Low carbohydrate diets- do they have a place?
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1 Low carbohydrate diets- do they have a place? Grant Schofield Professor of Public Health AUT University, Auckland
2 Atherogenic dyslipidemia is [primarily] driven by the glycemic environment, especially sugar and refined carbohydrate in the context of insulin resistance
3 A balanced diet [in the context of whole food] is one which normalises blood glucose and prevents the hypersecretion of insulin
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13 Inflammation Insulin resistance Stress Poor sleep Genes/ethnicity Age? Obesity Too much exercise High insulin Low physical activity Gluten diet High trans fat diet Smoking Pollution High sugar diet High alcohol diet environmental toxins Too much/too little sun High iron Poor gut microbes
14 High insulin NEUROPSYCHIATRIC Alzheimers / other dementias Peripheral neuropathy Retinopathy Neuro-psychiatric disorders Parkinson s disease Autism GASTROINTESTINAL Diabetes: Type 2 / Gestational Hypertriglyceridaemia Non-alcoholic fatty liver disease Ulcerative colitis ENDOCRINE Chronic inflammation Fatty liver Obesity PCOS Tinnitus Vertigo Meniere s disease Periodontal disease CIRCULATORY Atherosclerosis Cardiomyopathy Endothelial dysfunction (microvascular disease and peripheral vascular disease) Stroke Thrombosis (DVT) Hypertension SKELETAL Osteoporosis CANCER Breast, ovarian colon bladder, pancreas, liver, prostate UROLOGY Nephropathy, erectile dysfunction INFLAMMATION Osteoarthritis Rheumatoid arthritis rofts, Zinn, Wheldon & Schofield. In submission: (2014).
15 Low carb Zone Learn Low fat
16 Percent change Insulin Insulin Resistantsensitive Insulin Resistant Insulin sensitive Low fat Low carb
17 Glycemic environment markers HbA1C (CHO) C peptide [insulin secretion] (CHO) TG (sugar, CHO) HDL (more SFA and less CHO) Apo-B (CHO)
18 The importance of HbA1C
19 HbA1C
20 HbA1C Diabetes CHD Stroke Cancer
21 HbA1C
22 CVD presence adjusted odds 1141 angiography Non-diabetic HbA1C CVD severity CVD complexity 1 0 <5.5% <5.7% <6.1% >6.1% HbA1C quartile
23 C peptide [insulin secretion]
24 Population incidence / C peptide [insulin secretion] No IR No glycemia IR No glycemia IR + glycemia
25 Population incidence / AMI No IR No glycemia IR No glycemia IR + glycemia
26 Population incidence / AMI CAD No IR No glycemia IR No glycemia IR + glycemia
27 LDL-C, mmol/l Triglycerides, mmol/l HDL-C, mmol/l Dietary Fats & Blood Lipids ApoB 0.00 TG 0.05 HDL MUFA SFA PUFA MUFA SFA PUFA Δ ApoB? SFA LDL MUFA PUFA Meta-analysis of 60 feeding RCTs. Mensink & Katan, AJCN 2003
28 Odds ratio AMORIS ApoB Risk of MI Male Female ApoB HDL LDL ` Decile Decile
29 Cumulative % frequency 100 Phenotype A Large buoyant (benign) Phenotype B small dense (harmful) ApoB
30 Eat more fat?
31 Percent change Eat more fat? Ad lib Low carb high fat 10 0 Body mass Ab Fat TG TG AUC HDL TG/ HDL ApoB ApoB/ ApoA-1Small LDL Insulin Glu HOMA Low fat calorie restricted Lepti n Total SFA Insulin
32 Percent change Ad lib Low carb high fat Eat more fat? Low fat calorie restricted IL-6 IL-8 TNF-a MCP-1 I-CAM E-selectin PAI
33 Triglycerides (mg.dl) Eat more fat? Low fat Meal Low carb high fat Pre
34 Case control odds of incident CHD in EPIC (Norfolk) cohort of
35 Total Fatty acids - no effect Saturated fatty acids - harm Odd chain fatty acids - protection Even chain fatty acids - harm
36 Dietary Fats & CHD Events Meta-analysis SFA n-3 Trans fats Chowdury et al, Annals Intern Med 2014
37 Saturated Fat & CHD Events Meta-analysis 16 prospective cohort studies from around the world SFA Siri-Tarino et al, AJCN 2010 No Significant Association RR comparing extreme categories (highest vs. lowest) of saturated fat intake
38 Meta-analysis
39 Jackobsen Prospective Hooper Cocnrane review RCTs Meta-analysis All cause CVD CV events Fat intake mortality mortality RR 0.86 ( ) Mod evid combined Modified fat intake Reduced fat intake Saturated fat intake Substitutions
40 Substitutions asked Meta-analysis Carbs for saturated fat Monounsaturated fat for saturated fat Polyunsaturated fat for saturated fat Polyunsaturated fat for carbs
41 High fat dairy?
42 Food Sources: Dairy & CVD Mortality Meta-analysis Milk RR = 0.96 (0.81, 1.13) Cheese RR = 1.00 (0.81, 1.24) O Sullivan et al., Am J Public Health 2013
43 Dairy Foods & Diabetes RR of 1. Diabetes 0.95 Among 340,234 Europeans from 8 countries, with 12,403 cases of incident diabetes P-trend= P-trend=0.06 Milk Yogurt Cheese Quintiles of Consumption P-trend=0.01 Adjusted for age, sex, center, education, smoking, physical activity, alcohol intake, and consumption of fruits, vegetables, red meat, processed meat, sugar sweetened beverages, coffee, cereals, and cerearl products. Sluijis et al., AJCN 2012
44 We need a new pyramid
45 Evidence? Science Biology EpidemiologyExperiments Culture Practice
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50 6 things in Common 1. They Are Low in Added Sugar 2. They Eliminate Refined Carbohydrates 3. They Eliminate Industrial Vegetable Oils 4. They Eliminate Artificial Trans Fats 5. They Are High in Vegetables and Fibre 6. They Focus on Foods Instead of Calories
51 The REAL food guidelines Real food for real people, based on real evidence
52 The REAL food guidelines Real food for real people, based on real evidence 1. Enjoy nutritious foods everyday including plenty of fresh vegetables and seasonal fruit.
53 The REAL food guidelines Real food for real people, based on real evidence 1. Enjoy nutritious foods everyday including plenty of fresh vegetables and seasonal fruit. 2. Buy and prepare food from whole unprocessed sources of dairy, nuts, seeds, eggs, meat, fish and poultry.
54 The REAL food guidelines Real food for real people, based on real evidence 1. Enjoy nutritious foods everyday including plenty of fresh vegetables and seasonal fruit. 2. Buy and prepare food from whole unprocessed sources of dairy, nuts, seeds, eggs, meat, fish and poultry. 3. Keep sugar, added sugars, and processed foods to a minimum in all foods and drinks.
55 The REAL food guidelines Real food for real people, based on real evidence 1. Enjoy nutritious foods everyday including plenty of fresh vegetables and seasonal fruit. 2. Buy and prepare food from whole unprocessed sources of dairy, nuts, seeds, eggs, meat, fish and poultry. 3. Keep sugar, added sugars, and processed foods to a minimum in all foods and drinks. 4. If you drink alcohol, keep your intake low.
56 The REAL food guidelines Real food for real people, based on real evidence 1. Enjoy nutritious foods everyday including plenty of fresh vegetables and seasonal fruit. 2. Buy and prepare food from whole unprocessed sources of dairy, nuts, seeds, eggs, meat, fish and poultry. 3. Keep sugar, added sugars, and processed foods to a minimum in all foods and drinks. 4. If you drink alcohol, keep your intake low. 5. Prepare, cook, and eat minimally processed traditional foods with family, friends, and your community.
57 A note to physicians: Advise to restrict sugar and starches to the degree necessary to maintain stable BGL and to prevent hypersecreting insulin even with stable BGL
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