walter willett, harvard university "diets and incidence of ncds"
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Diets and Incidence of NCDs: Evidence to Guide Agricultural Research
Walter C. Willett, MD, DrPH
Department of Nutrition
Harvard School of Public Health
September 23, 2013
Lifestyle Objectives(modified summary of WHO/FAO, 2003)
• Avoid tobacco use
• Pursue physical activity
• Avoid overweight
• Consume a healthy (Prudent) diet− healthy types of fat (reduce trans and saturated fat)
− plenty of fruits and vegetables
− replace refined grains with whole grains
− limit sugar intake
− limit excessive caloric intake
− limit sodium intake
29.162R
29.516 (Ezzati & Riboli, NEJM 2013)
100
80
60
40
20
0
-20
-40
1%E 2%E 3%E 4%E 5%E
Trans
Sat
Mono
Poly
% C
hang
e in
CH
D
Hu FB, et al. N Engl J Med 1997;337:1491-99.131
Type of Dietary Fat and Risk of Coronary Heart DiseaseThe Nurses' Health Study
14-Year Follow-up
Relative Risk of NIDDM by Different Levels of Cereal Fiber & Glycemic Load
2,5 2,32,05
2,171,8
1,62
1,511,28
1
0
1
2
3
High Medium Low
High
Medium
LowRelativeRisk
>165 165-143 <143Glycemic Load
>5.8 g/day
2.5 -5.8 g/day
<2.5 g/day
(Salmeron et al,1997)
(ref)
WOMEN
25.002
Cereal Fiber
Combined
Nettleton, 2009
deKoning, 2010
Paynter Women, 2006
Paynter Men, 2006
Palmer, 2008
Bazzano, 2008
Study
Odegaard, 2010
Montonen, 2007
Schulze, 2004
1.25 (1.10, 1.42) 100.00
8.95
14.47
13.92
14.10
15.81
15.86
5.43
1.13
10.33
% Weight
.074 1 13.5
Sugar-sweetened beverage consumption and risk of T2DM, per increase in one 12 oz serving of SSB per day (random-effects
estimate)
(Malik et al. Diabetes Care 2010)37.014
CancerP-value, test for trend=0.88
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
<1.5 1.5-2.9 3-4.9 5-5.9 6-7.9 8+
Rel
ativ
e R
isk
Rel
ativ
e R
isk
Rel
ativ
e R
isk
Rel
ativ
e R
isk
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
<1.5 1.5-2.9 3-4.9 5-5.9 6-7.9 8+
Rel
ativ
e R
isk
Cardiovascular DiseaseP-value, test for trend=0.0003
(Hung et al., 2004)28.021Fruit/Vegetable Intake (Serving/Day)
25.179
Relative Risk of Type 2 Diabetes for Substitution of Specific Fruits (3 servings/ week) for Fruit Juice
(Muraki I. et al, BMJ 2013)
Substitution of Protein Sources (1 sv/day) and Risk of CHD in NHS, 1980-2006 (3162 cases)
9.202a Bernstein A, et al. Circulation. 2010;122(9):876-83
Relative Risk of type 2 diabetes for replacing 1 serving/day of total red meat with other foods. Data from NHS, NHSII, HPFS, including 13,759 cases of
diabetes (Pan A et al. AJCN, 2011)
25.161
Rel
ativ
e R
isk
High School Milk Intake and Multivariate RR of Hip Fracture
0
0,4
0,8
1,2
1,6
2
<1 1-1.9 2-2.9 3+
Number of Servings of Milk per Day
Rel
ativ
e R
isk
(Feskanich et al., preliminary analyses)
P, trend = 0.03
24.064
Changes in Food and Beverage Consumption
and Weight Changes Every 4 Years
According to Study Cohort
(Mozaffarian D et al., NEJM 2011)
Food Beverages
23.059
0
2
4
6
8
10
12
14
16
Lamb
Beef
Milk
(2%
)Chee
seSal
mon
PorkEggs
TofuDry
bea
nsChic
ken
Lentil
s
Estimated GHG Emissions per Protein
Food Product
(Derived from Clean Metrics / Environmental Working Group, Meat Eaters Guide Methodology, 2011)
GH
G/P
rote
in
14.003
Priorities for Agricultural Research1. Protein sources: Increase availability of nuts (including
peanuts), legumes, and fish. Limit production of red meat and avoid feed grains. Promote production of poultry (meat and eggs) for animal protein. Dairy production should be modest.
2. Dietary fats: Emphasize production of unsaturated oils (including olive oil), and include sources of N-3 fatty acids (e.g., rapeseed, mustard, and soybean). Develop unsaturated palm oils. Eliminate hydrogenation.
3. Carbohydrates: Reduce grain production as part of diversification; do not refine. Reduce sugar.
4. Fruits and vegetables (excluding potatoes): Encourage availability and affordability.
29.515
Socio-economic inequality in diet and ncd; role of agriculture
Jaap Seidell, VU University Amsterdam, The Netherlands
Reality: 80% of chronic disease deaths occur in low & middle income countries
Male Female
NCDs kill people at a younger age in developing countries
• Age-standardized deaths per 100,000 from cardiovascular disease
29
Source: WHO, 2008
Age-standardized deaths per 100,000 from cardiovascular disease and diabetes
The highest increases in NCDs are expected in Africa, South-East Asia, and the Southern Mediterranean—an over 20 percent increase expected by 2020.
Source: WHO, 2010
The mothers
24
25
26
27
28
29
30
31
32
Russia Poland Czech
Primary Vocational
Secondary University
H. Pikart: HAPIEE study, 2003/2004
0
5
10
15
20
25
30
35
Women 1993 Women 2001
IIIIIInmIIImIVV
Women’s BMI in Russia, Poland, Czech Republic By Education
Obesity trends by social class in women: England 1993-2001
Health Survey for England
The children
0
2
4
6
8
10
12
14
16
18
Leastdeprived
2nd 3rd 4th Mostdeprived
Per
cen
t
OR
Crude odds ratio (OR) for other nationality
2.23
OR for other nationality after adjusting for education of mother
1.52
OR after additional adjustment for watching TV on weekdays
1.37
OR after full adjustment
1.30
INCOMEFrance (2-17 y)
INDEX OF MULTIPLE DEPRIVATIONEngland(2-10 y)
ETHNICITYGermany
Jotangia et al., 2005 Kuepper-Nybelen et al (2005)
32
NCD risk factors by Urban/Rural (Malawi)
Risk factor Prevalence (%)
Urban Rural Both
Tobacco smoking 6.6 10.9* 10.4
Alcohol 13.4 12.5 12.6
Physical inactivity 24.1* 8.7 10.6
Overweight 38.6* 21.9 23.9
≥3 risk factors 22.6 15.5 16.2
Diets in urban slums
• Low (perishable and expensive):
• Fresh drinking water
• Fresh fruit en vegetables
• Fresh meats and fish
• High (non-perishable and cheap):
• Sugary beverages
• Highly processed food with added sodium, sugar and trans-fatty acids.
The economic burden of NCDs will overwhelm health systems and slow economic growth
35
NCDCOSTS
Health spending on diabetes ranges from 6% of all health costs in China to 15% in Mexico Source: P. Zhang, et al, 2010
Each 10% increase in NCD burden is associated with a 0.5% reduction in annual economic growthSource: WHO
23 high burden countries are projected to lose $84 billion in GDP between 2005-2015 from 3 NCDsSource: Abegunde, et al, 2007
NCDs will cost more than $47 trillion globally between now and 2030Source: D. Bloom, 2011
Tools for agriculture to improve health
36
Agriculture and FoodValue Chain Approaches
A value chain reveals social, environmental and health benefits in the production process.
EXAMPLES:
• New product formulation and cold chain innovations to reach people at the bottom of the pyramid
• Build capacity into local food chains to raise quality and lower price
Mutual Metrics
Mutual metrics are results indicators shared between agriculture and health.
EXAMPLES:
• Volume of fresh fruits and vegetables timely delivered to consumer markets
• Substitution of healthier oils for palm oil in processed foods
Agriculture can improve health by…
37
Partnering for New Programs and Policies
EXAMPLES:
• Limit marketing to children and reduce sodium and fat content in products. Report progress to the public and WHO
• Partner with companies in the developing world to help small food processors produce safe, nutritious, affordable food products
Creating New Policy for a Healthy Food Supply
EXAMPLES:
• Voluntary or mandatory reductions in salt and trans fat content of foods
• Limitations on sales and marketing of high-sugar products to children
• Calorie information on restaurant menus
thechicagocouncil.org/HealthyAgandNCD
Food & Nutrition Security, Poverty Reduction and Sustainable Economic Development
• Are hunger and malnutrition an outcome of poverty? - or a cause of poverty?
• Is the alleviation of poverty essential for reducing malnutrition, or is reducing malnutrition essential for alleviating poverty?
Food and Nutrition Security
Poverty Reduction Sustainable
Economic Development
Role of agriculture in the global economy
Agriculture provides much more than commodities. It is a way of life.
When practisedsustainably, it assures food security, conservation of national resources, environmental stability and employment. It contributes to social
stability and cohesion, and maintenance of cultural traditions.
FAO/WHO Fruit and Vegetable Initiative for Health
A framework for promoting fruit and vegetable was established by FAO and WHO in 2004 to guide the
development of cost-effective and effective interventions for the promotion of adequate consumption of fruits and vegetables for health at national or sub-national level.
Conclusions
• NCD related to poor dietary habits
• Socio-economic inequality in diets and health
• Agricultural policies van improve dietary habits.
• Local farming may provide a buffer to ensure better diets and health and less dependency on world trade and the agro-industrial complex.
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