Key:
NZ    Nahida Zaman
DM    Dr Dariush Mozaffarian

NZ    Good morning, hello and welcome to Diabetes Radio, I am your host Nahida Zaman.  My guest today is Dr Dariush Mozaffarian.  Dr Mozaffarian, hello and a very warm welcome to Diabetes Radio.

DM    Thank you very much.

NZ    Doctor, you are an Associate Professor in the Division of Cardiovascular Medicine at Brigham and Women’s Hospital at Harvard Medical School.  Could you give our Diabetes Radio listener some information about the focus of your research?

DM    I am a Cardiologist at Brigham and Women’s Hospital and also an Epidemiologist at Harvard School of Public Health and my research focuses on preventing cardiovascular disease before patients get to see me in the hospital and I really believe in the importance and the relative lack of emphasis on lifestyle and particular diet over the last 40 or 50 years relative to its potential impact, the research and policy emphasis on diet has been, I think, not as strong as it should be and so my research focus is on understanding what are the real dietary priorities to preventing cardiovascular disease and also once we know those priorities, how they should be implemented both in developed countries such as in Europe or in North America but also in developing countries.

NZ    Doctor, your recent research culminated in the publication of an important editorial in the British Medical Journal.  The editorial was published in the November 2011 issue of the BMJ and was titled United Nations Dietary Policies to Prevent Cardiovascular Disease.  Could you give our listeners a brief synopsis of your editorial?

DM    I wrote this with a colleague, Dr Simon Capewell at the University of Liverpool in the UK and we were really directing our editorial to the United Nations member states because the United Nations recently had a landmark meeting, a high level meeting on non-communicable diseases, non-communicable diseases being basically things other than typically infection or other diseases that we normally think of in the developing world and largely cardiovascular diseases and cancers being the major non-communicable diseases and so we really wanted to be sure that dietary priorities that were discussed and came out and hopefully will continue to come out of these efforts of the United Nations will be focused on the best evidence base on the best science because there are a lot of mixed messages about or mixed priorities I would say about what dietary factors are most important and if you look at various prior reports, for example the Institute of Medicine had a report on preventing cardiovascular disease globally and they talk about salt and sugar and saturated fats and trans fats and there has just been the focus on this handful of nutrients, generally reducing those nutrients and not really always supported with the best evidence base for what is actually important so what we wanted to do is describe what we thought was really the eight dietary priorities that should be prioritised and are different than many that are being discussed and also give an estimate from the best possible science of how big of an impact emphasising those dietary priorities could have on actually improving health.

NZ    Doctor, what are the current economic burdens of cardiovascular disease in high, middle and low income countries?

DM    I think it is well recognised that cardiovascular disease which includes heart disease, heart attacks, strokes and also broadly you could consider obesity and diabetes as cardiovascular diseases as well as long with hypertension and so forth, it is broadly recognised that cardiovascular diseases kill more men and women than any other condition in developed countries and high income countries but what is not recognised is they also are the number one killer of both men and women in middle income countries and almost every low income country as well.  Basically in the vast majority of countries in the world, the number one killer is cardiovascular disease.  There are just a few exceptions, countries that have very, very high rates of HIV for example and in Africa.  Other than that, cardiovascular disease is the big killer and in terms of the economic burden which was your question, it is a huge economic burden in developed countries so for in example in the United States the direct and indirect costs of cardiovascular disease is about $300 billion per year and we throw these numbers around a lot so to put $300 billion in context, that is one in eight of every dollar we spend on healthcare in the United States.  $300 billion is one in every $8 and actually if you look at the United States’ entire gross domestic product it is one in 50.  One in 50 of every dollar that we spend on anything in the United States is spent on cardiovascular disease so it is an enormous burden in developed countries, in high income countries.  Ironically one would think the economic burden would be less in middle and low income countries because they do not have these developed healthcare systems and while their absolute cost is certainly lower, they are not often doing these hi-tech fancy procedures and devices and drugs.  The relative economic burden is actually greater in middle and low income countries and that is because of two really important factors.  One is that cardiovascular disease strikes people in middle and low income countries, China, India, countries in Latin America, it strikes them at much younger ages than in high income countries so it strikes them in the prime of their working life and takes them out of the economic workforce.  Secondly there is not the system in place to take care of them and help them so the burden falls on the family and the family is often ill-equipped to deal with that.  There is often one wage earner and the family cannot deal with that and so you get this cyclical vicious cycle of poverty generally actually increasing risk of cardiovascular disease due to exposure to poor environments and then cardiovascular disease occurring, worsening poverty because the family has to take care of this as a sick individual and so forth and so you get this incredible economic burden and the Institute of Medicine report in 2010 actually felt that this was one of the major reasons that governments and policymakers should emphasise prevention of cardiovascular disease in middle and low income countries was because of the enormous economic burdens that it places on these countries.

NZ    On 19 September 2011 the United Nations General Assembly convened a landmark high level meeting on non-communicable diseases.  Could you please tell our listeners about this meeting and whether cardiovascular disease featured prominently on this agenda?

DM    The United Nations holds general assemblies relatively rarely, that is general assemblies with all the member states attending and actually in all of the history of the United Nations this was only the second time that this was related to health so the only other United Nations General Assembly with a high level meeting related to health was on HIV in 2006 and HIV and AIDS and so this second meeting on non-communicable diseases which again is generally cardiovascular diseases and cancers was really important because I think it marked the first time that on a global level in terms of the actual policymakers and governments, there was recognition that cardiovascular disease is a huge problem throughout the world, not just a problem of the United States and Europe.  For decades we have recognised that the developing countries, low and middle income countries have enormous problems with maternal mortality, infant mortality, infectious diseases like malaria and tuberculosis and HIV and those things remain problems and need to be addressed but the relative burden of cardiovascular disease both economically and in terms of death is at least as large, if not larger, in nearly every country in the world and yet it has been largely ignored in these middle and low income countries, so this meeting was important because of its focus on cardiovascular diseases and cancer and cardiovascular disease was a major topic since it is the leading killer of men and women in the world, about 20 million people die every year in the world from cardiovascular diseases, most of those in middle and low income countries so clearly this was an important meeting just to raise awareness.  The downside of the meeting is compared to the 2006 meeting on HIV or compared to prior meetings on tobacco control.  There was not really any final treaty or action item that was agreed upon, it was just an introduction, here is the problem, let us think of some things we should think about and whether this actually leads to real change or real action is so unclear.

NZ    Doctor, diet is a powerful common determinate of cardiovascular disease, obesity and diabetes.  Numerous trials and experiments have shown rapid reductions in cardiovascular disease after dietary improvements in populations.  Unfortunately both the optimal dietary targets and evidence based interventions to achieve them have been unclear for decades.  What impact has this had on clinicians and effective dietary policy?

DM    I think your question raises a couple of important points so the first point is that there is a real rapid effect of diet on cardiovascular diseases.  Everyone knows and agrees that diet is very important but somehow there is this feeling that if we needed to change diet in populations it would take decades to see those improvements and I have heard prominent scientists and prominent policymakers say diet is great but let us do something that works right away like set up high blood pressure clinics and treat people with drugs for high blood pressure because that works right away and diet is not going to work right away and that is a real mistake.  Very strong evidence shows how rapidly diet affects health.  There have been many well done controlled trials showing that within just 30 days, within a month of changing diet people have remarkable improvements in multiple risk factors like blood pressure and cholesterol levels and glucose and insulin and so forth, really remarkable in just 30 days and what I call natural experiments where a country population level changed the type of oil it was using or changed some other aspect of the diet in its population show that you can get rapid increases or decreases in heart disease within a year of changing diets at a population level so there is an incredibly rapid effective diet.  This is not a long term let us do something for 10 and 20 years down the line, this gives us immediate results which is important but the problem has been that the science of nutrition for studying chronic diseases like cardiovascular disease is relatively young, the science really started one could say in the 50s or so, it is only about a 50 year science.  For most of the several early decades of nutritional science in terms of cardiovascular disease, I think we did not have great scientific methods, we had the best we had at the time but we did not have great scientific methods and so the focus and priorities I think were not probably the best priorities and so for example total fat was a major priority for decades, reducing total fat, fat from all sources preventing cardiovascular disease, obesity and diabetes yet there is very good evidence, very strong evidence that total fat consumption has no effect on cardiovascular disease or diabetes and likely also in obesity.  That is just one example.  Now there is currently an enormous focus on just sugars alone without considering the bigger problem of refined carbohydrates, refined grains.  Similarly there is really little evidence that sugars alone, as compared to the bigger problem of sugars and refined grains, is a major problem by itself if you ignore refined carbohydrates so I feel like the priorities have been unclear and this has been worsened by industry who likes to, as we saw with tobacco for 50 years, industry likes to, whenever there is a little bit of a disagreement or a little bit of uncertainty in the evidence, they like to emphasise that.  I do not think food industry should be equated with tobacco industry directly, I think there is some similarities in that approach so what impact this has had is that we have been prioritising and focusing on the wrong things in some cases or at least not the best things and we have been confusing the public and we have also actually been confusing industry.  When we told industry to reduce fat in the diet they did and interestingly they were initially quite opposed to that but then they realised that refined carbohydrates, refined grains are much, much cheaper than fat and so they said this is great, we can sell low fat products, they cost us less and we can market them as healthy and there has just been an explosion of refined carbohydrate products, refined grain products in the world and that has actually probably had a big impact on obesity and diabetes so I think that the problem has been twofold, one is that policymakers have not realised how quickly diet can work, both for bad or for good and we are seeing the bad with the obesity epidemic, we have had an incredibly rapid obesity epidemic because of changes in diet and they do not recognise that that can be reversed and cardiovascular disease can be prevented very rapidly and secondly the dietary priorities have been not the best priorities based on the best modern science.

NZ    Dr Mozaffarian, have resistance and misdirection by industry also had a role here?

DM    I think there is a mixed answer to this question so certainly industry does what it can, food industry does what it can to make money and that is important and there are certainly companies that, regardless of the science, they push their agenda to sell as many products as possible without any care for what impact it has on health but on the other hand there are many companies that are more middle of the road and balance understanding that look, if we are selling an unhealthy product, ultimately the consumer is not going to like that, the public is not going to like that and let us try to make our foods more healthy and respond to demand and also science and there are even some companies that say we are just going to make healthy products because we really believe this, we have a belief in improving the health of the world and so I think there is a range of efforts by different companies in terms of how much they have had resistance in this direction versus others.  I think the second problem is that there has been unintentional misdirection by scientists and to industry so we, as I said, we told them that we should have low fat foods.  They responded to us, it was not them coming to us and saying we want to make low fat foods and in some sense we cannot hold the food industry completely at fault for the current state of foods and many have said that this is like the battle with cigarette companies and the food industry should be considered similarly.  I do not think that is entirely accurate because with cigarette companies it is a fight to the death, they have a product that is harmful under any circumstances at any dose and so basically it is try to eliminate that product and they do not really have any options.  Food companies have enormous options and if we can figure out and help them create products that are helpful and that sell and that can sell at a profit and I think we can do all of those things then they would be delighted to sell healthy foods at a profit and so I think that there clearly is strong resistance in this direction by industry invariably depending on the company but it clearly exists but I do not think fighting them exclusively as the enemy is the best approach, I think we need to take the companies that are willing to work with policymakers and scientists and help them, engage them and in some cases regulate some of their work to help guide them towards healthier foods.

NZ    Recent scientific advances have narrowed down on eight dietary targets.  These need to be prioritised for the prevention of cardiovascular disease.  What are these targets and what impact will they have if implemented?

DM    This was the focus of the editorial by Dr Capewell and myself, we felt that this is our opinion, our scientific judgement on what the best eight priorities should be globally to prevent cardiovascular mortality and we wish to emphasise there are many potential dietary priorities but we selected these eight both based on how strong the evidence was for their benefits, how consistent and how compelling the evidence was and also how strong an effect one would have by making these changes and so the eight priorities are to increase intake of a consumption of fruits, an increased consumption of vegetables, increased consumption of whole grains in place of starches, refined grain and sugars to increased consumption of nuts in place of starches, refined grain and sugars to increase a consumption of vegetable oils in place of animal fats, to increase fish and seafood and to limit dietary sodium and to limit industrial trans fat and I think there are two points worth highlighting, one is that six of these eight targets are actually increased so only two of these are reduced, limit dietary sodium and limit industrial trans fat.  The rest, fruits, vegetables, whole grains, nuts, vegetable oils and fish and seafood, they are all things to increase in the diet and I think that is a positive message about what is missing from the diet and what people and policymakers can add to the diet, that is a very positive message which has a much more profound impact and benefit for both individuals and populations and just this constant negative message about food and cardiovascular health, do not eat this, do not eat that, get this out of the food supply and so forth.  What is missing from the food supply is really what is actually probably most important for many people and many populations so I think that is one important point.  The second important point is that six of these eight dietary priorities are also foods, not nutrients and that is something that may be a little bit more subtle but for decades we have been focusing on a single nutrient, like a single vitamin or a single type of fat to say that the single nutrient is what causes cardiovascular disease and as I mentioned, for example, the Institute of Medicine report listed four nutrients, salt, sugar, saturated fats and trans fats.  They did not talk about foods, there are no foods on that list so we think, Dr Capewell and myself think that the evidence is very clear that actually in most cases the effect of the food is much more relevant than the effect of any one nutrient within it and you cannot really judge most foods by just one single nutrient and so the exceptions are sodium and trans fat, we do think those are nutrients that by themselves should be focused upon but other than that, the other six dietary priorities are all foods and I think that is another important message and the second part of your question is what impact would this have, based on very conservative estimates of very modest changes in the population so for example if fruits were on average increased by just one serving per day in the whole population, if vegetables were increased on average by just one serving per day in the whole population and so forth, very modest increases that are completely feasible and eminently achievable, what would the impact be and each of those eight targets by themselves would produce maybe a 5% to 10% reduction in heart disease deaths and stroke deaths so fairly modest 5% to 10% but you actually talk in a global level that is anywhere from one to two million deaths per year.  One to two million deaths per year with any one of these and if you put them together, conservatively these modest changes could potentially prevent 50% of half of all cardiovascular disease deaths in the world or about ten million deaths per year and so this could have enormous benefits for health and for reducing economic burdens on these countries.

NZ    Doctor, your paper also discussed new policy research which should allow the prioritisation of specific interventions and strategies.  What are these and what impact might they have?

DM    This is another important question.  Once we know what the dietary priorities are and I think we now do know what they are, how do we actually get them implemented in the population?  I think we know that just telling people to eat this or not eat that does have some effect, there are some benefits to just education but education alone has relatively small effects and so we need to have other strategies and the research on policy level or population level strategies to improve diet is even younger in a sense than the research on nutrition and cardiovascular disease so maybe in a decade or two even younger so I think the evidence is still emerging but I think that just this last decade we had enough science and if you look back at older studies as well, we have enough science and natural experiments over time to really be able to give, I think, a conclusive list of look, there is a set of strategies that we can put in the hands of policymakers and these strategies work and so I think that I would summarise them, this is not a comprehensive list, but things that I think there is good evidence for based on studies around the world.  I think that sustained and very focused media and education campaigns work so having a campaign, for example, a media education campaign just focused on let us say increasing fruits and vegetables or just focused on one specific thing that works, having subsidy strategies or tax strategies to subsidy strategies to lower prices of more healthy foods and tax strategies to increase prices of less healthy foods, that clearly works to improve diet.  Changing overall agricultural policies to create infrastructure which facilitates the production, transportation and marketing of healthier foods, that clearly works and has been shown for example in Finland and our school and workplace approaches that work and those could be very effective in developing countries and in urban areas where there is a lot of the population is in workplaces and in schools and so there are multi-component interventions that work in schools or workplaces and then finally there are some restrictions that should be set in place, specifically restrictions on advertising and marketing of certain less healthy foods and beverages to children and regulatory policies probably just related to trans fat and salt, I think those are probably the key nutrients as I mentioned of the eight dietary targets for which a direct regulation is warranted.

NZ    Is there evidence to support the effectiveness of any of these strategies?

DM    Yes I think there clearly is.  The list I gave you, there are many, many other potential things that could be done but the list I gave you is strongly supported by longitudinal studies showing how people’s food habits relate to things like food price and so forth from actual trials where there have been trials in communities where one community adopts or one school or one workplace adopts a certain approach and the other school or community does not and to see the difference and also just what I call again natural experiments where a government does something and compared to other governments in other countries that did not do anything, how their diet and their cardiovascular health change.  There is very good evidence for all those interventions that they are actually effective and as I say, we are at a nice moment where the science for the dietary priorities and the science for the strategies to change them have come together and I think we now have the science where it is really time for action.

NZ    Dr Mozaffarian, some observers will point to the inability of previous strategic initiatives to translate scientific evidence into political action.  What steps need to be taken to avoid this?

DM    This is I think now the multi trillion dollar question.  If we know the science on the dietary priorities and we can get enough people to recognise those and move beyond again this tired list of a few nutrients to reduce, if we can get people to move to this broader view of improving healthy foods, if we know the actual population based strategies that work, how do we actually turn that knowledge into action and that is something where that is beyond my expertise as a Cardiologist and Epidemiologist, this is really the realm of political science.  I have learned through necessity a little bit about this but you basically need a champion, a policymaker who is going to be a champion in a key leadership position who is really going to believe this and push this.  You need stakeholders to get involved, the public, food industry, schools, workplaces, other organisations like the American Heart Association in the US or similar organisations elsewhere and you need to get a grand effort and get all of this together and I think that we have good examples of things that have worked in the past, for example in the United States things like seatbelts, getting people to wear their seatbelts, smoking cessation, that is a huge unheralded victory in the United States, partial victory.  Smoking has gone down from a peak of about 55% in the 50s or 60s down to about 20% now, almost a two thirds decline and enormous victory and so I think it can be done.  We have examples of it having been done for other things but we just have to get the policymakers and the government involved and I think it is happening in bits and pieces here and therefore, for example, with the American Heart Association 20/20 impact goals with the First Lady Michelle Obama’s Let’s Move programme with other initiatives in other countries.  Demark banning trans fats, the UK having voluntary reductions in sodium, it is slowly happening but it is not happening nearly as fast as it should and without people really recognising the importance of these things, we could wait a long time before we actually benefit from this knowledge.

NZ    And a final question for you doctor, what lessons can the sections of the medical and scientific community who have focused on preventing deaths due to cardiovascular disease learn from the framework convention on tobacco control?

DM    This was a very important event in public health globally because this was actually a negotiated treaty where the World Health Organisation under the auspices of the United Nations actually negotiated a treaty that ultimately 168 countries signed which actually has a treaty about tobacco control and the treaty agreed on several measures for reducing tobacco consumption including price and tax measures including other things like protection against second hand smoke, regulating the contents of what is in tobacco products and making sure that companies disclose them, how tobacco products are packaged and labelled, how they are advertised and also public health education and other efforts for smoking cessation so treaties that need to be ratified, accepted and approved by individual countries by their parliaments or legislators, they need to actually then have action based on them so that is happening at various speeds in different countries but nonetheless, 168 countries signed a treaty with a health focus and so I think that we need to have a similar framework convention on improving diet and we need to have that framework convention I think ultimately lead to a set of dietary priorities, a set of policy actions and countries signing on to that.  Without that we may just, as I said, go decades and decades with watching the obesity epidemic, the cardiovascular disease epidemic ravage the health and economies of the world.

NZ    Dr Dariush Mozaffarian, thank you so much for taking the time to join Diabetes Radio today, it has been a pleasure speaking to you.