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FireFit 2005 Conference
Christopher Speed, MND APD
Dana Farber Cancer Institute
Nutrition Revolutions
1970’s Type of fat (“saturated fat”)
1980’s Amount of fat (“low fat”)
1990’s Low carbohydrate
2000’s Optimum eating pattern
(“Mediterranean-type”)
Wise
Eating
Keep Fit
Blood Pressure
Cholesterol
Weight
Fitness/activity
Manage Stress
Stress
Don’t Smoke
C A N C E R
4 Pillars of Health
Smoking
The Serious Pain of Obesity
Former severely obese patients:
• 100% preferred to be deaf, dyslexic, diabetic, or
have heart disease or bad acne than to be obese
again
• Leg amputation was preferred by 91.5% and
blindness by 89.4%
• 100% preferred to be a normal weight person
rather than a severely obese multimillionaire
Rand CSW, Macgregor AMC. Int J Obes. 1991;15:577–579.
So What Defines
Optimal Nutrition for
Cardiovascular Disease
and Cancer Prevention?
Fat
 Carbohydrate
 Protein
Alcohol
 Sodium
Seven-Countries Study: Dietary Total Fat
and 10-year CHD death rate, 1958-1974
Men, age 40-59 yr at entry
10-yr CHD deaths/1000
80
E. Finland
70
60
50
USA
Holland
40
30
Rome
W. Finland
Belgrade
Italy (rural) Croatia
Corfu Serbia
20
10
Japan
Serbia
0
0
10
20
30
Croatia
Crete
40
Dietary Total Fat (% energy)
Keys A. Harvard U. Press, 1980.
Fat: Quality more
Important than Quantity
Quality Fats:
Monounsaturated and
Polyunsaturated
Healthy Fats
Monounsaturated Fats
• Olive, canola and peanut oils
• Nuts
(almonds,cashews,peanuts,filberts,
macadamias,pecans,pistachios)
• Avocados
• Peanut butter and other nut butters
Randomized Clinical Trials of
Polyunsaturated Fats
N
Yrs
% Fat Cholesterol
CVD
Finnish Hospital ‘79 676
6
34
-15%
-43%*
Oslo ‘ 70
412
5
39
-14%
-25%*
MRC Soy Oil ‘68
393
4
46
-15%
-12%
8
39
-13%
846
Los Angeles ‘69
-34%*
(Dayton)
Linoleic was major fat that replaced saturated,
but alpha linolenic acid also increased.
*P < 0.05
Sacks F. Am J Med. 2002; Dec 30; supplement.
Clinical Trials of Fish Oil
After Myocardial Infarction
• GISSI (Lancet 1999;354:447)
– 1g/d n-3 PUFA for 3.5 years
– 5666 fish oil, 5658 control
– CVD Death reduced by 30%
• DART (Burr et al. Lancet 1989;ii:757
– 1015 fish oil, 1015 control
– 0.3g/d n-3 PUFA for 2 years
– IHD death reduced by 33%
• Non-fatal CVD not reduced
Healthy Fats
Polyunsaturated Fats
Omega 6’s
• Corn, safflower, sunflower, soybean
• Walnuts
Omega 3’s
• Fatty fish: salmon, sardines, bluefish,
herring, tuna, mackerel
• Flaxseeds, canola oil, wheat germ
Limit Unhealthy Fats:
Trans Fats and
Saturated Fats
Trans Fats
Nurses’ Health Study: the nurses who
ate 3% daily calories from trans fat were
50% more likely to develop CHD over
14 yrs than those who ate < 1% of daily
calories from trans fats
Saturated Fats and CAD
• In Key’s 7 Country study, direct
correlation between intake of
saturated fats and increased
risk of CHD
Saturated Fats and CAD
Ni-Ho San Study
•
•
•
•
Japan
Hawaii
California
Sat fat (% E)
7
Alcohol (%E) 8.9
Chol (mg/dl) 181
>120% wt.
22%
23
3.7
218
56%
26
2.5
228
63%
Kato.1973
Saturated Fat and CAD
Ni-Ho San Study
Age adjusted CAD rates (per 1000 person yr)
• Japan
1.6
• Hawaii
3.0
• California
3.7
Nurses’ Health Study
Replacing Saturated or Trans Fat: Change in CHD
N=80,052 women, 939 cases. Adjusted for CHD risk factors,
dietary monounsaturated, polyunsaturated and trans fatty acids.
Sat
Carb
(5% Energy)
Sat
Mono
(5% energy)
Sat
Poly
(5% Energy)
Trans
Cis Unsat
(2% Energy)
-80
-70
-60
-50
-40
-30
-20
-10
0
10
Change in CHD Risk (%)
Hu, F et al. N Engl J Med 1997
Dietary Fat, Carbohydrate and Risk of Type 2
Diabetes in the Nurses Health Study
40
2% isoenergetic substitutions
20
0
-20
-40
-60
trans
poly
Sat
poly
Carb
poly
Sat
mono
Salmerone et al., AJCN 2001; 73:1019
Abundance of Plant
Foods
Fruits, Vegetables,
Nuts
Fruits and Vegetables and
Coronary Heart Disease
from NHS and HPFS
• Men and women eating 8+ servings of fruits
and vegetables a day had a 20% lower risk of
developing CHD compared to those in the
lowest quintile (< 3 servings/day)
• Contributing most to the protective effect:
Green leafy vegetables
Vitamin C rich fruits
Joshipura,2001
Fruit and Vegetables and Coronary Heart Disease
Joshipura et al; Ann Int Med 2001
Fruit and Vegetable Intake
and Ischemic Stroke: NHS
and PHFS
• Those in highest quintile (median of 5
serv for men and 5.8 serv for women)
had a 31% lower risk compared to those
in the lowest quintile (< 3 serv/day)
• Contributing most to protective effect:
cruciferous vegetables, green leafy
vegetables, citrus fruit and citrus fruit
juice
Fruit and Vegetables and Ischemic Stroke
Joshipura et al; JAMA, 1999
Typical Nut Consumption
Coconuts
6%
Almonds
6%
Pecans
5%
Walnuts
5%
Other Tree Nuts
10%
Peanuts and
Peanut Butter
68%
Source:USDA Economic Research Service, 1997 Data
(Nutrition Insights No. 23, Dec. 2000)
Nut Consumption Lowers Risk of
Heart Disease: (Nurses Health
Study, 1980-97)
Frequency
Relative Risk
CI
1oz serving
Almost never
1/mo -1/wk
2-4/week
5+/week
1.0
0.89
0.77
0.68
(0.79-1.01)
(0.59-0.99)
(0.77-0.98)
Hu et al, 1997
Relative Risk of Type 2 Diabetes According to
Frequency of Nut Consumption, Stratified by BMI
Relative Risk
1.2
P for Trend = 0.003
.003
P for Trend = .01
0.001
PPfor
forTrend
Trend==.02
0.02
0.75
0.8
0.75
0.55
0.4
0
<25
25-30
BMI, kg/m2
Never/Almost never
1-4 Times/w k
>=30
<Once/w k
>=5 Times/w k
Nut Consumption and Risk of Obesity (BMI≥30)
Relative Risk
1.5
1
1
0.91
0.89
0.9
0.5
0
Never/Almost
never
<Once/w k
1-4 Times/w k
Intake of Nuts
>=5 Times/w k
Carbohydrates
• In the average Westernised
diet, carbohydrates contribute
at least half the calories
• Half of these calories come
from just seven sources
Carbohydrates
7 main sources of carbohydrate
•
•
•
•
•
•
•
Bread (15%)
Soft drinks and sodas (9.5%)
Cakes, cookies and donuts (7%)
Sugars, syrups, jams (6%)
White potatoes (5%)
Ready-to-eat cereals (5%)
Milk (5%)
Carbohydrates
How do we measure its effect on our
body?
Glycemic Index = type of carbohydrate
Glycemic Load = type of carbohydrate +
amount of carbohydrate
Risk of CHD According to Glycemic Load
Nurses’ Health Study 1984 -1994
3
RR of
CHD
2
1
0
1
2
3
4
5
Glycemic Load Quintiles
Liu 2000
Relative Risk of NIDDM 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
Cereal
Fiber
Glycemic Load
Salmeron, Willett. JAMA 1997;277:472
Fiber
• Nurses’ Health Study (n=75,521 women)
highest quintile whole grain
consumption
– 25% reduction in CHD
– 30% reduction in ischemic stroke
– 40% reduction in diabetes.
• Iowa Women’s Health Study (n=35,000
women 55yo+) highest quintile
– 30% reduction in coronary death
– 20% reduction in diabetes
Obesity: Diet
Intervention to
Support Long Term
Weight Loss
Why Are We Gaining Weight?
• Data from NHANES I, II, III (19711994)
– Total mean energy intake has
increased approximately 300 kcal
– Exercise/physical activity has
declined
Briefel et al. 1995
Low-Fat Weight Loss Trials
100
NDH (1968)
(35 vs 30% E)
90
Boyd (1990)
(37 vs 21% E)
85
Jeffery (1995)
(33 vs 26% E)
Black (1994)
(40 vs 21% E)
Body Weight (kg)
95
80
75
Sheppard (1991) (38 vs 20% E)
70
Kasim (1993)
(36 vs 17% E)
60
Simon (1997)
(34 vs 18% E)
55
Knopp (1997)
(27 vs 22% E)
65
50
0
6
12
Length of Follow-up (months)
26.062
21
McManus (2001) (35 vs 20% E)
Moderate Fat Weight Loss
Trials
Study Population
• Randomized, prospective 18 month trial in a
free-living population
• 101 overweight men and women
• mean BMI: 33.5 kg/m2
• mean age: 44 yrs
• all subjects had reported numerous previous
weight loss attempts
Nutrient Goals For The Diets
MOD FAT
• Calories 1200-1500
• Fat (%)
35%
-Sat
5%
-Mono
15-20%
-Poly
10%
LOW FAT
1200-1500
20%
5%
7-8%
7-8%
Nutrient Goals For The Diets
•
•
•
•
MOD FAT
LOW FAT
Protein (%)
15-20%
CHO(%)
45-50%
Fiber (gms)
25
Cholesterol(mg) <200
15-20%
60-65%
25
<200
PARTICIPATION RATES
100 100
MOD FAT
LOW FAT
* P = 0.057
** P < 0.002
100
90
80
% Active
70
64
58
60
54
45
50
40
27
30
19.6
20
10
0
Baseline
6*
12**
MONTHS
18**
Weight Loss at 18 Months
WK 78
WK 72
WK 66
WK 60
WK 54
WK 48
WK 42
WK 36
WK 30
WK 24
WK 18
WK 6
WK 12
(Active Participants throughout Entire Trial)
0
2
4
6
8
10
12
14
16
6.3
7.4
8.3
7.6
9.3
9.6
11.1
11.1
12.3
12.4
12.7
13.9
12.4
14.1
13.9
12.6
12.1
11.7
11.1
10.9
11.6
12.3
10.6
11.3
11.3
12
Mod Fat
Low Fat
n=25
IJO,2001
n=10
Difference (servings/day) from
Baseline -> 18 Months
FOOD ANALYSIS
2
1.2
1
0.7
**
0
-1
**
0.1
0.5
*
0.1
MOD FAT
LOW FAT
0.4
*
0.1
-0.9
** P = 0.002
* P < 0.01
-2
Veg
Peanut
Butter
Peanuts Tree Nuts
IJO, 2001
Adherence to Med-type Diets
Hedonic Rating
Moderate
fat diet
(opioid driven system)
Perceived
deprivation
Adherence
Reinforcing value
(cues/incentive to eat)
Mod fat diets = high adherence rates
Low fat diets = low adherence rates
Epstein LH. Effects of Deprivation on Hedonics and Reinforcing Value of Food.. Physiology and Behavior, 78, 221-227. 2003.
What is the Full
Potential of These
Dietary Changes to
Improve Health?
Primary Prevention of CVD:
5 Attributes for Low-Risk
1. Diet in upper 40% of cohort
– Good fat: Low saturated and trans fat, high
polyunsaturated fat, high fish oil
– Good carbohydrates: Low glycemic load, high
fiber (whole grains)
– High folate (vegetables, fruit)
2. Not currently smoking
3. Moderate alcoholic beverage drinking
1 drink every other day to daily
4. Regular Exercise
1/2 hour daily (e.g. 2 miles/hour walking)
5. Body mass index <25 kg/M 2 (optimal <21 kg/M 2)
Stampfer MJ, et al. N Engl J Med. 2000;343:16-22.
Primary Prevention of CVD:
5 Attributes for Low-Risk
Three low-risk attributes
Good diet, no smoking, regular exercise
13% of nurses,
51% of coronary events and strokes avoided
Four low-risk attributes
Good diet, no smoking, regular exercise, BMI <25
7% of nurses,
60% of events avoided
Five low-risk attributes
Above, plus moderate alcohol
3% of nurses, 74% CVD events, 82% coronary
events in the population avoided
Stampfer MJ, et al. N Engl J Med. 2000;343:16-22.
Is there a dietary
pattern that puts all
this together?
Are Whole Grains Good?
Liu et al 2000
Liu et al 1999
Jacobs et al 1997
Fraser et al 1992
Best
0.00
Better
-50
Bad
Good
0
+50
Effect on Heart Disease Risk (%)
Adapted from: Hu, FB, Am J Clin Nutr 2003
Are Fruit and Vegetables Really Good?
Bazzano. et al 2002
Liu. et al 2001
Joshipura. et al 2001
Liu. et al 2000
Joshipura et al 1999
Gaziano et al 1995
Gillman et al 1995
Knekt et al 1994
Best
Better
-50
Bad
Good
0
+50
Effect on Heart Disease Risk (%)
Adapted from: Hu, FB, Am J Clin Nutr 2003
Are Nuts Good?
Albert et al 2002
Ellsworth et al 2001
Brown et al 1999
Hu et al 1998
Fraser and Shavlik 1997
Fraser et al 1992
Best
Better
-50
Good
Bad
0
+50
Effect on Heart Disease Risk (%)
Adapted from: Hu, FB, Am J Clin Nutr 2003
There are 9 points to
Healthy Eating !
 high olive, canola, nut, seed, vegetable oil

consumption
 high consumption of legumes

 high consumption of cereals, mostly whole grain

 high consumption of fruits

 high consumption of vegetables

 MODERATE wine/alcohol consumption

 moderate consumption of dairy products

 moderate to high consumption of fish, poultry

 low consumption of meat and meat products

Hazard Ratios for Death Associated with a Two-Point
Increment in the Mediterranean-Diet Score
Variable
Death from any
cause
# Deaths/
# Participants
275/22,043
Hazard Ratio for Death
(95%CI)
Age- and SexAdjusted
Fully Adjusted
0.79 (0.69-0.91)
0.75
(0.64-0.87)
Death from
coronary heart
disease
54/22,043
Death from
cancer
97/22,043
0.74 (0.54-1.02)
0.67
(0.47-0.94)
0.85 (0.67-1.08)
0.76
(0.59-0.98)
(Trichopoulou et al, 2003)
Lyon Heart Study: A Mediterranean-Style Diet
After Myocardial Infarction
15
Control diet
Mediterranean-style diet
10
Event
Rate
(%)
25
24
- 56%
p=.03
5
19
17
14
- 65%
p=.01
6
0
Death
Cardiac
Mortality
- 70%
p<.01
8
Non Fatal
MI
- 61%
p<.05
7
Cancer
De Lorgeril. Arch Intern Med 1998;158:1161; Circulation 1999;99:779.
Indo-Med Diet Study
Proportion of patients with fatal myocardial infarction, non-fatal myocardial
infarction, or sudden cardiac death.
Graph taken from “Effect of an Indo-Mediterranean diet on progression of coronary artery disease in high risk patients (IndoMediterranean Diet Heart Study): a randomised single-blind trial” (2002) Elliot M Berry et al. The Lancet 360: 1455–61
The HALE Project
Europe-wide10-year follow-up
> 1500 men and women aged 70 to 90
Mediterranean diet
+ nonsmokers > 15 yrs
+ physically active,
+ moderate alcohol
years
Knoops K. JAMA 2004
= half the mortality
from all causes,
CHD,CVD
and cancer
Mediterranean-type diet staples and their
main therapeutic nutrients
Vitamin B1
Cereal (whole grains)
Legumes
Fruit and Vegetables
Plant oil, nuts (mono)
Wine
Fibre, Lignans
Isoflavones
Carotenoids Vitamin C
Phenolic componds
Folates, Glucosinolates
Allylic compounds
Isothiocyanates
Indoles, Terpenes
Mediterranean-type Diet Therapeutic
Nutrients and Cancer
Oxidative
Damage
Carotenoids,
phenolics,
terpenes,
tocopherols,
flavonoids
CARCINOGENS
Initiation
Coumarins,
flavonoids,
triterpenoids
Tumor Promotion
Sulfides,
isoflavone
s
PROSTAGLANDINS
Fibers,
phytosterols,
terpenes, sulfides,
phenolics, lignans,
isoflavones,
cruciferous
indoles
STEROID
HORMONES
Phenolics, salicylates,
flavonoids,
polyacetylenes,
sulfides, omega-3 fats
Journal of Nutrition (2001) 131;3056
The Mediterranean-type Diet Has
application to non-Mediterranean
regions
Med-type eating is achievable through foods from a
variety of traditions and supports expectations
surrounding food preparation, choice, taste and
sensory appeal
Speed C. (2004) European Journal of Cancer Prevention. 13(6):529-34.
Mortality (RR)
Percent Reduced Risk of Cardiovascular
100
90
80
70
60
50
40
30
20
10
0
Figure 1. Percent Reduced Risk of Cardiovascular Mortality (%RR) with treatments for Primary
Prevention of Cardiovascular Disease.
Adapted from What role for statins: a review and economic model [Treatment and prevention.] Center for Reviews and
Dissemination Reviewers Date of Most Recent Update: 31-05-2001 NHS Centre for Reviews and Dissemination. University of
York, York, U.K.
Why Do Too Few of
The General Community
Eat and Drink
What We Tell Them To?
Any reasons why?
But Why?
%
Why
don’t I
eat
wise?
Why don’t
I get more
exercise?
Why don’t
I stop
smoking?
Why don’t I
cope better
with stress?
Unsure how
13.6
2.3
3.0
43.0
Too difficult
15.3
4.1
47.7
6.9
No time
14.0
47.2
2.1
16.2
Too lazy
30.6
26.5
31.6
23.7
5.2
14.8
23.5
28.7
Other
New South Wales, Australia: Better Health Commission Report - 1986
Well…motivate them of
course?
No time –
Don’t know how –
BARRIERS
Too lazy –
Too difficult –
Those who don’t…
Too fat –
Family dislikes
No gear –
No cooking utensils
–
Travel too much –
Have kids –
Get home late –
TRADITIONAL
APPROACH
BARRIER
REMOVAL
Those who do…
I don’t shop –
Take out is easier –
Expectations –
MOTIVATION
The Human-Food Connection
celebrationrelationships compassion
self image
nurturing
childhood
religion
sustenance
culture
cost
sleep
appetite
time
pain
health
control
FOOD
choice
home
energy
weight
satisfaction
tradition
affection
support
loved ones
the past
maturity
love
festivities
guilt