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Evidence, Not Evangelism, for Dietary Recommendations

      The conundrum about what and how much to eat is a uniquely human predicament. Every other free-living animal on Earth eats and drinks according to instincts that compel them to consume the diet for which they are genetically adapted—which ensures optimal nutrition. We have similar intuitive abilities, and in fact, indigenous humans living in the wild generally do not develop obesity, diabetes, hypertension, coronary artery disease, or the other chronic noncommunicable diseases prevalent in modern societies.
      • O'Keefe Jr., J.H.
      • Cordain L.
      Cardiovascular disease resulting from a diet and lifestyle at odds with our Paleolithic genome: how to become a 21st-century hunter-gatherer.
      • Kaplan H.
      • Thompson R.C.
      • Trumble B.C.
      • et al.
      Coronary atherosclerosis in indigenous South American Tsimane: a cross-sectional cohort study.
      Yet, humankind abandoned this ancestral hunter-forager lifestyle, wresting our food supply away from Mother Nature and reengineering it to suit our tastes. Now victims of our own success and burdened with the tyranny of choice, we have around-the-clock access 365 days a year to an overabundance of delicious highly processed foods and beverages, many of which have been engineered via food chemistry to promote craving and overconsumption.
      • DiNicolantonio J.J.
      • O'Keefe J.H.
      • Wilson W.L.
      Sugar addiction: is it real? a narrative review.
      • DiNicolantonio J.J.
      • O'Keefe J.H.
      • Lucan S.C.
      Added fructose: a principal driver of type 2 diabetes mellitus and its consequences.
      • DiNicolantonio J.J.
      • O'Keefe J.H.
      • Lucan S.C.
      In reply—Fructose as a driver of diabetes: an incomplete view of the evidence [letter].
      • DiNicolantonio J.J.
      • Lucan S.C.
      • O'Keefe J.H.
      The evidence for saturated fat and for sugar related to coronary heart disease.
      Food is information; this unnatural eating pattern is noise that bewilders our genes and disturbs our hormones so that now our instincts, honed for survival in the natural world, have become unreliable.
      • O'Keefe E.L.
      • DiNicolantonio J.J.
      • Patil H.
      • Helzberg J.H.
      • Lavie C.J.
      Lifestyle choices fuel epidemics of diabetes and cardiovascular disease among Asian Indians.
      Today, 2 of 3 American adults are overweight or obese,
      National Center for Health Statistics
      FastStats: Obesity and overweight. Centers for Disease Control and Prevention website.
      and many are confused about this emotionally charged issue of what to eat. National guidelines based largely on expert opinion and dietary evangelism railing against fats and animal-based foods have further muddied the waters.
      • Archer E.
      • Pavela G.
      • Lavie C.J.
      The inadmissibility of What We Eat in America and NHANES dietary data in nutrition and obesity research and the scientific formulation of national dietary guidelines.
      • Archer E.
      • Pavela G.
      • Lavie C.J.
      A discussion of the refutation of memory-based dietary assessment methods (M-BMs): the rhetorical defense of pseudoscientific and inadmissible evidence [letter].
      • Davy B.M.
      • Estabrooks P.A.
      The validity of self-reported dietary intake data: focus on the "What We Eat In America" component of the National Health and Nutrition Examination Survey research initiative [editorial].
      • Davy B.M.
      • Estabrooks P.A.
      In Reply—A discussion of the refutation of memory-based dietary assessment methods (M-BMs): the rhetorical defense of pseudoscientific and inadmissible evidence [letter].
      Thankfully, recent landmark studies provide an emerging evidence-based approach that should be used to inform dietary recommendations for optimal health (Table).
      TableLandmark Studies Providing an Emerging Evidence-Based Approach to Inform Dietary Recommendations
      Study Design and populations studied Major findings
      Women's Health Initiative randomized controlled Dietary Modification Trial
      • Howard B.V.
      • Van Horn L.
      • Hsia J.
      • et al.
      Low-fat dietary pattern and risk of cardiovascular disease: the Women's Health Initiative randomized controlled Dietary Modification Trial.
      Randomized trial involving 48,835 women who were randomly assigned to a low-fat diet or control After a mean of 8.1 years, the low-fat dietary intervention, despite reducing fat intake, did not significantly decrease the risk of CV disease
      PREDIMED study
      • Estruch R.
      • Ros E.
      • Salas-Salvadó J.
      • et al.
      PREDIMED Study Investigators
      Primary prevention of cardiovascular disease with a Mediterranean diet.
      Randomized trial of 7447 volunteers testing 3 interventions: Mediterranean diet supplemented with either (1) EVOO or (2) mixed nuts or (3) a control diet in which participants were advised to reduce dietary fat After a mean of 4.8 years, the Mediterranean diet supplemented with either EVOO or nuts significantly reduced the incidence of major CV events by 30%
      PURE study
      • Dehghan M.
      • Mente A.
      • Zhang X.
      • et al.
      Prospective Urban Rural Epidemiology (PURE) study investigators
      Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study.
      An epidemiological cohort study of 135,335 adults from 18 countries with a median follow-up of 7.4 years Higher dietary carbohydrate consumption was associated with increased risk of all-cause mortality. In contrast, higher consumption of dietary fat was associated with lower risk of all-cause mortality
      Tsimane coronary atherosclerosis study
      • Kaplan H.
      • Thompson R.C.
      • Trumble B.C.
      • et al.
      Coronary atherosclerosis in indigenous South American Tsimane: a cross-sectional cohort study.
      Cross-sectional cohort study of hunter-foragers. Coronary atherosclerosis assessed by noncontrast CT coronary artery calcium scoring Hunter-gatherers consuming a diet of unprocessed natural foods (plants, fish, and wild game) had the lowest levels of CAD of any population ever studied
      Fruit and vegetable meta-analysis
      National Center for Health Statistics
      FastStats: Obesity and overweight. Centers for Disease Control and Prevention website.
      Meta-analysis of 95 cohort prospective studies, which focused on fruit and vegetable intake and health outcomes Fruit and vegetable intakes associated with reduced risk of CV disease, cancer, and all-cause mortality. Worldwide, up to 7 million premature deaths could be prevented annually if individuals consumed 6 to 8 servings of vegetables + fruits daily
      CAD = coronary artery disease; CT = computed tomography; CV = cardiovascular; EVOO = extra-virgin olive oil; PREDIMED = Prevención con Dieta Mediterránea (Prevention with Mediterranean Diet); PURE = Prospective Urban and Rural Epidemiology.
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