1182 Those who require brain biopsy for proof of infection may that these three patients had herpes encephalitis. However, Dr M. Longson will shortly be publishing confirmatory studies of serum:CSF ratios in patients with positive brain

deny

biopsies. The emergence of potentially active antiviral agents, the universal agreement for the need for early treatment, and the natural reluctance of many neurosurgeons to advise brain biopsy for patients with early encephalitic illness support the belief that the ability to prove herpetic xtiology in convalescence is a valuable addition to the management of this difficult illness. "Goatsmoor Hall", Goatsmoor Lane, Stock, Essex CM4 9RS

G. DONALD W. MCKENDRICK

PREVENTION OF CORONARY HEART-DISEASE

SIR,-Professor Morris (Nov. 3, p. 953) asks what

we are

with the knowledge we already have about the prevention of coronary heart disease. In the U.K., unlike some other countries, official caution about taking preventive measures without having absolute proof has led to paralysis of effective action. Reduction of cigarette smoking alone would have an immediate impact on coronary mortality, especially in Scotland where smoking rates are so high. At the Fourth World Congress on Smoking and Health, held in Stockholm in June, Y. Bostock and J. K. Davies reported that, in 1976, the average cigarette consumption per adult was greater in Scotland than in England and Wales, by 20% for men and 31% for women (General Household Survey). At least 25 000 deaths a year from cardiovascular disease in the U.K. can be attributed to cigarette smoking. A fall of only 20% in cigarette consumption could lead to 8000 fewer deaths each year, and a half of this saving would be from cardiovascular disease.’ There is an immediate opportunity for doctors, through their own members of Parliament or professional bodies, to press the Government to take a firm stand in the forthcoming negotiations with the tobacco industry so that the D.H.S.S. achieves its declared policy of phasing out tobacco advertising and sponsorship. At the Stockholm conference Sir George Young, Under-Secretary of State at the D.H.S.S., said: "The solution to many of today’s medical problems will not be found in the research laboratories of our hospitals but in our parliaments". But Parliamentary action on such issues would be much strengthened if backed by the unequivocal support of the medical profession. Morris rightly states that all the independent committees considering diet and coronary disease have recommended a reduction in saturated fats. The COMA Committee of the D.H.S.S. in 1974 recommended that "The amount of fat in the U.K. diet, especially saturated fat from both animal and plant sources should be reduced." Unfortunately almost nothing has been done to implement this recommendation, and it is not surprising that the Scottish consumption of fats remains so high or that Britain is one country where low-fat liquid milk is virtually unobtainable. This inaction has led the purveyors and promoters of saturated fats to take the initiative. I have just received a package of literature from the Butter Information Council, as no doubt have many other doctors, which includes extracts of the opinions and reprints of well-known opponents of the Department’s view that the consumption of saturated fats should be reduced. They even use the cover of the D.H.S.S. booklet Eating for Health to support their case. The Butter Information Council and the National Dairy Council are conducting a massive advertising campaign to per-

doing



public to disbelieve the conclusion of the international committees. A few months ago the Butter Information Council circulated general practitioners with a one-sided account of the coronary diet question, citing certain eminent physicians who publicly associate themselves with the Council’s view. The ethics of such promotional activities are to say the least dubious. Although I agree with many of Morris’s conclusions, it is hardly fair of him to blame the Joint Working Party of the Royal College of Physicians and British Cardiac Society (J.W.P.) for public inertia on diet and heart disease. The recent interest in the U.K. really followed the publication of the J.W.P.’s report in 1976. Almost no notice had been taken of the COMA report until that time. The J.W.P. covered many aspects of prevention of CHD and no more than a fifth of it was devoted to dietary advice. Of its many recommendations, the one which provoked most antagonism, although in conformity with the majority view, was that there should be a partial substitution of saturated with polyunsaturated fat. Anyone who has attempted to treat patients with a low fat diet, without any substitution with monounsaturated or polyunsaturated fats or oils, will know that most people find such diets unacceptable. Apart from this, polyunsaturated fats have important properties in controlling the concentration of plasma lipids and platelet function, and are the precursors of prostaglandins, which have many important properties in the context of atherosclerosis and CHD. Morris asks who should take the lead in coronary prevention. On the matter of diet is this not the responsibility of the Health Education Council? A clear recommendation from them along the lines of the consensus of international opinion would help to counteract the strident voices of commerce. Should not the profession take a stand against such unsolicited and one-sided dietary advertising, whichever interest it represents ? suade doctors and

Department of Community Medicine, Middlesex Hospital Medical School, Central Middlesex Hospital, London NW10 7NS

WHY BLAME CHOLESTEROL?

SIR,-Your Nov. 3 issue contains contributions implying anxiety about blood cholesterol and arterial disease. This narrow myopic view takes no account of much relevant, wellestablished pathological, clinical, and experimental evidence which cannot be ignored in any scientific appraisal. 1,2 Episeem to rely on less secure information like death certificates and speculative extraneous influences which would be unacceptable in laboratory science. (1) Only about 50% of plaques contain any visible cholesterol. Cholesterol is not seen in the early gelatinous phase of

demiologists

the plaque.’

(2) Homozygous hypercholesterolaemia causes heavy lipid deposition at the mouths of the coronary arteries often leaving the main coronary branches intact and thus does not reproduce the common type of coronary occlusion. The elevated cholesterol levels of myxcedema and nephrosis are not associated with increased coronary disease, even when the nephrosis becomes complicated by hypertension at a later stage.4 (3) Modest increases in cholesterol are often seen in arterial disease. Anitschkow5 knew this, but would not accept it as causal. He wrote "the occurrence of cholesterol in the aortic wall 1. McMichael J. Fats and atheroma: an inquest. Br Med J 1979; i 173-75. 2. McMichael J. Fats and atheroma. Br Med J 1979; i: 890. 3. Smith EB, Smith RH. Early changes in aortic intima. Atheroscler Rev 1976,

1: 119-36. 4. Wass

1.

Smoking and Health: A study of the effects of a reduction in cigarette smoking on mortality and morbidity rates. Department of Health and Social Security, 1972.

KEITH BALL

VJ, Jarrett RJ, Chilvers C, Cameron JS. Does the nephrotic syndrome the risk of cardiovascular disease. Lancet 1979; ii: 664-67.

increase

5. Anitschkow N. Die bedeutung des erhöten cholesteringehaltes fur die entstehung der aortenatherosklerose Dtsch Med Wschr 1914; 40: 1215-16

Prevention of coronary heart-disease.

1182 Those who require brain biopsy for proof of infection may that these three patients had herpes encephalitis. However, Dr M. Longson will shortly...
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