The Cholesterol Cult & Heart Mafia: How the process of science evolves into The Science™ of public policy
"Narrative selection" is a process by which scientific ideas evolve into public dogmas.
Summary of main points:
Diet-heart hypothesis remains culturally dominant: dietary saturated fat and cholesterol raise blood cholesterol, driving heart disease. Shapes everything from casual beliefs (steak & eggs = heart attack) to elite decisions (Bill Gates on plant-based meat).
Dietary cholesterol has diminishing effects on serum LDL due to negative feedback regulating endogenous synthesis. Both very high and very low cholesterol levels associate with worse health outcomes.
Scientific ideas spread via “narrative selection”: social utility—fitting institutional goals and status hierarchies—trumps empirical fit. Ideas become dogma when they justify policy and secure positions for high-status actors.
Mid-20th century heart disease crisis created pressure for quick solutions. Ancel Keys’ thesis gained traction despite cherry-picked data (Seven Countries Study).
Contradictory evidence suppressed: rigorous Framingham results showing no link between saturated fat and heart disease were buried; critics lost funding and were marginalized, manufacturing an illusion of expert consensus.
Large trials replacing saturated fat with PUFAs lowered cholesterol but failed to cut cardiovascular or total mortality. PURE study and reviews show saturated fat not linked to higher heart risk—and sometimes lower total mortality/stroke risk. U-shaped mortality curve: extremes of cholesterol both hazardous.
Institutions (AHA, NIH—“heart mafia”) protected the narrative through funding incentives and dogma enforcement, turning incomplete science into official public policy and dietary guidelines.
Your biology is the real test: population patterns and guidelines often don’t apply individually. Personal bloodwork before/after dietary shifts reveals your actual response—frequently defying diet-heart predictions. Treat life as an n=1 experiment.
A recent online interaction interaction with Elon Musk illustrates a common belief about human health which has been endemic to the Western world since the mid-1900s:
Musk: Wow, steak & eggs with coffee in the morning really feels like a powerup!
Some guy: Sounds like a heart attack in the long-term.
This response comes from a belief that higher cholesterol levels entail higher cardiovascular disease risk. Whether he realizes it or not, the gentleman above is espousing belief in the “diet-heart hypothesis”: dietary saturated fat and cholesterol increase blood cholesterol, driving heart disease. Hence the belief, steak & eggs = heart attack.
Knowingly or not, Bill Gates is another proponent of the diet-heart-hypothesis. It shapes his evaluation of what constitutes a healthy diet and steers his decision making about where to place investments. Here’s something he said about diet and human health:
Bill: Of all the categories, the one that has gone better than I would have expected five years ago is this work to make what’s called artificial meat. And so you have people like Impossible or Beyond Meat, both of which I invested in.
Some guy: Do you eat it as well? Do you like it?
Bill: Absolutely. You can go to Burger King and buy the Impossible Burger.
Some guy: Is it healthier for you, or just healthier for the atmosphere?
Bill: It’s slightly healthier for you in terms of less cholesterol.
I have no interest in wading into the economics or ethics here. Our focus will be on Mr. Gates’ health claims about cholesterol and plant-based meats, the psychology from which they arise, and the social mechanisms that can produce an illusion of consensus in science.
What does Bill mean when he says that plant-based artificial meat is, “healthier for you in terms of less cholesterol”? He means that it contains less cholesterol than animal meat and will therefore reduce your cardiovascular disease risk. Standard thinking among devotees of the diet-heart thesis.
But there’s a problem: dietary cholesterol intake has only a modest impact on cholesterol levels. There’s also a “diminishing returns” effect—the higher the baseline level of dietary cholesterol intake, the less serum cholesterol rises in response to consuming more. This is likely due to negative feedback mechanisms that reduce cholesterol synthesis within the body in response to dietary intake. The fact that our bodies synthesize cholesterol de novo and negative feedback mechanisms exist to regulate overall levels tells us something: the body “wants” cholesterol levels to be neither too high nor too low. (More on that, later).
Like most people, Mr. Gates doesn’t seem to know these things. Saturated fat intake can increase serum cholesterol, but the plant-based meats Bill invested in have similar saturated fat levels to animal meat. Artificial plant meats do have lower cholesterol content than real meat, which is why Bill said what he said. Like I once did, Gates appears to believe in the diet-heart hypothesis without knowing much about the relevant biology.
Why would somebody believe in a biological idea without a solid grasp of the underlying biology? Especially someone with a reputation as smart, evidence-based, and pro-science? Perhaps the answer is that, like me, Mr. Gates did not arrive at his beliefs regarding cholesterol from thorough examination of the relevant science. Perhaps, like me, his beliefs were given to him by fiat.
Mr. Gates and Mr. Musk represent two types of people with respect to the diet-heart hypothesis. The first type believes in it implicitly, likely without ever having held a different viewpoint: dietary saturated fat and cholesterol drive heart disease—therefore: steak and eggs bad, plant-based meat good. The second type represents a smaller slice of people who once endorsed the diet-heart thesis, but no longer do (they may also be totally unaware of this). I’ve been both types. As a child, I believed it was healthy to minimize saturated fat intake and replace cow’s milk with soy milk. Today, I eat lots of eggs, grass-fed beef, and butter.
How and why do these beliefs arise and evolve in different ways, in different people?
We’ll be delving into some of the biology and history relevant to the diet-heart hypothesis, but only insofar as it helps support my effort to analyze how science-based beliefs form and spread in modern society. More specifically, we’ll look at the ways in which scientific ideas can spread by non-scientific social transmission mechanisms. Doing this will reveal how many “evidence-based” claims are little more than religious beliefs masquerading as science in order to dictate how people’s behavior should be managed. Ultimately, this is done to promote social structures that secure the positions of high-status people within status hierarchies.
Fiat Science: How the public assimilates scientific ideas
As an old Millennial born in the late 1980s, I grew up at the height of the diet-heart hypothesis’ potent influence on American society. The low-fat craze. Plenty of grains. I Can’t Believe It’s Not Butter! The focus on low-fat dieting distracted people from how much added sugar was in their “heart healthy” cereal. The demonization of saturated fat caused us to feel good about spreading fake butter loaded with industrial trans fats onto our white bread. Ideas spread when they make people feel good about themselves.
Dietary guidelines are set by government institutions, made in consultation with credentialed experts. The official guidelines were distilled into the food pyramid, diligently uploaded to the minds of American school children by the public school system. People did heed the guidelines, as reflected in food consumption treads seen in the data (dissected more thoroughly, here). In the 1990s of my childhood, everyone was preaching the low cholesterol gospel.
I wish we could blame Fabio, but every adult who my young mind naturally viewed as an authority said the same things, for my entire childhood and adolescence. Today, many of those adults are either dead, obese, or shooting up Ozempic. Those living probably still believe that eating cholesterol is unhealthy. We received the ideas by fiat—credentialed experts told us it was The Science™.
It doesn’t feel like a cult while you’re in it. But I’m getting ahead of myself.
As an adolescent I remember explaining to my mother that Silk was healthier than milk. Like most teens, I knew it without ever reflecting on the origins of my belief, which did not arise from careful study of physiology. At the time, I had no interest in or knowledge of human metabolism. But believing the right thing made me feel good. It also felt good telling other people what to believe. I was a vector for a meme.
Like a cold, my belief was something I caught, something in the air—or rather, on the television. Just as we don’t choose to be infected by viruses, we don’t choose to be infected by memes. We catch them from the environment.
It was only after years of study that I renounced my faith in the tenets of the diet-heart creed. In that time, the same set of beliefs about the negative health effects of saturated fat and cholesterol continued spreading globally. I may have lost faith in the diet-heart hypothesis, but Bill Gates has not. Your family doctor almost certainly believes in it, which is why cholesterol-lowering drugs (statins) are among the most-prescribed pharmaceuticals ever. In fact, there is wide consensus among medical experts—people with stellar credentials and high-level positions in government agencies, global health organizations, and hospitals—that the diet-heart thesis is correct. Should we not trust the experts, especially when there’s consensus among them?
The diet-heart "consensus” is illusory. I’m certainly not the only one who has lost faith. To understand what’s going on here, we have to do two things:
See plainly that the diet-heart hypothesis is anything but settled science.
Understand how scientific ideas become dominant within institutions, enshrined in public policy, and exported to the masses in narrative form.
Doing this will reveal that scientific ideas do not spread solely based on the quality of supporting evidence, and that expert consensus is not merely a function of dispassionate truth-seeking. Our ideas serve social functions and spread based on their social utility. As social animals, our lot in life is determined by our position in social status hierarchies. We live in groups. Some of these are informal and form through spontaneous interaction, such as your circle of personal friends. Others are formally structured and explicitly designed to assemble and disseminate ideas into coherent narratives, such as institutions. The purpose of such narratives is to organize human group behavior
In the Darwinian battle of ideas, a meme will spread insofar as it can be integrated into a social narrative that justifies the growth and expansion of institutions. Institutions are designed to communicate ideas to people en masse, and are composed of humans—people who adopt and promote ideas that justify their social goals (e.g. career advancement). I’ve called this process, “narrative selection,” by analogy with natural selection.
The truth value of an idea is just one of many things that determine an idea’s social utility. As Mark Twain said, “A lie can travel halfway around the world while the truth is still putting on its shoes.” People routinely adopt and spread ideas for reasons other than truth. The word politics comes to mind.
Like most people, my implicit childhood belief in the diet-heart thesis came to me by fiat—I was told to believe those things by elements of culture, including corporate advertisements and who I perceived to be an expert. One way this occurs at scale is through an official (government) public education campaigns, built from the perception of expert consensus within key institutions dictating public policy.
Illusion of Consensus: How institutions manufactured the diet-heart “consensus”
The saga of the diet-heart hypothesis, how it spread, and why it never rested on compelling evidence, has been covered in detail elsewhere. For a concise history, I recommend this paper. I’ve also discussed this topic with multiple physician-scientists on the podcast:
M&M #135: History of Diet Trends & Medical Advice in the US, Fat & Cholesterol, Seed Oils, Processed Food, Ketogenic Diet, Can We Trust Public Health Institutions? | Orrin Devinsky, MD
M&M #140: Obesogens, Oxidative Stress, Dietary Sugars & Fats, Statins, Diabetes & the True Causes of Metabolic Dysfunction & Chronic Disease | Robert Lustig, MD
To repeat the diet-heart thesis: higher cholesterol levels are associated with higher rates of cardiovascular disease. When surgeons scoop plaque out of arteries, those plaques contain cholesterol. Saturated fat intake elevates serum cholesterol. Therefore, blood cholesterol is the main culprit in heart disease, and limiting saturated fat intake is the dietary solution.
Our society is ruled by consensus mechanisms. Elected officials are chosen by a majority consensus of voters. Public health policies and dietary guidelines are set by official institutions like the USDA, which constructs them by consultation with experts—people uniquely qualified to determine what is true, and communicate a reasonable consensus of the facts to policymakers. These experts are typically people with specific credentials granted to them by other institutions, such as universities. They are also humans, with the same self-interested social goals as anyone else.
Social crises increase the pressure to reach consensus
Since at least the 1950s, the diet-heart thesis has been the dominant narrative in medicine, promulgated to the masses by large institutions via public education campaigns. It was championed by the Dr. Ancel Keys in the mid-1900s. In a nutshell, his hypothesis spread due to the efforts of Keys and his supporters, who were able to get an out-sized amount of weight placed on the limited evidence they had to support it. Keys wasn’t just a hard-working researcher—he was socially successful, spreading his ideas via relationships with decision-makers in influential institutions.
A social crisis made the hasty adoption of Keys’ ideas possible: the US was in the midst of a cardiovascular disease epidemic, brought to the fore of public consciousness when President Eisenhower suffered a massive heart attack in 1955. A public health crisis creates intense pressure for policy solutions. For a high-profile national problem, those who are recognized as solving it will be granted much social status. Those working on the problem, like Dr. Keys, were highly motivated to provide a solution and receive recognition for it.
Here is a graph from the American Heart Association, showing deaths from heart disease and cancer over time:
Notice that heart disease deaths were rising by 1950, peaked by 1990, then mostly declined. In contrast, cancer rates have steadily increased over the same time period (keep that result in the back of your mind). If high cholesterol driven by saturated fat intake is the major driver of heart disease, we’d expect to see correlated change in saturated fat consumption over this interval. Likewise, because polyunsaturated fats (PUFAs) from vegetable oils and other processed foods lower cholesterol, we would expect to see an inverse relationship with heart disease under the diet-heart hypothesis.
What do we observe?
Saturated fat consumption was actually flat, even declining somewhat, from 1940 into the 1970s. In contrast, PUFA consumption has almost continually been rising since the early 1900s. These high-level trends were driven largely by the replacement of animal-based fats (higher in saturated fat) with PUFA-rich vegetable (seed) oils starting in the 1940s. In other words, during the heart disease panic of the 1950s and 60s, when Keys’ ideas were adopted, saturated fat intake had already begun to be replaced by PUFAs.
PUFAs are deemed “heart healthy” by the AHA and other major institutions. Coincidentally, AHA was paid over $20 million in today’s dollars by Procter & Gamble, makers of the PUFA-rich seed oil Crisco, back in 1948. That was a few years before Eisenhower’s heart attack, when the heart disease crisis came into full public view. In 1961 AHA provided the recommendation to limit saturated fat intake, which has been called, “arguably the single-most influential nutrition policy ever published, as it came to be adopted first by the U.S. government, as official policy for all Americans, in 1980, and then by governments around the world as well as the World Health Organization.” Virtually all major health institutions coalesced around one narrative, ostensibly because a scientific consensus had formed.
Public health crises demand solutions now, not later. Policymakers want to implement expert-approved solutions ASAP—jobs, promotions, and credibility are on the line. The experts they consult may therefore be motivated to sell the best ideas they have as more iron-clad than they really are. Experts closely connected to the policymaking apparatus will be biased to prematurely coalesce around the most ascendent ideas suggesting an implementable policy solution, so that they may gain social status by association with the winning idea. The greater the social pressure, the greater the chance for an illusory consensus to emerge.
While Keys and others did amass evidence for their claims, this evidence had major shortcomings:
Much of it was correlational, lacking the ability to establish cause-and-effect relationships between dietary saturated fat and cholesterol with heart disease.
Animal research, causally showing that dietary cholesterol (a) spiked blood cholesterol, and (b) led to cardiovascular disease, was often done in species metabolically distinct from humans. For example, many early studies in this field used rabbits. As herbivores, rabbits respond to dietary cholesterol in radically different ways from meat-eating omnivores like humans. Their bodies did not evolve for cholesterol intake.
Many of the human epidemiological studies showing a correlation between dietary fat consumption and heart disease were either highly undersampled, not representative of the populations they drew from, or composed of cherry-picked data. The most infamous example is Keys’ “Seven Countries Study.” The observed associations often disappeared when more robust datasets were analyzed, and have been contradicted by larger, more robust analyses since.
Despite those shortcomings, Dr. Keys’ hypothesis gained favor. Weaknesses in the evidence were overlooked due to the immense social pressure surrounding the very public spotlight that had been placed on solving the problem. The evidence was viewed as good enough, given the pressure policymaking institutions were under to implement a solution.
Competition for social status distorts the “marketplace of ideas”
If you study the history of Ancel Keys, you see clearly that Keys was not just a prolific and hardworking researcher, he was also a charismatic and ambitious career man. Even in science, ideas do not rise and fall based solely on the strength of evidence. Their adoption is a function of both the supporting data and social factors, such as salesmanship. Like anyone else, scientists are motivated by fame and glory (social status). Keys knew how to sell his ideas, and to cultivate a social network connecting him to decision makers within powerful institutions.
Ideas do not exist as disembodied Platonic forms, competing with one another in a rational “marketplace of ideas.” Ideas exist in human minds, which are only partially rational and truth-seeking. Ideas spread between minds through social interaction, battling for dominance based on their utility in putting people on a desired trajectory within social status hierarchies. People want either more status or security in what they have, choosing to endorse and spread ideas accordingly.
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