Diet and Non-Communicable Diseases (NCDs): latest evidence

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1 Diet and Non-Communicable Diseases (NCDs): latest evidence Fumiaki Imamura, MS, PhD 23 Nov 2016, London

2 publications in our field N journals=436 N publications: Pubmed

3 Million Deaths Global Burden of Disease Communicable Nutr Deficit CVD and Cancer Lozano et al., Lancet 2012; 380:

4 Diet Hypertension Nutr Deficit Smoking Obesity Alcohol Global Burdens of Diseases Physical activity % Loss of Life Years GBD 2013 Risk Factors Collaborators, Lancet, 2015

5 Studies of Diet and Health Nutrients e.g. Saturated fat Foods Meat/oils Overall Diet High-fat diet D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S 13S

6 SFA Heart disease??? The Elements of Physiology Blumenbach, 1828 in arteries by Gulliver G, Med Chir Trans, 1843 Keys A., 1980

7 Saturated fatty acids (SFA) consumption raises blood cholesterol. Publications N trials Mensink, Arteriosc Thromb, Clarke, BMJ, Mensink, Am J Clin Nutr, SFA PUFA SFA MUFA Cholesterol Decrease in total cholesterol (mmol/l)

8 Women s Health Initiative (WHI) 48835, randomised Low fat Usual Heart disease % Control Intervention Year Howard et al., JAMA, 2006

9 Dietary intakes in WHI % of energy Control group Low fat Total fat Total fat* 15 SFA 15 SFA * 0 Baseline Year 6 0 Baseline Year 6 *P<0.05 Howard et al., JAMA, 2006

10 Dietary intakes in WHI % of energy or gram/day 45 Control group Nuts Carb. 45 Low fat Carb. * Nuts * Baseline Year 6 PUFA 0 Baseline Year 6 PUFA* *P<0.05 Howard et al., JAMA, 2006

11 SFAs, High in what? sugars Energy from butter oil (PUFA) Is butter really back? Clarifying the facts on fat Harvard School of Public Health

12 SFA intake and heart disease Chowdhury et al, Ann Intern Med. 2014

13 Summary evidence on SFA intake and heart disease Meta-analysis N Relative Risk (95% CI) Observational Jacobsen, (0.77, 0.97) Mente, (0.96, 1.15) Siri-Tarino, (0.96, 1.19) Chowdhury, (0.98, 1.07) Farvid, (0.85, 0.94) de Souza, (0.95, 1.17) Trials Skeaff, (0.69, 1.00) Mozaffarian, (0.70, 0.95) Hooper, 2000/01/12/ (0.84, 1.02) Ramsden, 2010/13/ (0.82, 1.19) Schwingshackl, (0.54, 1.09) Horcombe, (0.78, 1.25) Effect On CHD

14 Summary evidence on SFA intake and heart disease Meta-analysis N Relative Risk (95% CI) Observational Jacobsen, (0.77, 0.97) Mente, (0.96, 1.15) Siri-Tarino, (0.96, 1.19) Chowdhury, (0.98, 1.07) Farvid, (0.85, 0.94) de Souza, (0.95, 1.17) Trials Skeaff, (0.69, 1.00) Mozaffarian, (0.70, 0.95) Hooper, 2000/01/12/ (0.84, 1.02) Ramsden, 2010/13/ (0.82, 1.19) Schwingshackl, (0.54, 1.09) Horcombe, (0.78, 1.25) Effect On CHD

15 SFAs, High in what? sugars olive oil Energy from butter Trans-fat-rich margarine Is butter really back? Clarifying the facts on fat Harvard School of Public Health

16 Summary evidence on SFA intake and heart disease Meta-analysis N Relative Risk (95% CI) Observational Jacobsen, (0.77, 0.97) Mente, (0.96, 1.15) Siri-Tarino, (0.96, 1.19) Chowdhury, (0.98, 1.07) Farvid, (0.85, 0.94) de Souza, (0.95, 1.17) Trials Skeaff, (0.69, 1.00) Mozaffarian, (0.70, 0.95) Hooper, 2000/01/12/ (0.84, 1.02) Ramsden, 2010/13/ (0.82, 1.19) Schwingshackl, (0.54, 1.09) Horcombe, (0.78, 1.25) Effect On CHD

17 Summary evidence on SFA intake and heart disease Meta-analysis N Relative Risk (95% CI) Observational Jacobsen, (0.77, 0.97) Mente, (0.96, 1.15) Siri-Tarino, (0.96, 1.19) Chowdhury, (0.98, 1.07) Farvid, (0.85, 0.94) de Souza, (0.95, 1.17) Trials Skeaff, (0.69, 1.00) Mozaffarian, (0.70, 0.95) Hooper, 2000/01/12/ (0.84, 1.02) Ramsden, 2010/13/ (0.82, 1.19) Schwingshackl, (0.54, 1.09) Horcombe, (0.78, 1.25) Effect On CHD

18 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

19 Studies of Diet and Health Nutrients e.g. Saturated fat Foods Meat/oils Overall Diet High-fat diet D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S 13S

20 Sodium and NCDs Nutrients e.g. Sodium Blood pressure Foods Overall Diet Cardiovascular diseases (CVD) D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S 13S

21 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

22 Sodium and NCDs Nutrients Foods e.g. Sodium Blood pressure Processed meats Overall Diet Cardiovascular diseases (CVD) D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S 13S

23 Smoking and health

24 Mediterranean Diet High good fat (Olive oil) Vegetables, fruits, fibre, beans, legumes, fish, yogurt, cheese, wine CHD mortality Key, Circulation, 1970

25 Lyon Diet Heart Study 605 CHD patients Mediterranean-type diet Risk= 77% Physicians advice only de Lorgeril et al., Circulation, 1999;99:

26 PREDIMED Study 7,447 adults at high risk of CHD* Total CHD 29% (10-44%) *with diabetes or 3 risk factors for heart diseases Estruch R et al., NEJM, 2013; Appel LJ, Van Horn L., NEJM, 2013

27 No effects on body weight (PREDIMED) Weight, kg Year Estruch et al., Lancet Diab Endcrinol, 2016

28 Is the diet healthy for the UK adults? The Mediterranean Diet Foundation

29 23,902 adults in the Norfolk region over 20 years (EPIC Norfolk Study) 20% Lower risk 10% ±0% Higher risk TYN Tong et al., BMC Medicine, 2016

30 How much of CVD (%) can be preventable by the diet??? PREDIMED Spain 8.5 Norfolk UK

31 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

32 Studies of Diet and Health Nutrients Foods Overall Diet How efficacious/effective? Generalisable? Comprehensive? Diet cost vs health cost Greenhouse gas emission

33 Nordic diet Emphasis on Oily fish Rye breads Rapeseed oil Berries Adamsson, J Intern Med, 2011;269: Uusitupa, J Intern Med, 2013;274:52-66 Poulsen, Am J Clin Nutr, 2014;99:35-45 Mithril, Public Health Nutr, 2013;16: Kanerva, Br J Nutr, 2013;109: Kolehmainen, Am J Clin Nutr, 2015;101:

34 Dietary patterns for nutrient studies Nutrients Foods e.g. Sat fat, sodium, Ecological or metabolic studies Overall Diet D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S 13S

35 Dietary patterns for nutrient studies Nutrients Foods What are the healthy/unhealthy components? Overall Diet D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S 13S

36 Healthy/Unhealthy diet Why? Resveratrol Trimethyl-amine oxide (TMAO) Oleocanthal

37 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

38 Healthy British Diet?

39 SFA intake on the globe. Micha et al, BMJ. 2014

40 Saturated fatty acids (SFA) high in solid fat and animal fat Saturated (SFA) Monounsaturated (MUFA) Polyunsaturated (PUFA) Coconut oil Butter Beef fat Pork fat (lard) Soybean oil Olive oil Corn oil Canola oil Safflower oil % of total fat Adapted from Dietary Guidelines for Americans 2010

41 SFAs and health The Elements of Physiology Blumenbach, 1828 in arteries Gulliver G, Med Chir Trans, 1843 Borch, Anal Chem, 1975.

42 High carb. Blood SFA dietary SFA Sugars/Alcohol Blood SFA

43 Fat and breast cancer 25 Breast Cancer per 100, Total Fat, g/day Carroll, Cancer Res, 1975;35: Bingham et al., Nat Rev Cancer,2004;4:206

44 Total fat, SFAs and breast cancer Total Fat UK Multi-countries* SFAs 20% Lower risk ±0% +20% Higher risk *US, Netherlands, Sweden, Canada Key, AJCN, 2011;94: Hunter et al., NEJM, 1996;334:356-61

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