Is Butter Back? And Other Vexing Questions from the ...€¦ · And Other Vexing Questions from the...
Transcript of 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.
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(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:
http://annals.org.ezp-prod1.hul.harvard.edu/article.aspx?articleid=1846638
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(unpublished, compiled from NHANES)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Unpublished data from Harvard Cohorts Courtesy of Frank Hu and colleagues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
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%
Obesity Trends* Among U.S. Adults 1996
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. Adults 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. Adults 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
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.
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)
BMJ, December 17, 2014
Is the Evidence Accurate?
BMJ, December 17, 2014
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
Wang et al: JAMA – Intern Med, 2014
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
Chomistek et al JACC 2015
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)
Chomistek et al JACC 2015
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
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
Evidence-based or not?
Wheat belly diet
Evidence-based or not?
DASH diet
Evidence-based or not?
Gluten-free diet
Evidence-based or not?
Low-fat diet
Evidence-based or not?
Low-carb diet
Evidence-based or not?
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
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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)
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.
-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
Bertoia and Rimm (In Prep)
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.
-4 -3 -2 -1 0 1 2
Winter Squash
Beans
Brussels Sprouts
Broccoli
String Beans
Green Leafy Vegetables
Summer Squash
Peppers
Cauliflower
Tofu/Soy
Weight Change Associated with Each Increased Daily Serving, per 4-year Interval (lbs)
NHS1
HPFS
NHS2
Bertoia and Rimm (In Prep)
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.
-2 -1 0 1 2 3
Corn
Tomatoes
Peas
Cabbage
Potatoes
Onions
Mixed Vegetables
Carrots
Celery
Weight Change Associated with Each Increased Daily Serving, per 4-year Interval (lbs)
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
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