AHS Slides_Staffan Lindeberg

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AHS Slides_Staffan Lindeberg

  1. 1. Ancestral Health Symposium, LA, August 2011<br />Food and Western Disease<br />Staffan Lindeberg MD PhD<br />Center for Primary Health Care Research<br />Lund University, Sweden<br />
  2. 2. Western diseases:<br />Cardiovascular diseases<br />diabetes <br />obesity<br />hypertension<br />dementia<br />cancers<br />osteoporosis<br />rickets<br />iron deficiency<br />autoimmune diseases<br />gastroesophageal reflux<br />irritable bowel syndrome<br />and many others<br />Lindeberg S. Food and Western Disease. Wiley-Blackwell 2010<br />
  3. 3. The basis of nutritional advice<br />
  4. 4. The basis of nutritional advice<br /><ul><li>Stories</li></ul>S. Graham<br />A. Lane<br />J.H. Kellogg<br />D. Burkitt<br />Battle Creek<br />M. Bircher-Benner<br />
  5. 5. The basis of nutritional advice<br /><ul><li>Stories</li></ul>A. Brillat-Savarin<br />C. Bernard<br />W. Banting<br />R. Atkins<br />
  6. 6. The basis of nutritional advice<br /><ul><li>Stories
  7. 7. Money</li></li></ul><li>The basis of nutritional advice<br /><ul><li>Stories
  8. 8. Money
  9. 9. Science
  10. 10. Epidemiology
  11. 11. Molecular biology
  12. 12. Clinical trials</li></ul>Placebo bread, <br />real meat<br />Real bread, <br />placebo meat<br />
  13. 13. The basis of nutritional advice<br /><ul><li>Stories
  14. 14. Money
  15. 15. Science
  16. 16. Epidemiology
  17. 17. Molecular biology
  18. 18. Clinical trials
  19. 19. Evolutionary medicine</li></li></ul><li>The basis of nutritional advice<br /><ul><li>Stories
  20. 20. Money
  21. 21. Science
  22. 22. Epidemiology
  23. 23. Molecular biology
  24. 24. Clinical trials
  25. 25. Evolutionary medicine</li></li></ul><li>The Trobriand Islands, Papua New Guinea<br />
  26. 26. The Trobriand Islands, Papua New Guinea<br />
  27. 27. The Trobriand Islands, Papua New Guinea<br />Kitava<br /><ul><li>tropical island, 4 x 7 km
  28. 28. 2,300 inhabitants (in 1990); 6% 60-96 years
  29. 29. diet: cultivated tubers (yam, sweet potato, taro, tapioka), fruit, fish, nuts and leafy vegetables — no western food
  30. 30. regular physical activity: ~1.7 x BMR</li></li></ul><li>13<br />Estimated amount of foods consumed by Kitavan <br />adults in Nov-Dec 1990<br />Daily intake Total Protein Fat CHO Energy<br />(medians) (g) (g) (g) (g) (kJ)<br />Tubers 1200 25 2 300 5600<br />Fruit 400 3 <1 50 920<br />Coconut 110 4 43 7 1865<br />Fish 85<br />Pork <1 - - - -<br />Other meat <2 - - - -<br />Other 200 5 <1 14 360<br />Western food <1 0 <1 <1 20<br />Total 2 000 54 50 370 9200<br />Lindeberg S et al. AJCN 1997;66:845<br />
  31. 31. The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease<br /><ul><li>myocardial infarction (Lindeberg S et al. J Intern Med 1993;233:269)</li></li></ul><li>The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease<br /><ul><li>myocardial infarction (Lindeberg S et al. J Intern Med 1993;233:269)
  32. 32. consistent with earlier observations (Schiefenhövel, Jüptner)</li></li></ul><li>The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease<br /><ul><li>myocardial infarction (Lindeberg S et al. J Intern Med 1993;233:269)
  33. 33. consistent with earlier observations (Schiefenhövel, Jüptner)
  34. 34. consistent with studies in Melanesia(Breinl -15, Clements -36, Devine -46, Backhouse -58, Whyte -58, Barnes -61, Campbell and Arthur -64, Dewdney -65, Kariks -67, Vines -70, Aiken -74, Hornabrook -74, Mathews -74, Page -74, Somers -74, Sinnett -77, Korner -80, Palmer -82, Ree -82)
  35. 35. consistent with studies in Africa(Donnison -29, Vint -37, Muwazi -44, Davies -48, Thomas -60, Trowell -60, Reef -62, Seftel -63, Tejada -68, Dodu -72, Edginton -72, Okuwobi -72, Shaper -72, Walker -75, Truswell -76, Isaacson -77, Trowell -81)
  36. 36. consistent with studies in South America (Groom -71, Connor -78, Baruzzi -81)
  37. 37. consistent with studies in the Arctic (Price -36, Kromann -80, Schaefer -81, Dyerberg -89)</li></li></ul><li>The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease<br /><ul><li>myocardial infarction (Lindeberg S et al. J Intern Med 1993;233:269)
  38. 38. stroke (Lindeberg S et al. J Intern Med 1993;233:269)</li></li></ul><li>The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease<br /><ul><li>myocardial infarction (Lindeberg S et al. J Intern Med 1993;233:269)
  39. 39. stroke (Lindeberg S et al. J Intern Med 1993;233:269)
  40. 40. consistent with earlier observations (Schiefenhövel, Jüptner)</li></li></ul><li>The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease<br /><ul><li>myocardial infarction (Lindeberg S et al. J Intern Med 1993;233:269)
  41. 41. stroke (Lindeberg S et al. J Intern Med 1993;233:269)
  42. 42. consistent with earlier observations (Schiefenhövel, Jüptner)
  43. 43. consistent with studies in East Africa (Trowell -81, Muwazi -44)</li></ul>Table. Incidence of stroke as proportion of acute neurologic disease in Kampala, Uganda.<br />
  44. 44. The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease<br /><ul><li>myocardial infarction (Lindeberg S et al. J Intern Med 1993;233:269)
  45. 45. stroke (Lindeberg S et al. J Intern Med 1993;233:269)
  46. 46. consistent with earlier observations (Schiefenhövel, Jüptner)
  47. 47. consistent with studies in East Africa (Trowell -81, Muwazi -44)
  48. 48. consistent with studies in Papua New Guinea (Breinl -15, Clements -36, Backhouse -58, Campbell -64, Dewdney -65, Stanhope -69, Vines -70, Sinnett -73, Hornabrook -74, Hornabrook -75, Nagurney -75, Sinnett, PF -77, Palmer -82, Ree -82)</li></li></ul><li>Fig. Stroke incidence per 1000 person-years in the 1990s among selected westernized populations.<br />Feigin VI et al. Lancet Neurol 2003;2:43<br />
  49. 49. The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease<br /><ul><li>myocardial infarction (Lindeberg S et al. J Intern Med 1993;233:269)
  50. 50. stroke (Lindeberg S et al. J Intern Med 1993;233:269)
  51. 51. diabetes type 2 (Lindeberg S et al. Metabolism 1999;48:1216)</li></ul>Fig. Fasting serum glucosein Kitava and Sweden.<br />
  52. 52. The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease<br /><ul><li>myocardial infarction (Lindeberg S et al. J Intern Med 1993;233:269)
  53. 53. stroke (Lindeberg S et al. J Intern Med 1993;233:269)
  54. 54. diabetes type 2 (Lindeberg S et al. Metabolism 1999;48:1216)
  55. 55. overweight (Lindeberg S et al. J Intern Med 1994;236:331)</li></li></ul><li>The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease<br /><ul><li>myocardial infarction (Lindeberg S et al. J Intern Med 1993;233:269)
  56. 56. stroke (Lindeberg S et al. J Intern Med 1993;233:269)
  57. 57. diabetes type 2 (Lindeberg S et al. Metabolism 1999;48:1216)
  58. 58. overweight (Lindeberg S et al. J Intern Med 1994;236:331)
  59. 59. hypertension (Lindeberg S et al. J Intern Med 1994;236:331)</li></ul>Table. Blood pressure at age 40-60 years among hunter-gatherers, in Kitava and in Sweden (mm Hg, mean ± standard deviation)(modified from Lindeberg S et al. J Intern Med 1994;236:331).<br />
  60. 60. The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease<br /><ul><li>myocardial infarction (Lindeberg S et al. J Intern Med 1993;233:269)
  61. 61. stroke (Lindeberg S et al. J Intern Med 1993;233:269)
  62. 62. diabetes type 2 (Lindeberg S et al. Metabolism 1999;48:1216)
  63. 63. overweight (Lindeberg S et al. J Intern Med 1994;236:331)
  64. 64. hypertension (Lindeberg S et al. J Intern Med 1994;236:331)</li></ul>Diastolic BP, mm Hg<br />Diastolic BP, mm Hg<br />Fig. Diastolic blood pressure among males (left) and females (right) from Sweden (grey) and Kitava (black) (modified from Lindeberg S et al. J Intern Med 1994;236:331).<br />
  65. 65. The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease<br /><ul><li>myocardial infarction (Lindeberg S et al. J Intern Med 1993;233:269)
  66. 66. stroke (Lindeberg S et al. J Intern Med 1993;233:269)
  67. 67. diabetes type 2 (Lindeberg S et al. Metabolism 1999;48:1216)
  68. 68. overweight (Lindeberg S et al. J Intern Med 1994;236:331)
  69. 69. hypertension (Lindeberg S et al. J Intern Med 1994;236:331)</li></ul>Systolic BP, mm Hg<br />Systolic BP, mm Hg<br />Fig. Systolic blood pressure among males (left) and females (right) from Sweden (grey) and Kitava (black) (modified from Lindeberg S et al. J Intern Med 1994;236:331).<br />
  70. 70. BMI 24.5<br />BMI 20.3<br />Fig. Z scores* of observed versus predicted mean cardiovascular risk factors in Kitavan males (left) and females (right) aged 40-65 years (after variable transformation when necessary).<br />*standard score, number of standard deviations below or above Swedish means.<br />
  71. 71. 28<br />Westernization affects everyone<br />Blood pressure<br />Fasting plasma glucose<br />Cruickshank JK. Int J Epidemiol 2001;30:111<br />Poulter NR et al. Am J Hypertens 1988;1:143S<br />
  72. 72. Ten-year risk of fatal cardiovascular disease in ’low-risk’ European populations. Chart based on total cholesterol (Conroy RM et al. Eur Heart J. 2003;24:987)<br />(Lindeberg S. Eur Heart J 2005;26:2605-6)<br />
  73. 73. Who wants to be normal?<br />Atherosclerosis is part of ’normal’ ageing in westernized populations<br />including japanese and chinese<br />Fig. 40-year old US woman with coronary atherosclerosis despite normal angiography(Nissen SE. Circulation 2001;103:604).<br />Fig. Percent of subjects with coronary atherosclerosis from birth to age 40 (Stary HC et al. AJCN 2000;72:1297S).<br />
  74. 74. 31<br />Atherosclerosis of left anterior descending coronary artery among 45-55 year-old men from four populations (Tejada -68)<br />
  75. 75. Who wants to be normal?<br />Atherosclerosis is part of ’normal’ ageing in westernized populations<br />No atheromas in other free-living mammals<br />No atheromas in experimental animals without prior dietary manipulation<br />fat, casein, lactose, peanut lectin etc.<br />uncertain impact of cereal grains<br />
  76. 76. Who wants to be normal?<br />Relative risk of Western disease<br />
  77. 77. Who wants to be normal?<br />“Your blood pressure is normal.”<br />
  78. 78. The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease despite<br /><ul><li>a fair amount of elderly
  79. 79. 6% between 60 and 95 years of age</li></li></ul><li>The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease despite<br /><ul><li>a fair amount of elderly
  80. 80. 6% between 60 and 95 years of age
  81. 81. age estimates based on historic events</li></li></ul><li>The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease despite<br /><ul><li>a fair amount of elderly
  82. 82. no indications of genetic resistance</li></li></ul><li>The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease despite<br /><ul><li>a fair amount of elderly
  83. 83. no indications of genetic resistance
  84. 84. 75% smokers</li></li></ul><li>The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease despite<br /><ul><li>a fair amount of elderly
  85. 85. no indications of genetic resistance
  86. 86. 75% smokers
  87. 87. energy expenditure not extreme (but high)</li></li></ul><li>The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease despite<br /><ul><li>a fair amount of elderly
  88. 88. no indications of genetic resistance
  89. 89. 75% smokers
  90. 90. energy expenditure not extreme (but high)
  91. 91. high intake of saturated fat from coconut
  92. 92. low total fat intake (~20 E%)</li></li></ul><li>The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease despite<br /><ul><li>a fair amount of elderly
  93. 93. no indications of genetic resistance
  94. 94. 75% smokers
  95. 95. energy expenditure not extreme (but high)
  96. 96. high intake of saturated fat from coconut
  97. 97. high intake of starch from yam, sweet potato, taro etc
  98. 98. 65-70 % of energy from carbohydrate</li></li></ul><li>42<br />Lindeberg S et al. AJCN 1997;66:845<br />
  99. 99. 43<br />Estimated dietary intakes for Kitavan adults<br />Daily intake Total Protein Fat CHO Energy<br />(medians) (g) (g) (g) (g) (kJ) <br />Tubers 1200 25 2 300 5600<br />Fruit 400 3 <1 50 920<br />Coconut 110 4 43 7 1865<br />Fish 85 17 4 0 445<br />Other 200 5 <1 14 360<br />Western food <1 0 <1 <1 20<br />Total 2 000 54 50 370 9200<br />Lindeberg S et al. AJCN 1997;66:845<br />
  100. 100. The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease despite<br /><ul><li>a fair amount of elderly
  101. 101. no indications of genetic resistance
  102. 102. 75% smokers
  103. 103. energy expenditure not extreme (but high)
  104. 104. high intake of saturated fat from coconut
  105. 105. high intake of starch from yam, sweet potato, taro etc
  106. 106. 65-70 % of energy from carbohydrate
  107. 107. Starch has not been shown to cause glucose intolerance</li></li></ul><li>The Trobriand Islands, Papua New Guinea<br />Striking absence of Western disease despite<br /><ul><li>a fair amount of elderly
  108. 108. no indications of genetic resistance
  109. 109. 75% smokers
  110. 110. energy expenditure not extreme (but high)
  111. 111. high intake of saturated fat from coconut
  112. 112. high intake of starch from yam, sweet potato, taro etc
  113. 113. 65-70 % of energy from carbohydrate
  114. 114. Starch has not been shown to cause glucose intolerance
  115. 115. Humans have a high capacity to digest starch</li></li></ul><li>Carbohydrate and fat – both to the left and to the right<br />46<br />
  116. 116. Is it time to shift focus?<br />47<br />
  117. 117. Part 2. Treatment of disease<br />
  118. 118. Grain-free, dairy-free diets in clinical practice<br />Fruit, roots, meat, organ meats, eggs, fish, shellfish, vegetables, nuts etc.<br />Beneficial effects in small clinical trials<br />Normalized glucose tolerance independent of weight loss in diabetes/IGT (Lindeberg S et al. Diabetologia 2007;50:1795)<br />Lower blood sugar, blood pressure, triglycerides and waist, and higher HDL, in diabetes type 2 (Jönsson T et al. Cardiovasc Diabetol 2009;8:35)<br />Lower LDL, triglycerides, fP-Insulin (by 68%), AUCInsulin (by 39%) and diastolic BP (Frassetto LA et al. Eur J Clin Nutr 2009;63:947)<br />
  119. 119. A paleolithic-like diet improved glucose tolerance independently of weight loss or waist change<br /><ul><li>29 patients with ischemic heart disease and impaired glucose tolerance or diabetes; age 61±9 years
  120. 120. randomized to one of two low-fat dietary models
  121. 121. Consensus diet: whole grains, low-fat dairy products, vegetables, fruit and foods rich in omega-3 fatty acids (n=15)
  122. 122. Paleolithic diet: lean meat, fish, vegetables and fruit (n=14; avoid cereals, dairy products, margarine, sugar, salt)
  123. 123. 25% lower reported energy intake in the Paleolithic group
  124. 124. Much less grains and dairy foods and more fruit and nuts in the Paleolithic group
  125. 125. No difference in reported intake of fat or fiber
  126. 126. No difference in reported absolute intake of protein</li></ul>(Lindeberg S et al. Diabetologia 2007;50:1795)<br />
  127. 127. A paleolithic-like diet improved glucose tolerance independently of weight loss or waist change<br />Paleolithic diet<br />Consensus diet<br />Before<br />Before<br />***<br />After<br />***<br />***<br />After<br />Fig. Plasma glucose during the oral glucose tolerance test (OGT) at baseline and after 12 weeks of a Paleolithic diet (left) and a Consensus diet (right). Values are means (SE). ***p <0.001; absence of asterisk denotes p >0.05.<br />(Lindeberg S et al. Diabetologia 2007;50:1795)<br />51<br />
  128. 128. A paleolithic-like diet improved glucose tolerance independently of weight loss or waist change<br />Fig. Change in glucose tolerance (left) and waist circumference (right) after 6 and 12 weeks of a Consensus diet (whole grains, lean dairy products, fruit, vegetables, foods high in omega-3 fatty acids; n=15) or a Paleolithic diet (n=14).<br />(Lindeberg S et al. Diabetologia 2007;50:1795)<br />52<br />
  129. 129. A paleolithic-like diet improved glucose tolerance independently of weight loss or waist change<br />Table. Number of subjects with OGT plasma glucose above diabetes limits according to WHO diagnostic criteria (1999).<br />(Lindeberg S et al. Diabetologia 2007;50:1795)<br />
  130. 130. A paleolithic-like diet was superior to ‘diabetes diet’ for patients with type 2 diabetes in a cross-over trial<br />Fig. HbA1c, HDL cholesterol, triglycerides, diastolic blood pressure, weight and waist circumference after 3 months with a ’diabetes diet’ (black) or a paleolithic diet (white) in 13 patients with diabetes type 2.<br />(Jönsson T et al. Cardiovasc Diabetol 2009;8:35)<br />
  131. 131. Grain-free, dairy-free diets in clinical practice<br />Fruit, roots, meat, organ meats, eggs, fish, shellfish, vegetables, nuts etc.<br />Beneficial effects in small clinical trials<br />Lindeberg S et al. Diabetologia 2007;50:1795<br />Jönsson T et al. Cardiovasc Diabetol 2009;8:35<br />Frassetto LA et al. Eur J Clin Nutr 2009;63:947<br />LDL –22%, TG –35%, fP-Insulin –68%, AUC Insulin –39%, diastolic blood pressure –4%<br />
  132. 132. Grain-free, dairy-free diets in clinical practice<br />Fruit, roots, meat, organ meats, eggs, fish, shellfish, vegetables, nuts etc.<br />Beneficial effects in small clinical trials<br />Many promising case reports<br />
  133. 133. Grain-free, dairy-free diets in clinical practice<br />Fruit, roots, meat, organ meats, eggs, fish, shellfish, vegetables, nuts etc.<br />Beneficial effects in small clinical trials<br />Many promising case reports<br />No obvious risks for most people<br />
  134. 134. Grain-free, dairy-free diets in clinical practice<br />Fruit, roots, meat, organ meats, eggs, fish, shellfish, vegetables, nuts etc.<br />Beneficial effects in small clinical trials<br />Many promising case reports<br />No obvious risks for most people<br />Uncertain effect of milk on bone strength<br />in children and adolescents (Winzenberg T et al. COCHRANE 2006; Lanou AJ et al. Pediatrics 2005;115:736)<br />in adults (Benetou V et al. EJCN 2011;65:132; Bischoff-Ferrari HA et al. J Bone Mineral Res 2011;DOI 10.1002)<br />
  135. 135. Grain-free, dairy-free diets in clinical practice<br />Fruit, roots, meat, organ meats, eggs, fish, shellfish, vegetables, nuts etc.<br />Beneficial effects in small clinical trials<br />Many promising case reports<br />No obvious risks for most people<br />Uncertain effect of milk on bone strength<br />Uncertain iodine requirements in paleo perspective<br />
  136. 136. Grain-free, dairy-free diets in clinical practice<br />Fruit, roots, meat, organ meats, eggs, fish, shellfish, vegetables, nuts etc.<br />Beneficial effects in small clinical trials<br />Many promising case reports<br />No obvious risks for most people<br />Possibly sustainable<br />Root vegetables, local production, no fertilizers, no dairy, sustainable meat, organ meats, involuntary calorie restriction<br />
  137. 137. Everyone agrees: This is not healthy<br />61<br />
  138. 138. Everyone agrees: This is healthy<br />62<br />
  139. 139. Conclusions<br />Common foods may cause common health problems<br />Food choice may be more important than counting fat, carbohydrate or calories<br />Nearly all Westerners get atherosclerosis and we don’t know why<br />Conventional dietary advice is somewhat unfounded <br />Is endocrinology more important than nutritionism?<br />Many possibe endocrine disruptors in grains, seeds and beans<br />Tyrosine kinase agonists, autoantigen mimics, goitrogens, phytoestrogens etc. <br />www.staffanlindeberg.com<br />staffan.lindeberg@med.lu.se<br />

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