus (a lightly colored ring around the iris of the eye).
   Deteriorating eyesight, loss of peripheral vision.
   Deteriorating hearing, loss of high frequency range.
   Slowing reactions, vagueness, lack of stamina.
   Low resistance to infection, colds.
   Drowsiness after eating.
   Dizziness on exertion.
   Poor circulation, sensitivity to cold.
   Shortness of breath.
   Swollen tissues.
   Leg pains.
   Angina (pain in chest, perhaps in arms, after meals or on exertion but sometimes at rest).
   Sweating for no apparent reason.
   High resting pulse rate.
   Increased thirst and appetite and rapid loss of body water (diabetic symptoms).

   Do not take these signs lightly just because they may not be regarded as clinical symptoms, and note well this remark of Dr Kenneth Cooper: "you have to keep in mind that the most common first symptom of severe underlying heart disease is sudden death. For a lot of people that's the only symptom they will ever have".

The causes of cardiovascular disease summarized

   Cardiovascular disease is caused by lipotoxemia which is a condition of the blood involving high blood fat and cholesterol levels. The viscosity of the blood increases, the oxygen-carrying capability decreases, and blood pressure increases. Cholesterol, fats, fibrin and sometimes calcium permeate the artery walls, as the deposits build up, the artery closes off blocking the flow of blood. The fatty substance is called atheroma, and the condition is atherosclerosis.

   The condition arises from improper diet but is enhanced by smoking, alcohol, lack of exercise and to a lesser extent caffeine, unremitting stress and lack of rest.

   The dietary substances most to blame are meat and other flesh foods, eggs and dairy products, all of which contain excessive amounts of fat, cholesterol and protein. A full description is given in Chapter 15.

Hypertension and heredity

   Hypertension: Note that high blood pressure (hypertension) has not been listed as a cause of cardiovascular disease. It is often a symptom (particularly when the kidneys are affected) as will be explained later. High blood pressure may occur without the presence of atherosclerosis, and atherosclerosis may occur without high blood pressure.

   The Japanese have the highest hypertension rate in the world, thought to be due to their heavy intake of salt, but have a low incidence of heart disease.

   Heredity: It is easy to see why heredity sometimes appears to be a factor in cardiovascular disease. But all degenerative diseases stem from poor living habits, and bad dietary habits are passed from generation to generation. They can be disastrous to a family, but they are not inherited. When people leave their family, migrate and adopt a different lifestyle, then regardless of their family back in Ireland, Japan, Yemen or the New Guinea Highlands, they, just like McCarrison's rats and laboratory monkeys, acquire the characteristic effects of their new lifestyle.

   However, as described in Chapter 8, heredity can influence the chance of a heart attack once a person has advanced cardiovascular disease and is all "set up" for one. This is by virtue of their personality which is inherited.

   Heredity appeared to be a factor in the case of my wife's heart disease which was described in Chapter 2. All her four brothers had heart attacks, three fatal. Of her two sisters one died of heart disease and stroke and the other of cancer. All occurred between the ages of 37 and 58.

   Notwithstanding such a disastrous family history and her failure to adopt an exercise program, she is now in better health than ever before and her physician's report substantiates this fact. She has changed her lifestyle. If she had inherited a stronger will she could have made better progress as she will not rigidly follow her program.

The protective effect of raw food

   The high consumption of meat and dairy products is undoubtedly the major cause of atherosclerosis in modern times. However, long research by Dr Edward Howell indicates that the animal protein, fat and cholesterol contained in meat and dairy products are far less harmful if these foods are consumed raw.

   Raw meat contains the proteolytic enzyme cathepsin and the fat-digesting enzyme adipose lipase. All animal fats, raw, contain lipase. When animal protein or fat is consumed raw, the enzymes accomplish a certain amount of predigestion in the cardiac (upper) stomach before being inactivated by the stomach acid further down, and so the final digestion of these substances in the intestine is more complete and they are assimilated in a relatively harmless form.

   It has always perplexed nutritionists how primitive Eskimos and Masai natives could maintain good health as long as they do on diets consisting of almost lethal quantities of animal protein and fat. The answer to that puzzle, according to Dr Howell, is that apart from other lifestyle factors in their favor, these people, like the wild carnivorous animals, eat most of their food raw. (The name Eskimo is derived from the Cree Indian expression: "he eats meat raw".)

   Dr Howell blames the cooking of food for practically every disease known to man. He points out that raw milk, containing 35 different enzymes, is an entirely different substance to the pasteurized dairy products of today, which are known to contribute to atherosclerosis. In his paper, "Lipase versus Cholesterol" (1983), Dr Howell says:

   "Lipase is destroyed by cooking. Could it be that the bad reputation of cholesterol starts in the human digestive tract when fat, divorced from its lipase companion, is forced to remain idle and unaltered in the stomach during the period of 2 or 3 or more hours after it is swallowed? While ptyalin and then pepsin digest carbohydrate and protein in the stomach, lipase is absent and fat cannot be digested. But when fat is eaten raw, with its lipase undamaged by heat, it also can be digested in the upper stomach prior to the time the acidity becomes strong enough to prevent further action.

   "When unaltered fat, deprived of its lipase companion, must confront strong hydrochloric acid in the human stomach, it faces a new and harsh experience. It may be left with a structural defect, or impairment with some undesirable trademark that prevents it from being properly digested in the intestine and hence improperly metabolized when it reaches the body tissues later. It must be remembered that in both animals and humans, it is impossible to prevent fat plus lipase from engaging in initial digestion during the first hour in the stomach.

   "It has been shown that even ptyalin, which is more effective on starch near neutral pH, digests in the cardiac and fundic portion of the stomach for a period approaching an hour. The lipase associated with fat, in common with other food enzymes, has a pH optimum further down on the acid side of the pH scale, and therefore can be expected to digest fat in the upper stomach (the food-enzyme stomach) for a period at least as long as ptyalin can work on starch. This happens every day in the stomachs of millions of wild animals, and for epochal periods before the cooking era, evolution contrived to make it a regular scheduled event in the human stomach. It appears, therefore, that fat is being denied its traditional digestive rites during its passage along the digestive tract. And this may well be the reason that animals and humans, eating raw fat with its lipase, are immune to cardiovascular disease. Thus a strong reason emerges why research to explore this promising area is long overdue and merits top priority for allocation of research funds."

   To conclude on cardiovascular disease, here are two extracts from Lifestyles, Major Risk Factors, Proof and Public Policy by Jeremiah Stamler MD in his George Lyman Duff Memorial Lecture, 1977:*

*The paper originates from the department of Community Health and Preventive Medicine, North-western Medical School, Chicago, and appears in Circulation, Vol. 58, No. 11 July 1978.

1. "An additional comparison has recently become available, with data on mortality, for three groups of Californian Seventh Day Adventists (nonvegetarian, lacto-ovo-vegetarians-- vegetarians who eat milk, cheese and eggs--and pure vegetarian) compared with the Californian general population. Seventh Day Adventists have lower mean serum cholesterol levels than Americans generally. For 47,000 Seventh Day Adventist men aged 35 and over, age-sex-standardized, mortality rates were 34 per cent lower for non-vegetarians, 57 per cent lower for the lacto-ovovegetarians and 77 per cent lower for the pure vegetarians compared to the general population. Seventh Day Adventists differ from the general population in other respects as well, eg. abstinence from both alcohol and tobacco."
2. "Since the data from both animal and human studies indicate that high blood pressure and cigarette smoking are minimally significant for atherogenesis in the absence of the nutritional metabolic prerequisites, it is further reasonable and sound to designate 'rich' diet as a PRIMARY, ESSENTIAL, NECESSARY CAUSE of the current epidemic of premature atherosclerotic disease raging in the Western industrialized countries. Cigarette smoking and hypertension are important secondary or complementary causes."