September 28, 2015
More than 80 percent of cardiovascular disease deaths occur in low- and middle-income countries. There are few data, however, on the impact of diet on cardiovascular disease in these countries.
In May 2014, the World Heart Federation consensus conference met in Ontario, Canada. Global scholars in the field worked to create an in-depth review of current knowledge on the role of diet in cardiovascular disease (CVD), the changing global food system, global dietary patterns and potential policy solutions.
Barry Popkin, PhD, W.R. Kenan Jr. Distinguished Professor of nutrition at the UNC Gillings School of Global Public Health, was a participant at the conference. He also is the corresponding author of the resulting article, which shares the findings of this major consensus review of what the world needs to do to change diets and reduce CVD.
The article, titled, “Food Consumption and its Impact on Cardiovascular Disease: Importance of Solutions Focused on the Globalized Food System,” was published online Sept. 28 by the Journal of the American College of Cardiology. A PDF copy is available here.
The expert reviewers considered evidence from different countries and factors such as age, race, ethnicity and socioeconomics, ultimately concluding that the understanding of foods and macronutrients in relationship to CVD is broadly clear. However, major gaps exist both in dietary pattern research and initiatives to change diets and food systems around the world. Additional research, including large cohort studies, is needed in different regions to address existing knowledge gaps.
This paper presents: 1) a consensus on the evidence relating various macronutrients and foods to CVD and its related comorbidities; 2) an overview of the development of the modern, globalized food system and its implications for the food supply; and 3) an outline of how changes to the global food system can address current diet-related public health problems while simultaneously having beneficial impacts on climate change.
Based on the current evidence, the optimal dietary pattern to reduce CVD is one that emphasizes whole grains, fruits and vegetables, legumes, nuts, fish, poultry and moderate dairy and heart-healthy vegetable oil intake. This healthy dietary pattern also needs to be low in refined grains, added sugars, trans-fats, sugar-sweetened beverages and red and processed meats. Following this pattern would likely reduce the CVD risk of the general population by about a third.
On the basis of current evidence, the traditional Mediterranean-type diet provides a well-tested healthy dietary pattern to reduce CVD. In the article, the reviewers provide translations of the Mediterranean diet to other regions of the world, with appropriate food replacements suggested on the basis of availability and preferences.
Understanding larger trends in the global food system, as well as identifying ways health providers can best advocate for improvements in their local settings, is another contribution of this paper. The reviewers outline the rapid shift to a very modern food system in all regions of the world.
While there have been some uneven changes, policies to liberalize trade and private-sector investment have revolutionized the entire system in many regions. Retailing, for example, has been transformed in low and middle-income countries through the growth of supermarkets. While this process originated with companies from industrialized countries looking for growth in foreign markets, now companies from both low and high-income country are leading the evolution.
The resultant dietary trends are rapidly increasing the risk of heart disease in low- and middle-income countries. The way people eat has changed greatly across the globe, and the pace of change in low- and middle-income countries continues to accelerate.
Snacking and available snack foods have grown in frequency and number; eating frequency has increased; away-from-home-eating in restaurants, in fast food outlets and from take-out meals is rising dramatically; both at-home and away-from-home-eating increasingly involve fried and processed food; and the overall proportion of highly-processed food in diets has grown.
In examining potential efforts to address the changing global food system, the authors acknowledge that dietary choices and recommendations should be made with consideration of the environmental implications of food choice (i.e., the environmental impact of poultry, livestock/cattle production and diminishing wild fish stocks) as well as the role of diet in other disease processes. Human health must be linked to environmental health, which is one tenant of the United Nations Sustainable Development Goals.
The modern food system is a major force in a range of serious environmental problems, including climate change, the loss of biodiversity and the strain on freshwater resources. This paper is unique in its focus on linking food system change with environmental change. The dietary alterations proposed in this consensus document would not only significantly reduce CVD across the globe, but also lessen current strains on the environment.
As this review makes clear, policy actions and interventions that improve food supplies and dietary patterns have social, cultural and environmental benefits. There are many opportunities to increase global access to healthy food that are also likely to have even broader beneficial effects.