1. Ancestral Health Symposium, LA, August 2011 Food and Western Disease Staffan Lindeberg MD PhD Center for Primary Health Care Research Lund University, Sweden

2. Western diseases: Cardiovascular diseases diabetes obesity hypertension dementia cancers osteoporosis rickets iron deficiency autoimmune diseases gastroesophageal reflux irritable bowel syndrome and many others Lindeberg S. Food and Western Disease. Wiley-Blackwell 2010

3. The basis of nutritional advice

8. Money

9. Science

10. Epidemiology

11. Molecular biology

12. Clinical trialsPlacebo bread, real meat Real bread, placebo meat

14. Money

15. Science

16. Epidemiology

17. Molecular biology

18. Clinical trials

20. Money

21. Science

22. Epidemiology

23. Molecular biology

24. Clinical trials

26. The Trobriand Islands, Papua New Guinea

28. 2,300 inhabitants (in 1990); 6% 60-96 years

29. diet: cultivated tubers (yam, sweet potato, taro, tapioka), fruit, fish, nuts and leafy vegetables — no western food

33. consistent with earlier observations (Schiefenhövel, Jüptner)

34. consistent with studies in Melanesia(Breinl -15, Clements -36, Devine -46, Backhouse -58, Whyte -58, Barnes -61, Campbell and Arthur -64, Dewdney -65, Kariks -67, Vines -70, Aiken -74, Hornabrook -74, Mathews -74, Page -74, Somers -74, Sinnett -77, Korner -80, Palmer -82, Ree -82)

35. consistent with studies in Africa(Donnison -29, Vint -37, Muwazi -44, Davies -48, Thomas -60, Trowell -60, Reef -62, Seftel -63, Tejada -68, Dodu -72, Edginton -72, Okuwobi -72, Shaper -72, Walker -75, Truswell -76, Isaacson -77, Trowell -81)

36. consistent with studies in South America (Groom -71, Connor -78, Baruzzi -81)

39. stroke (Lindeberg S et al. J Intern Med 1993;233:269)

41. stroke (Lindeberg S et al. J Intern Med 1993;233:269)

42. consistent with earlier observations (Schiefenhövel, Jüptner)

43. consistent with studies in East Africa (Trowell -81, Muwazi -44)Table. Incidence of stroke as proportion of acute neurologic disease in Kampala, Uganda.

45. stroke (Lindeberg S et al. J Intern Med 1993;233:269)

46. consistent with earlier observations (Schiefenhövel, Jüptner)

47. consistent with studies in East Africa (Trowell -81, Muwazi -44)

50. stroke (Lindeberg S et al. J Intern Med 1993;233:269)

51. diabetes type 2 (Lindeberg S et al. Metabolism 1999;48:1216)Fig. Fasting serum glucosein Kitava and Sweden.

53. stroke (Lindeberg S et al. J Intern Med 1993;233:269)

54. diabetes type 2 (Lindeberg S et al. Metabolism 1999;48:1216)

56. stroke (Lindeberg S et al. J Intern Med 1993;233:269)

57. diabetes type 2 (Lindeberg S et al. Metabolism 1999;48:1216)

58. overweight (Lindeberg S et al. J Intern Med 1994;236:331)

59. hypertension (Lindeberg S et al. J Intern Med 1994;236:331)Table. Blood pressure at age 40-60 years among hunter-gatherers, in Kitava and in Sweden (mm Hg, mean ± standard deviation)(modified from Lindeberg S et al. J Intern Med 1994;236:331).

61. stroke (Lindeberg S et al. J Intern Med 1993;233:269)

62. diabetes type 2 (Lindeberg S et al. Metabolism 1999;48:1216)

63. overweight (Lindeberg S et al. J Intern Med 1994;236:331)

64. hypertension (Lindeberg S et al. J Intern Med 1994;236:331)Diastolic BP, mm Hg Diastolic BP, mm Hg Fig. Diastolic blood pressure among males (left) and females (right) from Sweden (grey) and Kitava (black) (modified from Lindeberg S et al. J Intern Med 1994;236:331).

66. stroke (Lindeberg S et al. J Intern Med 1993;233:269)

67. diabetes type 2 (Lindeberg S et al. Metabolism 1999;48:1216)

68. overweight (Lindeberg S et al. J Intern Med 1994;236:331)

69. hypertension (Lindeberg S et al. J Intern Med 1994;236:331)Systolic BP, mm Hg Systolic BP, mm Hg Fig. Systolic blood pressure among males (left) and females (right) from Sweden (grey) and Kitava (black) (modified from Lindeberg S et al. J Intern Med 1994;236:331).

70. BMI 24.5 BMI 20.3 Fig. Z scores* of observed versus predicted mean cardiovascular risk factors in Kitavan males (left) and females (right) aged 40-65 years (after variable transformation when necessary). *standard score, number of standard deviations below or above Swedish means.

71. 28 Westernization affects everyone Blood pressure Fasting plasma glucose Cruickshank JK. Int J Epidemiol 2001;30:111 Poulter NR et al. Am J Hypertens 1988;1:143S

72. Ten-year risk of fatal cardiovascular disease in ’low-risk’ European populations. Chart based on total cholesterol (Conroy RM et al. Eur Heart J. 2003;24:987) (Lindeberg S. Eur Heart J 2005;26:2605-6)

73. Who wants to be normal? Atherosclerosis is part of ’normal’ ageing in westernized populations including japanese and chinese Fig. 40-year old US woman with coronary atherosclerosis despite normal angiography(Nissen SE. Circulation 2001;103:604). Fig. Percent of subjects with coronary atherosclerosis from birth to age 40 (Stary HC et al. AJCN 2000;72:1297S).

74. 31 Atherosclerosis of left anterior descending coronary artery among 45-55 year-old men from four populations (Tejada -68)

75. Who wants to be normal? Atherosclerosis is part of ’normal’ ageing in westernized populations No atheromas in other free-living mammals No atheromas in experimental animals without prior dietary manipulation fat, casein, lactose, peanut lectin etc. uncertain impact of cereal grains

76. Who wants to be normal? Relative risk of Western disease

77. Who wants to be normal? “Your blood pressure is normal.”

80. 6% between 60 and 95 years of age

83. no indications of genetic resistance

85. no indications of genetic resistance

86. 75% smokers

88. no indications of genetic resistance

89. 75% smokers

90. energy expenditure not extreme (but high)

91. high intake of saturated fat from coconut

93. no indications of genetic resistance

94. 75% smokers

95. energy expenditure not extreme (but high)

96. high intake of saturated fat from coconut

97. high intake of starch from yam, sweet potato, taro etc

99. 43 Estimated dietary intakes for Kitavan adults Daily intake Total Protein Fat CHO Energy (medians) (g) (g) (g) (g) (kJ) Tubers 1200 25 2 300 5600 Fruit 400 3 <1 50 920 Coconut 110 4 43 7 1865 Fish 85 17 4 0 445 Other 200 5 <1 14 360 Western food <1 0 <1 <1 20 Total 2 000 54 50 370 9200 Lindeberg S et al. AJCN 1997;66:845

101. no indications of genetic resistance

102. 75% smokers

103. energy expenditure not extreme (but high)

104. high intake of saturated fat from coconut

105. high intake of starch from yam, sweet potato, taro etc

106. 65-70 % of energy from carbohydrate

108. no indications of genetic resistance

109. 75% smokers

110. energy expenditure not extreme (but high)

111. high intake of saturated fat from coconut

112. high intake of starch from yam, sweet potato, taro etc

113. 65-70 % of energy from carbohydrate

114. Starch has not been shown to cause glucose intolerance

116. Is it time to shift focus? 47

117. Part 2. Treatment of disease

118. Grain-free, dairy-free diets in clinical practice Fruit, roots, meat, organ meats, eggs, fish, shellfish, vegetables, nuts etc. Beneficial effects in small clinical trials Normalized glucose tolerance independent of weight loss in diabetes/IGT (Lindeberg S et al. Diabetologia 2007;50:1795) Lower blood sugar, blood pressure, triglycerides and waist, and higher HDL, in diabetes type 2 (Jönsson T et al. Cardiovasc Diabetol 2009;8:35) Lower LDL, triglycerides, fP-Insulin (by 68%), AUCInsulin (by 39%) and diastolic BP (Frassetto LA et al. Eur J Clin Nutr 2009;63:947)

120. randomized to one of two low-fat dietary models

121. Consensus diet: whole grains, low-fat dairy products, vegetables, fruit and foods rich in omega-3 fatty acids (n=15)

122. Paleolithic diet: lean meat, fish, vegetables and fruit (n=14; avoid cereals, dairy products, margarine, sugar, salt)

123. 25% lower reported energy intake in the Paleolithic group

124. Much less grains and dairy foods and more fruit and nuts in the Paleolithic group

125. No difference in reported intake of fat or fiber

126. No difference in reported absolute intake of protein(Lindeberg S et al. Diabetologia 2007;50:1795)

127. A paleolithic-like diet improved glucose tolerance independently of weight loss or waist change Paleolithic diet Consensus diet Before Before *** After *** *** After Fig. Plasma glucose during the oral glucose tolerance test (OGT) at baseline and after 12 weeks of a Paleolithic diet (left) and a Consensus diet (right). Values are means (SE). ***p <0.001; absence of asterisk denotes p >0.05. (Lindeberg S et al. Diabetologia 2007;50:1795) 51

128. A paleolithic-like diet improved glucose tolerance independently of weight loss or waist change Fig. Change in glucose tolerance (left) and waist circumference (right) after 6 and 12 weeks of a Consensus diet (whole grains, lean dairy products, fruit, vegetables, foods high in omega-3 fatty acids; n=15) or a Paleolithic diet (n=14). (Lindeberg S et al. Diabetologia 2007;50:1795) 52

129. A paleolithic-like diet improved glucose tolerance independently of weight loss or waist change Table. Number of subjects with OGT plasma glucose above diabetes limits according to WHO diagnostic criteria (1999). (Lindeberg S et al. Diabetologia 2007;50:1795)

130. A paleolithic-like diet was superior to ‘diabetes diet’ for patients with type 2 diabetes in a cross-over trial Fig. HbA1c, HDL cholesterol, triglycerides, diastolic blood pressure, weight and waist circumference after 3 months with a ’diabetes diet’ (black) or a paleolithic diet (white) in 13 patients with diabetes type 2. (Jönsson T et al. Cardiovasc Diabetol 2009;8:35)

131. Grain-free, dairy-free diets in clinical practice Fruit, roots, meat, organ meats, eggs, fish, shellfish, vegetables, nuts etc. Beneficial effects in small clinical trials Lindeberg S et al. Diabetologia 2007;50:1795 Jönsson T et al. Cardiovasc Diabetol 2009;8:35 Frassetto LA et al. Eur J Clin Nutr 2009;63:947 LDL –22%, TG –35%, fP-Insulin –68%, AUC Insulin –39%, diastolic blood pressure –4%

132. Grain-free, dairy-free diets in clinical practice Fruit, roots, meat, organ meats, eggs, fish, shellfish, vegetables, nuts etc. Beneficial effects in small clinical trials Many promising case reports

133. Grain-free, dairy-free diets in clinical practice Fruit, roots, meat, organ meats, eggs, fish, shellfish, vegetables, nuts etc. Beneficial effects in small clinical trials Many promising case reports No obvious risks for most people

134. Grain-free, dairy-free diets in clinical practice Fruit, roots, meat, organ meats, eggs, fish, shellfish, vegetables, nuts etc. Beneficial effects in small clinical trials Many promising case reports No obvious risks for most people Uncertain effect of milk on bone strength in children and adolescents (Winzenberg T et al. COCHRANE 2006; Lanou AJ et al. Pediatrics 2005;115:736) in adults (Benetou V et al. EJCN 2011;65:132; Bischoff-Ferrari HA et al. J Bone Mineral Res 2011;DOI 10.1002)

135. Grain-free, dairy-free diets in clinical practice Fruit, roots, meat, organ meats, eggs, fish, shellfish, vegetables, nuts etc. Beneficial effects in small clinical trials Many promising case reports No obvious risks for most people Uncertain effect of milk on bone strength Uncertain iodine requirements in paleo perspective

136. Grain-free, dairy-free diets in clinical practice Fruit, roots, meat, organ meats, eggs, fish, shellfish, vegetables, nuts etc. Beneficial effects in small clinical trials Many promising case reports No obvious risks for most people Possibly sustainable Root vegetables, local production, no fertilizers, no dairy, sustainable meat, organ meats, involuntary calorie restriction

137. Everyone agrees: This is not healthy 61

138. Everyone agrees: This is healthy 62

139. Conclusions Common foods may cause common health problems Food choice may be more important than counting fat, carbohydrate or calories Nearly all Westerners get atherosclerosis and we don’t know why Conventional dietary advice is somewhat unfounded Is endocrinology more important than nutritionism? Many possibe endocrine disruptors in grains, seeds and beans Tyrosine kinase agonists, autoantigen mimics, goitrogens, phytoestrogens etc. www.staffanlindeberg.com staffan.lindeberg@med.lu.se