Pure, White and Deadly

Becoming a prophet in your own country can be difficult. So can becoming a medical classic in the BMJ. The travails of both are illuminated by John Yudkin and Pure, White and Deadly, his most famous and recently reissued book.

Despite its startling title, the work is a sober analysis of the health problems, especially heart disease, associated with sugar. Published in 1972, it seemed perfectly timed for rapid conversion from nutrition science into nutrition policy. Yudkin was then serving on the advisory panel on heart disease of the UK Department of Health’s Committee on the Medical Aspects of Food and Nutrition Policy (COMA).

But opponents, notably Ancel Keys, high priest of fat theorists, publicly ridiculed Pure, White and Deadly. Others ignored it. When COMA published its conclusions in 1974, Yudkin felt compelled to append a note of reservation, concluding that “the Report has exaggerated the possible role of dietary fat in causing IHD [ischaemic heart disease], and has minimized the possible role of dietary sucrose.” The 1984 version of COMA never mentioned Yudkin or the role of sugar at all. Its 1994 report on coronary heart disease included a section on carbohydrates, but Yudkin was not among the 414 references. Meanwhile, unobserved by medicine, Yudkin became a cult hero in dental public health, broadening concern about sugar beyond teeth.

The book went out of print, and Yudkin died in 1995 just as his greatest impact was developing—low carbohydrate diets. Controversy focused on Robert Atkins, not coincidentally a cardiologist and a more combative character than Yudkin. But dozens of low carb diets appeared, by Agatston, Sears, Kenton, Holford, Brand-Miller, and many others. A passionate and polemical debate over low fat versus low carb ensued, only subsiding after Atkins’ death in 2003. With hindsight, Yudkin played a largely unacknowledged role as John the Baptist to a multitude of low carb prophets.

Public attention on sugar and health, however, continued. The World Health Organization’s report on diet, nutrition, and chronic disease in 2003 drew attention to sugar and obesity, and provoked initially fury and then subsequent engagement from food multinationals. Regular pieces of journalism, such as those by Gary Taubes, and frequent television exposés, such as “The Men Who Made Us Fat” (BMJ 2012;345:e4465) earlier this year, kept the pot bubbling.

The turning point came with a 90 minute lecture by paediatrician Robert Lustig in 2009, which has attracted three million viewings on YouTube. It has been expanded into a book, Fat Chance: the Bitter Truth about Sugar, also just published in the UK.

Lustig also wrote the introduction to the reissue of Pure, White and Deadly, and was more generous than others in acknowledging his intellectual debt. “I’m proud to be a Yudkin disciple . . . Every scientist stands on the shoulders of giants . . . Dr John Yudkin was indeed a giant.”