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Diets and Incidence of NCDs: Evidence
to Guide Agricultural Research
Walter C. Willett, MD, DrPH
Department of Nutrition
H...
Lifestyle Objectives
(modified summary of WHO/FAO, 2003)
• Avoid tobacco use
• Pursue physical activity
• Avoid overweight...
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
%ChangeinCHD
Hu FB, et al. N Engl J Med 1997;337:1491-9
...
Relative Risk of NIDDM by Different Levels of
Cereal Fiber & Glycemic Load
2,5 2,3
2,05
2,17
1,8
1,62
1,51
1,28
1
0
1
2
3
...
Combined
Nettleton, 2009
deKoning, 2010
Paynter Women, 2006
Paynter Men, 2006
Palmer, 2008
Bazzano, 2008
Study
Odegaard, 2...
Cancer
P-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+
RelativeRiskRelative...
25.179
Relative Risk of Type 2 Diabetes for Substitution of Specific Fruits (3
servings/ week) for Fruit Juice
(Muraki I. ...
Substitution of Protein Sources (1 sv/day) and Risk of CHD in
NHS, 1980-2006 (3162 cases)
9.202a Bernstein A, et al. Circu...
Relative Risk of type 2 diabetes for replacing 1 serving/day of total red meat
with other foods. Data from NHS, NHSII, HPF...
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 Mi...
Changes in Food and Beverage Consumption
and Weight Changes Every 4 Years
According to Study Cohort
(Mozaffarian D et al.,...
0
2
4
6
8
10
12
14
16
Lam
b
B
eefM
ilk
(2%
)C
heese
Salm
on
Pork
Eggs
TofuD
ry
beansC
hicken
Lentils
Estimated GHG Emissio...
Priorities for Agricultural Research
1. Protein sources: Increase availability of nuts (including
peanuts), legumes, and f...
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
cardiovas...
The mothers
24
25
26
27
28
29
30
31
32
Russia Poland Czech
Primary Vocational
Secondary University
H. Pikart: HAPIEE study...
The children
0
2
4
6
8
10
12
14
16
18
Least
deprived
2nd 3rd 4th Most
deprived
Percent
OR
Crude odds ratio (OR)
for other ...
32
NCD risk factors by Urban/Rural
(Malawi)
Risk factor Prevalence (%)
Urban Rural Both
Tobacco smoking 6.6 10.9* 10.4
Alc...
Diets in urban slums
• Low (perishable and
expensive):
• Fresh drinking water
• Fresh fruit en vegetables
• Fresh meats an...
The economic burden of NCDs will overwhelm health
systems and slow economic growth
35
NCD
COSTS
Health spending on
diabete...
Tools for agriculture to improve health
36
Agriculture and Food
Value Chain Approaches
A value chain reveals social,
envir...
Agriculture can improve health by…
37
Partnering for New
Programs and Policies
EXAMPLES:
• Limit marketing to children and...
thechicagocouncil.org/HealthyAgandNCD
Food & Nutrition Security, Poverty Reduction and
Sustainable Economic Development
• Are hunger and malnutrition an outcome...
Role of agriculture in the global economy
Agriculture provides much more than commodities.
It is a way of life.
When pract...
FAO/WHO
Fruit and Vegetable Initiative for Health
A framework for promoting fruit and vegetable was
established by FAO and...
Conclusions
• NCD related to poor dietary habits
• Socio-economic inequality in diets and health
• Agricultural policies v...
Walter Willett, Harvard University "Diets and incidence of NCDs"
Walter Willett, Harvard University "Diets and incidence of NCDs"
Walter Willett, Harvard University "Diets and incidence of NCDs"
Walter Willett, Harvard University "Diets and incidence of NCDs"
Walter Willett, Harvard University "Diets and incidence of NCDs"
Walter Willett, Harvard University "Diets and incidence of NCDs"
Walter Willett, Harvard University "Diets and incidence of NCDs"
Walter Willett, Harvard University "Diets and incidence of NCDs"
Walter Willett, Harvard University "Diets and incidence of NCDs"
Walter Willett, Harvard University "Diets and incidence of NCDs"
Walter Willett, Harvard University "Diets and incidence of NCDs"
Walter Willett, Harvard University "Diets and incidence of NCDs"
Walter Willett, Harvard University "Diets and incidence of NCDs"
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Walter Willett, Harvard University "Diets and incidence of NCDs"

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Science Forum 2013 (www.scienceforum13.org)
Breakout Session 1 - NonCommunicable Diseases

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Walter Willett, Harvard University "Diets and incidence of NCDs"

  1. 1. 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
  2. 2. 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
  3. 3. 29.516 (Ezzati & Riboli, NEJM 2013)
  4. 4. 100 80 60 40 20 0 -20 -40 1%E 2%E 3%E 4%E 5%E Trans Sat Mono Poly %ChangeinCHD Hu FB, et al. N Engl J Med 1997;337:1491-9 9.131 Type of Dietary Fat and Risk of Coronary Heart Disease The Nurses' Health Study 14-Year Follow-up
  5. 5. Relative Risk of NIDDM by Different Levels of Cereal Fiber & Glycemic Load 2,5 2,3 2,05 2,17 1,8 1,62 1,51 1,28 1 0 1 2 3 High Medium Low High Medium LowRelative Risk >165 165-143 <143 Glycemic 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
  6. 6. 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
  7. 7. Cancer P-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+ RelativeRiskRelativeRiskRelativeRiskRelativeRisk 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+ RelativeRisk Cardiovascular Disease P-value, test for trend=0.0003 (Hung et al., 2004)28.021 Fruit/Vegetable Intake (Serving/Day)
  8. 8. 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)
  9. 9. 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
  10. 10. 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 RelativeRisk
  11. 11. 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 RelativeRisk (Feskanich et al., preliminary analyses) P, trend = 0.03 24.064
  12. 12. 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
  13. 13. 0 2 4 6 8 10 12 14 16 Lam b B eefM ilk (2% )C heese Salm on Pork Eggs TofuD ry beansC hicken Lentils Estimated GHG Emissions per Protein Food Product (Derived from Clean Metrics / Environmental Working Group, Meat Eaters Guide Methodology, 2011)GHG/Protein 14.003
  14. 14. Priorities for Agricultural Research 1. 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
  15. 15. Socio-economic inequality in diet and ncd; role of agriculture Jaap Seidell, VU University Amsterdam, The Netherlands
  16. 16. Reality: 80% of chronic disease deaths occur in low & middle income countries
  17. 17. 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
  18. 18. 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 I II IIInm IIIm IV V Women’s BMI in Russia, Poland, Czech Republic By Education Obesity trends by social class in women: England 1993-2001 Health Survey for England
  19. 19. The children 0 2 4 6 8 10 12 14 16 18 Least deprived 2nd 3rd 4th Most deprived Percent 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 INCOME France (2-17 y) INDEX OF MULTIPLE DEPRIVATION England (2-10 y) ETHNICITY Germany Jotangia et al., 2005 Kuepper-Nybelen et al (2005)
  20. 20. 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
  21. 21. 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.
  22. 22. The economic burden of NCDs will overwhelm health systems and slow economic growth 35 NCD COSTS 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 growth Source: WHO 23 high burden countries are projected to lose $84 billion in GDP between 2005-2015 from 3 NCDs Source: Abegunde, et al, 2007 NCDs will cost more than $47 trillion globally between now and 2030 Source: D. Bloom, 2011
  23. 23. Tools for agriculture to improve health 36 Agriculture and Food Value 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
  24. 24. 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
  25. 25. thechicagocouncil.org/HealthyAgandNCD
  26. 26. 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
  27. 27. Role of agriculture in the global economy Agriculture provides much more than commodities. It is a way of life. When practised sustainably, it assures food security, conservation of national resources, environmental stability and employment. It contributes to social stability and cohesion, and maintenance of cultural traditions.
  28. 28. 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.
  29. 29. 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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