Introduction
Total health may be defined as physical, social, mental and spiritual wellbeing of a person or community. As given in the Palaeontological records, the Homo sapiens and its predecessors, namely Homo erectus and Homo habilis were primarily and their total health was supposed to be better than the health status to day (Figure 1). The modern man, Homo economicus, has evolved from his primate precursors as an ever more skilled and organized hunter-gatherer (1-5). The Paleolithic diet was about naturally available wild foods: fruits, vegetables, green leaves, seeds, honey, eggs, fish, and meat from running animals (5-10). These foods were also available to pre-agricultural humans and obviously shaped modern man’s genetic nutritional requirement. Man started farming some 10,000 years ago, an adaptation which in turn led to unprecedented technical development, agriculture, industry and commerce. From that perspective, it seems that the biological functions of most social groups are to trigger the what/when hunter-gatherers expect to do, socially and physiologically (1,5). Early man also had enormous physical activity with limited or no mental stress, alcoholism, and other environmental markers of health and diseases. It is the modern affluent society of the 20th century in the Western World which added stress and started refining foods, storing and distributing them in the continuous search of a better economic model (10-14). This new lifestyle pattern which Homo economicus has entered, willingly or not, ie production and marketing led by profit, translates a new era into unprecedented challenges, opportunities and threats, for mankind (14). The Japanese and the Mediterranean traditional diets appear to share a common standard (omega-6/3 ~ 1/1) with the Paleolithic diet. Such standard support sustainable progress of brain function if only through the mind-body connection along the gut-liver-brain-heart axis (15, 16). If adopted by Homo economicus, such standard will help evolve Homo modestis, either directly or by epigenetic inheritance or by natural selection (Fabien De Meester, 2011, Personal communication).
The Health Indicators?
There is evidence that the levels of physical inactivity, occupational stress, dietary patterns, salt intake, alcohol consumption and tobacco use are important characteristics of various social classes (17-21). These risk markers of health can influence behavior and hence these are also called behavioral risk factors, which appear to be primary risk factors of noncommunicable diseases (NCDs) (17-21).
The evolutionary diet and dietary transition can be divided into four parts, which have different attributes of diets (1,5). a. Primitive hunter-gatherers b. Peasant agriculturists and pastoralists c. Urban slum dwellers and d. Affluent society. India is one country which has got all the four types of societies. There are very few primitive hunter-gatherers in the world today. India with its approximately 1.22 billion population mainly has farmers but the rapidly growing towns have increasing number of poor urban slum dwellers and a big affluent society and slum dwellers. Dietary intakes are different among these populations indicating evolution of foods from natural to dietary modernization. Social autopsy studies by verbal autopsy questionnaires indicate that the societal determinants of health may be dependent on various attributes of social classes and the dietary intakes also vary according to socioeconomic status (SES)(17-29).
The INTERHEART Study (29) showed that psychosocial risk factors appear to be independently associated with coronary artery disease (CAD). The sample included a case-control design with 11 119 patients with a first myocardial infarction and 13 648 age matched (up to 5 years older or younger) and sex-matched controls from 262 centres in Asia, Europe, the Middle East, Africa, Australia, and North and South America. Demographic factors, education, income, and cardiovascular risk factors were obtained by standardized questionnaires. Psychosocial stress was assessed by four simple questions about stress at work and at home, financial stress, and major life events in the past year. Additional questions assessed locus of control and presence of depression. Subjects with myocardial infarction (cases) reported higher prevalence of all four stress factors (p<0·0001). Of those cases still working, 23·0% (n=1249) experienced several periods of work stress compared with 17·9% (1324) of controls, and 10·0% (540) experienced permanent work stress during the previous year versus 5·0% (372) of controls. After adjustment for age, sex, geographic region, and smoking, odds ratios were 1·38 (99% CI 1·19-1·61) for several periods of work stress and 2·14 (1·73-2·64) for permanent stress at work,11·6% (1288) of cases had several periods of stress at home compared with 8·6% (1179) of controls (odds ratio 1·52 [99% CI 1·34-1·72]), and 3·5% (384) of cases reported permanent stress at home versus 1·9% (253) of controls (2·12 [1·68-2·65]). General stress (work, home, or both) was associated with an odds ratio of 1·45 (99% CI 1·30-1·61) for several periods and 2·17 (1·84-2·55) for permanent stress. Severe financial stress was more typical in cases than controls (14·6% [1622] vs 12·2% [1659]; odds ratio 1·33 [99% CI 1·19-1·48]). Stressful life events in the past year were also more frequent in cases than controls (16·1% [1790] vs 13·0% [1771]; 1·48 [1·33-1·64]), as was depression (24·0% [2673] vs 17·6% [2404]; odds ratio 1·55 [1·42-1·69]). These differences were consistent across regions, in different ethnic groups, and in men and women. It is clear that the presence of psychosocial stressors were associated with increased risk of acute myocardial infarction, suggesting that new approaches aimed at modifying societal factors should be developed. Recently, an American Heart Association statement also pointed out some areas in need of further research on psychosocial support to patients receiving intracardiac defibrillator (30). It is really important that we articulate a holistic and comprehensive approach to patient care. There is a need to highlight some of the research that generates guidance for educational intervention and psychological-support interventions. Among those potential research directions, the experts highlighted ongoing research on improving patients' family support and improving the effectiveness of multidisciplinary clinical teams that see these patients. It should be noted that it is not just the responsibility of the electrophysiologists or the cardiologist physician or the nurse, but it is about bringing the expertise of the team including sociologists and psychologists together to meet the societal needs.
Social Class and Nutrition?
The main attributes of social classes are; general education and health education, occupation, household income, housing and availability of automobiles, television and other luxury items (17-21). Nutritional health education appears to be most important societal attribute, because knowledge about healthy foods and physical activity can substantially reduce NCDs. These are important determinants of lifestyle and food consumption patterns, as well as social behavior, which may be societal determinants of health and NCDs, and misuse of any substance independently could cause mortality (19-29). The pathways for development of NCDs are sedentary behavior, excess eating of Western type foods, tobacco use, stress, and alcoholism among individuals and populations with underlying lack of general and health education. However, some experts have observed that poverty is the primary cause of disability and deaths due to NCDs. A recent study examined the association of social class and social determinants of health as risk factors for deaths due to NCDs (20). Randomly selected death records of 2,222 (1,385 men and 837 women) decedents, aged 25-64 years at time of death, out of 3,034 death records, were studied by verbal autopsy questionnaires, during 1999-2001 from the records at the Municipal Corporation in Moradabad. All the risk factors were assessed by questionnaires which were completed with the help of the victim’s spouse and a local treating doctor practising in the relevant field. Social classes were assessed, based on attributes of per capita income, occupation, education, housing, and ownership of consumer luxury items in the household. Poverty was considered if the total family income was <US$300per month. Lack of knowledge on health education about the role of exercise, prudent diet, and adverse effects of tobacco use and alcoholism was studied by the validated questionnaires (20).
This study showed that sedentary behavior, excess salt intake, and other typical Western dietary habits were significantly more common among decedents belonging to higher social classes 1-3, compared to those within lower social classes 4 and 5. Lack of knowledge regarding health education was significantly more common among decedents in lower social classes, who died more often due to communicable diseases. The study also revealed that deaths associated with diabetes mellitus and due to circulatory diseases were significantly more common among higher social classes 1-3, compared to lower social classes 4 and 5. However, deaths due to malignant diseases and chronic lung diseases were not associated with social class (except the social class of women with breast cancer), but total proportion of deaths due to NCDs including these causes were significantly greater among higher social classes 1-3, compared to lower social classes 4 and 5. The findings indicate that sedentary behavior, typical Western diet, and excessive salt intake, in conjunction with underlying lack of health education, may be the predisposing factors for deaths among decedents of higher social classes 1-3. Among lower social classes 4 and 5, general lack of health education may have caused more deaths due to communicable diseases, as well as injury and accidents. This study shows that lack of health education appears to be the major cause of deaths due to circulatory diseases and diabetes mellitus among higher social classes 1-3, whereas among lower social classes, this may be the underlying cause of deaths due to communicable diseases. Malignant diseases and chronic lung diseases were common among all social classes. It is clear that knowledge about health education on diet and lifestyle appears to be most important societal attribute which should be assessed if we wish to determine social class of the subjects and the population.
Economicu Status, Nutrition and Health
It seems that in developing populations, urban populations have a double burden of diseases, related to overeating as well as malnutrition because occupational physical activity decreases along with greater consumption of pro-atherogenic foods during transition from lower social classes 4-5 (poverty) to higher social classes 1-3 (17-23). In lower middle income and low income countries, like India, China, Indonesia, Brazil, higher social classes have been observed to have higher risk of cardiovascular diseases (CVDs) including coronary artery disease (CAD), hypertension and type 2 diabetes mellitus (17-23). However, in high income countries, lower social classes 3 and 4 have greater risk factors of cardiovascular and cancer mortality, as well as all-cause mortality than higher social classes (24-28). In high income countries, the higher social classes 1 and 2, appear to have greater access to health education, spare time to increase physical activity and additional resources to maintain prudent diets than lower social classes. This is in contrast to lower social class 3-5, who are living with a scarcity of foods and irregular employment in poor countries. Physically demanding occupations are common in developing countries but do not exist in developed countries, where they have only social classes 1-4 (24-28). These differences may be associated with differences in the food and nutrient intake among hunter-gatherers and among Western and Asian populations. Western type diet consumed by lower social classes in the developed countries and higher social classes in developing countries may be associated with marked reductions in the consumption of w-3 fatty acids, vitamins, antioxidants, and amino acids and significant increases in the intakes of carbohydrates, (mainly refined) fat (saturated, trans fat, and linoleic acid), and salt compared to Paleolithic period (Tables 1-5). The protein or amino acid intake was 2.5 fold greater (33 vs. 13 %) in the Paleolithic diet compared to modern diet (Table 3, Figure 1). Approximately 10,000 years ago, obviously prior to the Agricultural Revolution and notwithstanding the Neolithic Revolution, sometimes called the Agricultural Revolution concerned with the initial transition from hunter-gather to settled agriculture (BP 10,1000), our diet was based on an enormous variety of wild plants. However, today about 17% of plant species provide 90% of the world’s food supply which is mainly contributed by grains. Recent additions to dietary patterns are cereal grains (refined), and vegetable oils that are rich in w-6 fatty acids and trans fats and low in amino acids which represent dramatic departure from those foods and nutrients to which we are adapted (1-3).
Wheat, corn and rice account for three quartersof the world’s grain production on which humans are dependent for food supply. Eaton and co-workers (2,3,7,8) have estimated higher intakes for protein, calcium, potassium and ascorbic acid and a lower intake of sodium in the diet of late Paleolithic period than the current diets ofthe developed and developing countries. Green leafy vegetables are also rich sources of antioxidants, magnesium, w-3 fatty acids and carotenoids which appear to be high in the Mediterranean or Paleolithic type of foods (7-10).
Popkin has confirmed the above global nutrition dynamics in which the world is shifting rapidly toward a diet linked with NCDs (31).The role of fatty acids, essential and non-essential amino acids, antioxidants and vitamins in the prevention and pathogenesis of CVDs, type 2 diabetes and insulin resistance are well known (32-34). Humans appear to live in a nutritional environment which completely differs from that for which our genetic constitution was selected (19-24).
The role of a low w-6/w-3 ratio Paleolithic type of diet by increasing w-3 and by decreasing w-6 fatty acid in the Paleolithic style diet can cause significant decline in cardiovascular and all cause mortality (35).The experimental group received significantly greater amount of fruits, vegetables and whole grains, nuts and mustard oil and lower amount of refined bread, biscuits and sugar and butter and clarified butter compared to control diet group at one year of follow up. Total adherence score to Paleolithic style diet and prudent diet were significant in both the groups. Omega-
6/Omega-3 fatty acid ratio of the diet which was much higher before entry to the study (32.5±3.3), was brought down to significantly lower content in the Paleolithic style diet group A (n = 204, compared to control group diet B (n = 202) at entry to the study ( 3.5± 0.76 vs. 24.0± 2.4 KJ/day, p<0.001). The fatty acid ratio remained significantly much lower in the experimental group compared to control group after one year of follow up (4.4±0.56 vs. 22.3±2.1,KJ/day, p<0.001). Total mortality was 14.7% in the Paleolithic style diet group and 25.2% in the control group, after a follow up of two years. The association w-6/w-3 ratio of fatty acids with mortality showed a gradient in both the groups independently, as well as among total number of deaths. A lower w-6/w-3 ratio of fatty acids from 1-10 was associated with a significantly lower mortality whereas increase in w-6/w-3 fatty acid ratio to more than 10 was associated with greater mortality (Figure 2, Tables 6-8)
In the 1950s Halberg’s group demonstrated that eating moderate breakfast in the morning may have less increase in body weight compared to same amount for dinner (36). This observation is quite important for developing societies who had undernutrition in 1950s after world war II, but eating greater amount of breakfast may result in increased cardiovascular events among societies with overnutrition such as in affluent societies now (37).Adverse effects of Tamasic foods characteristics of the Western diet were also proposed by Indian ancient physicians; Charak and Sushruta in 600 BCE as well as by Confucius in China (500BCE) and by the Greek physician Hippocrates (500BCE)(36,37). Around 5000 years ago,Indians were aware of the harmful effects of dietary ingredients which are evident from ancient scripture of the Bhagwata Gita (3100 BC).
In brief, social characteristics, such as dietary changes in conjunction with sedentary behavior appear to be the main causes of hyperlipidemia, hyperglycemia, oxidative stress and inflammation which are important mechanisms in the pathogenesis and prevention of diet-related NCDs among various populations of the world (32-37). Food consumption patterns have changed significantly in various societies, during the last 100–160 years, causing increased intake of saturated fatty acids (SFA), trans fat, refined carbohydrates and linoleic acid, and decreased w-3 fatty acids, from grain-fed cattle, tamed at farm houses, rather than meat from running animals. Knowledge about health education and health behaviour on diet and lifestyle factors should be included as an important attribute of social class when determining the social class of the society, because poverty as such do not appear to be the major cause of NCDs as emphasized in the United States High Level Meeting in September 2011 (38). This has also been confirmed by health status in the United States which has wealth but no health compared to 16 other countries (39)
Acknowledgements
The International College of Nutrition and International College of Cardiology are thanked for supporting this study.
References
1. Singh RB, Reddy KK, FedackoJ, De MeesterF, WilczynskaA and D.W. Wilson, Ancient concepts in nutrition and diets in hunter-gatherers. The Open Nutra J 2011;4:130-135.
2. Eaton SB, Konner M, Shostak M. Stone agers in the fast lane: chronic degenerative diseases in evolutionary perspective. AmerJ Med 1988. 84:739-749.
3. Eaton SB, Eaton SB III, Sinclair AJ, Cordain L, Mann NJ. Dietary intake of long chain polyunsaturated fatty acids during the Paleolithic period. World Rev Nutr Diet 1998; 83: 12-23.
4. Lannan CR. Har Loomis WF. Skin pigment regulation of vitamin D biosynthesis in man. Science 1967; 157: 5016.
5. Lee RB. What hunters do for a living: A comparative study. In: LeeRB, Devore I, Eds. Man the Hunter, Aldine: Chicago 1968; 41-3.
6. Singh RB, De Meester F, Wilczynska A. The Tsim Tsoum approaches for prevention of cardiovascular diseases. Cardiology Research and PracticeVolume, 2010, ArticleID, 824938, 18pages,doi:10.4061/2010/824938.
7. Eaton SB, Eaton SB III, Sinclair AJ, Cordain I, Mann NJ. Dietaryintake of long chain polyunsaturated fatty acids during thePaleolithic period. In: Simopoulos AP Ed. The return of w-3 fattyacids in the food supply. Land based Animal Food Products andtheir Health Effects. World Rev Nutr Dietetics 1998; 83: 12-23.
8. Eaton B. Evolution and cholesterol. World Rev Nutr Diet 2009;100: 46-54.
9. Singh RB, Moshiri M, De Meester F, Juneja L, Muthusamy V,Manoharan S. The evolution of low w-6/w-3 ratio dietary pattern and risk of cardiovascular diseases and diabetes. J Altern MedRes 2011; 3:45-57.
10. De Meester F. Wild-type land based foods in health promotion anddisease prevention: the LDL-CC:HDL-CC model. In: Wild TypeFoods in Health Promotion and Disease Prevention, Ed. Fabien DeMeester, RR Watson, Humana Press, NJ 2008, 3-20.
11. Esposito K, Glugliano D. Diet and inflammation: a link to metabolic and cardiovascular diseases. Eur. Heart J 2006; 27: 15-20.
12. Katcher HI, Legro RS, Kunselman AR et al. The effects of whole grain- enriched hypocaloric diet on cardiovascular disease risk factors in men and women with metabolic syndrome. Am. J. Clin. Nutr. 2008;87:79-90.
13. Fung TT, Malik V, Rexroad KM, Manson JE, Willett WC, Hu FB. Sweetened beverage consumption and risk of coronary heart in women.Amer J ClinNutr 2009;89: 1037-42.
14. De Meester F. Progress in lipid nutrition: the Columbus conceptaddressing chronic diseases. World Rev Nutr Diet 2009; 100: 110-21.
15. Wang PY, Caspi L, Lam CK, Chari M, Li X, Light PE, Gutierrez-Juarez R, Ang M, Schwartz GJ, Lam TK. Upper intestinal lipids trigger a gut-brain-liver axis to regulate glucose production. Nature 2008;452: 1012-16.
16. Singh RB, De Meester F, Wilczynska A, Wilson DW, Hungin APS. The liver-pancreas and brain connection in the pathogenesis of obesity and diabetes mellitus. World Heart J 2010;2:319-326.
17. Singh RB, Singh V, Kulshrestha SK, Singh S, Gupta P, Kumar R, Krishna A, Srivastav SSL, Gupta SB, Pella D, Cornelissen G. Social class and all cause mortality in an urban population of north India. Acta Cardiol 2005: 60;611-617.
18. Singh RB, Fedacko J, Vargova V, Kumar A, Mohan A, Pella D, De Meester F, Wilson DW. Singh’s verbal autopsy questionnaire for assessment of causes of death, social autopsy, tobacco autopsy, and dietary autopsy based on medical records and interview. Acta Cardiol 2011:66;471-481.
19. Singh RB, Ghosh S, Niaz MA, Rastogi V. Validation of physical activity and socioeconomic questionnaire in relation to food intakes for the five city study and a proposed classification for Indians. J Assoc Phys India 1997:45;603-607.
20. Singh RB, Anjum B, Takahashi T, Martirosyan D, Pella D, De Meester F, Wilson DW. Poverty is the absolute cause of deaths due to noncommunicable diseases. Acta Cardiol 2012:(in press).
21. Singh RB, Beegom R, Mehta AS, Niaz MA, De AK, Mitra RK, Haque M, Verma SP, Dube GP, Siddiqui HM, Wander GS, Janus ED, Postiglion A, Haque MS. Social class, coronary risk factors and undernutrition, a double burden of diseases, in women during transition, in five Indian cities. Int J Cardiol, 1999:69;139-147.
22. Singh RB, Sharma JP, Rasogi V, Niaz MA, Ghosh S, Beegom R, Janus ED. Social class and coronary disease in a rural population of north India. Eur Heart J 1997:18;588-95.
23. Pednekar MS, Gupta R, Gupta PC. Illiteracy, low educational status and cardiovascular mortality in India. BMC Public Health. 2011:11;567.
24. Teo K, Chow CK, Vaz M, Rangarajan S, Yusuf S. The Prospective Urban Rural Epidemiology (PURE) study: examining the impact of societal influences on chronic noncommunicable diseases in low, middle, and high-income countries. Am Heart J. 2009:158;1–7.
25. Gillum RF. The epidemiological evolution in pattern of cardiovascular diseases in blacks. N Engl J Med 1996:335:1597-99.
26. Kesteloot H. Social class, all cause and cardiovascular mortality. Acta Cardiol 2004:59;117.
27. WHO. Mortality and burden of disease estimates for WHO Member States in 2008. Geneva: World Health Organization, 2010.
28. Smith SC, Collins A, Ferrari R, et al. Our time: A call to save preventable death from cardiovascular disease (heart disease and stroke). Circulation 2012; DOI:10.1161.CIR.0b013e318267e99f. Available at: http://circ.ahajournals.org.
29. Rosengren A, Hawken S, Ounpuu S, Sliwa K, Zubaid M, Almahmeed WA, Blackett KN, Amom CS, Sato H, Ysuf S. Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases, 13648 controls from 52 countries (the INTERHEART Study): case control study. Lancet 2004;364: 937-52.
30. Dunbar S, Dougherty C, Sears S, et al. Educational and psychological interventions to improve outcomes for recipients of implantable cardioverter defibrillators and their families. Circulation 2012; DOI: 10.1161/CIR.0b013e31825d59fd. Available at:http://circ.ahajournals.org.
31. Popkin BM. Global nutrition dynamics; the world is shifting rapidly toward a diet linked with noncommunicable diseases. Am J Clin Nutr 2006:83:289-298.
32. Simopoulos AP. Importance of the ratio of omega-6/omega-3 essential fatty acids: evolutionary aspects. World Rev Nutr Diet 2003;92: 1-22.
33. Simopoulos AP. Evolutionary aspects of the dietary omega-6/omega-3 fatty acid ratio: medical implications. In Simopoulos AP, De Meester F (eds), A Balanced Omega-6/Omega-3 Fatty acid Ratio. Cholesterol and Coronary Heart Disease. World Rev Nutr Diet, Basel, Karger 2009;100: 1-21.
34. Singh RB, DeMeester F, Mechirova V, Pella D, Otsuka K. Fatty acids in the causation and therapy of metabolic syndrome. In Wild type foods in health promotion and disease prevention, editors Fabien DeMeester and RR Watson, Humana Press, NJ 2008. pp 263-284.
35. Singh RB, Fedacko J, Vargova V, Pella D, Niaz MA, Ghosh S. Effect of Low W-6/W-3 Fatty Acid Ratio Paleolithic Style Diet in Patients with Acute Coronary Syndromes:A Randomized, Single Blind, Controlled Trial, World Heart J 2012;4:71-84.
36. Cornelissen G. When you eat matters: 60 years of Franz Halberg's nutrition chronomics. The Open Nutra J 2012;5(Suppl) 16-44.
37. Singh RB, Singh AK, Sharma JP, Singh RK, Kumar A, Singh G, Kartikey K, Rastogi SS, Singh S, Fedacko J, Pella D, De Meester F, Wilczynska A, Wilson DW. Nutrition in Chronocardiology: We are Indebted Professor Franz Halberg. The Open Nutr J 2012;5(supple)45-65.
38. Beaglehole R, Bonita R, Alleyne G, et al, for the Lancet NCD Group. UN High-Level Meeting on Non-Communicable Diseases: addressing four questions. Lancet 2011; 378: 449-55.
39. Editorial. Wealth but not health in USA. Lancet 2013;381:177. doi:10.1016/S0140-6736(13)60069-0
Source(s) of Funding
None
Competing Interests
None
Disclaimer
This article has been downloaded from WebmedCentral. With our unique author driven post publication peer
review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is
completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript
but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before
submitting any information that requires obtaining a consent or approval from a third party. Authors should also
ensure not to submit any information which they do not have the copyright of or of which they have transferred
the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to
the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor
replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the
WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm
that you may suffer or inflict on a third person by following the contents of this website.
All site content, except where otherwise noted, is licensed under a
