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How To Eat, Drink, and Be Healthy

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How To Eat, Drink, and Be Healthy
Walter C. Willett, MD, DrPH
Department of Nutrition
Harvard School of Public Health
April 26, 2007
10-Year Coronary Incidence Per 10,000 Men
(Keys 1980)
Incidence
3000
y=77+78x
r=0.73
east Finland
2000
west Finland
Crevalcore
Montegiorgio
1000
Zutphen
Belgrade
Corfu
Ushibuka
Zrenjanin
Slavonia
Velika Krsna
Tanushimaru
Crete
0
0
5
10
15
% Diet Calories from Saturated Fat
9.006
20
25
Keys, 1980
Colon Cancer Incidence / 100,000 Women
50
NZ
40
USA
30
CAN
DEN
20
SWE
NET
NOR
FDR
ISR
DDR
JAM
10
YUG
JAP
0
CHI
COL
FIN PR
ROM
UK
ICE
POL
HUN
NIG
0
40
80
120
160
200
240
280
320
Per Capita Daily Meat Consumption (grams)
2.003
(Armstrong and Doll, 1975)
Age Adjusted Death Rate / 100,000 pop
25
Netherlands
Switzerland
Belgium
UK
Canada
USA
Italy
15
New Zealand
Ireland
20
Germany
Austria
Denmark
Australia
Sweden
Norway
France
Czechoslovakia
Hungary
Finland
Portugal
10
5
Hong Kong
Poland
Bulgaria
Chile
Venezuela
Romania
Panama Greece
Yugoslavia
Puerto Rico
Spain
Columbia
Philippines
Mexico
Japan
Taiwan
Ceylon
Thailand
El Salvador
0
0
20
40
60
80
100
120
140
160
Animal Fat Intake (g/day)
0.001
0.001
Carroll, 1975
21.004
1: Use Nonfat Products
To reduce your fat intake:
Eat more fruits, vegetables, and their juices. Most are naturally low in
fat…and high in vitamins and minerals.
Here are some other ways to reduce fat in your food.
TRY
Butter-flavored granules
Nonfat yogurt
Nonfat salad dressings
Angel food cake
Fat-free cookies and crackers
9.071
INSTEAD OF
Butter or margarine
Regular yogurt
Regular salad dressings
Devil’s food cake
High-fat cookies and crackers
21.031
21.038
9.010
8.063
Effect of Trans and Saturated Fat (10% E) on
Blood Lipids (vs Monounsaturated fat)
(Mensink & Katan, 1990)
Trans fat
9.110
Saturated fat
Total cholesterol
+6%
+12%
LDL cholesterol
+14%
+18%
HDL cholesterol
-12%
0%
LDL/HDL ratio
+29%
+18%
Blood lipids
Blood pressure
Thrombotic tendency
Insulin resistance
Diet
CHD
Oxidation
Homocysteine
Inflammation/endothelial dysfunction
Ventricular irritability & arrhythmia
9.105R
Age-Adjusted Plasma CRP by Quintiles of Trans
Fatty Acid Intake in the Nurses’ Health Study
2
CRP (mg/L)
(P, trend = <0.001)
1.5
1
0.5
0
Q1
Q2
Q3
Q4
Q5
Trans Fat Intake (Quintiles)
(Lopez-Garcia 2005)
8.097
Nurses’ Health Study (n=121,700)
1976
1978
Ocs
Smoking
Weight/Ht
Med. Hist.
1980
Diet
1982
Nails
1984
1986
Diet
Diet
1988
1990
1992
Diet
Blood
1994
Diet
1996
1998
Diet
Health Professionals Follow-up Study (n=52,000)
1986
Diet
1988
Nails
1990
Diet
1992
1994
1996
Diet
Blood
1998
2000
Diet
Nurses’ Health Study II (n=116,000)
1989 1991 1993 1995 1997 1999
Diet
Diet Blood Diet
Investigators: Frank Speizer, Bernie Rosner, Meir Stampfer, Graham Colditz, David
Hunter, JoAnn Manson, Sue Hankinson, Eric Rimm, Edward Giovannucci, Alberto
Ascherio, Gary Curhan, Charlie Fuchs, Fran Grodstein, Michelle Holmes, Frank Hu
0.198R
2000
100
% Change in CHD
Trans
80
60
40
Sat
20
1%E
2%E
3%E
4%E
5%E
0
-20
Mono
-40
Poly
(Hu et al. 1997)
9.131
0.88
0.92
1.2
0.91
0.71
0.8
0.7
1.05
0.63
0.87
0.73
0.71
0.71
0.36
0.81
0.32
0.66
0.55
Q4
Quintiles of trans fat
Q1&Q2
(lowest)
Quintiles
of poly
Q1 (lowest)
Q2
Q3
Q5 (highest)
Q4
0
Q3
0.63
0.31
Q5 (highest)
Multivariate RR of CHD
1
Hu et al, 1997
9.049
Multivariate Relative Risk of Sudden Death
(Albert et al., 2002)
1
0.5
P = 0.007
0
3.6
4.8
5.6
6.9
Quartile of blood N-3 fatty acid (Mean, % of fatty acids)
9.129
Oil and Vinegar Salad Dressing and Risk of
Coronary Heart Disease
(NHS, 1980-1994) (Hu et al. 1992)
1.2
1
•
•
0.8
Multivariate
Relative
0.6
Risk
•
•
0.4
0.2
0
1/month
1-4/month
2-4/week
5+/week
Frequency of Salad Dressing Consumption
9.126
Conclusions
1. CHD rates can be dramatically reduced by
nutritional means, but this will not be achieved
by replacing saturated fat with carbohydrate.
2. We should abandon recommendations
regarding % of energy from fat and avoid
pejorative references to fat or “fatty foods”.
3. Advice about dietary fat should focus on
replacement of saturated and trans fat with
vegetable oil, including sources of N-3 fatty
acids.
9.062
(Howard et al. 2006)
9.152
Multivariate RR’s of type 2 diabetes according to quintiles of
specific types of dietary fat (mutually adjusted)
(Salmeron et al, 1999)
Multivariate RR
1.4
1.2
Saturated Fat
Mono
Poly
Trans
1
0.8
0.6
Q1
Q2
Q3
Q4
Quintiles of Fat Intake
25.004
Q5
Trans Fat and Weight Gain
A recent 5-year study of monkeys provides
evidence that on an isocaloric diet with 35% of
calories coming from fat, monkeys on the diet
with 8% E trans fat gained more weight (7.2% vs
1.8%) than monkeys on the diet with an
equivalent amount of fat, but as
monounsaturated cis fat.
(Kavanagh K, et al. Presented June 2006)
29.187
Change in Waist Circumference over 9 Years in
16,587 Men (Koh-Banerjee, 2003)
Variable
Waist Change
(cm)
+2.7*
<0.001
Total fiber (12 gm)
-2.21*
<0.001
Television watching (20
hr/wk)
Vigorous activity (25
MET/wk)
+0.59
<0.001
-0.38
<0.001
Weight training (>0.5 hr/wk)
-0.91
<0.001
Trans fat vs poly (2% E)
*Adjusted for measurement error
26.092
P
Fatty Acids Intake
All fats for carbs, 5% of
energy
-7
Saturated fat for carbs, 5%
of energy
-13
Mono unsaturated fat for
carbs, 5% of energy
-25
Poly unsaturated fat for
carbs, 5% of energy
14
trans fat for carbs, 2% of
energy
64
trans fat for n-6 poly fat, 2%
of energy
68
trans fat for mono fat, 2% of
energy
119
-100
0
100
200
300
Percent Change in Risk of Ovulatory infertility
36.005
400
“So scientists from Harvard
Medical School just found that
eating trans fat can cause
women to become infertile . . . .
[pause] . . . . . So, guys out there:
If your condom breaks, just buy
your girlfriend a bucket of KFC!”
--Jay Leno, Tonight Show (1/23/07)
8.102
Women ( 591cases )
Wolk et al., 1999
Men ( 734 cases )
Rimm et al., 1996
1.5
1.5
1
1
0.5
0.5
0
0
RR
of
CHD
2.2 3.1 3.8
4.9
7.7
2.2
3.7
5.0
6.8
Cereal Fiber, Energy- Adjusted, g/day
8.064
9.7
Easily Digested
Carbohydrate
Slowly Digested
Carbohydrate
Blood Glucose
Blood Glucose
Insulin
0 -
Insulin
0
25.027
1
2 3 4
Time (hr)
5
0
1
2 3 4
Time (hr)
5
Relative Risk of Type 2 Diabetes by Different
Levels of Cereal Fiber and Glycemic Load
WOMEN
2.5
2.3
2.05
2.17
1.8
3
Relative 2
Risk
1.51
1.62
Low
1.28
1
<2.5 g/day
1
Medium
(ref)
2.5 -5.8 g/day
High
0
>5.8 g/day
High
Medium
Low
>165
165-143
<143
Glycemic Load
(Salmeron et al,1997)
9.038
Relative Risk of Coronary Heart Disease
2
Relative Risk
2
2.5
2
1.81
1.16
1.5
0.94
1.19
1
0.5
1
1.1
<23
23-29
1.42
0
Tertile 3 (highest)
Tertile 2
Tertile 1 (lowest)
>29
Body Mass Index (kg/M2)
Liu et al., 2000
Attributable Risk of Coronary Heart Disease
Due to Modifiable Diet and Lifestyle Risk
Factors in the NHS (1980 to 1994)
Low Risk:
1. Non smoker
2. BMI < 25 kg/m2
3. Exercise > ВЅ hr of brisk walking/day
4. Good diet (upper 2 quartiles of score based on
low trans fat, high p/s ratio, low glycemic load,
high cereal fiber, high fish, high total folate)
5. Alcohol 5+g/day
• Proportion at low risk = 3.1%
• Population Attributable Risk = 82% (95% CI = 58-93%)
Stampfer et al, 2000
9.092
Percentage of Type 2 Diabetes Potentially
Preventable by Simultaneous Reduction of Five
Modifiable Risk Factors (NHS) (Hu et al.)
Low Risk
1. Nonsmoking
2. BMI < 25
3. Moderate to vigorous exercise
4. Diet score in upper 40% (low trans fat, high cereal
fiber, low glycemic load, high P:S ratio)
5. Alcohol 5+ grams/day
Percent in low risk group: 4.1%
Population attributable risk (PAR): 92% (82-96)
25.026R
Proportion of Colon Cancers that are Potentially
Preventable by Simultaneous Reduction 6
Modifiable Risk Factors (HPFS)
(Platz et al. 2000)
Low Risk
1. BMI ВЈ25 kg/m2
2. Physical activity £30 min/day of vigorous –
moderate activity
3. Alcohol <15 g/day or 15-30 g/day with
supplemental folic acid
4. Folic acid supplement of ≥100 µg/day
5. £3 pack – years of smoking
6. Red meat ВЈ2 servings/week
Joint low risk group = 3.1% of population
Population attributable risk (PAR): 71% (33-92)
2.116R
Lowfat products whenever
possible; calcium supplements
are and effective substitute for
preventing fractures
Ignores critical differences in
types of fat. Monos appear
desirable
Misleading as 2-3 servings of
meat/day is probably unhealthy
Importance is welldocumented; greens and dark
orange vegetables should be
included. Even more frequent
servings may be desirable
Whole-grain, minimally
processed products should
be emphasized
21.002
Support for generous
intake is well
documented
21.090
Healthy Eating Pyramid
Healthy Eating Pyramid
21.092
21.094
21.058
21.054
21.055
21.056
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