Dietary priorities for type 2 diabetes

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1 Dietary priorities for type 2 diabetes Edinburgh, 17 th July 2018 Nita Gandhi Forouhi MRC Epidemiology Unit, University of Cambridge MRC Epidemiology Unit World Congress on Prevention of Diabetes and its Complications

2 Disclosures Joint SACN/NHS-England/Diabetes-UK Working Group on lower carbohydrate diets compared to current government advice for adults with type 2 diabetes (invited unpaid member) Any views expressed are my own, not the Group s MRC Epidemiology Unit

3 Global Burden of Disease Study Diet Hypertension DM CVD Cancer M/C Nutr deficit Smoking Obesity Alcohol GBD 2013 Risk Factors Collaborators, Lancet, 2015 Physical activity DALYs (%) MRC Epidemiology Unit

4 But which diet? MRC Epidemiology Unit Micronutrients Macronutrients fats, carbohydrates protein Foods Drinks Dietary patterns Energy Quantity intake Quality Variety Meal frequency Snacking Probiotics Cooking Cost, methods access

5 Massive numbers of publications (PubMed ) 2018 by British Medical Journal Publishing Group Dariush Mozaffarian, and Nita G Forouhi BMJ 2018;360:bmj.k822

6 Dietary guidelines

7 Dietary messaging Eat Fat Importance. Interest. Passion. Confusion. Evidence?

8 Dietary priorities: from controversy to consensus Weight control Nutrients vs. foods Fats Carbohydrates

9 #1. Weight/obesity: calorie control Energy In (Intake) Energy Out (Expenditure) Obesity Type 2 diabetes A calorie is a calorie Chan Diabetes Care 1994; Colditz Ann Intern Med 1995

10 Energy (calorie) restriction works For weight loss prevention of weight gain

11 For remission of T2D Lean M. The Lancet, 2017

12 Which diet? Low-fat vs usual diet 53 RCTs; n=68,128 Low-fat vs any higher fat intervention Weighted mean difference in weight at follow-up (kg) Tobias DK et al; Lancet DE, 2015

13 Which diet? 53 RCTs; n=68,128 Low-fat vs low-carbohydrate intervention Tobias DK et al; Lancet DE, 2015

14 Which diet works best for weight loss? 48 RCTs; n=7286 overweight/obese Johnston B, JAMA 2014

15 #2. Dietary fat

16 Population nutrient goal WHO UK USA Goal (% of total energy) Total fat < Saturated fat <10 <10 <10

17 Saturated fat and type 2 diabetes incidence Micha & Mozaffarian. Lipids 2010

18 (1) Fat is not just fat: not one homogeneous entity Total fat Saturated fatty acids Unsaturated fatty acids Trans-fatty acids Monounsaturated fatty acids Polyunsaturated fatty acids Omega-3 Omega-6 Isocaloric intake balance of macronutrients within total energy intake CONSENSUS: Eliminate industrially produced trans-fa (hydrogenated fats)

19 label (2) The replacement nutrient matters Mozaffarian et al., ev n n6 con n6 PUFA (% energy) Rx Clinical Trial Events n Control Rx 8 randomized trials, 13,614 participants, 1,042 CHD events RR (95% CI) RR (95% CI) Mozaffarian et al., PLoS Med 2010 PLoS Med 2010 % Weight % Weight LA Veterans (0.53, 1.03) MRC soy (0.61, 1.22) Oslo Diet-Heart (0.57, 0.99) Finnish - Men (0.34, 0.88) 8.19 Finnish - Women (0.41, 1.00) 8.69 Minnesota CS (0.84, 1.37) DART (0.73, 1.14) STARS (0.09, 1.96) 0.94 Overall Pooled Effect 0.81 (0.70, 0.95) 0.81 (0.70, 0.95) NOTE: Weights are from random effects analysis

20 (3) Saturated fat is (ALSO) not a single entity Total fat Saturated fats Cis-unsaturated fats Trans-unsaturated fats Odd-chain Even-chain Very-longchain

21 Biomarkers: Blood saturated fatty acids & T2D 14, 16, 18 carbon atoms Complex: diet, metabolism 15, 17 carbon atoms From the diet: dairy fat Even-chain fatty acids France Italy Spain UK Netherlands Germany Sweden Denmark Overall Odd-chain fatty acids France Italy Spain UK Netherlands Germany Sweden Denmark Overall 12,403 T2D cases 8 European countries N=340,234 Subcohort n=16,154 Langenberg C et al, Diabetologia 2011 Hazard ratio (95%CI) 1.43 ( ) 0.70 ( ) SFAs not all the same Need careful interpretation Hazard Ratio (95% CI) Forouhi NG et al, Lancet_DE, 2014

22 (4) Food source of saturated fatty acids matters Food matrix Macronutrients Micronutrients Vitamins Additives Oher components Processing Cooking methods Probiotic effects Effects on microbiome

23 Diabetologia, 2013 Meat intake and diabetes: InterAct France France Italy Italy Spain Spain UK UK Netherlands Netherlands Germany Germany Sweden Sweden Denmark Denmark Overall 1.10 ( ) Overall 1.13 ( ) (I 2 =4.7%; p=0.39) (I 2 =37%; p=0.13) Red meat Per 50g/d Hazard Ratio (95% CI) Processed meat Per 50g/d Hazard Ratio (95% CI) 12,403 T2D cases Habitual intake; adjusted analyses

24 Dairy products intake & T2D France France Italy Italy Spain Spain UK UK Netherlands Netherlands Germany Germany Sweden Sweden Denmark Denmark Overall Overall 1.01 ( ) 0.88 ( ) (I 2 =0%; p=0.70) (I 2 =0%; p=0.68) Hazard Ratio (95% CI) Total dairy products 12,403 T2D cases Hazard Ratio (95% CI) Fermented dairy products (yoghurt, cheese) Habitual intake; adjusted analyses

25 Summary: dietary fats & T2D Beyond the low total fat era Type of fat is important: marker of fat quality Saturated fat is heterogeneous individual SFAs have different health effects Food matters, beyond the nutrient Food sources rich in SFA, with different links with T2D Red & processed meat Dairy products Focus on the types of foods & overall diet patterns MRC Epidemiology Unit

26 #3. Carbohydrates Carb quality indicators 50% of daily energy Whole grain or refined Fibre Glycaemic response (GI, GL) Food structure: solid/liquid

27 Sugary beverages Diabetologia SCALE 2013 DEPTH 2015 BREADTH 2015

28 Convinced by the evidence? Gavin Partington, director general of the British Soft Drinks Association, said: This is a health campaign statement masquerading as an academic study

29 Whole grains, refined grains, fibre & type 2 diabetes Aune D; Eur J Epidemiol 2013 InterAct Consortium; Diabetologia; 2015

30 Summary: Carbohydrates Quality matters Reduce refined carbs Consume whole grain & high fibre foods TIP: Choosing high quality carbs Whole grain stamp OR ingredients list Ratio of total carb to fibre >10:1 = avoid <10:1 = good choice <5:1 = great choice (fewer options) Mozaffarian RS et al, Public Health Nutr 2013

31 Nutrition & prevention: Challenges & opportunities Diet is complex Vested interests How to Measure? Analyse? Confusing media messages Research gaps Global populations; ethnic groups RCT evidence hard to obtain Wider determinants, beyond individual factors New horizons MRC Epidemiology Unit

32 Obesity dependent and independent pathways to type 2 diabetes Diet Obesity Type 2 diabetes

33 Take home message: Nutrient focus poor industry food formulation & poor consumer food choice

34 In all populations Manage weight Foods quantity matters quality is relevant Focus on foods, not isolated nutrients Consider overall eating patterns Non-dietary factors also important (physical activity, smoking, other lifestyle factors) Dietary advice for the prevention and management of type 2 diabetes General population Population at risk of type 2 diabetes People with T2D Specific considerations in management of T2D Co-ordinate dietary intake with type & dose of medication In specific approaches (low-carb or very-lowcalorie diet): monitor blood glucose adjust (or stop) medication to avoid hypoglycaemia Forouhi NG et al, BMJ 2018

35 Thank you MRC Epidemiology Unit Nick Wareham Fumiaki Imamura, Eirini Trichia, Jusheng Zheng, Albert Koulman, Claudia Langenberg, Stephen Sharp InterAct Consortium collaborators Funders

36 Hu T et al; Am J Epi trials; n=2,788. (LC 4-45%TE) 11 trials; n=1,369. (LC <20%TE) Low-carb vs low-fat diet Higher HDL-C, lower triglycerides Higher or less LDL, total Limitations: cholesterol Dose -definition low-carb & Weight loss: weight low-fat variable +++ differences at 6m lost at 12m Quality of carb/fat Energy intake Sample size, Duration Compliance, Completion Quality, Bias, Publication bias Mansoor et al; BrJNutr 2016

37 Focus on foods, diet pattern Mozaffarian; Circulation. 2016

38 Dairy consumption Milk Yoghurt Cheese Author Year CHD Stroke T2DM Guo 2017 Alexander 2016 Soedamah-Muthu 2011 Gijbers 2016 Aune 2013 Gao 2013 Elwood 2010 Guo 2017 Alexander 2016 Qin 2015 Gijbers 2016 Chen 2014 Aune 2013 Gao 2013 Tong 2011 Guo 2017 Alexander 2016 Qin 2015 Gijbers 2016 Dairy & health outcomes Summary evidence from systematic reviews & meta analyses of prospective studies Eirini Trichia, PhD student

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