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I. Origin: The Sugar Industry’s Anxiety and the Road to Project 226
By the early 1960s, the sugar industry faced a problem it could no longer ignore. A growing body of research was linking sucrose consumption to coronary heart disease, and the public was beginning to notice.
The industry’s response, preserved in internal documents unearthed decades later, reveals a deliberate strategy: rather than address the science on its merits, the Sugar Research Foundation commissioned a scientific review to protect sugar’s reputation by redirecting blame toward fat and cholesterol.
The commercial stakes were substantial. Internal Sugar Research Foundation (SRF) documents show the trade group recognized as early as 1954 that if Americans shifted toward low-fat diets, per capita sugar consumption would rise by more than a third—a powerful financial incentive to ensure that fat, not sugar, remained the dietary villain.
A decade later, with studies increasingly implicating sugar in heart disease, the industry moved from concern to action. In 1964, the group now known as the Sugar Association internally discussed a campaign to address “negative attitudes toward sugar,” according to documents recovered from public archives.
The key figure in this effort was John Hickson, the SRF’s research director and vice president. By July 1965, Hickson was approaching Harvard University, seeking scientists willing to produce a review to counter the emerging evidence against sugar. He found them in the Harvard School of Public Health’s nutrition department, chaired by Fredrick Stare, who was himself an ad hoc member of the SRF’s scientific advisory board.
That summer, the SRF approved what it called “Project 226″—a literature review to be written by Stare’s colleagues, with a clear objective: downplay sugar’s risks and emphasize saturated fat and cholesterol as the primary culprits in heart disease.
The financial arrangement was modest in absolute terms but revealing in its specificity. The SRF paid the Harvard researchers a total of $6,500—equivalent to roughly $48,000 to $50,000 in today’s dollars—for the review. More important than the money was the level of control the funder exercised.
Hickson did not simply commission a paper and wait for the result. He supplied the researchers with a curated list of studies he wanted included, effectively determining which evidence would be weighed and which would be ignored.
The researchers were also aware of the industry’s expectations. As one later analysis of the documents noted, D. Mark Hegsted, one of the three Harvard authors, assured the industry contact that they would cover the subject in a way that aligned with the SRF’s interests.
The project moved with remarkable efficiency. Before submitting their manuscript for publication, the Harvard authors sent a draft to Hickson. His reply, preserved in the correspondence, was unambiguous: “Let me assure you this is quite what we had in mind and we look forward to its appearance in print”.
The funder had seen the product before the public did, and it was approved. When the two-part review appeared in the New England Journal of Medicine in 1967, neither the Sugar Research Foundation’s funding nor its hands-on role in shaping the review was disclosed. The journal did not begin requiring authors to disclose funding sources until 1984, but the omission meant that readers—including physicians and policymakers who would rely on the review—had no way to evaluate the paper’s conclusions in light of its provenance.
In short, the origin of Project 226 was not a neutral inquiry into the causes of heart disease. It was a targeted intervention in a scientific debate, initiated by an industry with a direct financial interest in the outcome, executed by researchers who accepted both the funder’s money and its preferred evidence, and published in one of the world’s most influential medical journals without any indication of that arrangement. The stage was set for a review that would read as an authoritative synthesis but function as advocacy.
II. The Paper: A Tailor-Made 1967 NEJM Review
The product of Project 226 appeared in the New England Journal of Medicine in two parts, beginning with the July 27, 1967, issue. The article carried an unassuming title—”Dietary Fats, Carbohydrates and Atherosclerotic Vascular Disease”—and listed three authors from the Harvard School of Public Health: Robert B. McGandy, D. Mark Hegsted, and Fredrick J. Stare.
To a reader in 1967, it appeared to be an authoritative synthesis of the nutrition literature by leading academic researchers. Nothing on the page indicated that the Sugar Research Foundation had commissioned it, helped select the evidence, or reviewed the manuscript before publication.
The review’s central claim was sweeping. According to the analysis published decades later by Kearns and colleagues in JAMA Internal Medicine, the paper concluded there was “no doubt” that the only dietary intervention required to prevent coronary heart disease was to reduce dietary cholesterol and substitute polyunsaturated fat for saturated fat.
Sugar, by implication, was not a meaningful concern. The authors argued that blood cholesterol levels were the only significant risk factor for coronary heart disease—a framing that made the high sucrose content of the American diet appear far less hazardous than it would have if blood triglycerides had also been treated as a risk factor.
The asymmetry in how the authors handled the evidence was the review’s most consequential feature. The Kearns analysis found that the Harvard authors “heavily criticized studies linking sucrose to heart disease, while ignoring limitations of studies investigating dietary fats” . Studies that implicated sugar were picked apart over issues of dose, study design, or subject differences. Studies that supported the fat-and-cholesterol hypothesis received no comparable scrutiny. The result was a document that read as a balanced review but functioned as a selective one.
The industry’s fingerprints on the manuscript are documented in the correspondence. The Sugar Research Foundation “set the review’s objective, contributed articles for inclusion, and received drafts,” according to the JAMA Internal Medicine study.
John Hickson, the SRF’s research director, had made his expectations explicit in a July 1965 letter to Hegsted: “Our particular interest had to do with that part of nutrition in which there are claims that carbohydrates in the form of sucrose make an inordinate contribution to the metabolic condition, hitherto ascribed to aberrations called fat metabolism. I will be disappointed if this aspect is drowned out in a cascade of review and general interpretation” . Hegsted assured him that “We are well aware of your particular interest in carbohydrate and will cover this as well as we can”.
Nine months into the project, Hegsted wrote to the SRF that the review had been delayed because “every time the Iowa group publishes a paper, we have to rework a section in rebuttal”—a reference to researchers whose work linked sugar consumption to elevated serum cholesterol.
The funding disclosure in the published paper was, at best, partial. The authors’ note acknowledged support from the Nutrition Foundation, the Special Dairy Industry Board, and several other sources, but it did not mention the Sugar Research Foundation’s specific funding of the review.
The New England Journal of Medicine did not require authors to disclose all conflicts of interest until 1984, so the omission did not violate journal policy at the time. But it meant that physicians and policymakers reading the review had no way to weigh its conclusions against its provenance.
One caveat is worth noting. The Kearns study acknowledged that there is “no direct evidence that the sugar industry wrote or changed the NEJM review manuscript and evidence that the industry shaped its conclusions is circumstantial” .
The documents show that the SRF set the objective, supplied articles, and received drafts. They do not show an industry official dictating sentences. The argument that the review was shaped by its funder rests on the pattern of selective criticism and the correspondence revealing the funder’s expectations—not on a smoking-gun edit to the text.
What the published record does show is a review that arrived at exactly the conclusion the sugar industry wanted, published in exactly the journal it wanted, with exactly the disclosure it did not want.
III. The Proof: What the Documents Show and What They Don’t
The evidentiary case against the 1967 Harvard review rests on two distinct foundations: the internal sugar industry documents that reveal the funder’s role, and a close reading of the published paper that shows a systematic asymmetry in how the authors treated evidence. Neither foundation is uncontested, and a responsible account must reckon with both the strength and the limits of each.
The documentary record. The most comprehensive analysis came in 2016, when Cristin Kearns, Laura Schmidt, and Stanton Glantz published a study in JAMA Internal Medicine based on more than 340 internal sugar industry documents totaling roughly 1,582 pages.
These records show that the Sugar Research Foundation did not merely write a check. It “set the review’s objective, contributed articles to be included, and received drafts” .
The correspondence between SRF vice president John Hickson and Harvard’s D. Mark Hegsted is particularly revealing. In a July 1965 letter, Hickson made the funder’s expectations explicit: “I will be disappointed if this aspect is drowned out in a cascade of review and general interpretation”. Hegsted replied that the authors were “well aware of your particular interest in carbohydrate and will cover this as well as we can” . After receiving a draft, an industry official wrote: “Let me assure you this is quite what we had in mind and we look forward to its appearance in print” .
Marion Nestle, in the invited commentary accompanying the study, wrote that the documents “leave little doubt that the intent of the industry-funded review was to reach a foregone conclusion” . She called the evidence a “smoking gun” precisely because it captured the funder’s direct involvement in shaping the product, not merely the predictable correlation between funding and favorable conclusions.
The double standard in the published text. The scientific evidence of bias comes from comparing how the authors treated different bodies of research. Kearns and colleagues found that the review “heavily criticized studies linking sucrose to heart disease, while ignoring limitations of studies investigating dietary fats”.
Studies implicating sugar were picked apart over issues of dose, study design, or subject differences. In contrast, studies supporting the fat-and-cholesterol hypothesis received no comparable scrutiny.
The review further argued that blood cholesterol levels were the only significant risk factor for coronary heart disease—a framing that made high sucrose intake appear far less hazardous than if blood triglycerides had also been treated as a risk factor. Nestle noted that the authors “seem to have cherry-picked existing data” to minimize the association with sugar, even though both sugar and saturated fat had been identified as mortality risk factors by 1967.
The disclosure gap. When the two-part review appeared in the New England Journal of Medicine in 1967, the authors acknowledged support from the industry-funded Nutrition Foundation but did not mention the Sugar Research Foundation’s specific funding of the review itself.
NEJM did not begin requiring authors to disclose all potential conflicts of interest until 1984, so the omission did not violate journal policy at the time. But it meant that physicians and policymakers had no way to weigh the paper’s conclusions against its provenance.
The counterargument. Not all historians accept the “conspiracy” framing. In a 2018 article in Science, David Johns and Gerald Oppenheimer argued that the sugar industry’s role has been overstated.
Their key claims: the Harvard scientists, led by Hegsted, had already completed research showing saturated fat raised cholesterol and sugar had little effect before the sugar money arrived; the low-fat paradigm was already dominant, backed by Framingham and the American Heart Association; and the dairy industry funded key studies underpinning the fat hypothesis. “There was no ‘smoking gun,'” they wrote. “There was no ‘sugar conspiracy’—at least not one which we have identified” .
They also noted that Kearns and colleagues themselves acknowledged there is “no direct evidence that the sugar industry wrote or changed the NEJM review manuscript” and that the evidence of influence is circumstantial.
The Johns and Oppenheimer critique does not exonerate the undisclosed arrangement, nor does it dispute that the review reached the conclusion the funder wanted. It does, however, complicate the narrative that a single industry-funded review “derailed” nutrition science on its own. The more defensible conclusion is that Project 226 was an accelerant and legitimizer of an already-ascendant paradigm, not its sole cause.
The Sugar Association’s response. When the Kearns study was published, the Sugar Association issued a statement acknowledging that “the Sugar Research Foundation should have exercised greater transparency in all of its research activities,” but arguing that “when the studies in question were published, funding disclosures and transparency standards were not the norm they are today.” The association also questioned Kearns’s “continued attempts to reframe historical occurrences to conveniently align with the currently trending anti-sugar narrative” .
The downstream stakes. What is not seriously disputed is the review’s alignment with the policy trajectory that followed. Hegsted later became the top nutritionist at the U.S. Department of Agriculture and helped draft the federal government’s first Dietary Guidelines for Americans, which emphasized reducing saturated fat .
For decades afterward, the dominant public health message centered on cutting fat—a message that food manufacturers translated into low-fat products often loaded with added sugar. Concern about sugar’s role in heart disease did not regain mainstream traction until the 2010s. Whether the 1967 review was the cause or merely a well-timed accelerant, it helped cement a consensus that took half a century to revise.
IV. The Aftermath: Obesity, Diabetes, and Heart Disease Since 1967
Any honest accounting of the decades following the NEJM review must begin with a caveat: the trends are stark, but causation is not simple. The review helped entrench a paradigm, yet the rise in metabolic disease tracks a web of changes—food supply, portion sizes, physical activity, and economics—that no single 1967 paper can explain. The data show a trajectory that the low-fat era did not reverse.
The obesity curve. In 1960, roughly 16 percent of American adults were obese. By 1980, the year the first federal Dietary Guidelines appeared, the rate had climbed to 23.3 percent. By 2000, it reached 30.5 percent, and by 2020, it stood at 42.4 percent. The steepest acceleration occurred from the late 1970s onward—precisely the period when low-fat, high-carbohydrate eating was most aggressively promoted.
Type 2 diabetes. The prevalence of diagnosed type 2 diabetes followed a similar arc. In 1960, it was about 1.0 percent of the population. By 1990, it had nearly quadrupled to 3.9 percent; by 2010, it was 8.5 percent; by 2020, 11.3 percent. These figures likely understate the true burden, since they reflect only diagnosed cases.
Sugar consumption. Per capita sugar consumption rose alongside these trends, from 112 pounds per year in 1960 to 146 pounds in 2020. The low-fat era did not reduce America’s appetite for sugar. If anything, the food industry’s response to “cut fat” was to add sugar and refined carbohydrates to maintain palatability—a dynamic that Project 226’s framing made easier to ignore.
Heart disease. Here, the picture is more complicated. Age-adjusted death rates from heart disease have fallen substantially since the 1960s, driven by better acute care, smoking cessation, and pharmaceutical interventions including statins. But heart disease remains the leading cause of death in the United States. The decline in mortality does not mean the dietary advice was correct; it means medical treatment improved even as the underlying metabolic risk factors—obesity and diabetes—became more prevalent.
The interpretive caution. These trends are often presented as a verdict on the low-fat era. The honest version is narrower: the decades after Project 226 saw dramatic rises in obesity and type 2 diabetes while sugar remained abundant in the food supply and public health messaging focused on fat.
Whether a different 1967 review would have changed that trajectory is unknowable. What is clear is that the paradigm the review helped cement did not deliver the promised cardiometabolic benefits—and the diseases it was meant to prevent are now entangled with the very dietary factor it was designed to protect.
Conclusion: The Takeaway
- The sugar industry didn’t just fund research—it helped steer it. Internal documents show that the Sugar Research Foundation set the review’s objective, specified which studies it wanted included, and reviewed drafts before publication.
- The 1967 NEJM review reached exactly the conclusion the funder wanted. It dismissed sugar’s role in heart disease while accepting evidence on fat and cholesterol with far less scrutiny—and the industry official who saw the draft said it was “quite what we had in mind.”
- Readers were never told. The Sugar Research Foundation’s funding of the review was not disclosed when the paper appeared in one of the world’s most influential medical journals.
- The bias was methodological, not just financial. The Harvard authors applied a double standard: they aggressively criticized studies linking sugar to heart disease while ignoring the limitations of studies implicating fat.
- The review helped entrench a paradigm that shaped decades of policy. The low-fat message dominated federal dietary guidelines and food marketing for nearly fifty years, with added sugar largely escaping scrutiny until the 2010s.
- The decades that followed did not vindicate the paradigm. Obesity rose from roughly 16 percent of adults in 1960 to over 42 percent by 2020; diagnosed type 2 diabetes climbed from about 1 percent to over 11 percent; per capita sugar consumption rose rather than fell. Heart disease mortality declined, but largely because of better acute care and drugs—not because the dietary message worked.
- But it was an accelerant, not the sole cause. The low-fat hypothesis was already gaining ground before the sugar money arrived, and the rise in metabolic disease reflects many forces beyond the scope of one review. Project 226 legitimized and amplified an ascendant view—it did not invent it from scratch.
- The episode is a case study in why funding disclosure matters. The lack of transparency meant physicians and policymakers could not weigh the paper’s conclusions against its provenance. Modern disclosure rules exist precisely because of cases like this.
- The fight over the narrative is still live. The Sugar Association disputes the “conspiracy” framing; historians debate how much a single review can explain. What is undisputed is that the review aligned with the funder’s interests—and that the public had no way of knowing.
A Parting Thought
The story of Project 226 is not merely a historical curiosity. It is a reminder that the dietary advice generations of Americans received was shaped, at least in part, by forces more interested in protecting market share than in protecting health. That legacy persists on supermarket shelves and in the messages people absorb about what to eat.
Readers need not treat the 1967 review as the sole cause of today’s metabolic health crisis to recognize its lesson. Obesity, type 2 diabetes, and heart disease have risen dramatically since that paper appeared, and added sugar remains ubiquitous in the food supply.
The Dietary Guidelines for Americans still recommend limiting added sugars to less than 10% of daily calories, yet roughly 70% of Americans exceed that threshold. The American Heart Association sets an even stricter ceiling for added sugars. The evidence linking sugar-sweetened beverages to weight gain, type 2 diabetes, and cardiovascular disease is now robust and consistent.
At the same time, the saturated fat story is more complicated than the 1967 review suggested—but also more complicated than the backlash against it sometimes claims.
Recent research indicates that not all saturated fatty acids behave the same way, with even-chain saturated fats associated with higher cardiovascular risk while odd-chain and longer-chain subtypes show different patterns. This nuance does not vindicate the sugar industry’s framing. It simply means the science has moved on, while public messaging often has not.
The practical takeaway is not a new dogma. It is a call for skepticism—of industry-funded research, of single-nutrient villains, and of any narrative that promises one simple dietary fix.
Reevaluating sugar consumption is a reasonable starting point. Rethinking saturated fat with the nuance the evidence now demands is equally reasonable. What is not reasonable is to continue letting commercial interests set the terms of the debate.
Don’t Get Sick!
About Dr. Jesse Santiano, MD
Dr. Santiano is a retired internist and emergency physician with extensive clinical experience in metabolic health, cardiovascular prevention, and lifestyle medicine. He reviews all medical content on this site to ensure accuracy, clarity, and safe application for readers. This article is for educational purposes and is not a substitute for personal medical care.
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References:
Primary Sources: Project 226 and the 1967 NEJM Review
- Kearns CE, Schmidt LA, Glantz SA. Sugar Industry and Coronary Heart Disease Research: A Historical Analysis of Internal Industry Documents. JAMA Internal Medicine. 2016;176(11):1680-1685.
- Kearns CE, Schmidt LA, Glantz SA. Sugar Industry and Coronary Heart Disease Research [manuscript PDF with archival citations]. University of California, San Francisco.
- SugarScience, University of California, San Francisco. Sugar Papers Reveal Industry Role in Shifting Focus from Heart Disease to Saturated Fat. September 2016.
Industry Response
Historical Counter-Analysis
- Johns DM, Oppenheimer GM. Was There Ever Really a “Sugar Conspiracy”? Science. 2018;359(6377):747-750.
Post-1967 Health Data (Part IV)
- Centers for Disease Control and Prevention. Adult Obesity Prevalence Maps. 2020.
- Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020.
- CDC. Know Your Limit for Added Sugars: Get the Facts. Dietary Guidelines for Americans, 2020–2025.
Parting Thought (Sugar Limits and Saturated Fat Nuance)
- American Heart Association. Added Sugars Daily Limits (as summarized by ColumbiaDoctors).
- Shi F, Chowdhury R, Sofianopoulou E, et al. Associations of Saturated and Unsaturated Fatty Acids with Cardiovascular Disease. European Journal of Epidemiology / SAGE. 2024.
Disclaimer:
This article is for educational purposes and is not a substitute for professional medical advice, diagnosis, or treatment. Always consult your physician before making health decisions based on the TyG Index or other biomarkers.
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DrJesseSantiano.com does not provide medical advice, diagnosis, or treatment
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