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Since the late 1960s there have been dramatic falls in mortality from cardiovascular disease, across western and northern Europe and north America. In the UK, age-standardized death rates from cardiovascular disease declined by 74% from 1969 to 2013 and in the US the age-standardized death rate for coronary heart disease had fallen by 76% from its peak in 1968 to 2010. Death from cardiovascular disease, particularly coronary heart disease, is to a large extent a 20th century phenomenon— doubling between 1920 and 1960, then declining rapidly from the late 1960s (Figure 1a). This point was made very effectively by Grimes in his QJM review where he also suggested that appearance and later disappearance of a biological environmental factor might be responsible. Reduction in established risk factors such as smoking (down in the US from 42% of adults in 1965 to 18% by 2013), cholesterol and blood pressure has been estimated to account for between 44 and 76% of the decline in cardiovascular mortality and treatments to account for 23–47%. Different factors may have been more important over different time periods. For example, a Finnish study of 34 525 people followed during 1972–2012 showed that changes in smoking prevalence, serum cholesterol and systolic blood pressure accounted for nearly all observed reduction in coronary heart disease mortality during the first 10 years of the study but only about two-thirds of the continuing reduction in mortality during the last 10 years. Some of this more recent reduction in mortality will have resulted from advances in secondary prevention and treatment but this leaves substantial room for impact from other environmental factors acting either independently or via changes in serum cholesterol or blood pressure. One such factor is the reduction in particulate air pollution that followed the introduction of the Clean Air Act in the UK in 1956 and similar legislation in other western countries. Another factor considered here is the possible role of dietary exposure to emulsifiers and washing detergents. This could plausibly explain two odd features of the epidemiology of cardiovascular disease—the “French paradox”—the relative immunity of the French to coronary disease despite high smoking rates (Figure 1b) and the increased risk in areas with a soft drinking water supply. A “crazy hypothesis” which follows is that the decline in atheromatous disease over the past 50 years might be related in part to increasingly widespread use of dishwashing machines that will rinse away detergent.

Dietary exposure to emulsifiers and detergents and the prevalence of cardiovascular disease