11/12/2013

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Michel Lucas, Ph.D., Dt.P.

Épidémiologiste/Nutritionniste

www.michellucas.com @MichelLucasPhD

13 novembre 2013

Doit-on accorder davantage d’importance

à la qualité ou à la quantité

des apports alimentaires?

UNIVERSITÉ

LAVAL

Professeur adjoint − Département de médecine sociale et préventive, Université Laval

Chercheur associé − Axe santé des populations et pratiques optimales en santé, CHU de Québec

Visiting Scientist − Department of Nutrition, Harvard School of Public Health

Chercheur associé − Institut de la nutrition et des aliments fonctionnels (INAF)

Divulgation des conflits d'intérêts au cours

des 2 dernières années:

2

Honoraire de conférence, Mead Johnson Nutrition (2 oct. 2012)

Compagnies agroalimentaires, nutraceutiques

ou pharmaceutiques

Aucune subvention à vie (et pas intéressé dans le futur! )

Membre d'aucun comité à vie (et pas intéressé dans le futur! )

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Plan de la présentation

1. Obésité et diabètes

2. Un peu d'histoire

3. Transition nutritionnelle

4. Boissons sucrées

5. Qualité vs. Quantité

6. Hyperinsulinémie: le chariot ou le cheval

7. Environnement alimentaire toxique

8. Modèles d'alimentation et recommandations

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It’s all

obesity,

all the time

Obésité et diabète de type 2 Des épidémies qui menacent la santé et l’économie de toutes les nations

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Past and projected prevalence of overweight (BMI ≥25 kg/m2)

Wang YC et al. Lancet 2011; 378: 815–25 OECD: Organisation for Economic Co-operation and Development

Obésité et diabète de type 2 Des épidémies qui menacent la santé et l’économie de toutes les nations1,2

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% overweight or obese

by sex and age group

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66

Cree

9-17

(2005-09)

Canada (2004): Canadian Community Health Survey (CCHS). US (1999-2002): National Health and Nutrition Examination Survey

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6

26

20

Inuit

8-14

(2005-10) 7

9E

24

16

Qc

12-17

(2004)

2010 2030

Nb of adults with

diabetes (M)

Pr Nb of adults with

diabetes (M)

Pr % increase

in nb

Worldwide 284.8 6.4% 438.7 7.7% 54.1%

Estimated nb of adults with any type of diabetes mellitus & Pr

By region, in 2010 and 2030

Xu Y et al. JAMA.

2013;310(9):948-59

114 - T2D

493 - preDB

Nolan CJ et al. Lancet 2011; 378: 169–81

Shaw JE et al. Diabetes Res Clin Pract. 2010 Jan

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Estimates & projections of global diabetes prevalence

Diabetes Res Clin Pract. 2011 Whiting (IDF diabetes atlas)

2. La guerre des macronutriments

1970-1980

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Keys A, Aravanis C. Seven countries: a multivariate analysis of death CHD. Cambridge, MA: Harvard University Press, 1980.

p.262

Seven countries

Correlation of dietary fat with CHD

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Mozaffarian D. Current Atherosclerosis Reports 2005, 7:435–445 12

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Micha & Mozaffarian Lipids. 2010 Oct;45(10):893-905.

Saturated Fat

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Micha & Mozaffarian Lipids. 2010 Oct;45(10):893-905.

Replacing Saturated Fat

Dietary change (each 5% energy)

RCT’s NONE

RCT’s NONE

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Jakobsen MU et al. Am J Clin Nutr. 2010;91:1764–1768.

Intake of CHO compared with SFA

importance of the glycemic index (GI)

Design: Danish prospective cohort study included 53,644 M&W (50-64y) free of MI at baseline (no cancer).

During a median of 12 y of follow-up, 1943 incident MI cases occurred.

192-item semiquantitative FFQ

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“It’s Time to End the Low Fat Myth"

http://www.savorthebook.com/blog/lilian/2012/02/02/harvard-researchers-say-―it’s-time-to-end-the-low-fat-myth

Food packaging and diet trends can be misleading. Marketing

materials often lead us to believe that if we eat low-fat foods,

we will be low fat too. But for many people, low-fat diets just

don’t work.

―Dozens of studies have found that low-fat diets are no better

for health than moderate-or high-fat diets—and for many

people, they may be worse,” “Over the past 30 years in the

U.S., the % of calories from fat has actually gone down, but

obesity rates have skyrocketed‖

Dr. Walter Willett

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Austin GL et al. Am J Clin Nutr. 2011 Apr;93(4):836-43

carbohydrates fats

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“It’s Time to End the Low Fat Myth"

http://www.savorthebook.com/blog/lilian/2012/02/02/harvard-researchers-say-―it’s-time-to-end-the-low-fat-myth

Why low-fat diets fail

They often replace fat with refined CHO which the body

burns through quickly, leaving us hungry soon after we

eat. This pattern can lead to overeating, which in turn can

lead to weight gain. Plus, fast carbs (white rice, white bread,

potatoes, processed snacks) are just as bad for our heart as

SFA, and eating them in excess also raises our risk of

diabetes.

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La guerre des macronutriments

1970-1980

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Yudkin J. Proc Nutr Soc 1964; 23(2): 149-62

DIETARY FAT AND DIETARY SUGAR

IN RELATION TO ISCHAEMIC HEART-DISEASE AND DIABETES

Yudkin J. Lancet July1964 20

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Krauss RM. J Nutr 2001; 131: 340S–3S

50 40 30 20 10 %Fat

LDL particle size is responsive to

Dietary CHO

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Rizzo M & Berneis K. Q J Med 2006; 99:1–14

LDL heterogeneity & plasma TG & HDL

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http://www.cpc.unc.edu/projects/nutrans/popkin

Barry M. Popkin Director, U of North Carolina - Chapel Hill's

Interdisciplinary Center for Obesity

3. Transition nutritionnelle (TN)

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Popkin BM. Am J Clin Nutr 2006;84:289 –98.

Characteristics of the 5 patterns

of the nutrition transition

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...Economy,

Household production

Income & assets

Mortality & fertility

Age structure

Residency patterns

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Popkin BM. Public Health Nutr. 2002 Feb;5(1A):93-103.

Stages of the nutrition transition

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Sucres, céréales et huiles raffinés :

éléments prédominants du régime urbain moderne

Cordain L et al. Am J Clin Nutr 2005; 81:341-54.

Aliments et groupes alim. chez les N-Am qui étaient non disponibles aux hominidés avant la préagriculture1

1 Data adapted from references 22-24. 2 In the US diet. 3 Salt from processed foods, table salt use, and cooking; in g/d.

39%

56,6%

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Wo

lf A

et

al. O

be

sity r

evie

ws (

20

08

) 9

, 1

51

–6

4

1789

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Malik VS et al. Diabetes Care 33:2477–2483, 2010

4. (Sugar-Sweetened Beverages) SSB & Risk of T2D

MetS :19,431 pers. & 5,803 cases, pooled RR=1.20 [1.02–1.42]

310,819 pers. & 15,043 cases of T2D, highest SSB quantile (1–2 serv. /d) vs. lowest (0 or 1 serv./mo)

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Te Morenga L, et al. BMJ. 2012;346:e7492.

Incident overweight/obesity children (1 or + servings SSB/day vs. none or very little)

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- 224 OW & OB ado (15 yrs), ≥ 1 srvg (12 oz)/dr day of SSB or 100% fruit juice

AIM: displace SSB with nonCal bev. in the home as a strategy to decrease intake

Interventions:

1-yr intervention consisted of home delivery of nonCal bev.

(e.g., bottled water & ―diet‖ bevs)

every 2 wks, monthly motivational tel calls with parents, & 3 check-in visits.

mailed $50 supermarket gift cards to control group at 4 and 8 mo.

(did not provide instructions on what to purchase with the cards)

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Methods

18-mo trial involving 641 primarily normal-weight children (8 yrs, 4-12 yrs).

randomly assigned to receive 250 ml/d (8 oz) of ASB or SSB that provided 104 kcal.

beverages were distributed through schools.

Sept. 21, 2012 33

Odd Ratios (95% CI) of hyperinsulinemia (≥90 pmol/)

by intake level of SSB 307 Cree youth (9-18 y), Pr HI (68%), overweight/obesity (24%/42%)

SSB = regular soft drink + regular ice tea + fruit drinks or sport drinks (Tang, punch, Kool-Aid, Sunny D, Gatorade).

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Women Men

Calories 100 150

÷ 4 cal/g 25 37.5 g/d

÷ 4.2 g/tsp 6 9 tsp/d

93 g/d

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Étendus des objectifs pour les apports

en nutriments populationnels

a This is calculated as: total fat -- (SFA + PUFA + trans). b The % of total energy available after taking into account that consumed as protein and fat, hence the wide range. c refers to all monosaccharides & disaccharides added to foods by the manufacturer, cook or consumer, plus sugars naturally present in honey, syrups and fruit juices. d The suggested range should be seen in the light of the Joint WHO/FAO/UNU Expert Consultation, Geneva, April 2002 (2). e Salt should be iodized appropriately (6). f See page 58, under ‘‘Non-starch polysaccharides’’.

Diet, nutrition and the prevention of chronic diseases: report of a joint WHO/FAO expert consultation, Geneva, 28 January -- 1 February 2002. http://www.fao.org

Women Men

Calories 180 220

÷ 4 cal/g 45 55 g/d

÷ 4.2 g/tsp 11 13 tsp/d

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http://www.youtube.com/watch?v=RCrE26FYFuQ

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Lawsuits were filed in the United States in 2001

& 2006 by the United Steelworkers of America &

the International Labor Rights Fund on behalf of

SINALTRAINAL, several of its members who

were falsely imprisoned & the survivors of Isidro

Gil and Adolfo de Jesus Munera, two of its

murdered officers.

The lawsuits charged Coca-Cola bottlers

"contracted with or otherwise directed

paramilitary security forces that utilized extreme

violence and murdered, tortured, unlawfully

detained or otherwise silenced trade union

leaders."

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http://www.coca-colacompany.com/press-center/press-releases/

Here’s How Coke is Buying the Silence of Health Organizations.

For Pocket Change

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Profits and pandemics: prevention of harmful effects of tobacco, alcohol,

and ultra-processed food and drink industries. Moodie R, et al. The Lancet. 2013 Feb 23;381(9867):670-9.

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Mozaffarian D et al. N Engl J Med 2011;364:2392-404

- 3 Prospective Cohorts, 120,877 U.S. Women and Men

- NHS (N=50,422 women), NHSII (N=47,898 women), HPFS (N=22,557 men)

- Average 4-Year Lifestyle Changes

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N Engl J Med 2011;364:2392-404 44

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N Engl J Med 2011;364:2392-404

Les indicateurs diététiques traditionnellement retenus

(teneur en MG, densité énergétique, sucres ajoutés)

ne permettent pas d’identifier de façon fiable les facteurs

alimentaires associés à la prise de poids à long terme.

Aucun indicateur diététique unique ne saisit la

relation complexe entre l’alimentation et le gain de

poids

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N Engl J Med 2011;364:2392-404

Les efforts de recherche visant à prévenir l'obésité doivent

examiner davantage la structure et la transformation

alimentaire comme mesures pertinentes plutôt que les

indicateurs traditionnellement retenus.

Aucun indicateur diététique unique ne saisit la

relation complexe entre l’alimentation et le gain de

poids

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Chow-Hard

Western-Hard

High Fat-Hard

☐

Chow-Powder

Western-Powder

High Fat-Powder

Desmarchelier C et al. Br J Nutr 2013; 109: 1518–27 47

Mozaffarian D. The Lancet 2011; 378: 759

5. Diets from around the world quality not quantity

What is not eaten is probably

most relevant to poor health:

minimal fruits, vegetables, nuts,

whole grains, seafood, and

vegetable oils.

These deficits, combined with

global surfeits of refined grains,

processed meats, sodium,

sugars, and trans fat, create a

perfect recipe for our

contemporary pandemic of

chronic diseases. Profiles are laid out in order of increasing caloric intake, from a low of 800 calories a day for a Maasai herder in Kenya, to a high of 12,300 one day for a binge eater in England.

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Blanchet C, Plante C, Rochette L. 2009. La consommation alimentaire et les apports nutritionnels des adultes québécois. INSPQ 49

50 Blanchet C, Plante C, Rochette L. 2009. La consommation alimentaire et les apports nutritionnels des adultes québécois. INSPQ

Fruits 2,4 port./j Légumes 3,4 port./j

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Carbohydrates (CHO): quality matters

Mozaffarian R et al. Public Health Nutr. 2013 Jan 4:1-10.

1) Whole Grain stamp (WG-Stamp) (products containing at least 8 g of whole grains/srvg)

2) WG-first (1st listed ingredient, USDA’s MyPlate)

3) WG-first-no-added-sugars

4) word 'whole' before any grain in the ingredients (USDA’s Dietary Guidelines 2010)

5) total CHO/fiber ratio ≤ 10:1 (AHA 2020 Goals)

The amount of CHO in the diet – high or low – is less important

than the type of CHO in the diet.

http://www.hsph.harvard.edu/nutritionsource/carbohydrates/

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1. Start the day with whole grains.

2. Use whole grain breads for lunch or snacks.

3. Also look beyond the bread aisle.

4. Choose whole fruit instead of juice. (orange has 2 times + fiber and ½ as much

sugar as a 12-oz glass of orange juice)

5. Pass on potatoes, and instead bring on the beans.

Carbohydrates (CHO): quality matters

Good rules of thumb, choose:

Cereal ≥ 4 g of fiber and < 8 g of sugar (per serving).

Whole grains with total CHO/fiber ratio ≤ 10:1

The amount of CHO in the diet – high or low – is less important

than the type of CHO in the diet.

http://www.hsph.harvard.edu/nutritionsource/carbohydrates/ 52

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Digestion Rate, Not Dose

If F were toxic at high dosage, large amounts of fruit adverse effects

Examining the Health Effects of Fructose (F) Ludwig DS. JAMA 2013 June

The recommendation to replace F with G lacks an evidence basis.

Public health efforts should focus on reducing intakes

of all highly processed carbohydrates, not just refined sugar.

1) F in its primary natural form (whole fruit) is not associated with adverse effects

2) excessive refined sugar epidemiology of obesity & related diseases

because large amounts of rapidly absorbed F can overwhelm hepatic biochemical pathways

3) rapidly absorbed forms of G—present in both sugar & high GI starch—

contribute imp. to diseases due to their much greater caloric contribution to typical diets than F

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http://www.youtube.com/watch?v=dBnniua6-oM

Sugar: The Bitter Truth

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6. Childhood obesity:

behavioral aberration or biochemical drive?

Obesity

HI

Leptine resistance

Lustig RH. Nat Clin Pract Endocrinol Metab. 2006 Aug;2(8):447-58.

Reinterpreting the 1st Law of Thermodynamics

ΔE = Ein – Eout

Weight gain = Energy consumed – Energy expended

behaviors

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Hyperinsulinemia drives diet-induced obesity & its complications

Genetic evidence

Mehran AE et al. Cell Metabolism 2012; 16, 723–737 56

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Lustig RH. Nat Clin Pract Endocrinol Metab. 2006 Aug;2(8):447-58.

Algorithm describing the role of hyperinsulinemia

in the dysfunction of the energy balance pathway

empêche la recapture dopamine,

récompense associée à la nourriture, 57

Childhood obesity:

behavioral aberration or biochemical drive?

Reinterpreting the 1st Law of Thermodynamics

ΔE = Ein – Eout

Weight gain = Energy consumed – Energy expended

HI state

Weight gain

are secondary to obligate weight gain

1) E partitioning into adipose tissue

2) interference with leptin signal transduction

3) interference with extinction hedonic response to food

Lustig RH. Nat Clin Pract Endocrinol Metab. 2006 Aug;2(8):447-58.

behaviors causation this way?

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Hyperinsulinemia drives diet-induced obesity & its complications

Genetic evidence

Mehran AE et al. Cell Metabolism 2012; 16, 723–737 59

Corkey BE. Diabetes Care 2012 dec; 35:2432-7 60

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Corkey BE. Banting lecture 2011: hyperinsulinemia: cause or consequence? Diabetes. Jan 2012;61(1):4-13.

(mono-oleoyl-glycerol)

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Viandes et charcuteries

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Ingrédients

Porc, eau, inuline de racine de chicorée, sel de mer, saveur,

vinaigre, culture de poudre de céleri, saveur de fumée,

concentré de jus de citron, épices.

"Manger des bonnes charcuteries

sans se poser de questions!"

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Red Meat Consumption and Mortality:

results From 2 Prospective Cohort Studies

All-Cause Mortality

Cardiovascular Mortality

Cancer Mortality

1.8-2.7/d 0.13-0.61/d

Pan A, et al. JAMA Internal Med 2012 Apr 9;172(7):555-63 64

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Red meat consumption & risk of type 2 diabetes:

3 cohorts of US adults and an updated meta-analysis

1 One serving of unprocessed red meat equals 85 g (3 ounces) pork, beef, or lamb; one serving of processed red meat equals 28 g bacon or 45 g hot dog, sausage, salami,

bologna, or other processed red meats.

1.8-3.36/d 0.11-0.86/d

Pan A, et al. Am J Clin Nutr. 2011 Oct;94(4):1088-96. Pan A, et al. JAMA Intern Med. 2013 Jul 22;173(14):1328-35

HRs for 50 g processed red meat

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Viandes et leurs substituts Femmes = 159 g/d Hommes= 220 g/j

Blanchet C, Plante C, Rochette L. 2009. La consommation alimentaire et les apports nutritionnels des adultes québécois. INSPQ 66

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Impact of caloric restriction on health & survival

in rhesus monkeys from the NIA study

Mattison JA et al . Nature 2012 sep;318 (489) 67

Mattison JA et al . Nature 2012 sep;318 (489)

Age-related diseases

incidence and estimated proportions

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http://www.bluezones.com/

―Hara hachi bu‖

The Okinawan, 2500-year old Confucian mantra

said before meals reminds them

to stop eating when their stomachs are 80 percent full.

Okinawa, Japan Loma Linda, CA Nicoya Costa Rica Sardinia, Italy Ikaria, Greece

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7. Why We Overeat:

The Toxic Food Environment and Obesity

http://theforum.sph.harvard.edu/events/why-we-overeat/ 70

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PCRM (Physicians Committee for Responsible Medicine) won its lawsuit against

the USDA, bringing national attention to the heavy influence of the meat, dairy, and

egg industries in the creation of federal food policies.

U.S. District Court Judge James Robertson ruled that the USDA violated federal law

by withholding documents revealing bias among its advisory panel. (Sep 30, 2000)

http://www.pcrm.org/ 71

Doctors Sue Federal Government for Deceptive Language

on Meat, Dairy in New Dietary Guidelines.

Lawsuit Targets USDA & DHHS Double-Speak,

Says Agency Protecting Agribusiness & Fast-Food Cie

PCRM says the Dietary Guidelines are

clear about what to eat more of—

vegetables, fruits, and whole grains, for

example—but deliberately hide the foods

Americans should eat less of.

The Guidelines use biochemical terms,

such as ―saturated fat‖ & ―cholesterol‖

instead of specific food terms ―meat‖

and ―cheese.‖

http://www.pcrm.org/

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This deliberate omission can be traced to the USDA’s close ties to the meat & dairy

industries, including fast-food companies such as McDonald’s.

6 out of 11 committee members, including its chairperson, have either received

payments or served on corporate & industry boards for the likes of the National Dairy

Council, The National Cattleman’s Beef Association, the American Egg Board, ?

Dannone.

Doctors Sue Federal Government for Deceptive Language

on Meat, Dairy in New Dietary Guidelines.

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? DV

Added?

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8. The Obesity Prevention Source

Evidence shows that obesity prevention policy & environmental change efforts

should focus on facilitating a handful of key behaviors:

Choosing healthier foods (whole grains, fruits & vegetables, healthy fats & protein

sources) & beverages

Limiting unhealthy foods (refined grains & sweets, potatoes, red meat, processed

meat) & beverages (sugary drinks)

Increasing physical activity

Limiting television time, screen time, & other "sit time"

Improving sleep

Reducing stress www.hsph.harvard.edu/obesity-prevention-source 75

Lloyd-Jones DM et al, Circulation. 2010;121:586-613 76

La prevention primordiale :

un nouveau modele pour

mieux combattre les MCV

Després JP. Actualité du Coeur. 15 (2): Été 2012

http://www.santeducoeur.org/lesactualitesducoeur.php

1064 ml

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Hu F. N Engl J Med 2001. 345:790-7. 77

Hu F. N Engl J Med 2001. 345:790-7.

Multivariate RR of Type 2 Diabetes According to Quintiles of

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aHEI: alternative Health Eating Index

Chiuve SE et al. J. Nutr. 2012; 142: 1009–18

All AHEI-2010 components were scored from 0 (worst) to 10 (best). The total AHEI-2010 score ranged from 0 (nonadherence) to 110 (perfect adherence).

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

11)

≈5 servings/d

≈6 servings/d

≥3337 mg/d (W), ≥ 5271 mg/d (M) ≤1112 mg/d (W), ≤1612 mg/d (M)

≤1112 mg/d (W), ≤1612 mg/d (M)

≈2 X 4 oz fish/wk

Nurses’ Health Study

Inflammatory dietary pattern & depression risk

Lucas M et al. Brain Behav Immun. 2013 Oct 1 80

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Lucas M et al. Brain Behav Immun. 2013 Oct 1

Nurses’ Health Study

Inflammatory dietary pattern & depression risk

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PREDIMED (Prevención con Dieta Mediterránea)

Primary prevention of cardiovascular disease with a Mediterranean diet

Estruch R, Martínez-González MA, et al. N Engl J Med. 2013 Apr 4;368(14):1279-90.

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Estruch R, Martínez-González MA, et al. N Engl J Med. 2013 Apr 4;368(14):1279-90. 83

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gras saturés

fructose

oméga-3

calcium

probiotiques

antioxydants

polyphénols fibres

inuline

L’essence du message nutritionnel

devrait surtout être centrée

sur les aliments plutôt que les nutriments,

sur la qualité plutôt que la quantité !

dextrin

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Pourquoi ne pas manger moins

mais meilleur

plutôt que davantage et médiocre?

Jean-Pierre Coffe

Au secours le goût, éd. Le Pré aux Clercs, 1992.

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MERCI