Global, regional, and national consumption levels of dietary fats and oils in 1990 and 2010: a systematic analysis including 266 country-specific nutrition surveys
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2272 (Published 15 April 2014) Cite this as: BMJ 2014;348:g2272
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We are familiar with Dr. Ravnskov’s prior work and views on dietary fats and heart disease, and appreciate his interest in our recent work reporting global estimates of key dietary fats and oils by region, country, time, age, and sex.[1] The evidence for etiologic effects of these dietary fats and oils on chronic diseases was not the subject of this manuscript, and Dr. Ravnskov and interested readers can review our and others’ prior investigations on these topics.[2-5]
Renata Micha, Research Director/ Associate, PhD, Dariush Mozaffarian, Associate Professor, MD, DrPH
Departments of Epidemiology (RM, DM) and Nutrition (DM), Harvard School of Public Health, Boston, MA; Department of Food Science and Human Nutrition (RM), Agricultural University of Athens, Greece; and Division of Cardiovascular Medicine and Channing Laboratory (DM), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
References
1. Micha R, Khatibzadeh S, Shi P, et al. Global, regional, and national consumption levels of dietary fats and oils in 1990 and 2010: a systematic analysis including 266 country-specific nutrition surveys. BMJ (Clinical research ed) 2014;348:g2272.
2. Mozaffarian D, Micha R, Wallace S. Effects on Coronary Heart Disease of Increasing Polyunsaturated Fat in Place of Saturated Fat: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. PLoS Med 2010;7(3):e1000252.
3. Micha R, Mozaffarian D. Saturated fat and cardiometabolic risk factors, coronary heart disease, stroke, and diabetes: a fresh look at the evidence. Lipids 2010;45(10):893-905.
4. Jakobsen MU, O'Reilly EJ, Heitmann BL, et al. Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. The American journal of clinical nutrition 2009;89(5):1425-32.
5. FAO. Fats and fatty acids in human nutrition. Report of an expert consultation. Geneva, 2010.
Competing interests: No competing interests
We appreciate the interest from Dr. Winkler in our systematic investigation of global intakes of key dietary fats and oils by region, country, time, age, and sex.[1]
We agree with Dr. Winkler’s implications that interpretation of dietary data requires appropriate perspective, context, and recognition of strengths and limitations, as is true for any scientific research. Yet, Dr. Winkler’s concerns reflect only a partial understanding of the strengths and limitations of various nutritional assessment methods.
First, the interpretation and validity of individual-level dietary data depends on both the dietary assessment tool used (e.g., diet records, diet recalls, semi-quantitative food frequency questionnaires, tissue biomarkers), the level of assessment required (e.g., individual intake vs. population/group mean intake), and the nutrient, food, or dietary pattern of interest. In relation to these considerations, different dietary instruments have complementary pros and cons, and their validity and reliability have been extensively documented.[2 3]
Overall, both the validity and long-term reliability of foods, nutrients, and diet patterns assessed by such instruments are very reasonable, similar to other widely used measures such as blood pressure and blood cholesterol. Furthermore, when used to assess population means as in our study (rather than to assess individual intakes), these dietary instruments have even stronger validity, especially when using diet records or recalls which were the main instruments used in our analyses.
We agree with Dr. Winkler that, in contrast to measurement of specific nutrients and foods, total energy intake is poorly assessed by dietary questionnaires. Thus, few nutritional experts recommend use of dietary questionnaires to assess total energy, and total energy was not an endpoint in our investigation. On the other hand, due to correlated errors, total energy assessed by dietary instruments is very useful for energy-adjusting estimates of nutrient and food intakes to further increase their validity. Consequently, we reported intakes of these key dietary fats and oils adjusted for energy.
Renata Micha, Research Director/ Associate, PhD, Dariush Mozaffarian, Associate Professor, MD, DrPH
Departments of Epidemiology (RM, DM) and Nutrition (DM), Harvard School of Public Health, Boston, MA; Department of Food Science and Human Nutrition (RM), Agricultural University of Athens, Greece; and Division of Cardiovascular Medicine and Channing Laboratory (DM), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
References
1. Micha R, Khatibzadeh S, Shi P, et al. Global, regional, and national consumption levels of dietary fats and oils in 1990 and 2010: a systematic analysis including 266 country-specific nutrition surveys. BMJ (Clinical research ed) 2014;348:g2272.
2. Willett WC. Nutritional Epidemiology: Oxford University Press, 2013.
3. Gibson RS. Principles of Nutritional Assessment: Oxford University Press, 2005.
Competing interests: No competing interests
Micha and colleagues’ report on global consumption of fats deserves comment.(1)
First, they claim “suboptimal diet is the single leading modifiable cause of poor health in the world, exceeding the burdens due to tobacco and excess alcohol consumption combined” despite the only reference they cited concluded: “Despite declines, tobacco smoking including second-hand smoke remained the leading risk … Dietary risk factors and physical inactivity collectively accounted for 10•0% (95% UI 9•2-10•8) of global DALYs in 2010, with the most prominent dietary risks being diets low in fruits and those high in sodium.”(2)
Second, could Micah et al provide us a definition of suboptimal diet.
Last, adequate policies are still being sought for feasible long-term population wide changes in diet and shifting to the in fashion “chimp diet” offers limited benefit: the number needed to treat to avoid death from fatal ischemic heart disease during 8 years is 500 when shifting from 3 portions of fruits and vegetables per day to 8 portions per day.(3)
1 Micha R, Khatibzadeh S, Shi P, Fahimi S, Lim S, Andrews KG, et al. Global, regional, and national consumption levels of dietary fats and oils in 1990 and 2010: a systematic analysis including 266 country-specific nutrition surveys. BMJ. 2014;348:g2272.
2 Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2013;380:2224-60.
3 Braillon A. Number needed to treat: implementation for diets. Arch Intern Med 2011;171:1123-4.
Competing interests: No competing interests
The efforts in preparing the present study are laudable and the authors should be applauded for such a wonderful and enormous work. The systematic analysis presents an important aspect of dietary intake-pattern and trend in saturated and polyunsaturated fat intake in the global context, with possible inputs from various countries. It is interesting to note that in 1990 and 2010, the global intake of saturated fat, cholesterol, and trans fat remained stable while dietary omega 6, omega 3 (plant and seafood) intakes increased.
If we look at the available studies, there are differences in the methods used, the nature of data collection (either by research staff or trained survey personnel or nutritionists, etc. ), and estimation of dietary intake of fats and oils. Dietary methods adopted can be by 24 hour recall method, weighing of raw or cooked foods, food stock analysis, weekly or monthly consumption analysis, food record by diary, etc. These methods have wide variations in the approach and method of data collection leading to variations in the quality of data collection. There is no uniformity in the data collection process adopted in the various research articles used in the analysis of the present work. Can we really rely on the study results? Further, combining the results of such studies cannot give us the accurate information on the dietary fat and oil consumption pattern. Dietary food surveys have the disadvantage of relying on the reports by the study subjects, which itself is beset with recall bias and misinformation bias. To add further to complicate the results, the dietary intake does not show similar pattern over days or weeks or even months because of the seasonal variations in the food items intake and quantity of food consumption. Under such circumstances, can we rely on the reported quantity of food consumption in the studies? The systematic study has also reported that consumption of cholesterol is based on egg consumption. There are several other sources of cholesterol in the diet in addition to eggs. Unless we include the other animal sources, hydrogenated fats such as ghee, butter etc. we cannot get the exact figure on the quantity of cholesterol consumption. We need to identify these shortcomings in the study results before generalization of the data globally.
Although the authors have discussed the public health implications on the observations of the systemic study in terms of changes in the burden of chronic diseases including coronary heart diseases (CHD), stroke, etc., it is still not sure whether the changes in the trend of chronic diseases such as CHD, stroke, etc. over the years could be associated with the changing dietary fat and oil level. The doubt over the beneficial effects of omega 6 and omega 3 rich fats and oil is still not over. The findings of the present study need to be considered keeping all these things in mind.
Mongjam Meghachandra Singh
Professor,
Department of Community Medicine
Maulana Azad Medical College, New Delhi
Reeta Devi
Assistant Professor,
School of Health Sciences,
Indira Gandhi National Open University, New Delhi
Vasu Saini
Ex-intern, Maulana Azad Medical College, New Delhi.
Competing interests: No competing interests
From the text of this paper it is not obvious what the authors mean by a healthy diet. However, from table 2 and their references it appears that they recommend replacement of saturated fatty acids (SFA) with polyunsaturated fatty acids (PUFA), and to increase our intake of omega-3 from seafood. They have ”required convincing or probable evidence for effects on clinical events (such as myocardial infarction)”, and refer to the joint WHO/FAO expert consultation from 2003 as support.
In that report the authors do not present any evidence themselves, but refer to a consensus report from the Nutrition Committee of the American Heart Association (1). only evidence in that report is studies claiming that SFA raises cholesterol and a single paper from the Nurses’ Health Study (2). According to the abstract of the latter CHD may be prevented by replacing SFA and trans unsaturated fats with PUFA and unhydrogenated monounsaturated fatty acids. Their conclusion is based on complicated statistical calculations. The simple truth is that on average, there were just as many heart attacks among those with the lowest intake of SFA as among those with the highest; this fact appears clearly from the tables in the report, is also in accordance with many other reports from the Harvard researchers.
Lack of evidence appears also from a more recent WHO/FAO report (3). In the section about saturated fat the authors wrote that ”the available evidence from cohort and randomised controlled trials is unsatisfactory and unreliable to make judgements about and substantiate the effects of dietary fat on the risk of developing CHD.”
As support of their view Micha et al. also refer to Bradford Hill´s nine criteria for causation, but the idea that saturated fat causes atherosclerosis and CVD does not satisfy any of them. Let me mention the most striking deviations.
More than 25 cohort and case-control studies have shown that patients with CHD have not eaten more saturated fat than others. In fact, seven studies found that stroke patients had eaten significantly less; no study has shown the opposite (4,5).
In 63 of 103 time periods in 35 countries, consumption of saturated fat increased. In 33 of these periods CHD mortality increased as well, but in ten periods it was unchanged and in 23 it went down (4).
In a meta-analysis of ten cohort studies including more than 400,000 individuals the authors found that high-consumers of dairy products had a significantly lower CVD risk than low-consumers (6), and in a thorough review of the associations between dairy products and CVD the author did not find evidence of harmful effects either (7).
In a meta-analysis of the randomised, controlled dietary trials where the only intervention was a change of dietary fat, no significant effect was seen, neither on cardiovascular or total mortality (4).
It should be mentioned also that a systematic review of this issue by Chowdhury et al. published about a month before the review by Macha et al., the authors found no evidence that encourage an increased intake of PUFA or a decreased intake of SFA (8). These results must have been known by Macha et al. because Dariush Mozaffarian has been a co-author of both papers.
To recommend an exchange of SFA with PUFA without defining which type of PUFA is also a questionable advice because the dominating type of PUFA in today´s industrial food is omega-6, and a high intake of omega-6 is associated with many adverse health effects (9).
References
1. Kris-Etherton P, Daniels SR, Eckel RH, Engler M, Howard BV, Krauss RM et al. Summary of the scientific conference on dietary fatty acids and cardiovascular health: conference summary from the nutrition committee of the American Heart Association. Circulation 2001; 103: 1034–1039.
2. Hu FB, Stampfer MJ, Manson JE, Rimm E, Colditz GA, Rosner BA et al. Dietary fat intake and the risk of coronary heart disease in women. N Engl J Med 1997;337:1491–9.
3. Burlingame B, Nishida C, Uauy R, Weisell R (ed.). Fats and fatty acids in human nutrition. Joint FAO/WHO expert consultation. Ann Nutr Metabol 2009;55:1–302.
4. Ravnskov U. The questionable role of saturated and polyunsaturated fatty acids in cardiovascular disease. J Clin Epidemiol 1998;51:443-60.
5. Ravnskov U. Is saturated fat bad? In: Modern Dietary fat intakes in disease promotion. Nutr Health 2010, part 2, p 109-19.
6. Elwood PC, Pickering JE, Fehily AM, Hughes J, Ness AR. Milk drinking, ischaemic heart disease and ischaemic stroke. II. Evidence from cohort studies. Eur J Clin Nutr 2004;58:718–24.
7. Tolstrup T. Dairy products and cardiovascular disease. Curr Opin Lipidol 2006;17:1–10.
8. Chowdhury R, Warnakula S, Kunutsor S, Crowe F, Ward HA, Johnson L et al. Association of Dietary, Circulating, and Supplement Fatty Acids With Coronary Risk: A Systematic Review and Meta-analysis. Ann Intern Med 2014;160:398-406.
9. Ravnskov U, DiNicolantonio JJ, Harcombe Z, Kummerow FA, Okuyama H, Worm N, The questionable benefits of exchanging saturated fat with polyunsaturated fat. Mayo Clin Proc 2014;89:451-3
Competing interests: No competing interests
This is the latest in a series of articles in the BMJ [1] [2] [3] (and other health publications) attempting to measure the diets of countries, in order to show associations with diseases or the effects of possible preventive policies, like food taxes.
This is the grandest of the lot, positively heroic in assembling data on individual diets from 113 countries, and breaking new ground by breaking down “fats” into constituent types.
The extended description of their data analysis techniques may bemuse many BMJ readers (and perhaps some BMJ editors too). Surely authors of such statistical sophistication must know what they are talking about?
In fact, this research suffers from the same fundamental flaw as all such studies -– the poor quality of the primary data on food consumption. But the authors are less than fully candid about the causes and consequences of the problem.
While diet surveys vary in their methods, all effectively rely on subjects telling researchers honestly what they eat. But all such “self-report” data suffer from a deficiency that has been known to nutritionists for decades. In the trade, it is called “under-reporting”. In plain English, people lie.
Subjects respond normatively, not truthfully, more in line with the conventions of appropriate eating in their culture. In the West, these days, they claim to eat a healthier diet than they actually do, smaller in volume and a more nutritious mix.
These are not malicious lies. They are the ordinary lies that we all tell every day – putting our best foot forward, showing ourselves in the best possible light.
Nonetheless, they can be large lies. In the UK, for example, which does better diet surveys than most, separate research using a biomarker, “doubly-labelled water”, showed that adults under-report their calorie intakes by 25%,[4] late adolescents by 34%.[5]
In one study of soft drinks, subjects in the National Diet and Nutrition Survey claimed to be drinking barely a quarter of the products that manufacturers reported they were selling.[6]
In the US, a recent review of 39 years of the American national diet survey (NHANES) found that “data on the majority of respondents (67.3% of women and 58.7% of men) were not physiologically plausible”.[7] That is, subjects were claiming to eat less than is necessary to stay alive.
Readers receive no inkling of such problems from this text. The page-and-a-half section on “Methods” describes much subsequent effort, but not the methods used to gather the primary intake information.
They are only mentioned at the bottom of a diagram on the sixteenth page of the article. All consumption figures -- from all 113 countries -– started as various forms of “self-report” data (multiple diet recalls 14%, food frequency questionnaires 31%, single diet recalls 27%, and household availability/budget surveys 29%).
Nor does the word “under-reporting”, or anything like it, appear anywhere in the text. Still less is there any indication of the scale of possible mis-information.
The now conventional way of getting round the problem is to mention the issue briefly in a “Strengths and weaknesses of study” section towards the end of papers. Even that fig leaf does not appear in this article.
This is not just a matter of propriety, but of substance. No secondary data manipulations, no matter how sophisticated, can correct such gross flaws in the primary data.
The consequence is that the numbers presented here for fat consumption are not credible. With the current limitations of diet surveys, no one knows the true consumption of fats, but these estimates are almost certainly wrong.
The authors conclude by saying that they plan to continue the work. Before they do so, they might consider the recent advice of 17 obesity experts on the same problem in measuring calorie consumption (energy intake/EI).[8]
“Going forward, we should accept that self-reported (energy intake) is fatally flawed and we should stop publishing inaccurate and misleading (energy intake) data”.
1 Te Morenga L, Mallard S, Mann J (2012), Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies, BMJ; 345:e7492.
2 Briggs A, Mytton O, Kehlbacher A, Tiffin R, Rayner M, Scarborough P (2013), Overall and income specific effect on prevalence of overweight and obesity of 20% sugar sweetened drink tax in UK: econometric and comparative risk assessment modelling study, BMJ; 347:f6189.
3 Basu S, Babiarz K, Ebrahim S, Vellakkal S, Stuckler D, Goldhaber-Fiebert J (2013), Palm oil taxes and cardiovascular disease mortality in India: economic-epidemiologic model, BMJ; 347:f6048.
4 Rennie K, Coward A, Jebb S (2007), Estimating under-reporting of energy intake in dietary surveys using an individualised method, British Journal of Nutrition, 97, 1169–1176.
5 Rennie K, Jebb S, Wright A, Coward W (2005), Secular trends in under-reporting in young people, British Journal of Nutrition, 93, 241–247.
6 Briggs et al, op cit.
7 Archer E, Hand G, Blair S (2013), Validity of U.S. Nutritional Surveillance: National Health and Nutrition Examination Survey Caloric Energy Intake Data, 1971–2010, PLOS ONE, 1 October, Volume 8 | Issue 10 | e76632.
8 Schoeller D, Thomas D, Archer E, Heymsfield S, Blair S, Goran M, Hill J, Atkinson R, Corkey B, Foreyt J, Dhurandhar N, Kral J, Hall K, Hansen B, Lilienthal Heitmann B, Ravussin E, Allison D (2013), Self-report–based estimates of energy intake offer an inadequate basis for scientific conclusions, Am J Clin Nutr 2013 97: 1413-1415.
Competing interests: No competing interests
A RARE FEAST
============
" Here it is ! A feast indeed.
For young and all- in the field of
medicine or out.
From many a cook in many a land,
Ten of them, men and women
Raised in Greece, England and coast to
coast America.
Fuelled by the Gates duo.
Twenty nine pages of print and paint.
Foods and drinks
What we gulped and gulp,
Belying our bellies and brains.
Sneaky peaks at plates of our neghbors.
To the eye and the mind,
Pleasure and pain."
Competing interests: No competing interests
Serious errors in estimates for small countries
There appear to be some serious errors in the fat intake estimates for some small countries.
For example "Highest [SFA] intakes were identified in Samoa, Kiribati, and similar palm oil producing island nations;"
These nations do not produce palm oil; their palms are coconut palms but for reasons of scale copra is exported for coconut oil production elsewhere. The only saturated fat produced locally is in the coconut itself, and imported canned coconut cream and milk is also consumed.
"Lowest intake [of n-6 polyunsaturated fat] was seen in Kiribati, Samoa, and Vanuatu"
The source for Samoa is said to be "Western Samoa 1990 24 hr recall diet estimates". No source is given for other Pacific nations. If WHO/FAO estimates were used to complete missing data, we have found these to be wrong by a factor of 4 for New Zealand butter consumption, a relatively easy thing to get right.[1]
In eTable 3, n-6 PUFA in Samoa is listed at 1.5% and in neighbouring Tonga it is listed at 2%.
Because I live in Auckland New Zealand and have long visited shops that supply food to migrants from Samoa and Tonga, this seemed implausible to me. Cheap vegetable oils - canola, soy, corn - are the usual oils sold in these shops. Coconut oil is only really a cosmetic there and I have never seen palm oil. The tinned fish which makes up an important source of protein is always packed in oil, usually soy oil; this product, with refined carbohydrates, and unlike traditional sources of protein, fat, and carbohydrate regardless of their SFA/PUFA ratios, is associated with obesity in Vanuatu.[2]
So I wondered if there was evidence of what oils are used in these islands. I found online that Punja oils actually have a factory in Fiji.[3]
"Punjas imports and refines a range of bulk edible oils from Australia, Asia, Europe and South America.
Using European Desmet Rosedown equipment, we refine, bleach and deodorize these oils for the Pacific market.
When it comes to distribution in the South Pacific, we’ve got it covered. Punjas has established subsidiaries in Tonga, Kiribati, Vanuatu and Papua New Guinea ."
Punjas makes soybean oil, canola oil, vanaspati (hydrogenated oil - a ghee substitute), mustard seed oil, and coconut oil for the Pacific market. Of these oils, soybean and canola are probably the cheapest; the other oils are, as I said, not common items in shops supplying the Pasifika diaspora. I doubt Punja are the only supplier of these oils in the Pacific (why would American Samoa lack imported US oils? They have a Kentucky Fried Chicken outlet).
It seems that 1990 estimates were either inaccurate, or not adequate for a 2014 analysis; this error could have serious consequences for small nations. These nations are experiencing health transitions (Vanuatu) and health crises (Kiribati, Samoa, Tonga) in terms of type 2 diabetes since 1990. If it is wrongly assumed that n-6 consumption there is still very low, increasing intake could become a priority, and the true correlation of dietary changes with disease rates could be missed.
[1] https://profgrant.com/2017/02/02/rebuttal-to-rod-jackson-are-new-zealand...
[2] Dancause KN, Vilar M, Wilson M, et al. Behavioral risk factors for obesity during health transition in Vanuatu, South Pacific. Obesity (Silver Spring, Md). 2013;21(1):E98-E104. doi:10.1002/oby.20082.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3605745/
[3] http://www.punjas.com/our-companies/punjas-sons-oils-ltd/
Competing interests: No competing interests