Evolution of the Western Diet and the Origins of Modern Chronic

Disease

D. Barry Boyd, M.D., M.S.

Modern Diet and Lifestyle Declining nutrient diversity Altered dietary patterns (Western Diet) Non-whole food diets – “Food like

substances” Supplemental nutrients – 25 $ billion / year Modern agricultural practices leading to altered

growth conditions (nutrient loss) New exposures (POPs, metals)- “EDC”

Microbial food contamination Indoor lifestyle ( inadequate vitamin D)

Fundamental - Nutrition Transition Altered Energy Balance- No “feast or famine”

Early Man - 200,000 - 12,000 yrs

Paleolithic Diet (hunter-gatherer/forager)High diet diversity Nuts, seeds, tubers, roots (40+ plants) High meat (game), fish, shellfish (latitudinal) Caloric adequacy / high caloric expenditureNutrient adequacy Moderate to high protein High Complex Carbs Moderate fat ( PUFA [ N6=N3] >> SFA) High K+/Na++ Adequate Ca++ / Vitamin D Abundant micronutrients Disease / Health Tall stature, limited dental disease Low risk – chronic disease (HTN, DM, CHD, Ca)

Percent of Energy from Different Food Components

Hunter-Gatherers

PeasantAgriculturalists

Modern AffluentSocieties

15-20

50-70

15-20

10-15

60-75

10-15

34+

20

25-30

12

Salt (gr/d) 1 5 - 15 10

Fiber (gr/d) 40 60 - 120 20

Fat

Sugar

Starch

Protein

5

Fat Content & CompositionDomestic vs Wild Game

20

40

0

20% 21%17% 17%

21%

37%

Antelope Elk Eland Pasture-fedsteer

Grain-fedsteer

Deer

% C

alor

ies f

rom

Fat

from

fat

Saturated Monounsaturated Polyunsaturated

350300

500

250200150100

Fatty

Aci

d Co

nten

t(a

s % o

f Wild

Gam

e)

Wild GamePasture-fed steer

Grain-fed steer

Grain-fed beef has higher saturatedand

lower polyunsaturated fat content

Cancer In Pre Modern Man Paleopathology (paleo-oncology) - Evidence Skeletal (bone lesions)Mummified remains (limited soft tissue preservation)Capasso, L Antiquity of Cancer Int J Cancer 2005Bone Lesions in skeletal remains- rare

Primary/ Benign Bone Lesions, few Metastases176 cases / >28,000 separate skeletal remains ( <0.1%)

Mummified Remains – rare throughout all pre-modern populations (Egypt, Peru, Chile, Alaska, China)

Cancers- Nasopharyngeal Ca, MyelomaBenign Lesions- Osteoma, OsteomyelitisLimitation - Bone (vs soft tissue remains) Age (early mortality –median age 30 yrs)Cancer was a rare disease throughout

most of human history

Eskimo / Inuit Diet andDisease

Trad

ition

al F

ood

Ener

gy%

0

10

20

30

40

50

60

Fish &Fish Roe

Seal &Seal Oil

Game Meat

(caribou)Game(Fowl) Berries Organ

Meat Shellfish OtherAnimal

WildGreens

Contribution of nine food groups to traditional inuit food intake (%energy)

Inuits and Disease

Low Cardiovascular risk- Htn, ASCVD Low DM / Insulin Resistance Osteoporosis + - Low Fracture Risk Malignancy: Limited Breast, Colorectal, Endometrial, Prostate Different – Nasopharyngeal, Cervical, Liver “High Fat, Protein, Low plant-based carbohydrates” No or limited phytonutrients ! Nutrition Transition - Western Disease (+ rickets!)

Neolithic – Rise of Agriculture( 12,000 to Industrial Era)

Grain/ cereal- based (wheat, rice, maize)Declining diet diversity Micronutrient deficiencies (Fe, I, Zn) Lower meat intake, increasing dairyPeriodic food shortages – famineRapid population growth, rapid genetic changesDisease /Health Declining stature/height ( ~ 8-10” shorter) Increasing infectious disease/ parasite load

Early Neolithic sites of the Fertile CrescentNeolithic Origins in the FertileCrescent

WHEATBARLEY

CORN

RICE

Animal Domestication8,000 – 9000 yrs

prior

Nutrition in the Modern Era

Nutrient Deficiency – roleof

inadequate intake in illnessDietary Excess – role in

Non-communicableDisease

Diet &ChronicDisease

Diet &Chronic Disease

Dietary Pattern&

Nutrient Synergy

New Rolesfor Nutrients

in HealthDiscovery of

VitaminsGerm

Theory

Dominance ofInfectious

Disease

<1900 1910 –1940’s

1950’s –1980’s

1990’s –2000’s

RDA’s DRI’s

DietaryGuidelines

Evolution of Diet, Lifestyle &Health

Leading Causes of Death (per 100,000) 1900 2000 Cause of Death Rate Cause of Death Rate All Causes 1,719 All Causes 873 Pneumonia 202 CHD 258 Tuberculosis 194 Malignancy 200 Diarrhea 142 CVA 60 CAD 137 COPD 45 CVA 106 MVA 34 Nephritis 88 DM 25 Accidents 72 Pneumonia 24

Malignancy 63 Alzheimers 19

Diptheria 40 Septicemia 11

Dietary Fatvs

CHDMortality

New York State Journal ofMedicine 2343-2354, 1957.

Dietary Fat vs. Breast Cancer

JAPAN

US

McGovern Committee -1977

THE

Industrialization of FoodUSDA-Food Disappearance

Data

Increased FBCS correlates with Rising Obesity

Modern Edible OilProcessing

Fats and Oils: Formulating andProcessing for Applications,

Richard D. O’Brien 1998

28

Industrialization of Food

Industrialization of Food

10.6% of calories come from plant-based foods

89.4% of calories are derived from manufactured,

processed foods (refinedgrains,

oils, sugars) and meat anddairy

“Fiber” and Disease

Nutritional Reductionism

Wheat

Vitamin E

Dietary Fiber does not reduce Colonic Polyp Formation??

EPIDEMIOLOGY

NUTRITION

SUPPLEMENTS

SUMMARY

INTRODUCTION

From Nutrients to Food

Nutrient Synergy

Specific Nutrient / Single Phytochemical vs Whole Foods vs Dietary Pattern

“Thinking Food First”

Jacobs, D et al Am J Clin Nutr 2009; 89(suppl):1543S-8S

Endosperm(Protein,

Carbohydrate,Some B-complex

vitamins)BranFiber, B-complex

vitamins,trace minerals and

phytonutrients

GermEssential fatty acids,

Vitamin E, B-complexvitamins

And trace minerals

Percentage of nutrients remaining afterwhole

wheat flour is refined into white flour*

*

*

added

*

Percent of People in USA Not EatingAdequate Intakes of Various Nutrients

0204060801000

0

20

20

40

40

60

60

80

80

100

100

RiboflavinNiacinSeFeThiaminPCuFolateZnVitamin B6Vitamin CVitamin AMgVitamin ERiboflavin

Riboflavin

Niacin

Niacin

Se

Se

Fe

Fe

Thiamin

Thiamin

P

P

Cu

Cu

Folate

Folate

Zn

Zn

Vitamin B6

Vitamin B6

Vitamin C

Vitamin C

Vitamin A

Vitamin A

Mg

Mg

Vitamin E

Vitamin E

Inadequate Intakes < EAR (%)

Inadequate Intakes < EAR (%)

Moshfegh et al.,NHANES 2001-2002.

*

**

Whole Grains- Health BenefitsInversely associated with: All-cause mortality (IWS) Type II Diabetes in men (HPFS) and women (NHS) Coronary artery disease (NHS) Hypertension (HPFS, WHS) Ischemic Stroke (NHS) Colorectal Cancer (NIH-AARP) Periodontal Disease (HPFS) Small Intestinal Cancer (NIH-AARP) Congestive Heart Failure (Texas) Non- Cancer, Non-Cardiac Inflammatory Disease (IWS) Breast Cancer (NHS) Endometrial Cancer (IWS) Weight Gain, Inflammatory Markers (Homocysteine), Adverse Lipid Profile (TC,LDL-C) & IR (FBS, C-peptide)

“An Apple a day keeps the oncologist away!”Antioxidant and antitumor activity of fresh apples

tota

l ant

ioxi

dant

act

ivity

0.32

Vitam

in C

fro

m A+

SA+

S

A - S

Anti-proliferative Effect ofApples

on Caco-2 colon cancer cells Apple +Skin, Apple – SkinControl

Anti-proliferative Effect ofApples

HepG2 liver cancer cells Apple +Skin, Apple – SkinControl

Antioxidant Effect of Apples

Mean total antioxidant activityExpressed as total oxyradical

Scavaging capacity for Vitamin C/gr, Apple

+Skin,apple - skin

Eberhardt MV, Lee CY and LIU RH Nature 405:22-8,2000

Glucose

Bread

Lentils

GlycemicIndex

Sat Fat

Glc Load

Glycemic Load > Saturated Fatin Coronary Heart Disease and Diabetes

Risk

From Food to Dietary Patterns

Dietary PatternFrom Nutrient to Food to Lifestyle

Assess dietary patterns in populations vs riskutilize factor analysisMeasures: Healthy Eating Index Western vs Prudent Diet Mediterranean DietCharacteristics: Western – Processed meat, red meat, high fat dairy, eggs, refined grains, processed high calorie dense foods (FBCS), Prudent- High fruit, vegetable, legumes and nuts, whole grains, fish, low fat dairyOutcomes: CV risk and mortality Stroke risk and mortalityCancer risk and mortality *Obesity , Type II Diabetes risk

Vegetables

Legumes

Fish/Seafood

Whole Grains

Fruit

High Fat Dairy

Refined Grains

Butter

Butter

Processed Meat

Red Meat

Prudent Diet

Western Diet

Dietary Pattern

Both sexesMenWomenBoth sexes

Both sexes

Men

Men

Women

Women

010203040500

0

10

10

20

20

30

30

40

40

50

50

Prevalence (%)

Prevalence (%)

NHES I (1960-62)NHANES I (1971-74)NHANES II (1976-80)NHANES III (1988-94)NHANES 1999-2000NHES I (1960-62) NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94) NHANES 1999-2000

Trends in Obesity* Prevalence (%), By Gender, Adults Aged 20to 74, US, 1960-2000

*defined as a body mass index of 30 kg/m2 or greater

20

15

5

10

0

40

35

30

25

45

Both sexes Men Women

Growing Epidemic of Type IIDiabetes

in Relation to Obesity

Prevalence(%)

Relationship Between Weight (BMI) andCardiovascular Disease Mortality

Rel

ativ

e R

isk

of D

eath

Body Mass index

<18.5

Men

Women

Calle et al. N Engl J Med, 1999

18.5–

20.4

20.5–

21.9

22.0–

23.4

23.5–

24.9

25.0–

26.4

26.5–

27.9

28.0–

29.9

30.0–

31.9

32.0–

34.9

35.0–

39.9

>40.0

Lean Overweight Obese

MetabolicallyNormal

MetabolicallyAbnormal

MetabolicallyAbnormal

MetabolicallyNormal

MetabolicSyndrome

Insulin Resistance

All Cause Mortality - Weight vs. MetabolicStatus

BMI < 25

BMI < 25

BMI 25-29 BMI >30

BMI 25-29 BMI >30

Summary of Mortality from Cancer According to Body-Mass Index*

U.S. Men in the Cancer Prevention Study II, 1982 through 1998

MEN

*Highest body BMI category

T Y

P E

O

F

C A

N C

E R

R E L A T I V E R I S K O F D E A T H

Nutrition & Life-course Effects “ You are what your mother ate ! ”

The Prenatal Origins of the Obesity Epidemic and Developmental Programming

High infant mortality rate (1901-1910) and high death rate from coronary artery disease (1959-78)

The early ‘Barker‘studies

Evidence of Programming in HumanPopulations

-5.5-6.5-7.5-8.58.5+-5.5

-5.5

-6.5

-6.5

-7.5

-7.5

-8.5

-8.5

8.5+

8.5+

040801201602000

0

40

40

80

80

120

120

160

160

200

200

Birth weight

SBP(mm Hg)

Increasing Adult Systolic BP with Lower BirthWeight

Low Birthweight/Disproportionate size at Birthassociated with:

Coronary artery disease

Hypertension Glucose intolerance Asthma in childhood Immune dysfunction Chronic renal failure

Dyslipidemia Raised cortisol Raised fibrinogen

Developmental Origins HypothesisMaternal Undernutrition

Fetal Growth Retardation

“Fetal Programming”For calorie-restricted postnatal environment

(PredictiveAdaptive Response)

Abundant caloricenvironment

Rapid “catch-up” growth inchildhood

Hypertension Obesity / Insulin Resistance /DM Dyslipidemia

Ischemic Heart Disease RenalInsufficiency

“Trouble At Both Ends of the BW Spectrum”Both low and high birth weight linked to adulthood obesity

and CV disease

1.0

Rel

ativ

e R

isk

Birth Weight

Can we reverse fetal programming Prenatal folic acid supplementation

Prenatal N-3 Fatty Acid supplementation

Early post-natal Leptin (signal of adiposity)

Limit prenatal undernutrition ( ? overnutrition ) (calories, protein, micronutrients)

? Role in rising obesity epidemic -NutritionTransition

Barriers to Effective Weight Loss in Obesity

“Why can’t I lose weight? I am exercising more and eating less! “

The Role of Adaptive Thermogenesis

Adaptive Thermogenesis

Adaptive Thermogenesis

Weight Gain Increased EE to return to baselineweight

Weight Loss Decreased EE to return to baseline

Nutrition and Chronic DiseaseModern diet and lifestyle out of sync with our evolutionary legacy (50 yrs vs 150,000 yrs)Focus on nutrient constituents v whole foods: Food Synergy vs Nutritional ReductionismCritical importance of Dietary Pattern and LifestyleImportance of early (“very”) exposures altering later risk

Developmental Programming and role in global problemsof Nutrition Transition

Critical, new problem – Energy imbalance, obesity andhealth consequences and our maladaptation to thischallenge- Adaptive Thermogenesis

boysgirlsboysgirlsboysgirlsboys

boys

girls

girls

boys

boys

girls

girls

boys

boys

girls

girls

0.04.08.012.016.020.00.0

0.0

4.0

4.0

8.0

8.0

12.0

12.0

16.0

16.0

20.0

20.0

Percentage�

Percentage�

Obesity Trends Among Children in US (ages 6-11)

1971-1974 1988-1994 1999-2000

85thpercentile

malesfemalesmalesfemalesmalesfemalesmales

males

females

females

males

males

females

females

males

males

females

females

0.04.08.012.016.020.00.0

0.0

4.0

4.0

8.0

8.0

12.0

12.0

16.0

16.0

20.0

20.0

Percentage�

Percentage�

Obesity Trends Among Adolescents in US (ages 12-19)

1971-1974 1988-1994 1999-2000

85thpercentile

black mex-amerwhiteblack mex-amerwhiteblack

black

mex-amer

mex-amer

white

white

black

black

mex-amer

mex-amer

white

white

0.010.020.030.040.050.00.0

0.0

10.0

10.0

20.0

20.0

30.0

30.0

40.0

40.0

50.0

50.0

Percentage�

Percentage�

Obesity Prevalence among Children and Adolescents in US by Racial/Ethnic Group 1999-2000

Children ages 6-11 Adolescents 12-19

95th

percentile85th

percentile

USDA “MEDIUM” “LARGE” “SUPER-SIZE”

Serving Sizes

Salty DessertsSoftFruit French Ham-Cheese-PizzaMexican Salty

Salty

Desserts

Desserts

Soft

Soft

Fruit

Fruit

French

French

Ham-

Ham-

Cheese-

Cheese-

Pizza

Pizza

Mexican

Mexican

0.004.008.0012.0016.0020.0024.0028.000.00

0.00

4.00

4.00

8.00

8.00

12.00

12.00

16.00

16.00

20.00

20.00

24.00

24.00

28.00

28.00

Ounces

Ounces 1977-781989-911994-98Column 4Column 5Column 61977-78 1989-91 1994-98 Column 4 Column 5 Column 6

Portion Sizes for Selected Foods for Individuals Aged 2 and Older, USA 1977-1998

Snacks Drinks Drinks Fries burgers burgers Food

French FriesHamburgersCheeseburgersPizzaMexican FoodFrench Fries

French Fries

Hamburgers

Hamburgers

Cheeseburgers

Cheeseburgers

Pizza

Pizza

Mexican Food

Mexican Food

0.002.004.006.008.0010.000.00

0.00

2.00

2.00

4.00

4.00

6.00

6.00

8.00

8.00

10.00

10.00

Ounces

Ounces

HomeRestaurantFast FoodColumn 4Column 5Column 6Home Restaurant Fast Food Column 4 Column 5 Column 6

Portion Sizes for Foods Consumed by Location among Persons Aged 2 and Older 1994-98

Nielsen & Popkin (2003): JAMA 289:450

age 2-5age 6-10age 11-18age 2-18age 2-5

age 2-5

age 6-10

age 6-10

age 11-18

age 11-18

age 2-18

age 2-18

02004006000

0

200

200

400

400

600

600

kcals

kcals1977-781994-96Fast FoodColumn 4Column 5Column 6

1977-78 1994-96 Fast Food Column 4 Column 5 Column 6

Changes in Average Daily Energy Intake from Snacks 1977 to 1996

Jahns, Siega-Riz,&. Popkin, (2001): J Ped138:493

soft drinksfruit drinksdessertssugar and jelliescandyRTE cerealssoft drinks

soft drinks

fruit drinks

fruit drinks

desserts

desserts

sugar and jellies

sugar and jellies

candy

candy

RTE cereals

RTE cereals

040801201600

0

40

40

80

80

120

120

160

160

Calories/day of dietary intake from added sugar

Calories/day of dietary intake from added sugar1977-781989-911994-961977-78 1989-91 1994-96

Shifts in Food Sources of Caloric Sweetener Consumed by Persons Aged 2 and Older, United States

Source : Popkin and Nielsen (2003) in press

Physical Activity Patterns and TrendsWalking has declined significantlyActivity at work continues to declineActivity at home production and leisure

declined significantlyAttempts now focus on understanding

patterns and determinants of activity andinactivity

Research to date has ignored work andhome production [cleaning, cooking,etc]

US average= 73 mins/day of drivingOne-fourth of all trips made are one

mile or less, but three-fourths of theseshort trips are made by car

Children between the ages of 5-15walk/bike 40% less in 1995 than in1977

For school trips one mile or less, only31% are made by walking; within 2miles, only 2% are made by biking.

In the US, 6% of trips are bywalking/biking. In contrast, Italy (54%),Sweden (49%)

Travel

197719831990199519771977

19831983

19901990

19951995

0.02.04.06.08.010.00.0

0.0

2.0

2.0

4.0

4.0

6.0

6.0

8.0

8.0

10.0

10.0

Percent

Percent

197719831990199519771977

19831983

19901990

19951995

0.020.040.060.080.0100.00.0

0.0

20.0

20.0

40.0

40.0

60.0

60.0

80.0

80.0

100.0

100.0

Percent

Percent

Walk and Bike Trips

Automobile Trips

From the Surface Transportation Policy Project. Based on data from theNationwide Personal Transportation Survey and the Centers for DiseaseControl and Prevention.

Fewer People are Overweight in Places Where People Walk More

0.20

0.25

0.30

0.35

0.40

0.45

0.50

0.00 0.05 0.10 0.15 0.20 0.25

Average daily miles traveled on foot

Perc

ent o

f peo

ple

who

are

ove

rwei

ght

On target! The New American Way

The Built Environment: Encouraging PhysicalActivity

The Built Environment: Encouraging Walkability

Dan Burden, Walkable Communities Inc.

The Built Environment: Encouraging Walkability

Dan Burden, Walkable Communities Inc.

Can Johnny come out to eat?

Patterns Of Overweight & Obesity Globally For Nationally Representative Samples (Percentage overweight + Obese)