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Review
. 2016 Jan 12;133(2):187-225.
doi: 10.1161/CIRCULATIONAHA.115.018585.

Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review

Dariush Mozaffarian  1
Affiliations
Review

Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review

Dariush Mozaffarian. Circulation. .

Abstract

Suboptimal nutrition is a leading cause of poor health. Nutrition and policy science have advanced rapidly, creating confusion yet also providing powerful opportunities to reduce the adverse health and economic impacts of poor diets. This review considers the history, new evidence, controversies, and corresponding lessons for modern dietary and policy priorities for cardiovascular diseases, obesity, and diabetes mellitus. Major identified themes include the importance of evaluating the full diversity of diet-related risk pathways, not only blood lipids or obesity; focusing on foods and overall diet patterns, rather than single isolated nutrients; recognizing the complex influences of different foods on long-term weight regulation, rather than simply counting calories; and characterizing and implementing evidence-based strategies, including policy approaches, for lifestyle change. Evidence-informed dietary priorities include increased fruits, nonstarchy vegetables, nuts, legumes, fish, vegetable oils, yogurt, and minimally processed whole grains; and fewer red meats, processed (eg, sodium-preserved) meats, and foods rich in refined grains, starch, added sugars, salt, and trans fat. More investigation is needed on the cardiometabolic effects of phenolics, dairy fat, probiotics, fermentation, coffee, tea, cocoa, eggs, specific vegetable and tropical oils, vitamin D, individual fatty acids, and diet-microbiome interactions. Little evidence to date supports the cardiometabolic relevance of other popular priorities: eg, local, organic, grass-fed, farmed/wild, or non-genetically modified. Evidence-based personalized nutrition appears to depend more on nongenetic characteristics (eg, physical activity, abdominal adiposity, gender, socioeconomic status, culture) than genetic factors. Food choices must be strongly supported by clinical behavior change efforts, health systems reforms, novel technologies, and robust policy strategies targeting economic incentives, schools and workplaces, neighborhood environments, and the food system. Scientific advances provide crucial new insights on optimal targets and best practices to reduce the burdens of diet-related cardiometabolic diseases.

Keywords: cardiovascular diseases; delivery of health care; diabetes mellitus; diet; nutrition; obesity; policy; prevention and control; review.

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Figures

Figure 1
Figure 1. Diet and cardiovascular and metabolic risk – pathways and mechanisms
Each of these dietary factors influences many or even all of these pathways, which could also be modified in some cases by underlying individual characteristics. Selected major effects are detailed in the text sections on each dietary factor.
Figure 2
Figure 2. Contrasting results of randomized controlled dietary trials focusing on isolated nutrients (top panel) vs. food-based diet patterns (bottom panel)
The Women's Health Initiative (WHI, top panel) focused on nutrient targets and reducing total fat and achieved large long-term changes in these targets, yet had no significant effect on cardiovascular disease or diabetes. The PREDIMED trial (bottom panel) focused on food-based diet patterns and increasing specific healthful foods, especially nuts and extra-virgin olive oil (EVOO), with smaller dietary changes than in WHI yet demonstrating significant reduction in cardiovascular disease and diabetes. Both trials successfully altered long-term diets, although with more modest changes in PREDIMED, but only the food-based intervention resulted in clinical benefit. Figures adapted with permission from Howard et al., JAMA 2006; and Estruch et al., NEJM 2013.
Figure 3
Figure 3. Evidence-based dietary priorities for cardiometabolic health
The placement of each food/factor is based on its net effects on cardiometabolic health, across all risk pathways and clinical endpoints, as well as thestrength of evidence. For dietary factors not listed (e.g., coffee, tea, cocoa, etc.), the current evidence remains insufficient to identify these as dietary priorities for increased or decreased consumption (see Table 3).
Figure 4
Figure 4
Diet quality, obesity, and metabolic risk – a modern paradigm.
Figure 5
Figure 5
Protein-rich foods and long-term weight gain in three separate US prospective cohort studies, based on 16 to 24 years of follow-up. Weight changes every 4 years are shown for each 1-serving/day increase in consumption; decreased consumption would be associated with the inverse weight changes. To convert kg to lbs, multiply by 2.2. All weight changes were adjusted for age, baseline body mass index, sleep duration, and concurrent changes in smoking status, physical activity, television watching, alcohol use, and consumption of fruits, vegetables, glycemic load, and all of the dietary factors in the Figure simultaneously. Reproduced with permission from Smith et al., Am J Clin Nutr. 2015;101:1216-1224
Figure 6
Figure 6
Meta-analyses of foods and coronary heart disease, stroke, and diabetes.
Figure 7
Figure 7
Meta-analyses of nutrients and coronary heart disease, stroke, and diabetes.
Figure 8
Figure 8
For defining carbohydrate quality, several characteristics appear to independently alter the cardiometabolic health effects of carbohydrate-rich foods. These include whole grain content (panel a), i.e. based on the content of milled, semi-processed, or intact whole grain including the bran and germ; fiber content (panel b), influenced largely by the content of bran; food structure (panel c), in particular whether the food is solid or liquid (such as sugar-sweetened beverages); and glycemic response (panel c), determined by the amount and accessibility of starch and sugar.
Figure 9
Figure 9
Barriers and opportunities for healthy eating. Reproduced with permission from Afshin A, Micha R, Khatibzadeh S, Schmidt L, Mozaffarian D. Dietary Policies to Reduce Noncommunicable Diseases. In: Yamey G, ed. The Handbook of Global Health Policy. Wiley-Blackwell, San Francisco, 2014.
Figure 10
Figure 10. A roadmap for improving population dietary habits
A great public health success of the 20th century was a 90% reduction in deaths from motor vehicle accidents, from 18 to 1.7 deaths per 100 million vehicle miles (top panel). This remarkable triumph was achieved by a comprehensive, multi-component effort targeting the driver, car, road, and culture (bottom panel). This provides a road map for improving population diets: address the consumer, the product (foods and beverages), the environment (retailers, cafeterias, restaurants), and the culture (unhealthy eating). Top panel reproduced with permission from MMWR Morb Mortal Wkly Rep. 1999;48:369-374.
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