Foods, Obesity, and Diabetes Are All Calories Created Equal?

Transcription

1 Foods, Obesity, and Diabetes Are All Calories Created Equal? The State of U.S. Health, 2010 Dariush Mozaffarian, MD DrPH Dean, Friedman School of Nutrition Science & Policy 10 th Nestle Nutrition Conference Mexico City, Mexico November 12, US Burden of Disease Collaborators, JAMA Cardiometabolic Risk Factors Diet & Obesity/Diabetes: Conventional Wisdom Energy Out (Expenditure) Energy In (Intake) Adiposity Type 2 Diabetes Mellitus Total Fat Energy Density Calories In, Calories Out" 3 Mozaffarian, Wilson, & Kannel, Circulation 2008 Added Sugars 4 Advances in Nutritional Science Diet & Obesity/Diabetes: Modern Science Randomized Trials of Disease Outcomes Randomized Trials of Physiologic Measures / Risk Factors Prospective Cohorts of Disease Outcomes Energy Out (Expenditure) Energy In (Intake) Adiposity Type 2 Diabetes Mellitus Animal Studies Retrospective Case Control Studies of Disease Outcomes Ecologic Studies Prevalence Studies 5 Harris, Mozaffarian et al., J Nutrition 2009 Foods / Diet Quality : Carbohydrate Quality Nuts, Fruits, Vegetables, Dairy, Meats Specific Fats and Oils Overall Diet Patterns 6 1

2 Short-Term Weight Loss (Secondary Prevention) What About Primary Prevention? Prevention of Long-Term Weight Gain Mean BMI at baseline = 31 30% fat 33% fat 39% fat The average adult gains ~ 1 lb (0.45 kg) per year. Very small, but adds up: 20 lbs over 20 years. This gradual pace makes it very difficult for individuals (or controlled trials) to perceive specific causes or remedies. Dietary trials of short-term weight loss in obese patients are unlikely to inform causes of long-term, gradual weight gain in non-obese populations. 7 Shai et al NEJM Weight Change Associated with Each Increased Daily Serving of: Foods Carbohydrate Quality: Challenging to Define Simply Fiber content Whole grain Glycemic response Liquid vs. solid Beverages Mozaffarian et al., NEJM 2011 Among 120,877 men and women followed for 20 years, adjusted every 4-years for age, baseline BMI, sleep, and changes in activity, smoking, TV watching, and all dietary factors simultaneously. 9 Mozaffarian D. Curr Athero Reports Choosing Carbs: Best Rule of Thumb? Grains and Sugars: What's The Healthy Choice? Compared 5 recommended metrics: Industry-sponsored whole grain stamp Three USDA-recommended definitions, each based on the ingredients list Ratio of total carb to fiber per serving (AHA 2020 Goals) Best: Ratio of total carb to fiber > 10:1 = Avoid < 10:1 = A good choice (many options) < 5:1 = A great choice (fewer options) Mozaffarian RS et al, Public Health Nutr

3 Diet Quality and Obesity: All Calories are Not Created Equal Complex influences of different foods on: Hunger, fullness Insulin, adrenalin, other hormonal responses Liver fat production (de novo lipogenesis, conversion of carbohydrate to fat) Brain reward Microbiome Metabolic expenditure (energy out) 13 Fat quality alters long-term weight gain Gain in waist circumference (cm) per each 2% energy change in intake * *p<0.01 Among 16,587 men followed for 9 years, adjusted for other dietary, lifestyle, and behavioral risk factors. 14 Koh-Banerjee et al, AJCN 2003 Fat quality alters long-term weight gain Diet quality alters hepatic fat synthesis Weight Gain (% change) Due to abdominal (visceral) fat * 18 subjects with NAFLD Controlled, equal 5% weight loss with low calorie vs. low carb diets over 2 weeks Hepatic fat measured by H NMR Similar 5% weight loss Nearly two fold greater reduction in hepatic steatosis Randomized controlled trial among green monkeys fed caloriecontrolled diets containing cis or trans fat (8% energy) for 6 years. Kavanagh et al, Obesity * P= Browning et al. AJCN 2011 Diet quality alters brain reward activation Diet quality alters microbiome function Identical appearing and tasting liquid test meals. Equal calories, macronutrients, palatability, sweetness. Only difference: glycemic index. Less weight gain with either probiotic yogurt or purified Lactobacillus reuteri. No changes in microbial composition or total calorie consumption. Eating lactobacillus reuteri triggered changes in microbiome function and host immune system. Dependent on both CD4+ T cells and interleukin 10. flow in right nucleus acumbens (P=0.006) 17 Lennerz et al. AJCN 2013 Poutahidis et al., Plos ONE

4 Diet quality alters energy expenditure SSBs & Incident Diabetes Calorie controlled feeding study. No changes in weight. No changes in physical activity. Percent increase in risk of diabetes P trend <0.001 Risk for 1+ drink (12 oz) per day, compared with <1 per month Ebbeling et al. JAMA Among 91,249 women followed for 8 years. Schulze et al., JAMA Processed Meats & Incident Diabetes Nuts & Incident Diabetes Processed Meats (per 100 g/d) RR = 2.28 (1.56, 3.35) 21 Pan et al, AJCN 2011 Afshin et al, AJCN Dairy Foods & Incident Diabetes Preventing Chronic Diseases: Food Patterns P-trend=0.50 RR of Diabetes P-trend=0.06 P-trend=0.01 Quintiles of Consumption 340,234 Europeans, 8 countries, 12,403 cases of incident diabetes 23 Sluijis et al., AJCN

5 Dietary Priorities for Health Total Calories (or Single Nutrients): Misleading EAT: Fish, seafood Fruits Nuts Vegetables, legumes Vegetable oils Whole grains Moderate dairy LIMIT: Starches, refined grains, sugars Processed meats Sweetened drinks Industrial trans fat Salt Alcohol Mozaffarian, Appel, & Van Horn. Circulation Calorie/Fat Focus: Recipe for Confusion Calorie/Fat Focus: Recipe for Manipulation Low calorie = Less weight gain Fat free = Healthy" Low saturated fat = "Healthy" Barriers and Opportunities for Healthy Eating Lessons From Past Public Health Successes 29 Afshin A et al, The Handbook for Global Health Policy, 2014 US Centers for Disease Control and Prevention, MMWR Morb Mortal Wkly Rep,

6 Lessons From Past Public Health Successes Evidence-Based Policy Interventions for Diet Driver: Education. Licensing. Limits on phone use, texting. Car: Active: seat belts, child seats, motorcycle helmets. Passive: padded interiors, collapsible steering columns, shatterproof glass, air bags. Crash safety standards. Safety inspections. Road: Road engineering, guard rails, rumble strips. Speed limits. Stop signs, stop lights, caution signs. Culture: Designated driver campaign. Drunk driving legislation. Private advocacy, e.g. MADD. Mozaffarian, Hemenway, & Ludwig, JAMA Media and Education Labeling and Information Schools Workplaces Economic Incentives Bans and Mandates Sustained, focused media campaigns, especially combined with multicomponent strategies, focusedonspecific foods or drinks. Mandated nutrition facts, front of pack labels/icons, or menu labeling to influence industry behavior and product formulations. Multicomponent diet and activity program including classes, teacher training, supportive policies, environmental changes, family components. Comprehensive worksite wellness programs for diet, activity, tobacco. Increased availability of healthier options and/or strong nutrition standards, combined with on site prompts, labels, or icons. Subsidy strategies to lower prices of more healthful foods and beverages. Tax strategies to increase prices of less healthful foods and beverages. Long term changes in agricultural and related policies for infrastructure to facilitate production, transportation, and marketing of healthier foods. Restrictions on ads/marketing of less healthy foods/drinks to children on television, and near schools and public places, and on packages. Direct bans (e.g., sodium, trans fat) or mandates (e.g., vegetable oils). Mozaffarian et al, AHA Scientific Statement, Circulation Postdoctoral fellows Acknowledgements Doctoral students Biostatisticians Faculty members Liana Del Gobbo Qianyi Wang Peilin Shi Gitanjali Singh Ashkan Afshin Jessica Smith Colin Rehm Laura Pimpin Wenjie Ma Yawar Yakoob Project managers Namasha Schelling Ashley Wright Fred Cudhea Research assistants/ Junior fellows Siyi Shangguan Masha Shulkin Isaac Johnson Michael Kashaf Renata Micha Jose Penalvo Collaborating Faculty David Siscovick Eric Rimm David Herrington Walter Willett Frank Hu David Ludwig Simon Capewell Jason Wu Fumiaki Imamura Marcia Otto 33 6