Is There a Perfect Diet for Health- and Does Change Matter?

Transcription

1 Is There a Perfect Diet for Health- and Does Change Matter? Frank B. Hu, MD, PhD Chair, Department of Nutrition Professor of Nutrition and Epidemiology Harvard T.H. Chan School of Public Health

2 Unhealthy diets: the most important contributor to the global burden of diseases

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4 Saturated Fat Debate

5 Fats, Carbohydrates and Coronary Heart Disease Replacing 5% of energy from saturated fat with equivalent energy from polyunsaturated fat, monounsaturated fat, or whole grains associated with 25%, 15%, and 9% lower risk of heart disease Swapping 5% of saturated fat calories for same amount of energy from refined starch and sugars did not change heart disease risk Li et al., J Am Coll Cardiol 2015

6 Type of Fats and Mortality Wang et al., JAMA Intern Med 2016

7 Dairy Fat Dairy Fat Paradox 60% saturated fat Increases LDL increased risk of cardiovascular disease Replacing dairy fat with unsaturated fat associated with lower risk of cardiovascular disease 5% fatty acids Trans-palmitoleic acid (16:1n-7) associated with higher HDL and lower triglycerides, blood pressure, fasting insulin level and incidence of diabetes Current recommendation: consume low-fat dairy in moderation Sun et al. Am J Clin Nutr 2007; Mozaffarian et al. Ann Intern Med 2010; Yakoob et al. Am J Clin Nutr 2014

8 Coconut Oil Marketed as healthy (high in MCT, but mostly c:12:0) Shown to increase LDL compared with olive oil and safflower oil Similar LDL-raising effects as butter, beef fat and palm oil Higher LDL increased risk of cardiovascular disease Tropical oils such as coconut oil or palm oil should not be used as primary culinary fat Sacks et al. Circulation

9 Red Meat and Mortality NHS (P for trend, <0.001) HPFS (P for trend, <0.001) Unprocessed Relative Risk Relative Risk Q1 Q2 Q3 Q4 Q5 0.8 Q1 Q2 Q3 Q4 Q NHS (P for trend, <0.001) HPFS (P for trend, <0.001) Processed Relative Risk Relative Risk Q1 Q2 Q3 Q4 Q5 0.8 Q1 Q2 Q3 Q4 Q5 Pan et al., Arch Intern Med 2011

10 Red Meat and Mortality Substituting 1 serving per day of red meat with other foods associated with 7% to 19% lower mortality risk 9.3% of premature deaths in men and 7.6% in women could be prevented if everyone consumed fewer than 0.5 servings/d (~42 g/d) of red meat Pan et al., Arch Intern Med 2012

11 Plant-based diets as vegetarian diets Foods excluded in different types of dietary patterns NON-VEGETARIAN RED MEAT & POULTRY FISH & SEAFOOD EGGS DAIRY PESCO-VEGETARIAN LACTO-OVO-VEGETARIAN LACTO-VEGETARIAN VEGAN

12 Three Plant based Diet Indices Overall Plant-based Diet Index (PDI) High animal, low plant food intake High plant, low animal food intake Healthful Plant-based Diet Index (hpdi) High animal, high unhealthy plant, and low healthy plant food intake High healthy plant, low unhealthy plant, and low animal food intake Unhealthful Plant-based Diet Index (updi) High animal, high healthy plant, and low unhealthy plant food intake High unhealthy plant, low healthy plant, and low animal food intake

13 Associations between plant based diets and CHD risk: Not all plant based diets are created equal Pooled HRs (95% CI) for CHD according to deciles of the plant-based diet indices HR for extreme deciles: 1.32 (95% CI: ) HR (95% CI) HR for extreme deciles: 0.92 (95% CI: ) HR for extreme deciles: 0.75 (95% CI: ) D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 Deciles of the plant-based diet indices Multivariable model. P trend=0.003 for PDI, and <0.001 for hpdi and updi 13

14 Not all plant based diets are healthy Good Vegan, Bad Vegan by Jane E Brody New York Times, Oct Healthy plant based diets associated with reduced heart disease risk while unhealthy plant based diets associated with increased risk. Plant based diets do not need to exclude all animal products. A vegan who consumes no animal products can be just as unhealthy living on inappropriately selected plant foods as an omnivore who dines heavily on burgers and chicken nuggets. Satija et al. J Am Coll Cardiol 2017

15 Popular diets Low carb (Atkins) Quicker short term weight loss but long term effects uncertain Heart disease and mortality risk with high amounts of protein and animal fat Possible benefit with moderately low carb diet high in healthy protein and fat Ketogenic Very low carb, very high fat, difficult to maintain Ketosis- burn fat Prescribed for patients with epilepsy Long-term effects unknown, potentially problematic, need medical supervision Paleo Some beneficial evidence for weight loss and improved metabolic factors, but studies lack power Very restrictive: eliminates grains, legumes, dairy, refined sugar, potatoes, salt, processed foods

16 Popular diets Gluten free Unnecessary for individuals without celiac disease or gluten sensitivity Could lead to suboptimal intake of fiber and B vitamins Intermittent fasting Brief periods of fasting and normal eating Ex. 5:2 diet Designed to prevent metabolic adaptations that occur with conventional diets Some positive short-term evidence, no long term evidence Difficult to maintain

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19 Polyphenols Phenolic acids Lignans Flavonoids Stilbenes Chlorogenic acid Caffeic acid Ferulic acid Food sources: coffee, corn flour, blueberry, kiwi Seco isolariciresinol Matairesinol Food sources: linseed, lentile, cereal Resveratrol Food sources: red wine Anthocyanins Isoflavones Flavonols Flavanones Flavanols Cyanidin Peonidin Food sources: blueberry, blackberry, grapes, strawberry Genistein Daidzein Glycitein Food sources: soy foods Quercetin Kaempferol Isorhamnetin Food sources: onion, leek, kale Hesperetin Naringenin Food sources: citrus fruits, tomato Catechin Epicatechin Food sources: green tea, chocolate, beans

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21 Changes in Diet Quality and Total and Cause- Specific Mortality Sotos-Prieto M, Bhupathiraju SN, Mattei J, Fung TT, Li Y, Pan A, Willett WC, Rimm EB, Hu FB. New England Journal of Medicine (July 2017)

22 Fats: MUFA, SFA Mg Fruit, Vegetables Nuts, meat Single nutrients or foods Dietary patterns Mediterranean diet Healthy eating pattern DASH pattern Vegetarian pattern Diet quality scores AMED AHEI DASH Cespedes EM, Hu FB.. Am J Clin Nutr 2015;101: BACKGROUND

23 The Alternate Healthy Eating Index-2010 (AHEI) score Based on recommendations for food and nutrient consumption with current evidence of beneficial health effects The Alternate Mediterranean diet (AMED) score Comprised of foods and nutrients characteristic of the Mediterranean pattern The Dietary Approach to Stop Hypertension (DASH) score Developed from the DASH dietary recommendations aimed to reduce blood pressure AHEI: Chiuve et al., J Nutr. AMED Fung TT et al., Circulation. DASH: Fung TT et al., 2008 Arch Intern Med. BACKGROUND

24 2 We also examined shorter- and longer-term changes in diet quality and total and cause-specific mortality. 8 y change Diet Subsequent 16y mortality risk 16 y change Diet Subsequent 8 y mortality risk AIMS

25 Using 1986 as baseline for both cohorts, with follow up until 2010 Exclusions: CVD history and cancer at baseline Missing information on diet and other lifestyle covariates. Implausible total daily energy intake (i.e., men <800 or >4200 kcal/day; women <500 or >3500 kcal/day). Participants who died before ,100 men in the HPFS and 44,501 women in the NHS METHODS

26 12 year changes ( ) in diet quality scores and risk of total mortality Q1 Q2 Q3 Q4 Q5 P trend Alternative Healthy Eating Index (range 0 110) MV adjusted model (1.05, 1.19) Alternate Mediterranean Diet (range 0 9) MV adjusted model (0.99, 1.13) Dietary Approach to Stop Hypertension (range 8 40) MV adjusted model (1.00, 1.12) 1.06 (1.00, 1.13) 1 [Ref] 0.97 (0.91, 1.04) 1 [Ref] 1.01 (0.94, 1.07) 1 [Ref] 0.94 (0.88, 1.01) 0.93 (0.87, 0.98) 0.93 (0.87, 1.00) 0.91 (0.85, 0.97) < (0.78, 0.91) < (0.84, 0.95) <.0001 Improvement in diet quality (13 33%) Decrease in diet quality (9 22%) 9 16% total mortality 6 12% total mortality Abbreviations: MV, multivariable; Multivariable adjusted model adjusted for age (in month), Adjusted for age, initial diet quality score (quintiles), race (white vs. others), family history of myocardial infarction, family history of diabetes, family history of cancer, aspirin use, multivitamin use, initial body mass index (calculated as weight in kilograms divided by height in meters squared) (<23, , , , and 35), initial and changes in smoking status (never to never, never to current, past to past, past to current, current to past, current to current or missing indicator), initial and changes in smoking pack years (continuous) among ever smokers, initial and changes (all in quintiles) in physical activity and total energy intake and menopausal status and hormone use in womenhistory of hypertension (yes vs. no), history of hypercholesterolemia (yes vs. no), type 2 diabetes, weight change (quintiles), cholesterol lowering and antihypertensive medications. For DASH, we additionally adjusted for change and initial alcohol intake (in quintiles). Results for Nurses Health Study and Health Professionals Follow up Study were combined with the use of the fixed effects model. RESULTS

27 12 year changes ( ) in diet quality scores and total mortality, CVD mortality and cancer mortality per 20 percentile of increase in each score (calculated from the median value of each quintile ) Overall mortality AHEI (range 0 110) 0.83 MV model (0.78, 0.88) AMED (range 0 9) 0.92 MV model (0.89, 0.95) DASH (range 8 40) MV model 0.90 (0.86, 0.94) CVD mortality 0.85 (0.76, 0.96) 0.93 (0.88, 0.99) 0.96 (0.88, 1.05) Cancer mortality 0.94 (0.85, 1.04) 0.98 (0.93, 1.03) 0.91 (0.84, 0.98) A 20% increase was associated: 8 17% total mortality 7 15% CVD mortality RESULTS

28 Shorter- and longer-term changes in diet quality Alternate Healthy Eating Index 2010 (range 0 110) Alternate Mediterranean Diet (range 0 9) DASH (range 8 40) 8y Changes 12y Changes 16y Changes 8y Changes 12y Changes 16y Changes 8y Changes 12y Changes 16y Changes Hazard Ratio (95%CI) for total mortality INTRODUCCIÓN 1. INTRODUCCIÓN The association was strengthened when longer changes were evaluated

29 Improving adherence to ANY of the three diet quality scores over 12 y is associated with significantly lower risk of mortality, and CVD mortality. Longer term changes in diet strengthened the association Maintenance of your diet quality over time as an adult can have a meaningful effect on mortality and longevity. These results underscore the importance of the strategies to promote and sustain a healthy diet in improving longevity among middle-aged and older adults. CONCLUSION

30 As an example, a person increasing ~22 points (20%) out of 110 for the AHEI score over a 12 year lower the risk of total mortality by 20% Emphasizing even small dietary changes should be an important part of nutrition and public health policies. Monitoring national trends of diet quality over time

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32 Healthy diet & lifestyle factors and longevity Physical activity ( 3.5h/week) Not smoke Moderate alcohol Drinking Female 5 15 Male 5 20 g/day Alternative healthy eating index (top 40%) Body mass index ( kg/m 2 )

33 Overview of Data Source and Method US CDC WONDER Age and sex mortality rate 2014 NHANES NHS HPFS Prevalence of lifestyle factors Risk Ratio of mortality associated w.t lifestyle by age and sex Lifestyle-specific Mortality Rate LIFETABLES Lifestyle-specific Life Expectancy Woloshin S et al. J Natl Cancer Inst 2008;100(12):845 53; Angelantonio ED et al. JAMA. 2015;314(1):52 60.

34 Nurses Health Study (NHS, n=78,865, baseline age 46) FFQ FFQ FFQ FFQ FFQ FFQ FFQ FFQ FFQ Health Professionals Follow-up Study (HPFS, n=44,354,baseline age 53) FFQ FFQ FFQ FFQ FFQ FFQ FFQ Exclusion criteria: implausible energy intake, a Body Mass Index (BMI) <18.5 kg/m 2 at baseline, or with a missing value for BMI, physical activity, alcohol or smoking at baseline.

35 Lifestyle factors Lifestyle factors include diet, BMI, physical activity, smoking and alcohol; We calculated cumulative average levels of lifestyle factors using the latest two repeated measurements for diet, physical activity and alcohol consumption; Smoking status was updated every other year; To minimize the reverse causality bias resulting from weight loss due to preexisting illness, we applied the lifelong maximum BMI by age-at-risk (Yu E, Ann Intern Med 2017;166:613-20).

36 Calculation of low-risk lifestyle score Binary low risk score (0 or 1 for each, 0 5 for all) Expanded low risk score (1 5 for each, 5 25 for all) Score for individual factor Moderate or vigorous activity (hours/week): Smoking (cigs/day) never Current 25 Current Alternative healthy eating index Alcohol (g/day) 5 15 (female) or 5 30 g (male) current 1 14 past never Top 40% Fifth 1 Fifth 2 Fifth 3 Fifth 4 Fifth Body mass index (kg/m 2 )

37 Hazard ratios (95% CIs) of total and cause-specific mortality according to numbers of low-risk lifestyle risk factors Person Deaths from any cause Cancer deaths CVD deaths Years Cases RR (95% CI) Cases RR (95% CI) Cases RR (95% CI) Number of low-risk lifestyle factors ** Zero (ref.) (ref.) (ref.) One ( ) ( ) ( ) Two ( ) ( ) ( ) Three ( ) ( ) ( ) Four ( ) ( ) ( ) Five ( ) ( ) ( )

38 Estimated life expectancy at age 50 according to the number of low-risk lifestyle factors 50 Female Male Life Expectancy at age 50 (year) Zero None One Two Three Four Five Number of low-risk lifestyle factors 0 Zero None One Two Three Four Five Number of low-risk lifestyle factors xpect to live to age: US average life expectancy at age 50: Female: 33.6; Male: 29.8 based on CDC mortality rate of 2014

39 Estimated gained life expectancy by adopting healthy lifestyle factors as compared to zero low-risk factor 16 Female 16 Male Gained Life Expectancy (year) Number of low-risk lifestyle factors Ref: Zero Five Four Three Two One Age (year) Age (year)

40 Estimated life expectancy at 50 according to expanded low-risk lifestyle score Women Men Number of expanded low-risk lifestyle score Number of expanded low-risk lifestyle score US average life expectancy at age 50: Female: 33.6; Male: 29.8 based on CDC mortality rate in 2014

41 Stratified analysis by BMI Zero Zero

42 Stratified analysis by smoking status Zero Zero

43 Life Expectancy at birth of American Time trend of lifestyle factors of US adults Male Female Prevalence of obesity among adults, % AHEI Male Female 5 Flegal KM et al. JAMA 1994, 2012, Physical activity Wand DD et al. JAMA Intern Med Oct;174(10): ; Mozaffarian D et a. Circulation. 2015;133:e38 e360

44 Summary Adherence to a low-risk lifestyle could prolong life expectancy at age 50 by 14.0 years in US women and 12.2 years in US men as compared to individuals without any of the low-risk lifestyle factors. The gap in life expectancy between the US and other developed countries might be narrowed by improving lifestyle factors. Policy changes are needed to improve food and built environments and make healthy choices easier, accessible, more affordable, and normative.

45 Conclusions Replace saturated fat with unsaturated fat to reduce heart disease and mortality risk Healthy sources of unsaturated fat: Olive oil, canola oil and other vegetable oils, nuts/seeds, avocado, fish/seafood etc. Consume low-fat dairy in moderation Limit red and processed meats and replace them with healthy protein sources Healthy diets contain foods such as fruits, vegetables, legumes, nuts, whole grains and can include some animal products Reduce consumption of refined grains and sugars A healthy diet and lifestyle adds more years to life and more life to years

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47 Acknowledgement Harvard University Dong Wang Klodian Dhana Xiaoran Liu Mingyang Song Gang Liu Laila Al-Shaar Hyun Joon Shin Qi Sun Ellen Hertzmark Meir Stampfer Walter C. Willett Frank B. Hu Huazhong University of Science and Technology, China An Pan University of Cambridge, England Stephen Kaptoge Emanuele Di Angelantonio Erasmus Medical Center, the Netherlands Josje Schoufour Oscar Franco