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

Diet and Non-Communicable Diseases (NCDs): latest evidence Fumiaki Imamura, MS, PhD fumiaki.imamura@mrc-epid.cam.ac.uk 23 Nov 2016, London

publications in our field N journals=436 N publications: 90000 60000 30000 0 1960 1970 1980 1990 2000 2010 Pubmed

Million Deaths 25 20 15 10 5 0 Global Burden of Disease 1990 2010 Communicable Nutr Deficit CVD and Cancer Lozano et al., Lancet 2012; 380: 2095 128

Diet Hypertension Nutr Deficit Smoking Obesity Alcohol Global Burdens of Diseases Physical activity % Loss of Life Years 0 2.5 5.0 7.5 10.0 GBD 2013 Risk Factors Collaborators, Lancet, 2015

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

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

Saturated fatty acids (SFA) consumption raises blood cholesterol. Publications N trials Mensink, Arteriosc Thromb, 1993 27 Clarke, BMJ, 1997 395 Mensink, Am J Clin Nutr, 2003 60 SFA PUFA SFA MUFA Cholesterol Decrease in total cholesterol (mmol/l)

Women s Health Initiative (WHI) 48835, randomised 19541 Low fat 29294 Usual Heart disease % 0.06 0.05 0.04 0.03 0.02 0.01 Control Intervention 0 0 2 4 6 8 Year Howard et al., JAMA, 2006

Dietary intakes in WHI % of energy Control group Low fat 45 45 Total fat 30 30 Total fat* 15 SFA 15 SFA * 0 Baseline Year 6 0 Baseline Year 6 *P<0.05 Howard et al., JAMA, 2006

Dietary intakes in WHI % of energy or gram/day 45 Control group Nuts Carb. 45 Low fat Carb. * 30 30 Nuts * 15 15 0 Baseline Year 6 PUFA 0 Baseline Year 6 PUFA* *P<0.05 Howard et al., JAMA, 2006

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

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

Summary evidence on SFA intake and heart disease Meta-analysis N Relative Risk (95% CI) Observational Jacobsen, 2009 11 0.87 (0.77, 0.97) Mente, 2009 11 1.06 (0.96, 1.15) Siri-Tarino, 2010 16 1.07 (0.96, 1.19) Chowdhury, 2014 20 1.03 (0.98, 1.07) Farvid, 2014 10 0.90 (0.85, 0.94) de Souza, 2015 12 1.06 (0.95, 1.17) Trials Skeaff, 2009 8 0.83 (0.69, 1.00) Mozaffarian, 2010 7 0.81 (0.70, 0.95) Hooper, 2000/01/12/15 23 0.93 (0.84, 1.02) Ramsden, 2010/13/15 7 0.98 (0.82, 1.19) Schwingshackl, 2014 12 0.76 (0.54, 1.09) Horcombe, 2015 7 0.99 (0.78, 1.25) Effect On CHD

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

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

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

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

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

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

Smoking and health

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

Lyon Diet Heart Study 605 CHD patients Mediterranean-type diet Risk= 77% Physicians advice only de Lorgeril et al., Circulation, 1999;99:779-785

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

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

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

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

How much of CVD (%) can be preventable by the diet??? 30 20 27.8 10 0 PREDIMED Spain 8.5 Norfolk UK

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

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

Nordic diet Emphasis on Oily fish Rye breads Rapeseed oil Berries Adamsson, J Intern Med, 2011;269:150-159 Uusitupa, J Intern Med, 2013;274:52-66 Poulsen, Am J Clin Nutr, 2014;99:35-45 Mithril, Public Health Nutr, 2013;16:777-785 Kanerva, Br J Nutr, 2013;109:520-528 Kolehmainen, Am J Clin Nutr, 2015;101:228-239

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

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

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

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

Healthy British Diet?

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

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 0 20 40 60 80 100 % of total fat Adapted from Dietary Guidelines for Americans 2010

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

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

Fat and breast cancer 25 Breast Cancer per 100,000 20 15 10 5 0 Total Fat, g/day 0 40 80 120 160 Carroll, Cancer Res, 1975;35:3374-3383 Bingham et al., Nat Rev Cancer,2004;4:206

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;94:1043-52 Hunter et al., NEJM, 1996;334:356-61