2. Gary E. Fraser MB ChB, PhD, FACC, FRACP Professor of Medicine Professor of Epidemiology Loma Linda University

3. Why study Adventists? If we believe lifestyle (especially diet) affects risk here is a population which contains the whole spectrum. About 50% are vegetarians About 25% are relatively normal meat consumption Meat consumption is inversely related to intake of fruits, vegetables and nuts.

4. The Adventist Health Studies: A contribution to preventive medicine. 1958-2010

5. 2001 – 2011+

7. Our sincere thanks to the many of you who are members of AHS-2. Please remember to return the short biennial questionnaire about any hospitalizations

8. About 96,000 subjects More than 25,000 Black study members Mean age at enrolment 58.7 years Age range 30-110 years 35% male, 65% female

10. Subjects by Age Percentage

11. Black Subjects by Age

12. The Oldest-Old in AHS-2 90-99 years of age --- 1043 subjects 100+ --- 46 subjects They all completed a 50 page questionnaire!!

13. Education 8.98% 53.07% 20.63% 17.33%

14. Religion at Age 15 59.94% 34.32% 5.74%

15. Smoking Status 80.06% 18.79% 1.15%

16. Alcohol Use 59.43% 33.82% 6.75%

19. Religion Sub-study Population 10988 members enrolled 3764 are Black subjects These were an approximate 11% sample of all Adventist Health study-2 members 1/3 attend churches <100 members 1/10 attend churches >1000 members

20. Frequency of Church Attendance 42% 48.3% 5.7% 3.9%

21. Family Of 6,872 married subjects who were active Adventists, 10.4% had non-SDA or inactive SDA spouses Of their 26,614 children: 51% are active Adventists 61% spent at least some time at Adventist schools

22. Social Circle: Of the people you socialize with, what percentage are Adventist? 51.1% 20.1% 28.3% 20% of Adventists reported approx. 100% of their social circle was Adventist

23. Church: Do people whom you worship with make you feel loved and cared for? 25.1% 59.2% 15.7%

24. Church: How often are people whom you worship with critical of you? 38.3% 56.1% 5.6%

25. Yes to the question Church Size White Black <100 51% 50% 100-1000 41% 46% >1000 24% 47%

26. At Least Fairly Often Church size White Black <100 42% 42% 100-1000 36% 39% >1000 27% 37%

27. On Sabbath I feel relieved from tensions that I normally experience 72.7% 22.1% 5.2%

28. Bible Study: How often do you spend time in private Bible study? 47.1% 31.3% 14.2% 7.4%

29. Belief: Do you feel punished by God for a lack of devotion? 73.5% 15.8% 10.7%

30. Actions: I look to God for strength, support and guidance 66.5% 30.9% 2.6%

31. Actions: When coping, I have expressed anger at God for letting terrible things happen 77.4% 19.8% 2.9%

32. God: Saving vs. Damning SavingDamning 94.9% 4.8% 0.3%

33. Approving – Disapproving God ApprovingDisapproving 75% 6.9% 3.4% 11.9% 0.8%0.6%1.4%

34. A sense of justice is more on my mind than Gods mercy Not TrueVery True 62% 14.2% 4.8% 11.4% 2.1%2.2%3.3% Somewhat True

35. Stress: Traumatic Events We asked subjects the number of serious physical or emotional traumas they have experienced. Examples: Serious illness (cancer, AIDS, leukemia) Miscarriage or abortion Family member murdered Homelessness Unwanted sexual contact

36. Stress: Number of Traumas Experienced

37. Quality of Life in Black and White Adventists compared to Others

38. Figure 2. Physical and Mental Health based on SF-12 composite scores for Seventh-day Adventist Blacks and Whites and for SF-12 national norms (38). Numbers are scale scores (mean 50, SD 10) for individuals over 35 years of age. Physical and Mental Health

40. Depression 14.2% of subjects reported feeling somewhat or very depressed

44. AHS-2 Counts of vegetarians Vegans 9,062(9.4%) L-O vegetarians 30,103 (31.4%) Semi-vegetarians 4,801 (5.0%) Pesco-vegetarians 9,793 (10.2%) Non-vegetarians 42,241 (44.0%)

45. Dietary Categories: Whites 39.6% 9.7% 36.8% 8.3% 5.6%

46. Dietary Categories: Blacks 56.5% 8.7% 15.9% 15.6% 3.3%

47. Dietary Status by Age Group 34.4% 47.4% 52.4% 39.2% 25.7% 26%

48. Daily Meat Intake – Non-Vegetarians AHS-2 Results: Black Non-Vegetarians: 61.1 grams per day White Non-Vegetarians: 41.3 grams per day

49. Daily Meat Intake – Grams per Day

50. Dairy Intake

51. Diet: Mean Servings Per Week 4.27 4.69 20.44 0.84 6.16

52. Coffee Consumption 69.03% 22.48% 8.49%

53. Vitamin B12 Intake (Including Supplements)

54. Calcium Intake

55. Long chain n-3 acids

56. Diabetes Hypertension Overweight Hyperlipidemia

57. Weight Differences Between Vegetarians and Non-Vegetarians Pounds Female 5 6 tall Male 5 10 tall 0 146 161 193 181 188 177 161 180 164 171

58. Prevalent Treated High Blood Pressure and Diet % Reporting Hypertension

59. Prevalent Treated High Cholesterol and Diet % Reporting High Cholesterol Also supported by studies of non-Adventist vegetarians

60. Prevalent Treated Diabetes and Diet % Reporting Type 2 Diabetes

61. Examining the risk of major causes of death in California Adventists A. Total Mortality B. Heart disease C. Cancer D. Colon, Breast, Prostate cancers

62. 1. Confoundinga confusion in causality. 2. ImprecisionIs it just chance? 3. Complicated associations that differ by gender, age etc 4. Dietary and disease outcome measurement errors

63. Identified New Cancers---2700 Available New Cancers---3600 Required for analyses---5500 Identified Deaths (all causes)– 3300 Available Deaths (all causes)--4200

64. Diet and Total Mortality* Risk FactorRR95% Confidence Intervals Non- vegetarian 1.00 Vegan0.810.71-- 0.93 Lacto-ovo-0.890.82 – 0.96 Pesco-0.780.69 – 0.88 Semi-0.920.801.06 *Adjusted for Age, gender, and Ethnicity.

65. Diet and Total Mortality at Different Ages (RRs)* Risk Factor 55 years65 years80 years90 years Non- vegetarian 1.00 Vegan0.660.720.810.88 Lacto-ovo-0.440.570.821.05 Pesco-0.760.770.800.81 Semi-0.470.600.871.10 *Adjusted for Age, gender and ethnicity.

66. Diet and Total Mortality at Different Ages (RRs)* Risk Factor 55 years65 years80 years90 years Non- vegetarian 1.00 Vegetarian0.530.630.830.99 *Adjusted for Age, gender and ethnicity.

67. Red Meat and Total Mortality* Risk FactorRR95% Confidence Intervals No red meat1.00 1 oz/day1.271.19– 1.35 2 oz/day1.611.42 – 1.83 3 oz/day2.051.70 – 2.47 *Adjusted for Age, gender, and Ethnicity.

68. Red Meat and Total Mortality at Different Ages (RRs)* Risk Factor 55 years65 years80 years90 years None1.00 1 oz/day1.441.341.211.13 2 oz/day2.071.801.461.28 3 oz/day2.972.421.771.44 *Adjusted for Age, gender and ethnicity.

69. Dairy Fat and Total Mortality* Risk FactorRR95% Confidence Intervals No dairy1.00 5 g/day1.081.04– 1.11 10 g/day1.161.09 – 1.23 15 g/day1.251.14 – 1.37 *Adjusted for Age, gender and ethnicity.

70. Diet and CHD Mortality* Risk FactorRR95% Confidence Intervals Non- vegetarian 1.00 Vegan0.860.67– 1.10 Lacto-ovo-0.950.80 – 1.12 Pesco-0.820.64 – 1.05 Semi-0.790.581.07 *Adjusted for Age, gender and ethnicity.

71. Diet and CHD Mortality at Different Ages (RRs)* Risk Factor 55 years65 years80 years90 years Non- vegetarian 1.00 Vegan0.670.730.840.91 Lacto-ovo-0.360.490.781.06 Pesco-0.490.580.760.90 Semi-0.590.650.760.85 *Adjusted for Age, gender and ethnicity.

72. Diet and CHD Mortality at Different Ages (RRs)* Risk Factor 55 years65 years80 years90 years Non- vegetarian 1.00 Vegetarian0.440.550.790.99 *Adjusted for Age, gender and ethnicity.

73. Diet and Total Cancer* Risk FactorRR95% Confidence Intervals Non- vegetarian 1.00 Vegan0.780.65-- 0.93 Lacto-ovo-0.920.83 – 1.02 Pesco-0.950.82 – 1.11 Semi-0.800.660.97 *Adjusted for Age, gender and ethnicity.

74. Diet and Colon Cancer* Risk FactorRR95% Confidence Intervals Non- vegetarian 1.00 Vegan0.790.43– 1.46 Lacto-ovo-0.760.53 – 1.09 Pesco-0.430.21 – 0.88 Semi-0.580.271.24 *Adjusted for Age, gender and ethnicity.

75. Red Meat and Colon Cancer* Risk FactorRR95% Confidence Intervals No red meat1.00 1 oz/day1.351.07– 1.71 2 oz/day1.831.14 – 2.93 3 oz/day2.481.22 – 5.03 *Adjusted for Age, gender, and Ethnicity.

76. Diet and Breast Cancer* Risk FactorRR95% Confidence Intervals Non- vegetarian 1.00 Vegan0.560.36-- 0.88 Lacto-ovo-0.890.70 – 1.13 Pesco-0.810.57 – 1.16 Semi-0.760.491.19 *Adjusted for Age, gender and ethnicity.

77. Diet and Prostate Cancer* Risk FactorRR95% Confidence Intervals Non- vegetarian 1.00 Vegan0.680.44– 1.05 Lacto-ovo-0.990.83 – 1.18 Pesco-0.940.64 – 1.38 Semi-0.930.611.43 *Adjusted for Age, gender and ethnicity.

78. Calcium intake and Prostate Cancer* Risk FactorRR95% Confidence Intervals 600 mg/day1.00 1000 mg/day0.780.63– 0.96 1500 mg/day0.570.41 – 0.78 2000 mg/day0.420.27 – 0.64 *Adjusted for Age, gender, and Ethnicity.

79. A Healthy Dairy-free Vegetarian Diet Quality depends on the overall character of the diet, not just the absence of animal products. To obtain calories vegans usually eat more fruit, vegetables, legumes, seeds, nuts, and berries packed with healthy phyto-chemicals. What about vegan diets where this is NOT so? Exposed to downsides but not the upsides of the animal-free diet.

80. 1. If no dairy a) Ensure ample grains, vegetables, legumes, fruits, nuts, seeds and berries; b) Avoid replacing animal foods by refined, sweet, fatty commercial products, even if from plant sources; c) Obtain adequate sunlight and emphasize high calcium vegetables, or supplement calcium; d) Consider algal supplements high in omega-3 fatty acids; e) Supplement with vitamin B12.

81. The Optimum Vegetarian Diet! I dont know! So far vegans are looking very good, but not yet convincingly superior to lacto- ovo vegetarians. We will keep looking as the data grows more robust.

82. Overall Conclusions 1. Results for dietary patterns are much easier to investigate than those for individual foods, nutrients or phytochemicals. 2. Many phyto-chemicals look very exciting in laboratory work or in animals (anti-oxidant, anti-inflammatory, phytoestrogen, increase cell signalling, stimulate phase I and phase II enzymes). 3. Whether most of these will finally prove to be protective against chronic disease in the whole human organism, with our complex homeostatic mechanisms, remains to be seen.

83. Overall Conclusions The health advantage experienced by the more conforming Adventists over many years is remarkable. However, strong conclusions require strong evidence. AHS-2 will provide this. We have data from 96,000 Adventists across the U.S and Canada, a large number. This improves precision and helps rule out chance as an explanation.

84. The most important feature is the internal consistency of the evidence: a) We understand some of the factors that decrease risk of death and disease in the population. b) This population tends to have more optimal values of these factors. c) The direct evidence of decreased mortality and increased life expectancy is entirely in keeping with these observations. d) It would be even more astonishing if effects of this sort had not been found in this population.

85. Practical Conclusion The evidence is right now sufficient to support a diet that: i) may still include some lacto-ovo foods; ii) is otherwise plant-based, or trends strongly in that direction. If you wait to modify your lifestyle till all the details are known, for sure you will be dead!

86. For AHS-2 this is just the beginning, and a small fraction of what will be possible. The main results will be available in 2-3 years. We are very grateful for your support and interest as influential members of the Adventist community.