5. rethinking dietary fats - cedars cardiology la 11-17-16...• soon: thiamine (beriberi), niacin...
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Dariush Mozaffarian, MD DrPHDean
Jean Mayer Professor in Nutrition and Medicine
Controversiesand Advancesin the Treatment of CVD
LosAngeles, CA
Nov 17, 2016
RethinkingDietary Fats
• Research support: National Institutes of Health, GatesFoundation
• Ad hoc honoraria/consulting: Boston Heart Diagnostics,Haas Avocado Board, Astra Zeneca, GOED, DSM, LifeSciences Research Organization
• Royalties: UpToDatechapterson fish oil, dietary fats
Disclosures
Caus es of US Deaths in 2010
USBurden of DiseaseCollaborators, JAMA2013
Explos ion of In te res t: Pas s ion & Confus ion
Source: Google images
Diet & the Heart: Conventional Wisdom
Total Fat,
Saturated Fat
Serum Total and
LDLCholesterol
Coronary Heart
Disease
Ecologicstudies(acrossnationsor populations)
Short-term studiesof single surrogate
outcomes
Explos ion of Nutrition Sc ience
Source: Pubmed/Medline(through Aug2016)
Num
ber
of
Scie
nti
fic
Public
atio
ns
- 8.2 %Etotal fat
- 2.9 %Esaturated fat
+ 4.4 %Etotal fat
(no changein sat. fat)
Diet & Health: Modern Science
Mozaffarian D, Circulation 2016
Mozaffarian & Wu, JACC2011
Dietary Fats: Highly Bioactive
Meta-analysis of 60 randomized feeding trials. Mensink & Katan, AJCN 2003
0.00
0.01
0.02
0.03
0.04
0.05
0 1% 2% 3% 4% 5%
∆H
DL
-C,
mm
ol/
L
-0.15
-0.10
-0.05
0.00
0 1% 2% 3% 4% 5%∆T
rig
lyc
eri
de
s,
mm
ol/
L
-0.20
-0.16
-0.12
-0.08
-0.04
0.00
0.04
0 1% 2% 3% 4% 5%
∆T
ota
l:H
DL
-CR
ati
o
-0.10
-0.06
-0.02
0.02
0.06
0.10
0.14
0.18
0 1% 2% 3% 4% 5%
∆L
DL
-C,
mm
ol/
LDietary Fats & Blood Lipids
PUFA
MUFA
SFA
PUFA
MUFA
SFA
PUFA
MUFA
SFA
PUFA
MUFA
SFA
No ApoB
? ApoCIII
Saturated Fat & CHD Events
Siri-Tarino et al, AJCN 2010
No Sign ifican t As s oc ia tion
16 pros pec tivecohort s tud ies from
around the world
RR comparing extremecategories (h ighes t vs . lowes t)
of s a tu ra ted fa t in take
NOTE: Weights a re from random effects analys is
Ove rall
Finnish - Women
MRC soy
STARS
DART
Finnish - Men
label
Oslo Diet-Heart
Minnesota CS
LA Veterans
73
96
7
276
72
ev
142
252
124
357
393
55
2033
461
n
412
9057
846
4.3
4.4
5.2
6.4
4.3
con
5.2
5.2
4.0
n6
12.9
20.4
8.0
8.9
12.9
Rx
20.7
14.7
14.9
n6
0.81 (0.70, 0.95)
0.64 (0.41, 1.00)
0.86 (0.61, 1.22)
0.41 (0.09, 1.96)
0.91 (0.73, 1.14)
0.55 (0.34, 0.88)
RR (95% CI)
0.75 (0.57, 0.99)
1.08 (0.84, 1.37)
0.74 (0.53, 1.03)
100.00
8.69
12.48
0.94
20.60
8.19
We ight
16.87
18.79
13.44
%
0.81 (0.70, 0.95)
0.64 (0.41, 1.00)
0.86 (0.61, 1.22)
0.41 (0.09, 1.96)
0.91 (0.73, 1.14)
0.55 (0.34, 0.88)
RR (95% CI)
0.75 (0.57, 0.99)
1.08 (0.84, 1.37)
0.74 (0.53, 1.03)
100.00
8.69
12.48
0.94
20.60
8.19
We ight
16.87
18.79
13.44
%
1.33 .5 1 2 3
0.81 (0.70, 0.95)Overall Pooled Effec t
RR (95% CI) % WeightClin ica l Tria l Events n Control Rx
PUFA(% energy) 8 randomized trials, 13,614
participants, 1,042 CHD events
Polyunsaturated Fat & CHD Events: RCTs
Mozaffarian et al,PLoSMed 2010
Rela tive Ris k of CHD
Mozaffarian et al., PLoS Med 2010
SFA and CHD: Different Nutr ient Replacements
Carbohydra te Replac ing Satura ted Fat
0.90 (0.83, 0.97)
RR (95% CI)
0.7 1.0 1.5
Rela tive Ris k of CHD for Each 5% Energy Intake
Women's Hea lth Initia tive RCT 0.98 (0.88, 1.09)
Polyuns atura ted Fat Replac ing Satura ted Fat
Meta -Ana lys is of 8 RCTs
Monouns atura ted Fat Replac ing Satura ted Fat
0.91 (0.87, 0.95)Predicted Effe ct from TC:HDL-C Change
0.87 (0.77, 0.97)Pooled Analys is of 11 Obse rva tiona l Cohorts
Predicted Effe ct from TC:HDL-C Change 1.01 (0.98, 1.04)
Pooled Ana lys is of 11 Observa tiona l Cohorts 1.07 (1.01, 1.14)
RCTs – None --
Predicted Effect from TC:HDL-C Change 0.93 (0.89, 0.96)
Pooled Ana lys is of 11 Observa tiona l Cohorts 1.19 (1.00, 1.42)
Dieta ry Change (each 5% energy)
Average Sources of Calor ies in the US Diet
Sat fa t
Mono fa t
Poly fa t
Trans fa tPro te in
Other carbs
Pota toes
Whole grain
Refined grain
Added s ugar
Sources of Saturated Fat in the U.S.
Based on NHANES2005-06. From USDADietary Guidelines 2010
Meats & CVD Mortality
Total RedMeat (100 g/d)
RR = 1.09(1.00, 1.18)
ProcessedMeat (100 g/d)
RR = 1.69(1.37, 2.10)
Rohrmann et al., BMC Medicine 2013
Among 448,568 Europeanmen and women (EPIC),
including 5,556 CVD deaths
Dairy & CVD
RR = 0.88(0.81, 0.96)
Qin et al., Asia Pac Clin Nutr 2015Cheese & CHD: RR 0.91 (0.84, 0.99)
Cheese & Stroke: RR 0.84 (0.71, 1.00)
0.7
0.8
0.9
1
1.1
1.2
Milk Yogurt Cheese
P-trend=0.50
Quintile s of Cons umption
Sluijis et al., AJCN 2012
340,234 Europeans , 8 countries , 12,403 cas es
P-trend=0.06 P-trend=0.01RR of
Diabe tes
Probiotics, Fermentation ?
Dairy and Diabetes: Complex Influences
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
Q1 Q2 Q3 Q4 Q5
RR of
Inciden t
Diabetes
Quintilesof Phospholipid Trans-16:1n-7 (palmitoleic acid)
Mozaffarian et al., AnnalsIntern Med 2010
P trend < 0.001
Among 3,736 older US adults .
Dairy Fat & Diabetes
Rosqvist et al., AJCN2016
Milk Fat Globule Membrane
Chf
basm
Milk Fat Globule Membrane
Rosqvist et al., AJCN2016
Preventing Chronic Diseases: Food Patterns
Mozaffarian D,Circulation 2016
Dietary Pr ior ities: Healthy Food Patterns
Benefit
Harm
Eggs, Poultry, Milk
Butter
*Especiallyextra-virgin olive oil,oybean oil, canola oil
Calor ies, Fat, Single Nutr ients: Misleading
- 8.2 %Etotal fat
- 2.9 %Esaturated fat
+ 4.4 %Etotal fat
(no changein sat. fat)
twitter: @DMozaffarian www.nutritionletter.tufts.edu
Barr iers and Oppor tunities for Healthy Eating
Afshin A et al, The Handbook for Global Health Policy, 2014
Lessons From Past Public Health Successes
USCenters for Disease Control and Prevention, MMWRMorb Mortal Wkly Rep, 1999
Lessons From Past Public Health Successes
•Driver:– Education.– Licensing.– Limitson phone use, texting.
•Car:– Active: seat belts, child seats,
motorcycle helmets.– Passive: padded interiors,
collapsible steeringcolumns,shatterproof glass, air bags.
– Crash safety standards.– Safety inspections.
Road:– Road engineering, guard rails,
rumble strips.– Speed limits.– Stop signs, stop lights, caution
signs.
•Culture:– Designated driver campaign.– Drunk-drivinglegislation.– Private advocacy, e.g. MADD.
Mozaffarian D, Circulation 2016
J ohn Snow, London Cholera Epidemic , 1854
Snow, J. On the Mode of Communication of Cholera , C.F. Cheffins, London 1855
WHI Tria l: Hormone Replacement Therapy
Disease WHI Trial RR Observational RR
Heart disease 1.29 (1.02-1.63)
age<60: 0.59 (0.38-0.90) *
0.61 (0.45-0.82)
Stroke 1.41 (1.07-1.85) 1.45 (1.10-1.92)
Pulm. embolism/DVT 2.13 (1.39-3.25) 2.10 (1.20-3.80)
Breast cancer 1.26 (1.00-1.59) 1.15 (<5 yrs)
1.53 (5+ yrs)
Colorectal cancer 0.63 (0.43-0.92) 0.66 (0.59-0.74)
Hip fracture 0.66 (0.45-0.98) 0.75 (0.68-0.84)
*LaCroix et al., JAMA2011
• 15 reviews, totaling1,583meta-analysesof 228 medicalconditions
• Direct comparison of effectsseen in RCTsvs.observational studies:
–RCTsvs. all observational studies: ratio of RRs=1.08(0.96, 1.22)
–RCTsvs. prospective cohorts: ratio of RRs=1.04(0.89, 1.21)
Cochrane: Observational Studies vs. RCTs
Anglemyer A et al., 2014, The Cochrane Library
Micha & Mozaffarian, Lipids 2010
Saturated Fat and Incident Diabetes
Imamura et al., Plos Med 2016
Dietary Fat and Metabolic Health: RCTs
Dairy Fat and Diabetes: Benefits?
Mozaffarian D, EHJ2015
Butte r & CVD
Pimpin et al., Plos One 2016
Any CVD
CHD
Stroke
Total CVD
Rosqvist et al., AJCN2016
Milk Fat Globule Membrane: Genetic Effects
Benefit
Harm
Differenteffects ofanimal vs.vegetablesources ?
Differenteffects ofvarious
fatty acids ?
Likely - needsmore study
Differenteffects ofvarious
fatty acids ?
Why Our Infatuation with Single Nutr ients?
• In 1753, James Lind tes ted whether ea ting citrus fruits prevented scurvy.
• In 1932, Vitamin C isola ted, confirmed as the active protective nutrient.
One nu trien t → one dis eas e!
• Soon: Thiamine (beriberi), niacin (pe llagra ), iron (anemia),
iodine (goite r), vitamin A (night blindness ), vitamin D (ricke ts ).
• Early 20th century die ta ry guide lines thus focused on preventing nutrien t defic iency
dis eas es . Grea t Depres s ion and World War II food shortages → further emphas is .
• League of Nations , British Medica l Associa tion, and US DA formed panels to create
new minimum requirements for ca lories , prote in, ca lcium, phosphorus , iron, various
vitamins → Nationa l Nutrition Conference for Defens e , Firs t RDAs in 1941.
• Modern die ta ry guide lines were deve loped to meet these new RDAs . Se t precedent
to s ta rt with nu trien t ta rge ts and then trans la te these into food recommendations .
Mozaffarian D, Lancet Diabetes 2016
Nutr ient Focus: Recipe for Confusion
www.nhlbi.nih.gov/health/public/heart/obes ity/wecan/downloads /go-s low-whoa .pdf
What is Driving Policy and Public Choices ?
• Clean labels
• Gluten-free
• Organic
• Local
• Paleo
• Low-carb
• Vegetarian, vegan
• Total fat
• Saturated fat
• Added sugar
• Total calories
Evidence-Based Policy Strategies for Diet
AHAScientific Statement: Population Approaches to Improve Diet, Physical Activity, and Smoking Habits.Mozaffarian et al., Circulation 2012
Media andEducation
Sustained, focused media campaigns, especially aspart of multi-component strategies, focused on specific foodsor drinks.
Labeling andInformation
Mandated nutrition facts, front-of-pack labels, or menu labeling toinfluence industry behavior.
SchoolsMulticomponent nutrition programsincludingclasses, teacher training,supportive policies, environmental changes, and family components.
School garden programs.
WorkplacesComprehensive worksite wellnessprogramsfor diet and lifestyle.
Increased availability of healthier optionsand/or strongnutritionstandards, combined with on-site prompts, labels, or icons.
EconomicIncentives
Subsidy strategiesto lower pricesof more healthful foods.
Tax strategiesto increase pricesof lesshealthful foods.
QualityStandards
Restrictionson marketingof lesshealthy foodsto childrens.
Restrictions(e.g., salt, transfat) or mandates(e.g., vegetable oils).
AgriculturalPolicies
Long-term changesin agricultural policies for infrastructure to facilitateproduction, transportation, and marketingof healthier foods.
The Real Cost of Food –Dietary Taxesand Subsidies to Improve Public Health
Mozaffarian, Rogoff, & Ludwig, JAMA2014
Packaged andsupermarket foods
Restaurant and other foodservice establishments
Simple Flat Tax(10-30% )
Most packaged foods (e.g.,nearly all foods with alabel).
Most chain restaurants,large cafeteria vendors, andother similar food serviceestablishments.
Subsidy(from tax revenue)
Minimally processedhealthful foods, such asfruits, nuts, vegetables,beans, seafood, plainyogurt, vegetable oils, andminimally processed wholegrains.
School lunch andafterschool programs.
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