this positive association. In 2018, the WHO published an action package to reduce TFA use in the global food supply called the “REPLACE action package.” Based on a six‐step strategy, each country should implement actions to eliminate the industrially produced TFAs.
Key Point
Each country should implement actions to eliminate the industrially produced TFAs.
Carbohydrates and Dietary Fiber
The evidence linking simple carbohydrate‐rich foods with CHD is quite strong. High intake of refined carbohydrates, especially sugar‐sweetened beverages, has been consistently associated with increased risk of CHD. However, the characterization of carbohydrates according to their glycemic load (GL) may be a better way to categorize carbohydrates for predicting CHD risk, compared to the more simplistic categorization into “simple” and “complex” carbohydrates. Consumption of high GL meals has been associated with increased CHD incidence in female subjects followed prospectively for 10 years. Interestingly, those consuming a high GL diet had twice the likelihood to develop CHD, compared with those refraining from a high GL diet. In the NHS (76,000 female subjects), refined carbohydrates were associated with increased coronary heart disease, presumably due to increased dietary GL.
Key Point
Consumption of high GL meals has been associated with CHD incidence in female subjects followed prospectively for 10 years.
Dietary fiber intake seems to be beneficial for human health. A meta‐analysis of 185 prospective studies yielded a 15–30% reduction in all‐cause and cardiovascular mortality, T2DM, and colorectal cancer in individuals with the highest dietary fiber intake, compared with those in the lowest consumption category. In the same meta‐analysis, 58 clinical trials were separately analyzed, showing significantly lower body weight, systolic blood pressure, and total cholesterol in people in the high dietary fiber category compared to the lower fiber category. The best outcomes were observed when daily intake of dietary fiber was 25–29 g. In another meta‐analysis of 17 prospective studies from 1997 to 2014, it was found that for every 10 g/day increase in fiber intake, there is a 10% decrease in all‐cause mortality.
Key Point
For every 10 g/day increase in fiber intake, there is a 10% decrease in all-cause mortality.
According to the 2015–2020 dietary guidelines for Americans, the adequate daily intake of fiber is 14 g/1000 cal, or approximately 25 g/day for women and 38 g/day for men.
Foods and Food Groups
High red meat consumption, and especially processed meat like bacon, sausages, salami or other cold cuts, may increase the risk for chronic diseases (e.g., T2DM and cardiovascular diseases) and certain cancers, including colorectal cancer. Red meat consumption has also been associated with elevated blood pressure and all‐cause mortality.
There are several possible mechanisms by which red meat may increase mortality risk. Saturated fat, cholesterol, and heme iron in red meat may stimulate certain atherosclerotic processes and therefore affect the onset of the aforementioned chronic diseases. Moreover, it has been found that people who consume large quantities of meat may consume fewer fruits and vegetables, which have been shown to decrease cardiovascular risk.
During the high‐temperature cooking processes of red meat, several potential carcinogens, such as polycyclic aromatic hydrocarbons and heterocyclic amines, are formed, increasing the risk of cancer. Also, the high sodium content in processed meat has been shown to increase the risk for stomach cancer, hypertension, and vascular stiffness. The World Cancer Research Fund recommends no more than three portions of red meat per week, which is equivalent to no more that 350–500 g (cooked weight or 525–750 g raw weight), and minimal consumption of processed meat.
Key Point
Diets restricted in red meat may have little effect on cardiometabolic outcomes, cancer incidence, and mortality.
However, a systematic review of 12 randomized trials with 54,000 subjects suggested that diets restricted in red meat may have little effect on cardiometabolic outcomes and cancer incidence and mortality. Apparently, the effect of red meat consumption on human health is mediated by many other factors, mainly the specific genetic and lifestyle characterists of each individual.
Dietary Patterns
The Western dietary pattern is generally characterized by high intakes of red and processed meat, refined grains/carbohydrates, fast food, eggs, high‐sugar drinks and sweets/desserts, and low intake of fruits and vegetables. According to the INTERHEART study, a standardized case‐control study with participants from 52 countries (i.e., 5761 cases and 10,646 controls), an unhealthy diet increases CVD risk by 30%. Western‐type diets are considered a major risk factor for developing hypertension due to their high content of salt and have been linked to arterial stiffness. Findings from the ATTICA study in Greece suggest that the sodium content of processed foods can be several‐fold higher compared to similar homemade meals; this difference may explain, at least in part, the increased CVD risk in people eating processed foods.
The Western dietary pattern has also been associated with an increased risk for MetS, general and central obesity, and higher BMI and waist circumference in several countries. The Atherosclerosis Risk Communities (ARIC) study followed the dietary patterns of 3782 participants (aged 45–64 years) for 9 years; those with the highest Western dietary pattern scores had 18% greater risk of developing MetS compared to those with the lowest scores. Other prospective data have shown similar associations between Western‐type diets and the prevalence of obesity in adults.
A large body of literature suggests that such an unhealthy dietary pattern may also increase the risk of developing T2DM via exacerbating insulin secretion and insulin resistance. Furthermore, Western‐type diets increase the production of ROS, promote low‐grade inflammation, and abnormally activate the sympathetic nervous system and the renin‐angiotensin system. Finally, high‐fat diets seem to alter the structure of the microbiome even in the absence of obesity; these changes have been associated with metabolic diseases, including cancer, T2DM, and others.
Physical Inactivity
Inactivity is defined as doing less physical activity (PA) than the recommended levels. In 2021, the recommendation for children and youth aged 5–17 was to do at least 60 minutes of moderate‐ to vigorous‐intensity PA daily, preferably aerobic and performed as play. For adults, the 2021 recommendations call for at least 150 minutes of moderate‐intensity aerobic PA per week, or at least 75 minutes of vigorous‐intensity aerobic PA throughout the week, or an equivalent combination of moderate‐ and vigorous‐intensity activity.
More than one in four adults globally (~1.5 billion people) were physically inactive in 2018. Women were less active than men (32% men were active vs. 23% women). Citizens from high‐income countries were more inactive (37%) compared with citizens from middle‐income and low‐income countries (16%). Older adults were less active than younger adults (Figures 3.1 and 3.2a and b).
Regarding the pediatric population, 81% of adolescents aged 11–17 years did not meet
