Most of the Whole World is Struggling with Healthy Eating

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Obesity and other consequences of a poor diet are not just affecting Americans. According to a recent study published in the Lancet, researchers from the Global Burden of Disease study have discovered 15 factors in 195 countries that could be improved through better diet (1).

The study, which tracks trends in consumption, estimates that internationally, one in five deaths (11 million) is linked with poor diet. A range of chronic illnesses around the world could be prevented with better diet. According to the study, in 2017, diets with limited amounts of whole grains, fruit, nuts, and seeds and high intakes of trans fat, sugar, red, and processed meats were key causes of many deaths.

This  research focuses on an urgent need for global collaboration on improving diets, including policies that enforce and encourage healthier diets. It highlights this need based on its investigation of the impact of poor diets on death and disease from cancers, cardiovascular diseases, and diabetes. Trends were tracked from 1990 to 2017.

In the past, population assessments of the health impact of poor diets has been difficult due to variations in dietary intake across nations. This study includes and evaluates data from epidemiological studies without the use of long-term randomized control trials, which are not always able to be completed in nutrition. Research was done to find associations between dietary factors and non-communicable diseases.

The research identified 15 dietary factors to evaluate -- diets low in fruits, vegetables, legumes, whole grains, nuts and seeds, milk, fiber, calcium, seafood omega-3-fatty acids polyunsaturated fats and diets containing high amounts of red meat, processed meat, sugar-sweetened beverages, trans fatty acids and sodium. Varying levels of data were available for each dietary element, which affects the statistical uncertainty of estimates. As an example, data on the number of people eating most of the dietary elements was available for most countries (95%), information for sodium estimates was available for only four countries.

Diets low in whole grains and fruit and diets high in sodium were responsible for over half of all diet-related deaths. Causes of these deaths were attributed to cardiovascular disease (10 million), 913,000 deaths from cancer, and nearly 339,000 deaths from type 2 diabetes. Deaths due to poor diet increased from 8 million in 1990, primarily due to the increase in population and the aging population.

For nearly every region of the world, the study authors discovered that consumption of 15 dietary elements were less than optimal. No region ate the desirable amount of all 15 dietary factors and not one dietary compound was consumed in the right amount by all 21 regions of the world.

A few regions did consume some dietary elements in correct amounts. In central Asia, consumption of vegetables was optimal, as was seafood rich in omega-3-fatty acids in high-income Asia Pacifica. Legume intake in the Caribbean, tropical Latin America, South Asia, western sub-Saharan Africa, and eastern sub-Saharan Africa was also in line with health recommendations.

In  terms of missing the mark, poor intake was especially noteworthy with nuts and seeds, milk, and whole grains, while the largest excesses included sugar-sweetened beverages, processed meat, and sodium. Globally, the world on average ate only 12% of the recommended amount of nuts and seeds (about 3 grams per day instead the advised 21 grams per day) and drank about 10 times the recommended number of sugar-sweetened drinks (49 grams daily) compared to the advised 3 grams per day.

For other dietary elements such as milk, the global diet reached 16% of the recommended amount (71 grams average intake versus 435 grams recommended daily), 23% of the recommended intake of whole grains (29 grams per day verses 125 grams advised per day), 90% more of the recommended range of processed meat (4 grams compared to 2 grams advised) and 86% more sodium (6 grams daily compared with 24 hr urinary sodium of 3 grams per day).

Intake of certain nutrients varied by region. For example, in China, Japan and Thailand, sodium intake was high (over 3 grams per day). In the US, India, Brazil, Pakistan, Nigeria, Russia, Egypt, Germany, Iran and Turkey, intake of whole grains was poor (below 125 grams daily). Low consumption of fruit was seen in Bangladesh (less than 250 grams per day) and in Mexico, nuts and seed intake ranked low (less than 21 grams daily). In highly-populated countries, increased intake of red meat (over 23 grams per day), processed meat (over 2 grams per day), trans fat (over .5% of total calories), and sugar-sweetened beverages (over 3 grams per day) were near the bottom rank of nutritional risks for death and disease.

A ten-fold difference was seen between the country with the highest rate of diet-related deaths (Uzbekistan) and the country with the lowest (Israel) in 2017. The following countries had lowest rates of diet-related deaths: Israel (89 deaths per 100,000 people), France, Spain Japan and Andorra. The UK had 127 deaths per 100,000 (ranked 23rd), above Ireland (24th) and Sweden (25th). The US ranked 43rd (171 deaths per 100,000 people) behind Rwanda and Nigeria (41st and 42nd respectively). China was ranked 140th (350 deaths per 100,000 people) and India 118th (310 deaths per 100,000 people). Countries with the most diet-related deaths included Uzbekistan (892 deaths per 100,000 people), Afghanistan, the Marshall Islands, Papua New Guinea, and Vanuatu.

Study author Dr. Christopher Murray, Director of the Institute for Health Metrics and Evaluation at the University of Washington, states, "This study affirms what many have thought for several years -- that poor diet is responsible for more deaths than any other risk factor in the world" (emphasis mine). High intakes of sodium, fat, and sugar are leading risk factors for disease, as are lacks of whole grains, nuts, seeds, fruits, and vegetables in many eating patterns. Murray's paper focuses on the importance of multiple interventions to encourage the production, distribution, and consumption of nutritious foods across the world.

The prevalence of diet-related conditions brings to light the fact that many existing diet-improvement programs have not been effective. The study authors advise new food system interventions to recalibrate eating patterns globally. They advocate for changes that take into account environmental effects of the global food system to avoid adverse impact on climate change, loss of biodiversity, degradation of land, and the depletion of freshwater and soil.

Recently, the Lancet published the EAT-Lancet Commission to provide the first scientific targets for a healthy diet from sustainable food production systems that operates within the earthly boundaries for food. This commission uses the 2016 data from the Global Burden of Disease report to estimate how far we are globally from the proposed healthy diet.

Limitations of this program were cited by the authors. For example, while it utilizes the best available data, gaps exist to nationally represent individual-level data for consumption of key foods and nutrients around the world. Further, generalizing the results may be inappropriate as most studies on diet and disease outcome are based largely on populations of European descent and more research in other populations is desirable. Epidemiological evidence linking dietary factors with death and disease relies on observational studies and is not as strong as evidence linking other lifestyle risk factors such as tobacco use and high blood pressure to poor health. However, short term randomized control trials offer data related to diet and health associations with risk factors for disease as the results. In this study, the authors did not factor in weight (over or underweight) and only looked at food and nutrient intake. Finally, some deaths could have been due to more than one dietary component, resulting in an overestimation of the burden of diseases due to poor diet.

Estimates of sodium intake were based on 24-hour urinary sodium measurements instead of spot urine samples, which were available for about 25% of the countries studied. Accurate estimation of nutrients such as fiber, calcium and polyunsaturated fatty acids is complicated. The authors advise increased national observance and systems to monitor key dietary risk factors and for collaborative efforts to collect and synthesize dietary information from cohort studies.

Dietitians can use information from this study to inform their clients about the benefits of a balanced, sustainable diet to prevent chronic disease.

For example, if clients are averse to including more nuts in their diet, whole or ground seeds can be used in yogurt, salads or smoothies to offer similar nutrients.

Suggesting seasonal fruits and vegetables be used to flavor water may be acceptable when trying to reduce sugar-sweetened beverages. Cucumbers, citrus fruit, melon and berries offer flavor without sugar.

Using fresh or dried herbs in dishes offers flavor without added sodium.

Using half whole grains with enriched grains may gradually move clients over to whole grains.

Providing a variety of simple solutions is often what clients are looking for to make long term changes to stay healthy.

Foods for individuals to increase include whole fruits and vegetables, beans and legumes, a variety of nuts and seeds and low-fat dairy products. Whole grains such as barley, bulgur, brown rice, whole wheat couscous, farro, quinoa and whole grain breads, cereals and pasta like 100% whole wheat bread, shredded wheat, bran cereal and steel cut oatmeal should be encouraged in place of refined bagels, cereal, bread, crackers and other non-nutritious carbohydrates.

Items to limit or decrease in our diets are regular soft drinks, alcohol and sports drinks, full fat dairy, red meat and processed meats such as hot dogs, lunch meat, bacon or sausage. High fat/high calorie desserts like cake, pie, doughnuts, ice cream, cookies and candy should be consumed less often as well. Canned soup or stew, frozen meals, bottled sauces or dressings and fast food should be limited due to their high sodium content. Snack foods such as chips or crackers should be consumed less frequently, too.

By Lisa Andrews, MEd, RD, LD

Journal Reference:

GBD 2017 Diet Collaborators. Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet, April 3, 2019; DOI: 10.1016/S0140-6736(19)30041-8

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