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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.66,NO.14,2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.07.050
THEPRESENTANDFUTURE
STATE-OF-THE-ARTREVIEW
Food Consumption and its Impact
on Cardiovascular Disease:
Importance of Solutions Focused on
the Globalized Food System
AReport From the Workshop Convened by the
World Heart Federation
Sonia S. Anand, MD, PHD,*y Corinna Hawkes, PHD,z Russell J. de Souza, SCD, RD,x Andrew Mente, PHD,y
Mahshid Dehghan, PHD,y Rachel Nugent, PHD,k Michael A. Zulyniak, PHD,* Tony Weis, PHD,{
AdamM.Bernstein, MD,# Ronald M. Krauss, MD,** Daan Kromhout, MPH, PHD,yy
David J.A. Jenkins, MD, PHD, DSC,zzxx Vasanti Malik, SCD,kk Miguel A. Martinez-Gonzalez, MPH, MD, PHD,{{
Dariush Mozaffarian, MD, DRPH,## Salim Yusuf, MD, DPHIL,y Walter C. Willett, MD, DRPH,{{ Barry M. Popkin, PHD***
ABSTRACT
Major scholars in the field, on the basis of a 3-day consensus, created an in-depth review of current knowledge on the
role of diet in cardiovascular disease (CVD), the changing global food system and global dietary patterns, and potential
policy solutions. Evidence from different countries and age/race/ethnicity/socioeconomic groups suggesting the health
effects studies of foods, macronutrients, and dietary patterns on CVD appear to be far more consistent though regional
knowledge gaps are highlighted. Large gaps in knowledge about the association of macronutrients to CVD in low-
and middle-income countries particularly linked with dietary patterns are reviewed. Our understanding of foods and
macronutrients in relationship to CVD is broadly clear; however, major gaps exist both in dietary pattern research and
ways to change diets and food systems. On the basis of the current evidence, the traditional Mediterranean-type diet,
including plant foods and emphasis on plant protein sources provides a well-tested healthy dietary pattern to reduce
CVD. (J Am Coll Cardiol 2015;66:1590–614) © 2015 by the American College of Cardiology Foundation.
From the *Department of Medicine, McMaster University, Hamilton, Ontario, Canada; yPopulation Health Research Institute,
HamiltonHealthSciencesandMcMasterUniversity,Hamilton,Ontario,Canada;zCentreforFoodPolicy,CityUniversity,London,
United Kingdom; xDepartment of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada;
kDepartmentofGlobalHealth,UniversityofWashington,Seattle,Washington;{DepartmentofGeography,UniversityofWestern
Ontario, London, Ontario, Canada; #Center for Lifestyle Medicine, Cleveland Clinic, Lyndhurst, Ohio; **Children’s Hospital
Oakland Research Institute, Oakland, California; yyDivision of Human Nutrition, Wageningen University, Wageningen, the
Netherlands; zzDepartment of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada;
xxClinical Nutrition & Risk Factor Modification Center, St. Michael’s Hospital, Toronto, Ontario, Canada; kkDepartment of
Nutrition, Harvard School of Public Health, Boston, Massachusetts; {{Departamento de Medicina Preventiva y Salud Publica,
Universidad de Navarra-CIBEROBN, Pamplona,Spain; ##Friedman School of Nutrition Science & Policy, Tufts University, Boston,
Massachusetts; and the ***Department of Nutrition, School of Public Health, University of North Carolina, Chapel Hill, North Car-
olina.Dr.deSouzahasservedasanexternalresourcepersonontransandsaturatedfatstotheWorldHealthOrganization’sNutrition
GuidelinesAdvisoryGroup.Dr.BernsteinbeganworkingatRallyHealthinApril2015.Dr.Krausshasreceivedgrantsupportfromthe
U.S.NationalDairyCouncil,theDairyResearchInstitute,theAlmondBoardofCalifornia,andQuestDiagnostics;andhasservedasa
consultant for Quest Diagnostics. Dr. Jenkins has served on the scientific advisory boards of Unilever, Sanitarium Company, Cali-
fornia Strawberry Commission,LoblawSupermarket,HerbalLifeInternational,NutritionalFundamentalforHealth,PacificHealth
Laboratories, Metagenics, Bayer Consumer Care, Orafti, Dean Foods, Kellogg’s, Quaker Oats, Procter & Gamble, Coca-Cola, NuVal
GriffinHospital,Abbott,PulseCanada,SaskatchewanPulseGrowers,andtheCanolaCouncilofCanada;hasreceivedhonorariafor
scientificadvicefromtheAlmondBoardofCalifornia,theInternationalTreeNutCouncilNutritionResearchandEducationFoundation,
JACC VOL. 66, NO. 14, 2015 Anand et al. 1591
OCTOBER 6, 2015:1590–614 Diet, Cardiovascular Disease, and the Food System
here is much controversy surrounding the increasing global attention to the importance ABBREVIATIONS
optimal diet for cardiovascular health. Data of improving food systems by the interna- ANDACRONYMS
Trelating diet to cardiovascular diseases tional developmentandnutritioncommunity
(CVDs) has predominantly been generated from (9–11). Although the “food system” may seem CHD=coronary heart disease
high-income countries (HIC), but >80% of CVD remotetoacliniciansittinginanofficeseeing CI = confidence interval
deaths occur in low- and middle-income countries a patient, its impact on the individuals they CVD=cardiovascular disease
(LMIC). Relatively sparse data on diet and CVD exist aretryingtotreatareveryreal.Thispaperison GI = glycemic index
from these countries though new data sources are the basis of a World Heart Federation inter- GL=glycemic load
rapidly emerging (1,2). Noncommunicable diseases national workshop to review the state of HDL-C = high-density
are forecasted to increase substantially in LMIC knowledge on this topic. This review of diet, lipoprotein cholesterol
because of lifestyle transitions associated with in- dietarypatterns,andCVDisnotonthebasisof HIC = high-income countries
creasing urbanization, economic development, and newsystematicreviewsormeta-analysesbut LDL-C = low-density
globalization. The Global Burden of Disease study representsacarefulreviewofmanypublished lipoprotein cholesterol
cites diet as a major factor behind the rise in hyper- meta-analyses, seminal primary studies, and LMIC = low- and middle-
tension, diabetes, obesity, and other CVD compo- recent research by the scholars who partici- income countries
nents (3). There are an estimated >500 million patedintheConsensusconference. MI = myocardial infarction
obese (4,5) and close to 2 billion overweight or obese This paper presents: 1) an overview of the OR=oddsratio
individuals worldwide (6). Furthermore, unhealthy development of the modern, globalized food RCT=randomized controlled
dietary patterns have negative environmental im- system and its implications for the food trial
pacts, notably on climate change. supply; 2) a consensus on the evidence RR=relative risk
Poor quality diets are high in refined grains and relating various macronutrients and foods to SSB=sugar-sweetened
beverage
added sugars, salt, unhealthy fats, and animal-source CVD and its related comorbidities; and 3) an
foods; and low in whole grains, fruits, vegetables, outline of how changes to the global food T2DM=type2diabetes
mellitus
legumes, fish,andnuts.Theyareoftenhighinpro- system can address current diet-related pub-
cessed food products—typically packaged and often lic health problems, and simultaneously have bene-
readytoconsume—andlightonwholefoodsandfreshly ficial impacts on climate change.
prepared dishes. These unhealthy diets are facilitated
by modern food environments, a problem that is THECHANGINGFOODSYSTEMAND
likely to become more widespread as food environ- FOODSUPPLYANDIMPLICATIONSFOR
ments in LMIC shift to resemble those of HIC (5,7,8). DIETSANDTHEENVIRONMENT
In this paper, we summarize the evidence relating
food to CVD, and the powerful forces that underpin THEDEVELOPMENTOFTHEMODERN,GLOBALIZED
the creation of modern food environments—what we FOOD SYSTEM. Food systems were once dominated
call the global food system—to emphasize the impor- bylocalproductionforlocalmarkets,withrelatively
tanceofidentifyingsystemicsolutionstodiet-related little processing before foods reached the household
health outcomes. We do this in the context of (OnlineAppendix,Box1)(12).Incontrast,themodern
Barilla, Unilever Canada, Solae, Oldways, Kellogg’s, Quaker Oats, Procter & Gamble, Coca-Cola, NuVal Griffin Hospital, Abbott, the
Canola Council of Canada, Dean Foods, the California Strawberry Commission, Haine Celestial, and the Alpro Foundation; has
served on the speakers panel for the Almond Board of California; has received research grant support from Loblaw Brands Ltd,
Unilever, Barilla, the Almond Board of California, Solae, Haine Celestial, Sanitarium Company, Orafti, the International Tree Nut
Council, and the Peanut Institute; has received travel support to attend meetings from the Almond Board of California, Unilever,
theAlproFoundation,theInternationalTreeNutCouncil,theCanadianInstitutesforHealthResearch,theCanadaFoundationfor
Innovation, and the Ontario Research Fund; has received salary support as a Canada Research Chair from the federal government
of Canada; and discloses that his wife is a director of Glycemic Index Laboratories, Toronto, Ontario, Canada. Dr. Martinez-
Gonzalez has had a research contract with Danone to support research on yogurt in the SUN cohort; and received a depart-
mental grant from the International Nut Council. Dr. Mozaffarian has served on the scientific advisory board of Unilever North
America; received ad hoc honoraria from Bunge and the Haas Avocado Board; received consulting fees from Nutrition Impact,
Amarin, AstraZeneca, Life Sciences Research Organization, and Boston Heart Diagnostics; and receives royalties for an online
chapter on fish oil entitled “Fish Oil and Marine Omega-3 Fatty Acids.” Dr. Popkin has received funding to speak on sugar-
sweetened beverages (SSB) behaviors globally from Danone water research center at 2 international conferences in the past 5
years; and was a coinvestigator to a water versus SSB randomized controlled trial funded by Danone to the Mexican National
Institute of Public Health in Cuernavaca, Mexico. All other authors have reported that they have no relationships relevant to the
contents of this paper to disclose. Drs. Anand and Hawkes contributed equally to this work.
Listen to this manuscript’s audio summary by JACC Editor-in-Chief Dr. Valentin Fuster.
Manuscript received May 5, 2015; revised manuscript received July 16, 2015, accepted July 20, 2015.
1592 Anand et al. JACC VOL. 66, NO. 14, 2015
Diet, Cardiovascular Disease, and the Food System OCTOBER 6, 2015:1590–614
FIGURE1 FoodSystemImpactonNutrition-Related NCDs
Food Food Intermediate Nutrition Nutrition Health
system system factor consumption outcomes outcomes
drivers factors
Public sector Retailers Price and Quantity Balanced Wellness
institutions availability diet
Agriculture Packaged Under/over NCD
sector food sector Diversity nutrition vulnerability
development
Climate Agrochemical-seeds/ Nutrient Ecosystem
change/ Agro-processing Quality deficiencies health
Biodiversity loss
Street food/fast
food/restaurant
sector
Source: revised version of Nugent, 2011 ”Bringing Agriculture to the Table“ Chicago Council on Global Affairs. NCD ¼ noncommunicable disease.
food system is characterized by a global web of in- (e.g., wheat, corn, rice) cheaply available, in order to
teractions between multiple actors from farm to fork, simultaneously address hunger in LMIC and national
geared toward maximizing efficiency to reduce costs food insecurity in HIC (23). In addition to vastly
and increase production (Figure 1). The major actors increasing the calorie supply, the ensuing produc-
whocontrolthissystemhavechangeddramaticallyin tivity boom also provided the basis of cheap feed for
HIC and LMIC, as described subsequently (13). livestock and cheap inputs for processed foods, in
The shift to a global food system started in the turn creating incentives for the growth of manufac-
United States and other high-income industrialized turers of processed foods (24). This coincided with
countries, and was driven initially by government huge technological innovations in food processing,
investment and intervention in markets, infrastruc- (24–28), the rise of mass marketing to persuade con-
ture and research intended to raise farm-sector pro- sumers to eat more, supermarket retailing, and fast
ductivity. Building on actions taken in the late 19th food (29,30). As a result of these changes, the trans-
century (14), policies on agricultural research and formation of raw commodities into food and the dis-
supporting on-farm production introduced in the tribution of consumable food items beyond the farm
periodfrom1930to1960intheUnitedStates(14)and gate has become far more important (31). Today,
Europe focused on few major crops, particularly integration and control of our farm-to-fork food
grains (e.g., wheat, corn, rice), oilseeds (e.g., soy- supply by major agribusinesses, food manufacturers,
beans), livestock (e.g., pigs, poultry, cattle), and retailers, and food service companies is more the rule
critical cash crops, especially sugar cane and other than the exception (13). Meanwhile, production of
sources of sugar (15–18). State intervention in most less processed foods such as coarse grains (e.g., mil-
LMIC took a different form, such as policies to sub- let, sorghum), roots, tubers, and legumes has
sidize food, taxes on agricultural products, and sys- declined (32,33) whereas animal source food produc-
tems to control the supply and marketing of key tion has grown dramatically (34).
commodities (19–22). The 1960s also saw the start of Figure 2 sets out the stages of change involved in
significant agricultural transformation in LMIC, with leading to this modern food system. This model has
the “Green Revolution,” which focused on increasing spread unevenly to most LMIC (35–37). Many coun-
productivity of corn, rice, and wheat. tries retain various forms of state intervention in
These investments and changes in production agriculture and food systems (18,38–41), but policies
systems were designed to make calories from staples to liberalize trade and private sector investment have
JACC VOL. 66, NO. 14, 2015 Anand et al. 1593
OCTOBER 6, 2015:1590–614 Diet, Cardiovascular Disease, and the Food System
FIGURE2 Stages of Global Agricultural System Development
Scientific and technological change, economic change, urbanization, globalization
Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6
1800s mainly 1900-1944 Post-WWII massive Systematically Commercial sector Healthier food
scientific investments modern transmitted globally shifts major drivers of supply
underpinnings system (1955-2008) system change
(present)
Create the modern Retailers,agricultural
Expansion food system focused Farm research, input & processing, Price incentives,
Science and technologies; on staples, animal extension systems, businesses, and food taxation, and system
institution building science source foods, and cash and education mirror manufacturers investments
crops those of the West dominate farm-level
decision-making
Fossil energy, Extensive funding for Investment training, Food industry farm links
modern genetics, major infrastructure, institutions, drive production and
fertilizer, beginning Expansion of science; systems, input and infrastructure, marketing decisions, Investments in
agriculture science develop reaper; many enhanced seeds, and CGIARC (consoritum incentives and infrastructure and
and experimental other technologies major technology global international economic drivers training
work, & land grant/ development agricultural research) change
agriculture universities
High income
Farming systems countries see rapid Reduced
developed; mechanization; Green revolution, Production linked to noncommunicable
Farming remains the underpinnings post- development of new irrigation, credit, farm the needs of food diseases, reduced
major source of the WWII revolution food processing extension, and manufacturers and climate footprint,
food supply; added modernization technologies (e.g. agricultural institutions retailers, ignoring achieve total
Industrial/large-scale of agricultural extraction of edible mirror those of the climate, sustainability, sustainability, fewer
monoculture initiated production inputs and oils from oil seeds); west; modernizing of and health concerns animal source foods
machinery and investment in food processing consumed
transportation/
irrigation/
electrification/
modernization of
agriculture
Source: ª (copyright) Barry M. Popkin, 2015.
revolutionized the entire sector in many regions carbohydrates—refined grains and added sugars.
(13,42). Retailing has been transformed in LMIC Rapidlyincreasingproductionofstarchystaplescom-
through the growth of supermarkets (18,38–41). binedwithprocessingtechnologiesmeanthatrefined
Although this process originated with companies in flourisincreasinglydominantindiets.Whitebread,for
industrialized countries looking for growth in foreign example, once rarely consumed in Latin America,
markets, companies based in LMIC are now also became widespread after the introduction of high-
investing back into HIC. yield wheat varieties. In Asia, white rice became
DIETARY IMPACTS. Thewaypeopleeathaschanged dominant as a staple over legumes and coarse grains,
greatlyacrosstheglobe;moreover,thepaceofchange with a more recent trend being rapidly rising con-
inLMICisquickening.Snackingandsnackfoodshave sumption of instant noodles as a staple (52,53).
growninfrequencyandnumber(43–48); eating fre- Since1964,averagetotalcarbohydrateintakein
quencyhasincreased;away-from-homeeatinginres- theUnitedStateshasincreasedfromabout375g/dayto
taurants,infastfoodoutlets,andfromtake-outmeals 500g/day(from2to6kg/yearofready-to-eatcereals),
is increasing dramatically in LMIC; both at home and but the percent of carbohydrate that is fiber has
away-from-home eating increasingly involves fried not substantially changed over this time, reflecting
andprocessedfood(47,49);andtheoverallproportion increasedrefinedcarbohydratesandsugar-sweetened
ofhighlyprocessedfoodindietshasgrown(50,51). beverages(SSBs)ishighinHIC(54).In the period from
These changes in the global food system coupled 1985 to 2005 extensive added sugar intake occurred
with these food behavior shifts have enabled some across HIC (55) but more recently large increases
critical changes to the global food supply, all with have occurred in LMIC, particularly in consumption
dietary implications. First is the shift to refined of SSBs and processed foods (56–59). Today in the
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