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How To Eat, Drink, and Be Healthy
Walter C. Willett, MD, DrPHDepartment of Nutrition
Harvard School of Public Health
April 26, 2007
10-Year Coronary Incidence Per 10,000 Men
Keys, 1980
Incidence
0
1000
2000
3000
0 5 10 15 20 25% Diet Calories from Saturated Fat
Velika KrsnaZrenjanin
BelgradeMontegiorgio
Crevalcore
Corfu
Crete
Slavonia
Zutphen
west Finland
east Finland
Ushibuka
Tanushimaru
y=77+78xr=0.73
9.006
(Keys 1980)
0
10
20
30
40
50
0 40 80 120 160 200 240 280 320Per Capita Daily Meat Consumption (grams)
Col
on C
ance
r Inc
iden
ce /
100,
000
Wom
en
(Armstrong and Doll, 1975)
ROMCHI
COL
YUG
JAM
JAP
NIG
ISRNOR
PRPOL
HUN
FIN
DEN
SWENET FDR
ICEDDR
NZ
USA
CAN
UK
2.003
Carroll, 1975
TaiwanJapan
Ceylon
El SalvadorThailand
Panama
PhilippinesMexico
ColumbiaSpain
Greece
Poland
Puerto Rico
ChileVenezuela
Hong Kong
RomaniaYugoslavia
CzechoslovakiaItaly
Portugal
Bulgaria
Australia
NorwayFrance
FinlandHungary
BelgiumSwitzerland
SwedenGermanyAustria
CanadaUKNetherlands
USA Ireland
New ZealandDenmark
0.001
0
5
10
15
20
25
0 20 40 60 80 100 120 140 160Animal Fat Intake (g/day)
Age
Adj
uste
d D
eath
Rat
e / 1
00,0
00 p
op
0.001
21.004
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 INSTEAD OF
Butter-flavored granules Butter or margarine Nonfat yogurt Regular yogurt Nonfat salad dressings Regular salad dressings Angel food cake Devil’s food cake Fat-free cookies and crackers High-fat cookies and crackers
1: Use Nonfat Products
9.071
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 Saturated fat
Total cholesterol +6% +12%
LDL cholesterol +14% +18%
HDL cholesterol -12% 0%
LDL/HDL ratio +29% +18%
9.110
Blood lipids
Blood pressure
Thrombotic tendency
Insulin resistance
Oxidation
Homocysteine
Inflammation/endothelial dysfunction
Ventricular irritability & arrhythmia
Diet CHD
9.105R
Age-Adjusted Plasma CRP by Quintiles of Trans Fatty Acid Intake in the Nurses’ Health Study
0
0.5
1
1.5
2
Q1 Q2 Q3 Q4 Q5
CR
P (m
g/L)
Trans Fat Intake (Quintiles)
(Lopez-Garcia 2005)
(P, trend = <0.001)
8.097
Nurses’ Health Study (n=121,700)
Health Professionals Follow-up Study (n=52,000)
Nurses’ Health Study II (n=116,000)
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
1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000
DietOcsSmokingWeight/HtMed. Hist.
Diet Diet DietBlood
Diet Diet
1986 1988 1990 1992 1994 1996 1998 2000
Diet Diet DietBlood
Diet
1989 1991 1993 1995 1997 1999
Diet Diet Diet
0.198R
Nails
Nails
Blood
100
80
60
40
20
0
-20
-40
1%E 2%E 3%E 4%E 5%E
Trans
Sat
Mono
Poly
% C
hang
e in
CH
D
(Hu et al. 1997)9.131
Quintiles of poly
Quintiles of trans fat
Mul
tivar
iate
RR
of C
HD
Hu et al, 1997
(lowest)
9.049
1
0.7
0.880.8
0.710.92 0.91
0.63 0.73 0.71
1.05
0.870.71
0.360.320.81
0.66 0.55 0.630.31
0
1.2
Q5
(hig
hest
)
Q4
Q3
Q2
Q1
(low
est)
Q5 (highest)
Q4
Q3
Q1&Q2(lowest)
0
0.5
1
3.6 4.8 5.6 6.9
Multivariate Relative Risk of Sudden Death(Albert et al., 2002)
P = 0.007
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)
0
0.2
0.4
0.6
0.8
1
1.2
1/month 1-4/month 2-4/week 5+/week
Multivariate Relative
Risk
Frequency of Salad Dressing Consumption
••
•
•
9.126
Conclusions1. 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
0.6
0.8
1
1.2
1.4
Q1 Q2 Q3 Q4 Q5
Saturated FatMonoPolyTrans
Multivariate RR’s of type 2 diabetes according to quintiles of specific types of dietary fat (mutually adjusted)
(Salmeron et al, 1999)
Quintiles of Fat Intake
Mul
tivar
iate
RR
25.004
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)
P
Trans fat vs poly (2% E) +2.7* <0.001
Total fiber (12 gm) -2.21* <0.001
Television watching (20 hr/wk)
+0.59 <0.001
Vigorous activity (25 MET/wk)
-0.38 <0.001
Weight training (>0.5 hr/wk) -0.91 <0.001
*Adjusted for measurement error26.092
Fatty Acids Intake
-7
-13
-25
14
64
68
119
-100 0 100 200 300 400
All fats for carbs, 5% ofenergy
Saturated fat for carbs, 5%of energy
Mono unsaturated fat forcarbs, 5% of energy
Poly unsaturated fat forcarbs, 5% of energy
trans fat for carbs, 2% ofenergy
trans fat for n-6 poly fat, 2%of energy
trans fat for mono fat, 2% ofenergy
Percent Change in Risk of Ovulatory infertility
36.005
“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
0
0.5
1
1.5
Women ( 591cases )Wolk et al., 1999
Men ( 734 cases )Rimm et al., 1996
RRof
CHD
Cereal Fiber, Energy- Adjusted, g/day
0
0.5
1
1.5
2.2 3.1 4.93.8 7.7 2.2 3.7 5.0 6.8 9.7
8.064
Blood Glucose
Insulin
Easily Digested Carbohydrate
-
Blood Glucose
Insulin
Slowly Digested Carbohydrate
0
0 1 2 3 4 5 0 1 2 3 4 5 Time (hr) Time (hr)
25.027
Relative Risk of Type 2 Diabetes by Different Levels of Cereal Fiber and Glycemic Load
2.5 2.32.05
2.171.8 1.62
1.511.28 1
0
1
2
3
High Medium Low
High
Medium
LowRelativeRisk
>165 165-143 <143Glycemic Load
>5.8 g/day
2.5 -5.8 g/day
<2.5 g/day
(Salmeron et al,1997)
(ref)
WOMEN
9.038
Liu et al., 2000Body Mass Index (kg/M2)
Rel
ativ
e R
isk
9.072
1.16
2 2
0.94 1.19
1.81
1 1.1 1.42
0
0.5
1
1.5
2
2.5
<23 23-29 >29
Tertile 1 (lowest)Tertile 2
Tertile 3 (highest)
Relative Risk of Coronary Heart Disease
Attributable Risk of Coronary Heart DiseaseDue to Modifiable Diet and Lifestyle Risk
Factors in the NHS (1980 to 1994)Low Risk:
1. Non smoker2. BMI < 25 kg/m2
3. Exercise > ½ hr of brisk walking/day4. 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, 20009.092
Percentage of Type 2 Diabetes Potentially Preventable by Simultaneous Reduction of Five
Modifiable Risk Factors (NHS) (Hu et al.)
Low Risk1. Nonsmoking2. BMI < 253. Moderate to vigorous exercise4. 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 Risk1. BMI £25 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/day5. £3 pack – years of smoking6. Red meat £2 servings/week
Joint low risk group = 3.1% of populationPopulation attributable risk (PAR): 71% (33-92)
2.116R
Lowfat products whenever possible; calcium supplements are and effective substitute for preventing fractures
Importance is well-documented; greens and dark orange vegetables should be included. Even more frequent servings may be desirable
Whole-grain, minimally processed products should be emphasized
Ignores critical differences in types of fat. Monos appear desirable
Misleading as 2-3 servings of meat/day is probably unhealthy
Support for generous intake is well documented
21.002
21.090
Healthy Eating Pyramid
Healthy Eating Pyramid
21.092
21.094
21.058
21.054
21.055
21.056