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5. The Fall and Rise of a Risk Factor: Cholesterol and Its Remedies
- Johns Hopkins University Press
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c h a p t e r f i v e The Fall and Rise of a Risk Factor Cholesterol and Its Remedies Those drugs thou hast, and their adoption tried; grapple them to thy soul with hoops of steel; But do not dull thy palm with entertainment of each new-hatch’d unfledged remedy. —The Pharmacological Basis of Therapeutics, 1954 Cholesterol is a familiar figure in contemporary American life. Even if the average consumer is not conversant with the chemical structure of this fiveringed sterol or its role in the biosynthesis of bile acids,sex hormones,and gallstones , chances are that he or she knows cholesterol to be an agent of progressive disease of the heart and blood vessels, to be avoided in one’s diet and minimized in one’s bloodstream to prevent illness and promote longevity.High cholesterol was one of the first identified risk factors for coronary heart disease. It shared top billing with high blood pressure as one of the two “prepathological ”categories found, in the initial Framingham Study publications of 1957, to be firmly predictive of heart disease.1 By 1974 these two had been joined by diabetes , gout, smoking, obesity, and a host of other behavioral and physiological states to form the Framingham risk factors for heart disease.2 As we have seen, by the mid-1970s asymptomatic treatment of such categories on a basis of pharmaceutical prevention had already become standard practice in many medical arenas. Not so with cholesterol. Over the course of the 1970s, while consensus developed around high blood pressure as a condition demanding preventive treatment,the status of high cholesterol as a treatable state had,if anything,deteriorated . It had not, like hypertension, attracted effective and palatable new medications in the 1950s and 1960s. Drugs devised to lower cholesterol either didn’t work, weren’t safe, or were found to have unpleasant side effects that made the calculus of preventive therapy untenable. The benefits of nonpharmaceutical interventions such as low-cholesterol diets were difficult to substantiate . Over the course of the 1970s, popular accounts of cholesterol and health began with broadly confident attempts to mobilize readers against high cholesterol and shifted to paranoid criticism of elevated cholesterol as a healthfad fabrication. In 1980 the National Academy of Sciences issued a report suggesting that widespread efforts to control cholesterol levels lacked justification in the clinical and scientific literature, sparking a new wave of controversy over the value of cholesterol to individual health. How did cholesterol lose its relevance in the growing canon of physiological prevention? And how, in the period since 1980, did the perseverant compound find its way back into the sphere of mainstream clinical activity and mobilized public anxiety? Although pharmaceutical developments did not single-handedly determine this trajectory, both the fall and the rise of cholesterol as a risk factor were intimately related to the performance and promotion of discrete drug entities. Chapter 4 depicts a category of preventive pharmacotherapy —the treatment of asymptomatic diabetes with oral hypoglycemics— whose usage persisted even after the principal therapeutic agent was deemed ineffective and potentially harmful by a supposedly definitive clinical trial.This chapter offers a complementary contrapositive, for the story of cholesterol in the 1970s and 1980s recounts the failure of a category of risk reduction to survive in the absence of an appealing intervention. Atherosclerosis and Its Germ Equivalent By the mid-twentieth century, cholesterol had accumulated the most convincing causal claims of any putative etiological agent of coronary heart disease . Unlike the obliquely relevant physiology of blood pressure and blood sugar, or the behavioral fuzziness of weight gain and smoking habits, the role of cholesterol in the development of heart disease was borne out by an explicitly lesion-based model of disease. The molecule of cholesterol itself was present , and always present, in the fatty streaks, plaques, and clots that plagued the inner arteries of patients with atherosclerotic heart disease. It is deeply ironic 152 Mevacor and Cholesterol, 1970–2000 [3.83.87.94] Project MUSE (2024-03-28 21:47 GMT) The Fall and Rise of a Risk Factor 153 that cholesterol—perhaps the closest thing to a germ that the search for causal agents of coronary heart disease could muster—would take so long to be legitimated in clinical practice. To describe cholesterol as equivalent to a germ is not to claim that cholesterol was ever seen as an infectious agent...