Diet is mediterranean diet indeed better

Diet: Is Mediterranean diet indeed better?

WCC, Dubai 18-21.4.2012

Pekka Puska, professor, MD, PhD,MPolScPast President, World Heart Federation (WHF)Director General, National Institute for Health and Welfare (THL)Vice President, Int. Ass. of National Public Health Institutes (IANPHI)

Pekka Puska, Director General04/10/23

0 1000 2000 3000 4000 5000 6000 7000 8000

Occupational risk factors for injury

Unsafe health care injections

Vitamin A deficiency

Zinc deficiency

Urban air pollution

Iron deficiency

Indoor smoke from solid fuels

Unsafe water, sanitation, and hygiene

Alcohol

Physical inactivity

High Body Mass Index

Fruit and vegetable intake

Unsafe sex

Underweight

Cholesterol

Tobacco

Blood pressure

WORLDWORLDDeaths in 2000 Attributable to Selected Deaths in 2000 Attributable to Selected Leading Risk Leading Risk

FactorsFactors

Number of deaths (000s)

Source: WHR 2002

Pekka Puska, Director General04/10/23

Six of the Nine Top Determinants of Six of the Nine Top Determinants of Mortality in the World Relate to How Mortality in the World Relate to How We Eat, Drink and MoveWe Eat, Drink and Move

Diet and physical activity, together Diet and physical activity, together with tobacco and alcohol, are key with tobacco and alcohol, are key determinants of contemporary determinants of contemporary public healthpublic health

Pekka Puska, Director General04/10/23

Diet influences many biological risk factors

• Serum LDL cholesterol

• Other lipids

• Blood pressure

• Body weight

• Serum glucose

• Other (antioxidants etc.)

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Mediterranean diet: Origins of the concept

• The Seven Countries Study

by: Ancel Keys & C. Aravanis,

H. Blackburn, R. Butzino, B. Djordjevic, A. Fontas, F. Fidanza, M. Karvonen,

N. Kimurc, A. Menolti etc.

04/10/23 Pekka Puska, Director General

04/10/23 Pekka Puska, Director General

04/10/23 Pekka Puska, Director General

04/10/23 Pekka Puska, Director General

04/10/23 Pekka Puska, Director General

04/10/23 Pekka Puska, Director General

Ancel Keys (1904-2004)

Ancel Keys and Italy

Pioppi, Italy: ” Home of the Medirerranean diet”

Ancel & Margaret Keys: ”Eat well and stay well” (1959)

Ancel & Margaret Keys: ”How to eat well and stay well the Mediterranean way” (1975)

04/10/23 Pekka Puska, Director General

What is the Mediterranean diet?

• Based on ”food patterns typical of Crete, much of the rest of Greece and Southern Italy in the early 1960’s”

• Emphasizes ”abundant plant foods, fresh fruit as the typical deily dessert, olive oil as the principal source of fat, dairy products (principally cheese and yogurt), and fish and poultry products consumed in low to moderate amounts, zero to four eggs consumed weekly, red meat consumed in low amounts, and wine consumed in low to moderate amounts; in addition to physical activity

• Total fat: 25-35 %, saturated fats <8 %(Walter Willet)

04/10/23 Pekka Puska, Director General

04/10/23 Pekka Puska, Director General

Evidence of benefits of Mediterranean diet 1.

Nordman et al. Meta-analysis (Am J Med 2011): Compared to low fat diets; 2 years follow-up

• BMI: -2.2 kg

• Syst. Blood pressure: -1,7 mmHg

• Fasting plasma glucose: -3.3 mg/dL

• Total cholesterol: -7.4 mg/dL

”Mediterranean diets appea to be more effective than low fat diets”

The Mediterranean diet puts emphasis on the quality rather than quantity of dietary fat

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Evidence of benefits of Mediterranean diet 2.

• Kastorini et al. (j. Am Coll Card, 2011): Meta-analysis of 50 studies

”Mediterranean diet is associated with lower blood pressure, blood sugar and triglycerides”

04/10/23 Pekka Puska, Director General

Evidence of benefits of Mediterranean diet 3.

Sofi et al. Meta-analysis (Am J. Clin Nutr. 2010) 2-point increase in adherence to Mediterranean diet

• Overall mortality: RR=0,92• Cardiovascular: incidence/mortality: RR=

0,90• Neurodegenerative diseases: RR=0,87 ”Significant and consistent protection of

provided by adherence to the Mediterranean diet”

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The Mediterranean diet in secondary prevention of coronary heart disease: The Lyon Heart Study (Largevil & Salen, Clin Invest Med 2006)

50-70 % reduction of the risk of recurrence after four years of follow-up in CHD patients

04/10/23 Pekka Puska, Director General

What effect and what component importantEffects on

– Serum LDL cholesterol– Other lipids– Blood glucose– Other?

Components– Type of fat– Fruit and vegetables– Meat (fish & poultry vs red meet)?– Wine?– Other?

Also: Physical activity, portion sizes, pleasure in food, etc?

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Lipids and diet

• Serum lipids, and especially LDL cholesterol, are major causal factors in the atherosclerotic process

• Important factor in the Mediterranean diet

• Numerous studies show how diet influences strongly serum LDL cholesterol and other lipids (Keys, Hegstedt, Mensink & Katan)

• Numerous expert recommendations

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Iacono, Puska, Pietinen, Huttunen, Ehnholm et al.: Finland – Italy diet CHD risk study

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The Finnish experience:The North Karelian Project

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Serum Cholesterol in Men Aged 30–59 Serum Cholesterol in Men Aged 30–59 YearsYears

FINRISK Studies 1997 & 2002

mmol/l

5

5,5

6

6,5

7

7,5

1972 1977 1982 1987 1992 1997 2002 2007

North Karelia

Kuopio

Turku/Loimaa

Helsinki/Vantaa

Oulu

Lapland

Pekka Puska, Director General04/10/23

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Age-adjusted mortality rates of coronary heart disease in North Karelia and the whole of Finland among males aged 35–64 years from 1969 to 2006.

Mortality per 100 000 populationAge-standadized to European population

start of the North Karelia Project

extension of the Project nationally

North Karelia

All Finland

- 85%

- 80%

Observed and Predicted Declines in Coronary Mortality in Eastern Finland, Men

-90

-80-70

-60

-50-40

-30

-20-10

0

1972 1977 1982 1987 1992 1997 2002 2007Year

%

ObservedPredictedCholesterolBlood pressureSmoking

Pekka Puska, Director General04/10/23

Estimates of S-Chol changes in Estimates of S-Chol changes in 19821982––2002*2002*

Men

-0,6

-0,5

-0,4

-0,3

-0,2

-0,1

0

0,1

1982 1992 2002

mm

ol/l

PUFA

DietarycholesterolSFA

Keys

SFA+trans

Keys (trans) **

MeasuredS-Chol

* Based on calculated intakes of dietary fatty acids and cholesterol. Standardized to the 2001 Finnish population. Users of cholesterol lowering medication excluded in -92 and -02. ** Trans fatty acids included as SFA

(Source: KTL/Valsta, Tapanainen, Laatikainen, Männistö, Vartiainen, in preparation )

Comment

Ancel Keys’ original message was (esp. In the USA) lost in ”fat-is-bad mantra – although the message was in the ”Mediterranean diet” of Ancel Keys was unsaturated fats over saturated.

Thus fats in esp. the USA were replaced with sugars, with obesity epidemic as result.

Mediterranean diet is a balanced diet, with quality of fat plus fruits and vegetables as key – with proper amount of calories with regular physical activity.

04/10/23 Pekka Puska, Director General

Mediterranean diet is one way to enjoy diet that complies with current evidence, expressed by the WHO/FAO recommendations and numerous other national and other expert recommendations.

You don’t need to eat Mediterranean diet to have heart healthy diet – you can base your diet on different cultural patterns, but following the expert recommendations.

04/10/23 Pekka Puska, Director General

04/10/23 Pekka Puska, Director General

WHO/FAO Expert ReportRecommendations• Limit saturated fat (<10 %) and replace by unsaturated

• Total fat intake: 15-30 %

• Limit salt (sodium) intake (<5 g)

• Limit sugar intake (<10 %)

• Increase fruit and vegetable intake (>400 g)

• Ensure physical activity: at least 30-60 min

• Ensure energy balance

RECOMMENDATIONS OF WHO/FAO EXPERT REPORT ON DIET, NUTRITION AND PREVENTION OF CHRONIC DISEASES (WHO/TRSNS. 16;2003)

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General dietary recommendations for lipid control

• Reduce saturated fat and avoid trans fats

• Replace saturated fat with unsaturated (esp. polyunsaturated) fats

• Reduce dietary cholesterol

• Increase soluble fibers

• Maintain normal weight

04/10/23 Pekka Puska, Director General

04/10/23 Pekka Puska, Director General

National policies to promote healthy diet

WHO Global Strategy on Diet, Physical Activity and Health

04/10/23

Thanks

Pekka Puska, Director General