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

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. 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. 29.516 (Ezzati & Riboli, NEJM 2013)

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Socio-economic inequality in diet and ncd; role of
agriculture
Jaap Seidell, VU University Amsterdam, The Netherlands

16. Reality: 80% of chronic disease deaths
occur in low & middle income countries

29. 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

30. 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

31. 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)

32. 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

34. 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.

35. 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

36. 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

37. 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

38. thechicagocouncil.org/HealthyAgandNCD

39. 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

40. 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.

41. 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.

42. 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.