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Eat like Greeks, live healthier lives and save our planet

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Each year unhealthy diets are linked to 11m deaths worldwide a global study concludes
Red and processed meat not only cause disease and premature death from chronic non-communicable diseases (NCD) but also put the planet at unnecessary risk
Evidence suggests that the health benefits of a Mediterranean diet reduces the risk of NCDs and is better for the Planet

Eat like Greeks, live healthier lives and save our planet

Findings of an international research project about the relationship between diet and chronic diseases are reported in a paper entitled, “Health effects of dietary risks in 195 countries 1990-2017. A systematic analysis for the Global Burden of Disease Study 2017”, which is published in the April 2019 edition of The Lancet. The paper suggests that millions of people throughout the world consume an unhealthy diet comprised of too much processed meat, sodium and sugar and too little plant-based foods, such as fruits and vegetables, whole grains and nuts. This results in a significant increase in the prevalence of chronic non-communicable diseases (NCD) such as coronary heart disease, cancer and diabetes and each year causes some 11m avoidable deaths worldwide - 22% of all adult deaths: 10m from cardiovascular disease, 913,000 from cancer and some 339,000 from type-2 diabetes. According to the paper’s authors, “A suboptimal diet is responsible for more deaths than any other risks globally, including tobacco smoking, highlighting the urgent need for improving human diet across nations”.

In this Commentary

This Commentary reviews evidence of recent large-scale epidemiology studies, which suggest that “you are what you eat”. Not only do unhealthy diets cause ill health and premature death for millions, they also harm the environment and push the Earth beyond its planetary boundaries. All the studies we describe conclude that we know the answer to this vast and escalating health problem: eat like Greeks or indeed the Japanese. Notwithstanding, changing the way populations collectively eat is a massive challenge facing governments, healthcare systems and individuals.

The Global Burden of Disease project

The Lancet paper’s findings described above are based on the Global Burden of Disease (GBD) enterprise, which is one of the world’s largest scientific collaborative research projects, which was started in the early 1990s by the World Bank to measure the impact of disability and death from hundreds of diseases worldwide. Over the past two decades its work has grown, and the endeavour has become institutionalized at the World Health Organization (WHO). Today, the GBD project is an international consortium of more than 3,600 researchers, its findings are updated annually and they influence health policy throughout the world.

Red meat and bowel cancer

Findings of a more narrowly focussed but nonetheless significant study, published in the April 2019 edition of the International Journal of Epidemiology warn that red-processed meat consumption is linked with bowel cancer. According to Tim Key, the study’s co-author, Professor of Epidemiology and Deputy Director at Oxford University's Cancer Epidemiology Unit, “Results strongly suggest that people who eat red and processed meat four or five times a week have a higher risk of developing bowel cancer than those who eat red and processed meat less than twice a week . . . . There’s substantial evidence that red and processed meat are linked to bowel cancer and the World Health Organization classifies processed meat as ‘carcinogenic’ and red meat as ‘probably carcinogenic’”. Notwithstanding, Key warns that, “Diet studies are problematic because those who take part often either forget what they have eaten or fail to tell the truth”. Key also suggests that, “Most previous research [on diet and cancer] looked at people in the 1990s or earlier and diets have changed significantly since then”.

Chronic non-communicable diseases

Chronic non-communicable diseases (NCD) are largely caused by humans and are therefore preventable. Notwithstanding, they account for more than 70% of all deaths globally and emergent NCDs pose significant systemic challenges for both nation states and individuals. Forty percent of all adults in the world are overweight and 1.4bn suffer from hypertension: both critical risk factors of NCDs. In 2016, 18m people died from cardiovascular disease (CVD), representing 31% of all global deaths. In the US an estimated 92m adults are living with CVD. By 2030, 44% of the US adult population is projected to have some form of CVD. There are around 7m people living with heart and circulatory disease in the UK. Worldwide some 0.5bn people have diabetes and in 2018 there were 17m new cases of cancer worldwide. Although there are some encouraging signs associated with the slowing of the prevalence rates of NCDs globally, prevalence of NCDs is expected to rise because of population growth and aging, misaligned healthcare policies and institutional inertia.

The paradox of food insecurity and obesity

Paradoxically, food scarcity and obesity are both forms of malnutrition and represent a vast and escalating burden on the worlds limited and diminishing resources. This is because food insecurity can contribute to people being overweight and obese. Nutritious fresh foods often tend to be expensive, so when household resources for food become scarce, people choose less expensive foods that are often high in calories and low in nutrients. As a result, adult obesity rates continue to rise each year, from 11.7% in 2012 to 13.2% in 2016. In 2017 the World Health Organization estimated that more than one in eight adults, or more than 672m people in the world, were obese and 2bn were classified as overweight. A report from the Center for Strategic and International Studies, a think-tank based in Washington DC, US, suggests that worldwide each year, "Malnutrition costs US$3.5trn, with overweight- and obesity-related NCDs, such as cardiovascular disease and type 2 diabetes, adding US$2trn”.

The EAT-Lancet Commission on Food, Planet and Health

Not only do unhealthy diets result in NCDs and premature death, but they also harm the environment. The dual aspects of unhealthy diets causing disease and harming the planet are described in research conducted by the EAT-Lancet Commission on Food, Planet and Health, and reported in the January 2019 edition of The Lancet.

EAT is an independent non-profit organisation based in Oslo, Norway, dedicated to food-system reform, which collaborated with The Lancet. The report took 3-years to complete and brought together 37 world-renowned scientists from 16 countries with expertise in health, nutrition, environmental sustainability, food systems, economics and political governance; and tasked them with reaching a consensus that defines a sustainable “healthy planetary diet”, which the authors suggest approximates a Mediterranean diet, see below.

The EAT-Lancet research, financed by the Wellcome Trust,analysed the diets of people in 195 countries using survey data, as well as sales data and household expenditure data to estimate the impact of unhealthy diets on the risk of death and morbidity from NCDs. The Commission’s authors provide a comprehensive picture of the consumption of 15 dietary factors across nations and quantify the potential impact of suboptimal intake of each dietary component on NCD mortality and morbidity among 195 countries. Also, researchers calculate mortality related to other risk factors,such as smoking and drug use, at the global level.

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Criticism of the EAT-Lancet Commission

The EAT-Lancet Commission’s report has its critics. One is the UK’s National Farmers’ Union whose Vice President Stuart Roberts said, “Scientific communities agree that red meat plays a vital role in a healthy, balanced diet as a rich source of essential nutrients, minerals, amino acids and protein. It is overly simplistic to target one food group for a significant reduction in consumption, and it ignores its medically accepted role as a key part of a healthy, balanced diet . . . It is clear that climate change is one of the greatest challenges of our time and British farmers are continuing to take action. A combination of policies and practises will be needed to enable farmers to meet their ambitions, but we must not forget the impact of a changing climate on food production”.

Benefits of red meat

Roberts is right to point out that red meat has health benefits. Heme iron, which is found in red meat (also in poultry, seafood and fish) is easily absorbed by your body and is a significant source of your dietary iron. Red meat also supplies you with vitamin B12 and zinc. The former is required for red blood cell formation, neurological function and DNA synthesis, and the latter helps stimulate the activity of at least 100 different enzymes and helps to keep your immune system working effectively. Further, red meat provides protein, which helps to build your bones and muscles. People have been eating meat for millennia and have developed digestive systems well equipped to handle it.

Notwithstanding, the overwhelming majority of red meat consumed in the developed world today is processed: raised in a factory environment, fed grain-based feed and given growth-promoting hormones and antibiotics and some animals, after being slaughtered, are further treated with nitrates, preservatives and various chemicals. The findings of all three studies described above demonstrate the harm of eating too much red and processed meat and stress the health and environmental benefits of a Mediterranean diet.

An urgent challenge

According to the EAT-Lancet Commission’s authors, “Providing healthy diets from sustainable food systems is an urgent and pressing challenge”. As the global population continues to grow - projected to reach 10bn by 2050 - and become wealthier, there is expected to be a concomitant increase in unhealthy diets comprised of red meat, processed food and sugar. To address this vast and escalating challenge, populations will need to combine significant dietary changes with enhanced food production and reduced food waste.

The impact of food waste

Before broaching some of the challenges associated with changing the way we eat collectively let us briefly describe the magnitude and effect of food wastage. According to the United Nation’s (UN) 1.3bn tonnes of food are wasted every year, which is about 33% of the total produced. The cost of global food losses and waste amounts to roughly US$990bn and yet some 800m people worldwide do not get enough to eat and 2bn people are overweight.

Further, food wastage is estimated to release the equivalent of 3.3bn tonnes of CO₂ into the atmosphere each year. The total volume of water used annually to produce food that is lost or wasted (250km³) is equivalent to three times the volume of Lake Geneva. Similarly, 1.4bn hectares of land - 28% of the world's agricultural area - is used to produce food that is lost or wasted. And agriculture is responsible for a majority of threats to at-risk plant and animal species tracked by the International Union for Conservation of Nature.

Changing what we eat and how we produce food will save lives and the planet

According to Alan Dangour, Professor in Food and Nutrition for Global Health at the London School of Hygiene & Tropical Medicine (LSHTM), “The EAT-Lancet Commission’s analysis demonstrates that shifts in our diets can have enormous beneficial effects on health and also substantially reduce our impacts on the environment. This significant ‘win-win’ for health and the environment is not a new finding, but this analysis, which for the first time defines environmental boundaries for the food system, is the most advanced ever conducted”.

In a similar vein, Tara Garnett, a contributor to the EAT-Lancet Commission and a principal investigator of another research project on the future of food, also suggests that there’s nothing new in the Commission’s report but its fundamental message is that, “We’re not going to address our environmental problems unless we address the problems caused by the food system and we’re not going to address the problems caused by the food system unless we shift the way we eat collectively and globally”.

Rebalancing unhealthy diets is a significant challenge

Changing how we eat collectively, which Garnett and others suggest is necessary to reduce NCDs and enhance our environment, is not going to be easy. This is because it would involve cutting by half our consumption of red meat, processed food and sugar, and doubling our consumption of vegetables, fruit, pulses and nuts. For people living in the US and UK it would be even more challenging because the EAT-Lancet Commission ranks the US 43^rd and the UK 23^rd for their respective unhealthy diets out of the 195 nations in its study. It is suggested that in order to adopt a healthy diet Americans would need to eat 84% less red meat and six times more beans and lentils, and British people would have to eat 77% less red meat and 15 times more nuts and seeds.

Countries with the lowest rates of diet-related deaths are Israel, France, Spain and Japan. The highest rates are reported to be found in Uzbekistan, Afghanistan and the Marshall Islands. According to the Commission’s authors a Mediterranean-type-diet, “is what we should all be eating if we are concerned about our health and that of the planet”: it lowers the incidences of heart disease, diabetes and cancer, enables more environmentally helpful use of land and reduces carbon emissions.

The Mediterranean diet

The Mediterranean diet has been around for millennia and tends to be more of a lifestyle than a diet. It entails significantly lower amounts of beef, dairy products, sugar, soft drinks, pastries and processed foods; higher amounts of fish, fruit, nuts and salads, and no pasta, French fries and pastries. Unlike fashionable commercial diets associated with the weight management market, the Mediterranean diet does not have a set of specific rules that focus on losing weight, but instead emphasises eating fresh food over a lifetime. Also, the Mediterranean diet has been well studied. Research suggests that it is associated with a reduced risk of heart disease and cardiovascular mortality because of its significantly lower amounts of oxidized low-density lipoprotein (LDL) cholesterol, (the "bad" cholesterol) which is more likely to build up deposits in your arteries. Other benefits include reduced incidence of cancer, Parkinson's and Alzheimer's diseases. Further, women who follow a Mediterranean diet have a reduced risk of breast cancer.

The PREDIMED study

Findings of a landmark clinical trial, entitled “Primary Prevention of Cardiovascular Disease with a Mediterranean Diet”, was published in the June 2013 edition of the New England Journal of Medicine (NEJM). Popularly known as the PREDIMED study (Prevencion con Dieta Mediterranea), it tested the impact of two Mediterranean diets on cardiovascular risk. The first included a Mediterranean diet plus 30 grams of mixed nuts per day and the second was a Mediterranean diet plus at least four tablespoons a day of extra-virgin olive oil. The two diets were then compared to a low-fat diet, which is popularly advocated and pursued in the US and UK and among other developed nations and discourages the consumption of any high-fat items such as butter, cheese, oil, meats and pastries.

The low-fat diet

In the 1960s low-fat diets as opposed to high-fat, high-cholesterol diets were considered to promote heart health. By the late 1980s and early 1990s the low-fat diet was advocated by doctors, policy makers, the food industry and the media although there was no hard evidence to demonstrate it prevented heart disease and promoted weight loss. Notwithstanding, the low-fat-diet became an important part of the large and rapidly growing global weight management market, which is valued at some US$169bn and projected to grow at a CAGR of 2.4% and reach a value US$279bn by 2023. Interestingly, in the 80s and 90s, as the low-fat diet became an institution in the US and UK so the prevalence of overweight and obesity increased. Only recently has the low-fat diet been challenged as scientific evidence about fats increased.

A significant study with some methodological challenges

The PREDIMED study involved 7,447 people between 55 and 80 who were free from heart disease, came from 11 study centres across Spain and were randomly assigned to one of the three diets for five years. Findings suggested that the Mediterranean diet significantly reduced the risk of heart attack, stroke and cardio-vascular mortality compared to the low-fat diet. However, researchers discovered flaws with the study’s methodology and withdraw their findings. Most significantly, not all participants were randomly assigned to their diet and this could have influenced their findings.

Revised study of the Mediterranean diet

Researchers adjusted their methodology for its "irregularities in the randomization procedures" and published “new” findings in the June 2018 edition of the New England Journal of Medicine (NEJM), which confirmed the health benefits of a Mediterranean diet for adults at high risk for heart disease and found that the Mediterranean diet, plus olive oil or nuts, reduced risk for heart events by 30% compared to a low-fat diet. Lead author Miguel Ángel Martínez-González suggested that only about 10% of participants were affected in their earlier study reported in 2013, and their 2018 analysis made researchers, "More convinced than ever of the robustness of the protection by the Mediterranean diet against cardiovascular disease”. According to Jeffrey Drazen, editor-in-chief of the NEJM, "Medical professionals and their patients can use the republished information with confidence". While reaction to the study’s initial findings was disappointing, experts are encouraged by the adjusted findings, which confirm the heart-health benefits of a Mediterranean diet, particularly in adults at high risk for heart disease. Notwithstanding, experts emphasise the significance of sustaining a healthy diet over time.

The health benefits of the Japanese diet

The Mediterranean diet is not the only diet, which has proven to have significant health benefits. The Japanese diet, which is low in calories and saturated fat and high in nutrients, especially phytonutrients such as antioxidants and flavonoids, found in different coloured vegetables, also has considerable health benefits. Findings of two studies; one published in the April 2017 edition of PLOS.ONE, and another published in the March 2016 edition of the British Medical Journal demonstrate that, closer adherence to a Japanese diet resulted in a significantly lower risk of death from NCDs and in particular from cardiovascular disease or stroke. Japan has the highest life expectancy of any country: 90 years for women and 84 for men. Okinawa, in southernmost Japan, has the highest number of centenarians in the world as well as the lowest risk of age-related diseases such as cancer and heart disease. There are nearly 800 centenarians in Okinawa, which has a population of 1,368,000. The diet of the Okinawan people has been little influenced by the dietary changes influenced by western culture, which also have been seen in more urban Japan.

Takeaways

All the research findings we describe in this Commentary confirm the adage that, “You are what you eat”. Nutrients from the food you eat provide support for all the cells in your body, which have different “shelf lives”. For example, your skin cells live for about a month and your red blood cells for about four months. So, your body is constantly regenerating new cells to replace those that have “expired”. The health of your new cells is partly determined by how well you have been eating. A diet high on processed red meat and low on nutrients does not help in this regeneration process. But a nutrient rich, whole food diet can help to build your cells so that they work better to help you recover from common illnesses and the wear-and-tear of everyday life and make you less susceptible to disease.

Although our concern about healthy eating has intensified in recent years, the phrase, “you are what you eat” is not new. In 1826 Anthelme Brillat-Savarin wrote in Physiologie du Gout, ou Meditations de Gastronomie Transcendante, "Dis-moi ce que tu manges, je te dirai ce que tu es" [Tell me what you eat, and I will tell you what you are]. However, the phrase did not emerge in English until the 1920s when nutritionist Victor Lindlahr, who believed that food controls health, developed the Catabolic Diet. According to Lindlahr, "Ninety per cent of the diseases known to man are caused by cheap foodstuffs. You are what you eat". And in 1942, he published a book entitled, “You Are What You Eat: how to win and keep health with diet”. Eat like the Greeks, live healthier lives and save our planet.

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Healthcare Unplugged: Meeting the challenges of affordable quality healthcare

Gordon Moore

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Health Policy

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affordable healthcare

affordable quality healthcare

chronic illnesses

GPs

healthcare expenditure

health-related costs

national health systems

NCDs

Gordon Moore

Professor of Population Medicine
Harvard University Medical School

'We must tap into the largest unused source of manpower: the patients themselves.'

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Meeting the challenges of affordable quality healthcare

Health care systems throughout the world are about to be hit by a tsunami. Dramatically escalating GP demand is driven by the growth of life-style-related chronic illness, the surge of baby-boomers, a primary-care doctor shortage in some countries, and, in America, the surge of unmet needs now paid for by Obamacare. Either the current system will seize up, or new ways of caring for patients must be found.

Traditional responses unsustainable
Typically, healthcare systems respond to increased demand by adding manpower: usually nurses and other health workers. Increasing manpower reduces the potential for economies of scale in which increased volume reduces costs. Even worse, with additional workers added to a healthcare practice, efficiency actually decreases as downtime, communication costs, turnover, coverage, duplication and re-work increases.

Healthcare systems must find a way to reduce the costs as they struggle to meet this surge of demand. The old manpower-based responses, which at first seem attractive solutions, are unsustainable in the long run.

4 musts
What are the answers?

First, we must tap into the largest unused source of manpower: the patients themselves. Anyone who cares for patients with diabetes, smoking, or high blood pressure knows that the best plans of GPs often are not carried out despite many repeated visits to the doctor or nurse.

Second, to activate patients, care support for them must be truly patient-centred. Patients need help to gain confidence necessary to take control of their own therapeutic pathways. Such a system of support requires “having your doctor in your pocket”, which should be entertaining, engaging, educational, available 24/7, continuously helpful, personalized, and safe.

Third, “having your doctor in your pocket,” can only be achieved if IT is used in new and innovative ways. The most cost-effective avenue by which we can move patients with chronic illnesses to become more actively involved in their own care is through the Internet, where dramatic shifts in user interfaces, devices, and process interactions are taking place almost daily. By transferring expert knowledge to patients and thereby creating a truly patient-centred system, caring for ones’ own illness will be no more difficult than using a cash machine or mastering a smart phone.

Finally, if the Internet can facilitate the transfer of knowledge from the medical system to the patient, then also it can facilitate the transfer of expert health knowledge to lower the cost of all clinical personnel from doctors to nurses to health coaches. If guidelines, such as those produced by NICE in the UK, are built into the process of care that health professionals use, we would have developed a system that significantly extends the capacity of health professionals while maintaining the safety and quality aspects of care that increasingly people expect and demand. An apt analogy is the way that today’s cockpit technology enables all pilots to be as good as the best. Through the use of technology, we can do the same in medical care.

The past is no indication of the future
Today, healthcare is largely using IT to reproduce what doctors have done in the past. The electronic record is little different to paper records. In the evolution of any new technology, its application development goes through this stage. However, we must put IT to use in doing new things, in innovation that reduces our dependence on expensive manpower and in producing more value for less money.

Making such a transition will not be easy or inexpensive. But the costs of remaining the same and trying to meet escalating healthcare demands by adding more costly inputs are higher and more threatening in the long run. We should be investing in the future, not tinkering with the present.