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.