Cardiovascular Disease Resulting From a Diet and Lifestyle at Odds With Our Paleolithic Genome: How to Become a 21st-Century Hunter-Gatherer

Mayo Clin Proc, January 2004, Vol 79
Becoming a 21st-Century Hunter-Gatherer
101
Review
Cardiovascular Disease Resulting From a Diet and Lifestyle at Odds With
Our Paleolithic Genome: How to Become a 21st-Century Hunter-Gatherer
JAMES H. O’KEEFE, JR, MD, AND LOREN CORDAIN, PHD
Our genetic make-up, shaped through millions of years of
[?-3] fatty acids), monounsaturated fats, fiber, vitamins,
evolution, determines our nutritional and activity needs.
minerals, antioxidants, and other beneficial phytochemi-
Although the human genome has remained primarily un-
cals. Historical and anthropological studies show hunter-
changed since the agricultural revolution 10,000 years ago,
gatherers generally to be healthy, fit, and largely free of
our diet and lifestyle have become progressively more di-
the degenerative cardiovascular diseases common in mod-
vergent from those of our ancient ancestors. Accumulating
ern societies. This review outlines the essence of our hunter-
evidence suggests that this mismatch between our modern
gatherer genetic legacy and suggests practical steps to re-
diet and lifestyle and our Paleolithic genome is playing a
align our modern milieu with our ancient genome in an
substantial role in the ongoing epidemics of obesity, hyper-
effort to improve cardiovascular health.
tension, diabetes, and atherosclerotic cardiovascular dis-
Mayo Clin Proc. 2004;79:101-108
ease. Until 500 generations ago, all humans consumed only
wild and unprocessed food foraged and hunted from their
HDL = high-density lipoprotein; LDL = low-density lipo-
environment. These circumstances provided a diet high in
protein
lean protein, polyunsaturated fats (especially omega-3
Humans evolved during the Paleolithic period, from macological and technological advances, the pandemic of
approximately 2.6 million years ago to 10,000 years
cardiovascular disease continues. At least for today, the
ago. Although the human genome has remained largely
genes we are born with are those that we will live and die
unchanged (DNA evidence documents relatively little
with. Thus, the most practical solution for reducing the
change in the genome during the past 10,000 years),1 our
incidence of chronic degenerative diseases such as athero-
diet and lifestyle have become progressively more diver-
sclerosis is to realign our current maladaptive diet and
gent from those of our ancient ancestors. These maladap-
lifestyle to simulate the milieu for which we are genetically
tive changes began approximately 10,000 years ago with
designed.
the advent of the agricultural revolution and have been
Living organisms thrive best in the milieu and on the
accelerating in recent decades. Socially, we are a people of
diet to which they were evolutionarily adapted; this is a
the 21st century, but genetically we remain citizens of the
fundamental axiom of biology. All of the food consumed
Paleolithic era.
daily by our ancient ancestors had to be foraged or hunted
Today most of us dwell in mechanized urban settings,
from wild plants and animals in their natural world. In
leading largely sedentary lives and eating a highly pro-
many respects, that Paleolithic world is gone forever, but
cessed synthetic diet. As a result, two thirds of Americans
insights gained from a wide array of disciplines are provid-
are overweight or obese.2 The lifetime incidence of hyper-
ing a clear picture of the ideal diet and lifestyle for humans.
tension is an astounding 90%,3 and the metabolic syndrome
The hunter-gatherer mode of life became extinct in its
is present in up to 40% of middle-aged American adults.4
purely non-westernized form in the 20th century.6 At the
Cardiovascular disease remains the number 1 cause of
beginning of the 21st century, we are the first generation to
death, accounting for 41% of all fatalities, and the preva-
have the genetic and scientific understanding to allow us to
lence of heart disease in the United States is projected to
reconstruct the essence of this lifestyle and the means to
double during the next 50 years.5 Despite remarkable phar-
afford it.
Historical and archaeological evidence shows hunter-
From the Mid America Heart Institute, Cardiovascular Consultants,
gatherers generally to be lean, fit, and largely free from
Kansas City, Mo (J.H.O.); and Department of Health and Exercise
signs and symptoms of chronic diseases.7 When hunter-
Science, Colorado State University, Fort Collins (L.C.).
gatherer societies transitioned to an agricultural grain-
Individual reprints of this article are not available. Address corre-
based diet, their general health deteriorated.8,9 Average
spondence to James H. O’Keefe, Jr, MD, Mid America Heart Insti-
adult height was substantially shorter for both men and
tute, Cardiovascular Consultants, 4330 Wornall Rd, Suite 2000,
Kansas City, MO 64111 (e-mail: jhokeefe@cc-pc.com).
women who consumed cereals and starches compared with
Mayo Clin Proc. 2004;79:101-108
101
© 2004 Mayo Foundation for Medical Education and Research

---

102
Becoming a 21st-Century Hunter-Gatherer
Mayo Clin Proc, January 2004, Vol 79
Table 1. Comparison of Diets
Low-carbohydrate
Traditional low-fat
Traditional
Hunter-gatherer
(Atkins diet)
(Ornish diet)
Mediterranean
Protein (%)
High (19-35)
Moderate (18-23)
Low (<15)
Moderate (16-23)
Carbohydrates (%)
Moderate (22-40)
Low (4-26)
High (80)
Moderate (50)
Total fat (%)
Moderate (28-47)
High (51-78)
Low (<10)
Moderate (30)
Saturated fat
Moderate
High
Low
Low
Monounsaturated fat
High
Moderate
Low
High
Polyunsaturated fat
Moderate
Moderate
Low
Moderate
Omega-3 fat
High
Low
Low
High
Total fiber
High
Low
High
High
Fruits and vegetables
High
Low
High
High
Nuts and seeds
Moderate
Low
Low
Moderate
Salt
Low
High
Low
Moderate
Refined sugars
Low
Low
Low
Low
Glycemic load
Low
Low
High
Low
their hunter-gatherer ancestors who consumed lean meats,
sumption of omega-3 (?-3) fats from either fish or plant
fruits, and vegetables.10 Furthermore, studies of bones and
sources such as nuts; and (3) eating a diet high in various
teeth reveal that populations who changed to a grain-based
fruits, vegetables, nuts, and whole grains and avoiding
diet had shorter life spans, higher childhood mortality, and
foods with a high glycemic load (a large amount of quickly
a higher incidence of osteoporosis, rickets, and various
digestible carbohydrates). Despite common mispercep-
other mineral- and vitamin-deficiency diseases.8,9 When
tions, this report found no strong evidence for a link be-
former hunter-gatherers adopt Western lifestyles, obesity,
tween risk of cardiovascular disease and intake of meat,
type 2 diabetes, atherosclerosis, and other diseases of civi-
cholesterol, or total fat.
lization become commonplace.11,12
These broad characteristics are consistent with the diet
This review outlines the essence of the hunter-gatherer
that Paleolithic humans evolved eating. This is the diet that
lifestyle and diet and suggests practical steps to realign our
our hunter-gatherer ancestors thrived on until the advent of
modern milieu with our ancient genome in an effort to
the agricultural revolution. Through the millennia, our ge-
improve cardiovascular health, vigor, and longevity.
nome and physiology became adapted to this diet. Of
course, this diet varied by paleontological period, geo-
THE IDEAL HUMAN DIET
graphic location, season, and culture, but many characteris-
Perhaps no scientific topic has generated more controversy
tics remained consistent until recent times (Table 1).
and confusion in recent times than the question of the ideal
human diet. Medical experts espouse divergent views of
REAL FOOD, NOT SYNTHETIC FOOD
human nutrition with evangelical zeal, each citing scien-
Our remote ancestors consumed only natural and unpro-
tific data to validate their respective contradictory con-
cessed food foraged and hunted from their environment.
clusions. This confusing dialogue is epitomized by the
This subsistence strategy provided a diet of lean protein
Atkins13 vs Ornish14 debate. The Atkins diet includes high
that was high in fiber, vitamins, minerals, antioxidants, and
protein, high saturated fat, and avoidance of nearly all
other beneficial phytochemicals16 (Table 2). The typical
carbohydrates. In contrast, the Ornish diet consists of 80%
Paleolithic diet compared with the average modern Ameri-
carbohydrates and minimized consumption of all animal
can diet contained 2 to 3 times more fiber, 1.5 to 2.0 times
protein fats. Proponents of both diets insist theirs is the
more polyunsaturated and monounsaturated fats, 4 times
answer to the American epidemics of obesity and cardio-
more ?-3 fats, but 60% to 70% less saturated fat. Protein
vascular disease; however, the advice for these diets is
intake was 2 to 3 times higher, and potassium intake was 3
mutually exclusive and diametrically opposed.
to 4 times higher; however, sodium intake was 4 to 5 times
In truth, the ideal diet is neither of these extremes nor
lower.17 Finally, the Paleolithic diet contained no refined
what many medical professionals now promote. In a re-
grains and sugars (except for seasonally available honey).
cently published large review of approximately 150 studies
Clearly, the ongoing epidemic of cardiovascular diseases is
on the link between diet and cardiovascular health,15 the
at least in part due to these striking discrepancies between
authors concluded that 3 major dietary approaches have
the diet we are designed to eat and what we eat today.
emerged as the most effective in preventing cardiovascular
In growing season, abundant fruits, berries, and veg-
events: (1) replacing saturated and trans-fats with mono-
etables were consumed. The one variable on which nearly
unsaturated and polyunsaturated fats; (2) increasing con-
all nutritional experts can agree is the need for increased

---

Mayo Clin Proc, January 2004, Vol 79
Becoming a 21st-Century Hunter-Gatherer
103
intake of fruits and vegetables in our modern diet. We do
Table 2. Fundamentals of the Hunter-Gatherer Diet
not fully understand all the health-promoting components
and Lifestyle
of unprocessed whole-plant foods; thus, the only way to
Eat whole, natural, fresh foods; avoid highly processed and
ensure the benefits is to consume these foods regularly in
high-glycemic-load foods
their natural and unprocessed state. Most experts recom-
Consume a diet high in fruits, vegetables, nuts, and berries and low in
refined grains and sugars. Nutrient-dense, low-glycemic-load fruits and
mend an intake of 5 servings of fruits and vegetables per
vegetables such as berries, plums, citrus, apples, cantaloupe, spinach,
day; studies indicate that only 16% of adults are meeting
tomatoes, broccoli, cauliflower, and avocados are best
this goal.18 However, approximately 8 or more daily serv-
Increase consumption of omega-3 fatty acids from fish, fish oil, and plant
ings of fresh fruits and vegetables (avoiding potatoes and
sources
bananas because of their high glycemic loads) are neces-
Avoid trans-fats entirely, and limit intake of saturated fats. This means
sary to replicate the dietary composition that we evolved
eliminating fried foods, hard margarine, commercial baked goods, and
most packaged and processed snack foods. Substitute monounsaturated
eating17 and to lower the risk of coronary heart disease.19
and polyunsaturated fats for saturated fats
Large randomized controlled trials recently have shown
Increase consumption of lean protein, such as skinless poultry, fish, and
antioxidant supplements to be ineffective in improving
game meats and lean cuts of red meat. Cuts with the words round or loin
cardiovascular outcomes.20,21 In contrast, many epidemio-
in the name usually are lean. Avoid high-fat dairy and fatty, salty
processed meats such as bacon, sausage, and deli meats
logical studies have shown cardiovascular protection from
Incorporate olive oil and/or non–trans-fatty acid canola oil into the diet
diets that contain foods naturally high in antioxidants, such
as vitamins A, C, and E.19,22 The hunter-gatherer diet is high
Drink water
in beneficial phytochemicals and antioxidants, thus render-
Participate in daily exercise from various activities (incorporating aerobic
and strength training and stretching exercises). Outdoor activities are
ing multivitamin and mineral supplements superfluous.17
ideal
Caloric Intake
Throughout most of human history, food consumption
in inducing weight loss,25 but its high levels of saturated fat,
(energy intake) was obligatorily linked to food acquisition
low levels of antioxidants, and net metabolic acidosis, which
(energy output). Accordingly, our ancient ancestors ex-
may promote osteoporosis and atherosclerosis, make this a
pended more energy finding and obtaining food calories
suboptimal eating style.26,27 A growing consensus indicates
than do typical sedentary, westernized citizens for whom
that a diet containing moderate amounts of beneficial fat and
there is virtually no connection between energy intake and
protein in addition to carbohydrates consisting exclusively
energy expenditure.
of low-glycemic-load foods (nonstarchy vegetables and
Our cravings for calorie-dense foods, such as fats,
fruits) in conjunction with daily exercise is the most effective
sweets, and starches, are legacies of our Paleolithic ances-
way to achieve and maintain ideal body weight and prevent
tors, who sought these foods because they conferred posi-
cardiovascular disease.15,23,24,26 This approach was the eating
tive survival value in an environment in which these food
pattern and lifestyle of prehistoric humans.
types were scarce. These cravings betray us in our modern
world, where calorie-dense foods are abundant and inex-
?-3 Fats
pensive, and most people die of caloric excess manifested
The polyunsaturated fats are classified as ?-6 (generally
as obesity, the metabolic syndrome, hypertension, and car-
proinflammatory) and ?-3 (anti-inflammatory with several
diovascular disease. Compounding the issue is the fact that
other inherent cardioprotective effects). ?-3 Fats were
our genome became adapted to an environment in which
abundant in the diet of our Paleolithic ancestors.28 In the
caloric intake was often sporadic and sometimes inad-
natural world, the broad base of the food chain is composed
equate. This promoted efficient energy use and storage,
of ubiquitous algae in the sea and of grasses and leaves on
commonly referred to as the thrifty gene hypothesis. Al-
land. The small amount of fat in algae, grasses, and leaves
though this genetic adaptation (which results in storage of
is rich in ?-3 fatty acids, which become more concentrated
excess calories as intra-abdominal fat) provides a survival
in larger animals up through both the land and marine food
advantage in an environment of scarcity, it becomes a
chains, especially in fish and larger grazing animals. To-
liability in the setting of long-term excessive caloric intake.
day, meat from domesticated animals is low in ?-3 fats
Although the key to weight loss is simply the daily
because these animals are generally grain-fed or corn-fed
consumption of fewer calories than are expended, it is
rather than grass-fed.29 This and other issues have resulted
easier to moderate caloric intake in a diet that has adequate
in much lower intake of ?-3 fats today compared with our
quantities of protein and fat because of superior satiety
remote ancestors.28,29
compared with a high-carbohydrate, low-fat diet.15,23,24 This
The correction of this ?-3 deficiency in the modern diet
strategy in part accounts for the success of the Atkins diet
is a key step to improving the cardiovascular risk in our

---

104
Becoming a 21st-Century Hunter-Gatherer
Mayo Clin Proc, January 2004, Vol 79
diet vs a traditional Mediterranean diet (similar in composi-
0.3
Control diet
tion to our ancestral hunter-gatherer diet; Table 1). The
Inter vention diet
patients on the Mediterranean diet rich in ?-3 and
monounsaturated fats, fruits, vegetables, legumes, and nuts
experienced 50% to 70% reductions in risk of cardiovascu-
0.2
lar events during long-term follow-up.
The Gruppo Italiano per lo Studio della Sopravvivenza
P<.001
nell’Infarto Miocardico Prevenzione study33 randomized
more than 11,000 myocardial infarction survivors to 1 g/d
tion with events
of an 85% ?-3 supplement or control. The ?-3 group
0.1
opor
Pr
experienced a 45% reduction in sudden cardiac death and a
20% decrease in all-cause mortality during a 31/2-year pe-
riod33 (Figure 2). Prospective studies indicate that in-
creased intake of fat in the form of ?-3 fatty acids from
0.0
either plant sources (?-linolenic) or fish oils (eicosahexa-
0
20
40
60
80
100
noic acid and docasahexanoic acid) will reduce cardiovas-
Weeks
cular risk up to 32% to 50%.29-34 Recently, for the first time,
the American Heart Association recommended that a nutri-
ent, ?-3 fatty acids, be consumed as a supplement if the
Figure 1. The Indo-Mediterranean Diet Heart Study32 showed a
diet contained an insufficient amount of this fat.35
reduction of cardiac deaths and myocardial infarctions in patients
on the intervention diet (a traditional Mediterranean diet high in
omega-3 fats, fruits, and vegetables and low in saturated fat)
Monounsaturated Fats
compared with a standard American Heart Association (control)
Monounsaturated fats made up approximately half of
diet.
the total fat in the diets of most hunter-gatherers.36 Mono-
unsaturated fats reduce cardiovascular risk, especially
population.30 Two randomized trials, the Lyon Diet Heart
when substituted for easily digestible starches and sugars.37
Study,31 which involved 600 postinfarction patients, and
Nuts are a valuable source of monounsaturated fats and
the Indo-Mediterranean Diet Heart Study32 (Figure 1),
have been shown to be cardioprotective in at least 6 epide-
which involved 1000 coronary heart disease patients,
miological studies.15,22,38 Our hunter-gatherer ancestors re-
evaluated a standard low-fat American Heart Association
lied on nuts as an easily accessible source of calorie-dense,
highly nutritious food that was often available in non-
summer months. The calories in nuts typically are 80%
from fat, but most of this is in the form of healthy
100
monounsaturated and polyunsaturated fatty acids (includ-
ing some ?-3 fat). Epidemiological studies show that fre-
99
quent nut consumption (5 or more times per week) is
associated with up to a 50% reduction in risk of myocardial
98
infarction compared with the risk of people who rarely or
om SCD (%)
never eat nuts.38 Other studies show that nut consumption
97
reduces the risk of developing type 2 diabetes,39 lowers the
atherogenic low-density lipoprotein (LDL) cholesterol
eedom fr
level without lowering the high-density lipoprotein (HDL)
Fr
96
Control
level,40 and provides plant-based protein and other poten-
Omega-3 fats
tially cardioprotective nutrients such as vitamin E, folate,
95
0
180
360
540
720
900
1080
1260
magnesium, copper, zinc, and selenium. Because of their
Days
high levels of fiber, protein, and fat, nuts also provide better
and longer-lasting satiety compared with high-glycemic-
load snack foods typically consumed today. Oleic acid is
Figure 2. The Gruppo Italiano per lo Studio della Sopravvivenza
the major monounsaturated fat in our diets and is found in
nell’Infarto Miocardico Prevenzione study33 showed a 45% re-
meats, nuts, avocados, dark chocolate, and olive oil. Al-
duction in sudden cardiac death (SCD) among patients receiving a
though some of these foods were not part of the ancient
concentrated fish oil supplement containing approximately 850
mg of omega-3 fats.
ancestral diet, they can improve the cardiovascular risk

---

Mayo Clin Proc, January 2004, Vol 79
Becoming a 21st-Century Hunter-Gatherer
105
profile when substituted for sugar, starches, trans-fats, and
saturated fats that are prevalent in the modern diet. Studies
70
suggest that replacing saturated fat with monounsaturated
60
fat would result in a 30% reduction in risk, or 3 times the
50
risk reduction achieved by replacing saturated fat with
40
carbohydrates.37
(kg) 30
20
Vegetarian vs “Breaditarian”
All evidence points to the fact that hunter-gatherers
10
were omnivorous.41 Strictly vegetarian diets are difficult to
arly sugar intake per person
0
Ye
0
0
0
1815
follow and are not necessarily associated with better health.
30
44
48 52 55 70
181518301846186018701880
191
1895
19151918192 19 194 19 194619 19
19 2000
19
A study of 2 groups of Bantu villagers in Tanzania com-
Year
pared 618 people who lived on a lakeshore and consumed
large amounts of fish to 645 people who lived in the nearby
Figure 3. Average per capita consumption of sugar in England
hills and were vegetarians.42 The lifestyles, gene pools, and
(1815-1970) and in the United States (1970-2000).44
diets (except for the fish) were similar in the 2 groups. The
fish-consuming group had lower blood pressure levels;
lower triglyceride, cholesterol, and leptin levels; and high-
The flesh of wild game is typically about 2% to 4% fat
er plasma ?-3 fat levels than the vegetarian group.42,43
by weight and contains relatively high levels of monoun-
Many current vegetarians would be more appropriately
saturated and ?-3 fats compared with fatty grain-produced
labeled “breaditarians.” Modern vegetarian diets often rely
domestic meats, which can contain 20% to 25% fat by
heavily on processed carbohydrates such as white rice,
weight, much of it in the form of saturated fat.27 Wild game
potatoes, and white flour and sugars. The South Asian
meat is not widely accessible today, and many people do
paradox refers to the relatively high prevalence of coronary
not prefer the “game” taste, which is at least in part con-
heart disease despite low levels of LDL cholesterol and low
ferred by a higher ?-3 content and by aromatic oils from
prevalence of obesity in urban vegetarians from India who
plant foods consumed by the herbivore. The modern-day
consume a diet high in refined carbohydrates.32 In west-
alternative is to choose animal protein sources that are low
ernized societies, sugar intake has increased substantially
in saturated fat, such as skinless poultry, fish, eggs (espe-
during the past 2 centuries (Figure 344). A recent study
cially high–?-3 varieties), and lean cuts of red meat with
showed that a high-glycemic-load diet is the most impor-
visible fat trimmed.
tant dietary predictor of HDL level (as an inverse relation-
It is not the amount of meat eaten but rather the compo-
ship).45 A high-glycemic-load diet predisposes a person to
sition of the meat and cooking methods that determine the
the metabolic syndrome and cardiovascular disease and is
health effects of this food. Accumulating scientific evi-
one of the most atherogenic features of our modern eating
dence indicates that meat consumption is not a risk for
pattern.45-48
cardiovascular disease, but instead, the risk is secondary to
high levels of saturated fat typically found in the meat of
Can Meat Be Cardioprotective?
most modern domesticated animals.44,49 Diets high in lean
Comprehensive studies of diverse hunter-gatherer pop-
protein can improve lipid profiles and overall health, espe-
ulations show that these people typically derived 45% to
cially if care is taken to trim any visible fat from the meats
60% of their calories from animal food.36,41 Only 14% of
and to allow the fat to drain when cooking.50-55 Lean animal
hunter-gatherer societies obtained more than 50% of their
protein eaten at regular intervals (with each meal) improves
calories from plant sources.36,41 Paleolithic humans often
satiety levels,56-58 increases dietary thermogenesis,56,59,60 im-
lived in temperate climates and were confronted with win-
proves insulin sensitivity,55,61,62 and thereby facilitates
ters during which most plant-based food was unavailable.
weight loss51,63,64 while providing many essential nutri-
Early humans adapted to these conditions by eating meat,
ents.65 However, cooking red meats at high temperatures
organs, marrow, and fat from animals during the winter
produces charring and high levels of heterocyclic amines,
months. Paradoxically, these meat-based hunter-gatherer
which have been implicated in the risk of gastrointestinal
diets were nonatherogenic.36,41 Although increased meat
and prostate cancers.66 Highly salted and preserved meats
consumption in Western diets has been associated with
may also contain carcinogens. Lean, fresh meat cooked
increased cardiovascular risk, the hunter-gatherer societies
appropriately is a healthy and beneficial component of a
were relatively free of the signs and symptoms of cardio-
varied diet, especially in conjunction with a high intake of
vascular disease.7
vegetables and fruits.65

---

106
Becoming a 21st-Century Hunter-Gatherer
Mayo Clin Proc, January 2004, Vol 79
Trans-Fatty Acids
natural beverage that may help prevent cardiovascular dis-
Trans-fatty acids are found in small quantities in the fat
ease, although more randomized prospective data are
tissues of all ruminant animals. However, in recent de-
needed.
cades, intake of trans-fatty acids has increased markedly
because of their ubiquitous presence in commercially pre-
HUNTER-GATHERER FITNESS
pared foods. Trans-fatty acids are synthesized when hydro-
Our Paleolithic ancestors exerted themselves daily to se-
gen is applied to edible oils under high pressure and tem-
cure their food, water, and protection.72,73 Although modern
perature in the presence of a catalyst. Hydrogenation of the
technology has made physical exertion optional, it is still
edible oils is typically done in the prepared food industry to
important to exercise as though our survival depended on
prolong shelf-life in commercial baked goods such as
it, and in a different way it still does. We are genetically
cookies, crackers, donuts, croissants, and processed snack
adapted to live an extremely physically active lifestyle. A
foods. Trans-fatty acids are also found in shortenings, most
sedentary existence predisposes us to obesity, hyperten-
margarines, and deep-fried foods, and recently in many
sion, the metabolic syndrome, diabetes, and most types of
brands of commercially available canola oils.67 Trans-fats
cardiovascular disease, whereas regular exercise decreases
lower HDL levels, increase LDL levels, and increase risk
the risks of developing all these diseases. Even in times of
of both cardiovascular disease and cancer.24,37
caloric excess, hunter-gatherers avoided weight gain in part
Studies indicate that replacing trans-fatty acids (typi-
because they were extremely physically active. Studies of
cally 2% of total daily calories in the American diet) with
obesity consistently show that the best way to maintain
the same amount of natural unsaturated fatty acids would
weight loss (regardless of the type of diet used) is by daily
result in a large (50%) decrease in risk of coronary heart
physical exercise.74
disease.37
Our remote ancestors participated in various physical
activities daily. They walked and ran 5 to 10 miles daily as
Beverages
they foraged and hunted for their food sources.72,73 They
Our Paleolithic ancestors drank water almost exclu-
also lifted, carried, climbed, stretched, leaped, and did
sively. Recent data suggest that generous water intake, 5 or
whatever else was necessary to secure their sustenance and
more glasses daily, is associated with a lower risk of coro-
protection. Days of heavy exertion were followed by re-
nary heart disease.68 This may be simply a function of the
covery days. In modern terms, these people cross-trained
fact that water, when consumed frequently, displaces calo-
with aerobic, resistance, and flexibility exercises. Accord-
rie-dense beverages such as sugared sodas from the diet. Or
ing to recent data on physical activity, fitness programs that
it may be that water provides adequate hydration and re-
use various exercises are the most effective in preventing
duces blood viscosity better than other commonly ingested
cardiovascular diseases.75
drinks. In any event, water is the beverage we are adapted
to drink, and evidence suggests that it should remain the
SUMMARY
principal fluid we drink.
The hunter-gatherer diet and lifestyle are the milieu for
Sugared sodas are the predominant beverage consumed
which we remain genetically adapted. Although it is nei-
in America today. These are calorie-dense, nutritionally
ther practical nor even possible to replicate all prehistor-
barren drinks that have contributed to the rise in obesity
ic living conditions today, these general characteristics
and insulin resistance. Generally, fruit juices are also high
should serve as a template to design and test effective
in sugar, and thus it is preferable to eat the whole fruit,
interventions to reduce the incidence of degenerative car-
which provides fiber and a lower glycemic load.19,47
diovascular diseases.
Tea (Camellia sinensis) has been brewed for thousands
of years as a favorite drink in several parts of the world.
We acknowledge Connie Smith for her assistance with the prepa-
This beverage has been shown to be high in natural antioxi-
ration of the submitted manuscript.
dant phytochemicals (polyphenolic compounds). Drinking
tea has been shown to reverse endothelial vasomotor dys-
REFERENCES
function in people with coronary artery disease,69 which
1.
Macaulay V, Richards M, Hickey E, et al. The emerging tree of
may in part explain the inverse relationship between tea
West Eurasian mtDNAs: a synthesis of control-region sequences
and RFLPs. Am J Hum Genet. 1999;64:232-249.
consumption and cardiovascular disease seen in observa-
2.
Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and
tional studies. In 2 recent epidemiological studies, tea con-
trends in obesity among US adults, 1999-2000. JAMA. 2002;288:
sumption (>2-3 cups per day) was associated with approxi-
1723-1727.
3.
Vasan RS, Beiser A, Seshadri S, et al. Residual lifetime risk for
mately half the risk of myocardial infarction compared
developing hypertension in middle-aged women and men: the
with non–tea consumption.70,71 Thus, tea appears to be a
Framingham Heart Study. JAMA. 2002;287:1003-1010.

---

Mayo Clin Proc, January 2004, Vol 79
Becoming a 21st-Century Hunter-Gatherer
107
4.
Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syn-
factors in healthy women. J Clin Endocrinol Metab. 2003;88:1617-
drome among US adults: findings from the third National Health
1623.
and Nutrition Examination Survey. JAMA. 2002;287:356-359.
26.
Bravata DM, Sanders L, Huang J, et al. Efficacy and safety of low-
5.
Foot DK, Lewis RP, Pearson TA, Beller GA. Demographics and
carbohydrate diets: a systematic review. JAMA. 2003;289:1837-
cardiology, 1950-2050. J Am Coll Cardiol. 2000;35(5, suppl B):
1850.
66B-80B.
27.
Reddy ST, Wang CY, Sakhaee K, Brinkley L, Pak CY. Effect of
6.
Lee RB, Daly R, eds. The Cambridge Encyclopedia of Hunters and
low-carbohydrate high-protein diets on acid-base balance, stone-
Gatherers. Cambridge, UK: Cambridge University Press; 1999.
forming propensity, and calcium metabolism. Am J Kidney Dis.
7.
Eaton SB, Konner M, Shostak M. Stone agers in the fast lane:
2002;40:265-274.
chronic degenerative diseases in evolutionary perspective. Am J
28.
Eaton SB, Eaton SB III, Sinclair AJ, Cordain L, Mann NJ. Dietary
Med. 1988;84:739-749.
intake of long-chain polyunsaturated fatty acids during the
8.
Cohen MN. The significance of long-term changes in human diet
paleolithic. World Rev Nutr Diet. 1998;83:12-23.
and food economy. In: Harris M, Ross EB, eds. Food and Evolu-
29.
Cordain L, Watkins BA, Florant GL, Kelher M, Rogers L, Li Y.
tion: Toward a Theory of Human Food Habits. Philadelphia, Pa:
Fatty acid analysis of wild ruminant tissues: evolutionary implica-
Temple University Press; 1987:261-283.
tions for reducing diet-related chronic disease. Eur J Clin Nutr.
9.
Cassidy CM. Nutrition and health in agriculturalists and hunter-
2002;56:181-191.
gatherers: a case study of two prehistoric populations. In: Jerome
30.
O’Keefe JH Jr, Harris WS. From Inuit to implementation: omega-3
NW, Kandel RF, Pelto GH, eds. Nutritional Anthropology: Con-
fatty acids come of age. Mayo Clin Proc. 2000;75:607-614.
temporary Approaches to Diet & Culture. Pleasantville, NY:
31.
de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle
Redgrave Publishing Co; 1980:117-145.
N. Mediterranean diet, traditional risk factors, and the rate of
10.
Cohen MN. Health and the Rise of Civilization. New Haven, Conn:
cardiovascular complications after myocardial infarction: final re-
Yale University Press; 1989:118-119.
port of the Lyon Diet Heart Study. Circulation. 1999;99:779-785.
11.
Daniel M, Rowley KG, McDermott R, Mylvaganam A, O’Dea K.
32.
Singh RB, Dubnov G, Niaz MA, et al. Effect of an Indo-Mediterra-
Diabetes incidence in an Australian aboriginal population: an 8-year
nean diet on progression of coronary artery disease in high risk
follow-up study. Diabetes Care. 1999;22:1993-1998.
patients (Indo-Mediterranean Diet Heart Study): a randomized
12.
Ebbesson SO, Schraer CD, Risica PM, et al. Diabetes and impaired
single-blind trial. Lancet. 2002;360:1455-1461.
glucose tolerance in three Alaskan Eskimo populations: the Alaska-
33.
Marchioli R, Barzi F, Bomba E, et al, GISSI-Prevenzione Investi-
Siberia Project. Diabetes Care. 1998;21:563-569.
gators. Early protection against sudden dealth by n-3 polyunsatu-
13.
Atkins RC. Dr. Atkins’ The New Diet Revolution. New York, NY:
rated fatty acids after myocardial infarction: time-course analy-
Avon Books; 1998.
sis of the results of the Gruppo Italiano per lo Studio della
14.
Ornish D. Dr. Dean Ornish’s Program for Reversing Heart Dis-
Sopravvivenza nell’Infarto Miocardico (GISSI)-Prevenzione. Cir-
ease: The Only System Scientifically Proven to Reverse Heart
culation. 2002;105:1897-1903.
Disease Without Drugs or Surgery. New York, NY: Random
34.
Lemaitre RN, King IB, Mozaffarian D, Kuller LH, Tracy RP,
House; 1990.
Siscovick DS. N-3 Polyunsaturated fatty acids, fatal ischemic heart
15.
Hu FB, Willett WC. Optimal diets for prevention of coronary heart
disease, and nonfatal myocardial infarction in older adults: the
disease. JAMA. 2002;288:2569-2578.
Cardiovascular Health Study. Am J Clin Nutr. 2003;77:319-325.
16.
Eaton SB, Eaton SB III, Konner MJ. Paleolithic nutrition revisited:
35.
Kris-Etherton PM, Harris WS, Appel LJ, American Heart Associa-
a twelve-year retrospective on its nature and implications. Eur J
tion, Nutrition Committee. Fish consumption, fish oil, omega-3 fatty
Clin Nutr. 1997;51:207-216.
acids, and cardiovascular disease [published correction appears in
17.
Cordain L. The nutritional characteristics of a contemporary diet
Circulation. 2003;107:512]. Circulation. 2002;106:2747-2757.
based upon Paleolithic food groups. J Am Neutraceut Assoc.
36.
Cordain L, Eaton SB, Miller JB, Mann N, Hill K. The paradoxical
2002;5:15-24.
nature of hunter-gatherer diets: meat-based, yet non-atherogenic.
18.
DeBoer SW, Thomas RJ, Brekke MJ, et al. Dietary intake of fruits,
Eur J Clin Nutr. 2002;56(suppl 1):S42-S52.
vegetables, and fat in Olmsted County, Minnesota. Mayo Clin
37.
Ascherio A. Epidemiologic studies on dietary fats and coronary
Proc. 2003;78:161-166.
heart disease. Am J Med. 2002;113(suppl 9B):9S-12S.
19.
Joshipura KJ, Hu FB, Mason JE, et al. The effect of fruit and
38.
Albert CM, Gaziano JM, Willett WC, Manson JE. Nut consump-
vegetable intake on risk for coronary heart disease. Ann Intern
tion and decreased risk of sudden cardiac death in the Physicians’
Med. 2001;134:1106-1114.
Health Study. Arch Intern Med. 2002;162:1382-1387.
20.
Heart Protection Study Collaborative Group. MRC/BHF Heart
39.
Jiang R, Manson JE, Stampfer MJ, Liu S, Willett WC, Hu FB. Nut
Protection Study of antioxidant vitamin supplementation in 20,536
and peanut butter consumption and risk of type 2 diabetes in
high-risk individuals: a randomised placebo-controlled trial. Lan-
women. JAMA. 2002;288:2554-2560.
cet. 2002;360:23-33.
40.
Lovejoy JC, Most MM, Lefevre M, Greenway FL, Rood JC. Effect
21.
GISSI-Prevenzione Investigators (Gruppo Italiano per lo Studio
of diets enriched in almonds on insulin action and serum lipids in
della Sopravvivenza nell’Infarto miocardico). Dietary supplemen-
adults with normal glucose tolerance or type 2 diabetes. Am J Clin
tation with n-3 polyunsaturated fatty acids and vitamin E after
Nutr. 2002;76:1000-1006.
myocardial infarction: results of the GISSI-Prevenzione trial [pub-
41.
Cordain L, Miller JB, Eaton SB, Mann N, Holt SH, Speth JD. Plant-
lished correction appears in Lancet. 2001;357:642]. Lancet. 1999;
animal subsistence ratios and macronutrient energy estimations in
354:447-455.
worldwide hunter-gatherer diets. Am J Clin Nutr. 2000,71:682-692.
22.
Curtis BM, O’Keefe JH Jr. Understanding the Mediterranean diet:
42.
Pauletto P, Puato M, Caroli MG, et al. Blood pressure and athero-
could this be the new “gold standard” for heart disease prevention?
genic lipoprotein profiles of fish-diet and vegetarian villagers in
Postgrad Med. 2002;112:38, 41-45.
Tanzania: the Lugalawa study. Lancet. 1996;348:784-788.
23.
Willett WC, Stampfer MJ. Rebuilding the food pyramid. Sci Am.
43.
Winnick M, Somers VK, Accurso V, et al. Fish-rich diet, leptin,
2003;288:64-71.
and body mass. Circulation. 2002;106:289-291.
24.
Sacks FM, Katan M. Randomized clinical trials on the effects of
44.
Cordain L, Eades MR, Eades MD. Hyperinsulinemic diseases of
dietary fat and carbohydrate on plasma lipoproteins and cardiovas-
civilization: more than just Syndrome X. Comp Biochem Physiol A
cular disease. Am J Med. 2002;113(suppl 9B):13S-24S.
Mol Integr Physiol. 2003;136:95-112.
25.
Brehm BJ, Seeley RJ, Daniels SR, D’Alessio DA. A randomized
45.
Ford ES, Liu S. Glycemic index and serum high-density lipoprotein
trial comparing a very low carbohydrate diet and a calorie-
cholesterol concentration among US adults. Arch Intern Med.
restricted low fat diet on body weight and cardiovascular risk
2001;161:572-576.

---

108
Becoming a 21st-Century Hunter-Gatherer
Mayo Clin Proc, January 2004, Vol 79
46.
Leeds AR. Glycemic index and heart disease. Am J Clin Nutr.
to hypocaloric high-carbohydrate diet. Metabolism. 1994;43:1481-
2002;76:286S-289S.
1487.
47.
Ludwig DS. The glycemic index: physiological mechanisms relat-
62.
Layman DK, Shiue H, Sather C, Erickson DJ, Baum J. Increased
ing to obesity, diabetes, and cardiovascular disease. JAMA. 2002;
dietary protein modifies glucose and insulin homeostasis in adult
287:2414-2423.
women during weight loss. J Nutr. 2003;133:405-410.
48.
Liu S, Willett WC. Dietary glycemic load and atherothrombotic
63.
Skov AR, Toubro S, Ronn B, Holm L, Astrup A. Randomized trial
risk. Curr Atheroscler Rep. 2002;4:454-461.
on protein vs carbohydrate in ad libitum fat reduced diet for the
49.
O’Dea K, Traianedes K, Chisholm K, Leyden H, Sinclair AJ.
treatment of obesity. Int J Obes Relat Metab Disord. 1999;23:528-
Cholesterol-lowering effect of a low-fat diet containing lean beef is
536.
reversed by the addition of beef fat. Am J Clin Nutr. 1990;52:491-
64.
Baba NH, Sawaya S, Torbay N, Habbal Z, Azar S, Hashim SA.
494.
High protein vs high carbohydrate hypoenergetic diet for the treat-
50.
Wolfe BM, Piche LA. Replacement of carbohydrate by protein in a
ment of obese hyperinsulinemic subjects. Int J Obes Relat Metab
conventional-fat diet reduces cholesterol and triglyceride concen-
Disord. 1999;23:1202-1206.
trations in healthy normolipidemic subjects. Clin Invest Med. 1999;
65.
Red Meat and Health Expert Advisory Committee. The Role of Red
22:140-148.
Meat in Healthy Australian Diets. February 2001. Available at:
51.
Parker B, Noakes M, Luscombe N, Clifton P. Effect of a high-
http://www.dbctalkabouttaste.com.au/nushelth/meat4health.pdf.
protein, high-monounsaturated fat weight loss diet on glycemic
Accessibility verified November 21, 2003.
control and lipid levels in type 2 diabetes. Diabetes Care. 2002;
66.
Rohrmann S, Linseisen J, Becker N, et al, European Prospective
25:425-430.
Investigation into Cancer and Nutrition (EPIC). Cooking of meat and
52.
Wolfe BM, Giovannetti PM. Short-term effects of substituting
fish in Europe—results from the European Prospective Investigation
protein for carbohydrate in the diets of moderately hypercholester-
into Cancer and Nutrition (EPIC). Eur J Clin Nutr. 2002;56:1216-
olemic human subjects. Metabolism. 1991;40:338-343.
1230.
53.
Layman DK, Boileau RA, Erickson DJ, et al. A reduced ratio of
67.
Vermunt SH, Beaufrere B, Riemersma RA, et al, TransLinE In-
dietary carbohydrate to protein improves body composition and
vestigators. Dietary trans ?-linolenic acid from deodorised rapeseed
blood lipid profiles during weight loss in adult women. J Nutr.
oil and plasma lipids and lipoproteins in healthy men: the TransLinE
2003;133:411-417.
Study. Br J Nutr. 2001;85:387-392.
54.
O’Dea K, Traianedes K, Ireland P, et al. The effects of diet differing
68.
Chan J, Knutsen SF, Blix GG, Lee JW, Fraser GE. Water, other
in fat, carbohydrate, and fiber on carbohydrate and lipid metabo-
fluids, and fatal coronary heart disease: the Adventist Health Study.
lism in type II diabetes. J Am Diet Assoc. 1989;89:1076-1086.
Am J Epidemiol. 2002;155:827-833.
55.
Torbay N, Baba NH, Sawaya S, et al. High protein vs high carbo-
69.
Duffy SJ, Keaney JF Jr, Holbrook M, et al. Short- and long-term
hydrate hypoenergetic diet in treatment of obese normoinsulin-
black tea consumption reverses endothelial dysfunction in patients
emic and hyperinsulinemic subjects. Nutr Res. 2002;22:587-
with coronary artery disease. Circulation. 2001;104:151-156.
598.
70.
Mukamal KJ, Maclure M, Muller JE, Sherwood JB, Mittleman
56.
Westerterp-Plantenga MS, Rolland V, Wilson SA, Westerterp KR.
MA. Tea consumption and mortality after acute myocardial infarc-
Satiety related to 24 h diet-induced thermogenesis during high
tion. Circulation. 2002;105:2476-2481.
protein/carbohydrate vs high fat diets measured in a respiration
71.
Geleijnse JM, Launer LJ, Van der Kuip DA, Hofman A, Witteman
chamber. Eur J Clin Nutr. 1999;53:495-502.
JC. Inverse association of tea and flavonoid intakes with incident
57.
Stubbs RJ. Macronutrient effects on appetite. Int J Obes Relat
myocardial infarction: the Rotterdam Study. Am J Clin Nutr.
Metab Disord. 1995;19(suppl 5):S11-S19.
2002;75:880-886.
58.
Long SJ, Jeffcoat AR, Millward DJ. Effect of habitual dietary-
72.
Cordain L, Gotshall RW, Eaton SB, Eaton SB III. Physical activity,
protein intake on appetite and satiety. Appetite. 2000;35:79-88.
energy expenditure and fitness: an evolutionary perspective. Int J
59.
Crovetti R, Porrini M, Santangelo A, Testolin G. The influence of
Sports Med. 1998;19:328-335.
thermic effect of food on satiety. Eur J Clin Nutr. 1998;52:482-
73.
Cordain L, Gotshall RW, Eaton SB. Evolutionary aspects of exer-
488.
cise. World Rev Nutr Diet. 1997;81:49-60.
60.
Johnston CS, Day CS, Swan PD. Postprandial thermogenesis is
74.
Wing RR. Physical activity in the treatment of the adulthood over-
increased 100% on a high-protein, low-fat diet versus a high-
weight and obesity: current evidence and research issues. Med Sci
carbohydrate, low-fat diet in healthy, young women. J Am Coll
Sports Exerc. 1999;31(11, suppl):S547-S552.
Nutr. 2002;21:55-61.
75.
Tanasescu M, Leitzmann MF, Rimm EB, Willett WC, Stampfer
61.
Piatti PM, Monti F, Fermo I, et al. Hypocaloric high-protein diet
MJ, Hu FB. Exercise type and intensity in relation to coronary heart
improves glucose oxidation and spares lean body mass: comparison
disease in men. JAMA. 2002;288:1994-2000.

---