diet and non-communicable diseases (ncds): latest...
TRANSCRIPT
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Diet and Non-Communicable Diseases (NCDs): latest evidence
Fumiaki Imamura, MS, PhD [email protected]
23 Nov 2016, London
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↑↑↑ publications in our field ↑↑↑
• N journals=436
• N publications:
Pubmed
0
30000
60000
90000
1960 1970 1980 1990 2000 2010
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Global Burden of Disease
0
5
10
15
20
25
Communicable Nutr Deficit CVD and Cancer
1990 2010
Million Deaths
Lozano et al., Lancet 2012; 380: 2095–128
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Global Burdens of Diseases
GBD 2013 Risk Factors Collaborators, Lancet, 2015
% Loss of Life Years
0 2.5 5.0 7.5 10.0
Diet
Smoking Nutr Deficit
Alcohol
Physical activity
Obesity
Hypertension
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Studies of Diet and Health
D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S
Overall Diet
Nutrients
Foods
e.g.
• Saturated fat
• Meat/oils
• High-fat diet
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↓ SFA ↓ Heart disease ???
in arteries by Gulliver G,
Med Chir Trans, 1843
The Elements of Physiology Blumenbach, 1828
Keys A., 1980
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Saturated fatty acids (SFA) consumption raises blood cholesterol.
Publications N trials
Mensink, Arteriosc Thromb, 1993 27
Clarke, BMJ, 1997 395
Mensink, Am J Clin Nutr, 2003 60
SFA→PUFA
SFA→MUFA
↓ Cholesterol
Decrease in total cholesterol (mmol/L)
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Women’s Health Initiative (WHI)
48835, randomised
19541 Low fat
29294 Usual
0 2 4 6 8
Year
0.06
0.05
0.04
0.03
0.02
0.01
0
Heart disease %
Howard et al., JAMA, 2006
Control
Intervention
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Dietary intakes in WHI
Howard et al., JAMA, 2006
0
15
30
45
Baseline Year 6
0
15
30
45
Baseline Year 6
Control group “Low fat” % of
energy
Total fat
SFA
Total fat*
SFA *
*P<0.05
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Dietary intakes in WHI
Howard et al., JAMA, 2006
0
15
30
45
Baseline Year 6
0
15
30
45
Baseline Year 6
Control group “Low fat” % of energy
or gram/day Nuts Carb.
PUFA
Nuts *
Carb. *
PUFA*
*P<0.05
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↓ SFAs,
High in what?
Energy from butter
oil (PUFA)
sugars
Is butter really back? Clarifying the facts on fat Harvard School of Public Health
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SFA intake and heart disease
Chowdhury et al,
Ann Intern Med. 2014
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Summary evidence on ↓ SFA intake and heart disease
Meta-analysis N Relative Risk
(95% CI) Effect
On CHD
Observational
Jacobsen, 2009 11 0.87 (0.77, 0.97)
Mente, 2009 11 1.06 (0.96, 1.15)
Siri-Tarino, 2010 16 1.07 (0.96, 1.19)
Chowdhury, 2014 20 1.03 (0.98, 1.07)
Farvid, 2014 10 0.90 (0.85, 0.94)
de Souza, 2015 12 1.06 (0.95, 1.17)
Trials
Skeaff, 2009 8 0.83 (0.69, 1.00)
Mozaffarian, 2010 7 0.81 (0.70, 0.95)
Hooper, 2000/01/12/15 23 0.93 (0.84, 1.02)
Ramsden, 2010/13/15 7 0.98 (0.82, 1.19)
Schwingshackl, 2014 12 0.76 (0.54, 1.09)
Horcombe, 2015 7 0.99 (0.78, 1.25)
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“Summary evidence” on ↓ SFA intake and heart disease
Meta-analysis N Relative Risk
(95% CI) Effect
On CHD
Observational
Jacobsen, 2009 11 0.87 (0.77, 0.97)
Mente, 2009 11 1.06 (0.96, 1.15)
Siri-Tarino, 2010 16 1.07 (0.96, 1.19)
Chowdhury, 2014 20 1.03 (0.98, 1.07)
Farvid, 2014 10 0.90 (0.85, 0.94)
de Souza, 2015 12 1.06 (0.95, 1.17)
Trials
Skeaff, 2009 8 0.83 (0.69, 1.00)
Mozaffarian, 2010 7 0.81 (0.70, 0.95)
Hooper, 2000/01/12/15 23 0.93 (0.84, 1.02)
Ramsden, 2010/13/15 7 0.98 (0.82, 1.19)
Schwingshackl, 2014 12 0.76 (0.54, 1.09)
Horcombe, 2015 7 0.99 (0.78, 1.25)
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↓ SFAs,
High in what?
Energy from butter
olive oil
sugars
Is butter really back? Clarifying the facts on fat Harvard School of Public Health
Trans-fat-rich margarine
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“Summary evidence” on ↓ SFA intake and heart disease
Meta-analysis N Relative Risk
(95% CI) Effect
On CHD
Observational
Jacobsen, 2009 11 0.87 (0.77, 0.97)
Mente, 2009 11 1.06 (0.96, 1.15)
Siri-Tarino, 2010 16 1.07 (0.96, 1.19)
Chowdhury, 2014 20 1.03 (0.98, 1.07)
Farvid, 2014 10 0.90 (0.85, 0.94)
de Souza, 2015 12 1.06 (0.95, 1.17)
Trials
Skeaff, 2009 8 0.83 (0.69, 1.00)
Mozaffarian, 2010 7 0.81 (0.70, 0.95)
Hooper, 2000/01/12/15 23 0.93 (0.84, 1.02)
Ramsden, 2010/13/15 7 0.98 (0.82, 1.19)
Schwingshackl, 2014 12 0.76 (0.54, 1.09)
Horcombe, 2015 7 0.99 (0.78, 1.25)
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“Summary evidence” on ↓ SFA intake and heart disease
Meta-analysis N Relative Risk
(95% CI) Effect
On CHD
Observational
Jacobsen, 2009 11 0.87 (0.77, 0.97)
Mente, 2009 11 1.06 (0.96, 1.15)
Siri-Tarino, 2010 16 1.07 (0.96, 1.19)
Chowdhury, 2014 20 1.03 (0.98, 1.07)
Farvid, 2014 10 0.90 (0.85, 0.94)
de Souza, 2015 12 1.06 (0.95, 1.17)
Trials
Skeaff, 2009 8 0.83 (0.69, 1.00)
Mozaffarian, 2010 7 0.81 (0.70, 0.95)
Hooper, 2000/01/12/15 23 0.93 (0.84, 1.02)
Ramsden, 2010/13/15 7 0.98 (0.82, 1.19)
Schwingshackl, 2014 12 0.76 (0.54, 1.09)
Horcombe, 2015 7 0.99 (0.78, 1.25)
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Meta-analysis of SFA intake and heart disease
• If we consider single macronutrients,
we need to consider possible substitution/comparison.
• Mutivariate / ‘network’ meta-analysis in nutritional epidemiology: • Clarke et al., BMJ, 1997
• Johnson et al., JAMA, 2014
• Imamura et al., PLoS Med, 2016
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Studies of Diet and Health
D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S
Overall Diet
Nutrients
Foods
e.g.
• Saturated fat
• Meat/oils
• High-fat diet
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Sodium and NCDs
D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S
Overall Diet
Nutrients
Foods
e.g.
• Sodium →
Blood pressure
• Cardiovascular diseases (CVD)
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High sodium in urine was not related to higher risk of CVD or deaths (n=69,559)
Risk of CVD/deaths
Urinary sodium
Mente et al., Lancet, 2016
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Sodium and NCDs
D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S
Overall Diet
Nutrients
Foods
e.g.
• Sodium →
Blood pressure
• Processed meats
• Cardiovascular diseases (CVD)
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Smoking and health
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Mediterranean Diet
• High “good” fat (Olive oil)
• Vegetables, fruits, fibre, beans, legumes, fish, yogurt, cheese, wine
CHD mortality
Key, Circulation, 1970
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Lyon Diet Heart Study 605 CHD patients
↓ Risk= 77%
de Lorgeril et al., Circulation, 1999;99:779-785
Physicians’ advice only
Mediterranean-type diet
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PREDIMED Study 7,447 adults at high risk of CHD*
Total CHD
*with diabetes or 3 risk factors for heart diseases Estruch R et al., NEJM, 2013; Appel LJ, Van Horn L., NEJM, 2013
↓ 29% (10-44%)
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No effects on body weight (PREDIMED)
Weight, kg
Year
Estruch et al., Lancet Diab Endcrinol, 2016
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Is the diet healthy for the UK adults?
The Mediterranean Diet Foundation
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23,902 adults in the Norfolk region over 20 years (EPIC Norfolk Study)
±0% –20%
Higher risk Lower risk
–10%
TYN Tong et al., BMC Medicine, 2016
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How much of CVD (%) can be preventable by the diet???
27.8
8.5
0
10
20
30
PREDIMED Spain
Norfolk UK
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Limitations in the Mediterranean diet (and other patterns)
• Not comprehensive
• No info on beverages • Sugar-sweetened drinks
• Coffee
• Tea
• No info on cooking methods • Fried or grilled fish
• Weak emphasis on subtypes… • Starchy vegetables or not
• Yoghurt, cheese, milk
• Grain products
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Studies of Diet and Health
Overall Diet
Nutrients
Foods
• “How efficacious/effective?”
• Generalisable?
• Comprehensive?
Diet cost vs health cost
Greenhouse gas emission
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Nordic diet
Emphasis on
• Oily fish
• Rye breads
• Rapeseed oil
• Berries…
Adamsson, J Intern Med, 2011;269:150-159 Uusitupa, J Intern Med, 2013;274:52-66
Poulsen, Am J Clin Nutr, 2014;99:35-45 Mithril, Public Health Nutr, 2013;16:777-785
Kanerva, Br J Nutr, 2013;109:520-528 Kolehmainen, Am J Clin Nutr, 2015;101:228-239
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Dietary patterns for nutrient studies
D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S
Overall Diet
Nutrients
Foods
e.g. Sat fat, sodium, …
• Ecological or metabolic studies
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Dietary patterns for nutrient studies
D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S
Overall Diet
Nutrients
Foods
• What are the healthy/unhealthy components?
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Healthy/Unhealthy diet Why?
Resveratrol
Oleocanthal
Trimethyl-amine oxide (TMAO)
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Remarks
• Research on nutrients/foods help understand mechanisms and justify benefits/harm • Be careful about fit to a dietary pattern
• Research on dietary patterns has provided useful evidence • Comprehensive?
• Generalisable?
• Food culture, acceptability, affordabiilty
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Healthy British Diet?
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SFA intake on the globe.
Micha et al, BMJ. 2014
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Coconut oil
Butter
Beef fat
Pork fat (lard)
Soybean oil
Olive oil
Corn oil
Canola oil
Safflower oil
0 20 40 60 80 100
Adapted from Dietary Guidelines for Americans 2010
% of total fat
Monounsaturated (MUFA)
Polyunsaturated (PUFA)
Saturated (SFA)
Saturated fatty acids (SFA) high in solid fat and animal fat
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SFAs and health
in arteries
Gulliver G,
Med Chir Trans, 1843
The Elements of Physiology Blumenbach, 1828
Borch, Anal Chem, 1975.
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Blood SFA≠dietary SFA Sugars/Alcohol → Blood SFA
High carb.
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25
20
15
10
5
0 0 40 80 120 160
Total Fat, g/day
Breast Cancer
per 100,000
Carroll, Cancer Res, 1975;35:3374-3383 Bingham et al., Nat Rev Cancer,2004;4:206
Fat and breast cancer
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Total fat, SFAs and breast cancer
±0% +20% –20%
Higher risk Lower risk
Total Fat
SFAs
Multi-countries*
UK
Hunter et al., NEJM, 1996;334:356-61 Key, AJCN, 2011;94:1043-52
*US, Netherlands, Sweden, Canada