diet and non-communicable diseases (ncds): latest...
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Diet and Non-Communicable Diseases (NCDs): latest evidence
Fumiaki Imamura, MS, PhD [email protected]
23 Nov 2016, London
↑↑↑ publications in our field ↑↑↑
• N journals=436
• N publications:
Pubmed
0
30000
60000
90000
1960 1970 1980 1990 2000 2010
Global Burden of Disease
0
5
10
15
20
25
Communicable Nutr Deficit CVD and Cancer
1990 2010
Million Deaths
Lozano et al., Lancet 2012; 380: 2095–128
Global Burdens of Diseases
GBD 2013 Risk Factors Collaborators, Lancet, 2015
% Loss of Life Years
0 2.5 5.0 7.5 10.0
Diet
Smoking Nutr Deficit
Alcohol
Physical activity
Obesity
Hypertension
Studies of Diet and Health
D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S
Overall Diet
Nutrients
Foods
e.g.
• Saturated fat
• Meat/oils
• High-fat diet
↓ SFA ↓ Heart disease ???
in arteries by Gulliver G,
Med Chir Trans, 1843
The Elements of Physiology Blumenbach, 1828
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
0 2 4 6 8
Year
0.06
0.05
0.04
0.03
0.02
0.01
0
Heart disease %
Howard et al., JAMA, 2006
Control
Intervention
Dietary intakes in WHI
Howard et al., JAMA, 2006
0
15
30
45
Baseline Year 6
0
15
30
45
Baseline Year 6
Control group “Low fat” % of
energy
Total fat
SFA
Total fat*
SFA *
*P<0.05
Dietary intakes in WHI
Howard et al., JAMA, 2006
0
15
30
45
Baseline Year 6
0
15
30
45
Baseline Year 6
Control group “Low fat” % of energy
or gram/day Nuts Carb.
PUFA
Nuts *
Carb. *
PUFA*
*P<0.05
↓ SFAs,
High in what?
Energy from butter
oil (PUFA)
sugars
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) Effect
On CHD
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)
“Summary evidence” on ↓ SFA intake and heart disease
Meta-analysis N Relative Risk
(95% CI) Effect
On CHD
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)
↓ SFAs,
High in what?
Energy from butter
olive oil
sugars
Is butter really back? Clarifying the facts on fat Harvard School of Public Health
Trans-fat-rich margarine
“Summary evidence” on ↓ SFA intake and heart disease
Meta-analysis N Relative Risk
(95% CI) Effect
On CHD
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)
“Summary evidence” on ↓ SFA intake and heart disease
Meta-analysis N Relative Risk
(95% CI) Effect
On CHD
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)
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
D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S
Overall Diet
Nutrients
Foods
e.g.
• Saturated fat
• Meat/oils
• High-fat diet
Sodium and NCDs
D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S
Overall Diet
Nutrients
Foods
e.g.
• Sodium →
Blood pressure
• Cardiovascular diseases (CVD)
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
D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S
Overall Diet
Nutrients
Foods
e.g.
• Sodium →
Blood pressure
• Processed meats
• Cardiovascular diseases (CVD)
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
↓ Risk= 77%
de Lorgeril et al., Circulation, 1999;99:779-785
Physicians’ advice only
Mediterranean-type diet
PREDIMED Study 7,447 adults at high risk of CHD*
Total CHD
*with diabetes or 3 risk factors for heart diseases Estruch R et al., NEJM, 2013; Appel LJ, Van Horn L., NEJM, 2013
↓ 29% (10-44%)
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)
±0% –20%
Higher risk Lower risk
–10%
TYN Tong et al., BMC Medicine, 2016
How much of CVD (%) can be preventable by the diet???
27.8
8.5
0
10
20
30
PREDIMED Spain
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
Overall Diet
Nutrients
Foods
• “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
D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S
Overall Diet
Nutrients
Foods
e.g. Sat fat, sodium, …
• Ecological or metabolic studies
Dietary patterns for nutrient studies
D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S
Overall Diet
Nutrients
Foods
• What are the healthy/unhealthy components?
Healthy/Unhealthy diet Why?
Resveratrol
Oleocanthal
Trimethyl-amine oxide (TMAO)
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
Coconut oil
Butter
Beef fat
Pork fat (lard)
Soybean oil
Olive oil
Corn oil
Canola oil
Safflower oil
0 20 40 60 80 100
Adapted from Dietary Guidelines for Americans 2010
% of total fat
Monounsaturated (MUFA)
Polyunsaturated (PUFA)
Saturated (SFA)
Saturated fatty acids (SFA) high in solid fat and animal fat
SFAs and health
in arteries
Gulliver G,
Med Chir Trans, 1843
The Elements of Physiology Blumenbach, 1828
Borch, Anal Chem, 1975.
Blood SFA≠dietary SFA Sugars/Alcohol → Blood SFA
High carb.
25
20
15
10
5
0 0 40 80 120 160
Total Fat, g/day
Breast Cancer
per 100,000
Carroll, Cancer Res, 1975;35:3374-3383 Bingham et al., Nat Rev Cancer,2004;4:206
Fat and breast cancer
Total fat, SFAs and breast cancer
±0% +20% –20%
Higher risk Lower risk
Total Fat
SFAs
Multi-countries*
UK
Hunter et al., NEJM, 1996;334:356-61 Key, AJCN, 2011;94:1043-52
*US, Netherlands, Sweden, Canada