is butter back? and other vexing questions from the ...€¦ · and other vexing questions from the...

Is Butter Back? And Other Vexing Questions from the Nutrition Science and News World Eric B Rimm, ScD Professor of Epidemiology and Nutrition Harvard School of Public Health Harvard Medical School

Ann Intern Med. 2014;160:398-406.

Conclusion from Chowdhury Abstract

“Current evidence does not clearly support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats.”

(Chowdhury R. et al. Ann Intern Med 2014:160:398-406)

Mark Bittman

Butter is Back March 25, 2014

Julia Child, goddess of fat, is beaming somewhere.

29.533

http://topics.nytimes.com/top/reference/timestopics/people/b/mark_bittman/index.html

(One double bond)

(Many double bonds)

Classification by number (and location) of double bonds and carbon chain length

• Comprehensive look at multiple fats • Inclusion of cohort studies of diet and

biomarkers and randomized trials • Based on “hard endpoints” • Consistent methods across dietary fats

Strengths of Chowdhury et al. See comments on Ann Intern Med website:

http://annals.org.ezp-prod1.hul.harvard.edu/article.aspx?articleid=1846638


• Gross errors in data abstraction from original papers

• Omission of important studies, especially on polyunsaturated fat

• Omission of important bodies of evidence (e.g. feeding studies)

• Lack of specific comparisons, and failure to acknowledge this

• Other issues ….

Problems with Chowdhury et al. See comments on Ann Intern Med website:



Estimated Sources of Calories in US Diet

Sat fat

Mono fat

Poly fat

Trans fat Protein

Other carbs

Potatoes

Whole grain

Refined grain

Added sugar

(unpublished, compiled from NHANES)

Saturated Fat

Trans Fat

Refined Starch, Sugar

Whole Grains

Unsaturated Vegetable Fats --High monounsaturated vegetable fats --High polyunsaturated vegetable fats

Carbohydrates

29.536 W Willett

Replacing Saturated Fat: The Type of Carbohydrate Matters!

Jakobsen et al, AJCN 2010

Risk of CHD among 53,644 adults followed for 12 years. *p<0.05

-20 -10 0 10 20 30 40

Change in CHD Risk for Each 5% Energy

SFA → Low GI Carb

SFA → Med GI Carb

SFA → High GI Carb *

Unpublished data from Harvard Cohorts Courtesy of Frank Hu and colleagues

The stakes are high The steaks are high?

IOM Report on Food Availability, 2015

The stakes are high !

0 100,000 200,000 300,000 400,000 500,000 600,000 700,000

Suicide

Kidney disease

Flu and pneumonia

Diabetes

Alzheimer's

Accidents

Stroke

Respiratory disease

Cancer

Heart disease

The Top Ten Causes of Death in the U.S.

0 500000 1000000 1500000 2000000

Others

Diet related

Diet-related vs. non-diet related causes of death in the U.S. (among the top 10)

Obesity Trends* Among U.S. Adults 1986

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Behavioral Risk Factor Surveillance System, CDC.

Prevalence* of Self-Reported Obesity Among U.S. Adults BRFSS, 2012

*Prevalence reflects BRFSS methodological changes in 2011, and these estimates should not be compared to those before 2011.

15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%

Source: Behavioral Risk Factor Surveillance System, CDC.

15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%

Prevalence* of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2013

*Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.

CA

MT

ID

NV UT

AZ NM

WY

WA

OR

CO

NE

ND

SD

TX

OK

KS

IA

MN

AR

MO

LA

MI

IN

KY

IL OH

TN

MS AL

WI

PA

WV

SC

VA

NC

GA

FL

NY

VT

ME

HI

AK

NH MA RI CT NJ DE MD DC

PR GUAM

People are trying to lose weight

Wendy's removes soda option from kids' meal

USA Today Network Mary Bowerman, USA TODAY Network 4:45 p.m. EST January 15, 2015

Wendy's is the latest fast-food chain to remove the soda option from kids' meal menus. That means when parents drive through a pick-up window, they won't see soda as an option on the menu board, but if they decide to order one, they won't be turned down. McDonald's made a similar commitment to drop soda from Happy Meals in 2013.

http://www.usatoday.com/staff/7781/mary-bowerman/

Are Non-nutritive Sweeteners the Magic Bullet?

FDA - Approved Sucralose

Saccharin

Aspartame

Acesulfame potassium

Neotame

Stevia Luo han guo extract

Randomized trials of weight loss where SSB were replaced by Low Calorie Sweetner (LCS)

Miller and Perez, AJCN 2014

Sucralose Affects Glycemic and Hormonal Responses to an Oral

Glucose Load

Pepino et al Diabetes Care 2013

$60 billion $ spent annually by Americans to try to lose weight

108 million Number of Americans who diet each year

45% % of Americans who worry about their weight “all” or “some of” the time

But there are obstacles

7.6 Million reported cases of weight loss fraud

71% % of Americans surveyed who said they heard moderate or high levels of contradictory information about nutrition.

35 # of diets evaluated by US News and World Reports for 2015 rankings

Source: Consumer Fraud in the United States, 2011: The Third FTC Survey, Staff Report of the Bureau of Economics, Federal Trade Commission, April 2013

“Mir

acle

in a

B

ottl

e”

BMJ, December 17, 2014

Review of randomly selected TV shows form Dr. Oz and The Doctors

(n=40 episodes each)


Is the Evidence Accurate?


How did we get here?

What can we do?

Wang et al: JAMA – Intern Med, 2014

THE ALTERNATE HEALTHY EATING INDEX 2010

Component Minimum score (0) Maximum score (10)

Vegetables (serv) 0 per day 5 per day

Whole fruits (serv) 0 per day 4 per day

Nuts and legumes (serv) 0 per day 1 per day

Red meat and processed meat (serv) ≥1.5 per day <1 per month

Sugar sweetened beverages (serv) ≥1 per day <1 per month

Alcohol (drinks/day) Women: >2.5 Men: >3.5

Women: 0.5 - 1.0 Men: 0.5 - 2.0

Polyunsaturated fat (% kcal) <2% ≥10%

Trans fat (% kcal) ≥4% ≤0.5%

Omega-3 fat (mg/day) 0 250

Sodium (mg/day) Highest decile (>5000 mg)

Lowest decile (<1600 mg)

Whole grains (g/day) 0 Women: 75; Men: 90

Wang et al: JAMA – Intern Med, 2014

What can we do?

Study Population and Outcome Ascertainment

Nurses’ Health Study II Prospective cohort study that began in 1989 116,808 women who were 25 – 42 years of age at baseline

(Mean: 34.8 yrs ± 4.7)

Incident cases of clinical cardiovascular risk factors Type 2 diabetes, hypertension, hypercholesterolemia n = 30,988

Incident CHD Nonfatal myocardial infarction or fatal CHD n = 455

Chomistek et al JACC 2015

Definition of Healthy Lifestyle

Physical activity: ≥ 2.5 hrs/wk of moderate or vigorous activity

Smoking: Not currently smoking Diet: Top two quintiles of Alternative Healthy Eating

Index-2010 score BMI: 18.5 – 24.9 kg/m2 Alcohol: ≥ 0 – 15 g/day

T.V. watching: ≤ 7 hrs/wk


CHD risk and PAR% according to optimal lifestyle factor status

Lifestyle Factor

Definition of Optimal

PY at Optimal Level, %

MV-adjusted HR, all factors in model PAR%

BMI 18.5 – 24.9 kg/m2 49.2% 0.67 (0.55, 0.83) 22.8 (9.9, 34.9)

Exercise ≥ 2.5 hrs/wk 43.7% 0.72 (0.59, 0.89) 19.9 (7.3, 31.8)

Diet Top 40% of AHEI-2010 score 41.9% 0.70 (0.57, 0.86) 19.4 (8.1, 30.2)

Smoking Not currently smoking 91.0% 0.29 (0.23, 0.36) 19.0 (13.8, 24.1)

Alcohol > 0– 15 g/day 53.4% 0.78 (0.64, 0.94) 12.8 (3.3, 22.1)

T.V. ≤ 7 hrs/wk 45.9% 1.03 (0.85, 1.24) _________

All 6 Factors 4.6 0.08

(0.03, 0.23) 72.7

(39.0, 89.2)


Healthy Heart Score (Online risk calculator)

Chiuve et al JAHA 2014

Other races, ethnicities and ages Markers of preclinical disease and CVD risk factors Evaluate the effectiveness of the model in clinical settings

NEXT STEPS

How are people trying to lose weight now? Eric B Rimm, ScD Professor of Epidemiology and Nutrition

Harvard School of Public Health Harvard Medical School

http://www.amazon.com/gp/product/images/0959708707/sr=1-13/qid=1189960439/ref=dp_image_0/002-4803551-3796831?ie=UTF8&n=283155&s=books&qid=1189960439&sr=1-13

http://www.amazon.com/gp/reader/097878510X/ref=sib_dp_pt/002-4803551-3796831

http://www.amazon.com/gp/reader/1594866244/ref=sib_dp_pt/002-4803551-3796831

Can we give evidence-based weight loss advice

Large observational data sets with decades of follow-up

Confirmed by

Long term randomized efficacy trials with at least 2 years of follow-up

Evidence-based or not?

Paleo diet


Wheat belly diet


DASH diet


Gluten-free diet


Low-fat diet


Low-carb diet


Mediterranean diet

Paleo diet

Eat Grass-produced meats (lean) Fish/seafood Fresh fruit/vegetables Eggs Nuts/Seeds Oils (olive, walnut, flaxseed, avocado, coconut)

Avoid Grains Dairy Potatoes Refined sugar Legumes (& peanuts) Refined vegetables oils Processed foods Salt Alcohol

Avoid

Paleo diet

Claims

• Humans were built to eat a diet similar to Paleolithic man. We have not evolved to eat in a post-agricultural revolution world.

• Hunter-gatherers did not experience the chronic diseases we do now. If humans adopt a Paleo diet, we would be less likely to have chronic disease.

Eat

Wheat belly diet

Non-starchy vegetables Organic, full fat dairy Fish/shellfish Organic meats (grass-fed, uncured) Eggs Gluten-free flours

Oils (avocado, coconut, olive, flaxseed, macadamia nut, sesame, walnut) Raw nuts/seeds Unsweetened almond or coconut milk Stevia

Avoid Avoid All gluten-containing foods

Dried fruit with added sugar

Processed foods

Gluten-free diet

Claim

• Wheat Belly diet claims genetic changes of wheat strains over time resulted in changes to how we react to consuming wheat.

• Increased inflammation/immune response

Eat

The DASH Diet

Vegetables

Fruits

Dairy (fat-free or low-fat)

Whole grains

Fish

Poultry

Nuts

Lean meats

Avoid Limit Red meat Higher fat meats

Sweets

Sugars & sugary beverages

Sodium

The DASH diet

Claims

• Lowers blood pressure

• Helps with weight loss

The DASH diet

Guidelines

• Provides guidelines for servings of food groups/day

• Limit on sodium per day (either 2300 mg/day or 1300 mg/day)

• Low in salt, saturated fat, cholesterol, total fat

Abundance

The Mediterranean diet

Fruits

Vegetables

Whole grains

Olive oil

Fish

Avoid Moderate Wine

Limited Meat

Poultry

Dairy

We know what works from comparative studies

Comparative studies look at:

Dietary plans

Counseling & support

Long-term vs short-

term results

Dietary plans

0%

25%

50%

75%

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Diet

Macronutrient composition of popular diets

Fat

Carb

Protein

Bertoia and Rimm (submitted)

Change in Vegetable and Fruit Intake and Weight Change over 4 Years Among 125,000 Men and

Women with up to 24 Years of Follow-up.

Bertoia and Rimm (In Prep)



-3.5 -3 -2.5 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2

Avocados

Peaches, Plums, Apricots

Oranges

Melon

Bananas

Grapefruit & Juice

Raisins & Grapes

Apples & Pears

Strawberries

Blueberries

Prunes & Juice

Weight Change Associated with Each Increased Daily Serving, per 4-year Interval (lbs)

NHS1

HPFS

NHS2




-4 -3 -2 -1 0 1 2

Winter Squash

Beans

Brussels Sprouts

Broccoli

String Beans

Green Leafy Vegetables

Summer Squash

Peppers

Cauliflower

Tofu/Soy


NHS1

HPFS

NHS2




-2 -1 0 1 2 3

Corn

Tomatoes

Peas

Cabbage

Potatoes

Onions

Mixed Vegetables

Carrots

Celery


NHS1

HPFS

NHS2

Low-fat diets

Low-fat diets don’t work

Short-term trials Modest weight loss

Moderate compliance

Longer trials Little or no weight loss

Poor compliance

Not a viable weight loss option for most Often fat is replaced with highly processed carbohydrates

Mediterranean diets

Shai I et al. NEJM 2012

Low-carb vs low-fat diet vs. Mediterranean

Estruch et al. NEJM 2013

Men: 55-80 yr Women: 60-80 yr High CV risk without CVD

type 2 diabetics 3+ risk factors

PREDIMED TRIAL: DESIGN

Random

1. Smoking 2. Hypertension 3. ↑ LDL 4. ↓ HDL 5. Overweight/obes 6. Family history

Estruch et al. NEJM 2013

Mediterranean diet and CVD

Working report

Why does the Mediterranean diet work so well?

Calorie control is more acceptable to people than restricting fat.

Mediterranean model encourages culinary diversity.

Enjoyment of eating is maintained and even enhanced.

What’s going on here? Adherence No diet works if people can’t stick to it. Most diets work if people can stick to it. If at first you don’t succeed …..

Dansinger, ML et al. JAMA, 2005;293:43-53

Atkins vs. Zone vs. Weight Watchers vs Ornish

One-year change in body weight by adherence level

Support is also an important component

Appel et al. NEJM, 2011

Remove vs. in-person vs. no support

Takeaways Successful diets for weight loss can emphasize a large range of macronutrient intakes, although low-fat diets are least effective.

All biomarkers of risk are improved when people lose eight.

Ongoing support or counseling is important to achieve and maintain weight loss in all groups.

Successful diets for weight loss can be tailored to individual patients’ personal and cultural preferences to achieve long-term success. Adherence !

The Mediterranean Plate

Another look… Does it pass the Evidence-based test ?

Paleo diet

Paleo Diet: The Evidence on Health

• Sparse knowledge

• A few randomized trials, small numbers, some uncontrolled

• Most studies show improved risk factors

• Could be healthful depending on the specific diet

Paleo diet

Gluten-free diet

Low-fat diet

Wheat belly diet

China Study diet

DASH diet

Mediterranean diet

- Claims about universally effectiveness

- Evidence based on

- Short term feeding

- Excessive weight loss

- Anecdotal reports

- Animal Studies

How to investigate or spot a fad diet

“Mir

acle

in a

B

ottl

e”

Takeaways Some popular diets are grounded in more science than others

-Dash

-Mediterranean

-Low Fat is a definite Fail

Overlap in components of diets may explain why many may work in the right setting

Be wary of the latest diet book or headline. No magic bullet works for everybody

Summary

• The evidence base is strong for the beneficial effects of all aspects of the Mediterranean Diet

• The Mediterranean Diet as a whole has been successfully tested in settings of both weight loss and hard clinical events

Mark Bittman

Butter is Back March 25, 2014

Julia Child, goddess of fat, is beaming somewhere.

29.533

NOT

http://topics.nytimes.com/top/reference/timestopics/people/b/mark_bittman/index.html

Summary

• The evidence is particularly strong that a Mediterranean Diet or other diets high in healthy fats are much more acceptable (and healthy) than a low fat diet and most strongly related to long term health

• www.nutritionsource.org

Even in the absence of weight loss, a good diet is important

CHD risk by # of lifestyle factors: Nurses Health Study II (24-42y)

Chomistek, et al. Submitted

Essential questions

What claims are being made by popular diets?

What foods are popular diets advising people eat and avoid?

Why do we call them fad diets?

What we know There is no perfect diet

Many diets show promise in some people.

Adherence rules! Give people options—the best diet is the one they can follow

Sometimes changing up the diet can help with adherence

Dietary fat is not the enemy

Diets work best with external support systems

is butter back? and other vexing questions from the ...€¦ · and other vexing questions from the...

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