11/12/2013
1
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! )
11/12/2013
2
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
3
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
4
11/12/2013
3
5
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
6
11/12/2013
4
% overweight or obese
by sex and age group
42
66
Cree
9-17
(2005-09)
Canada (2004): Canadian Community Health Survey (CCHS). US (1999-2002): National Health and Nutrition Examination Survey
24
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
11/12/2013
5
Estimates & projections of global diabetes prevalence
Diabetes Res Clin Pract. 2011 Whiting (IDF diabetes atlas)
2. La guerre des macronutriments
1970-1980
10
11/12/2013
6
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
11
Mozaffarian D. Current Atherosclerosis Reports 2005, 7:435–445 12
11/12/2013
7
Micha & Mozaffarian Lipids. 2010 Oct;45(10):893-905.
Saturated Fat
13
Micha & Mozaffarian Lipids. 2010 Oct;45(10):893-905.
Replacing Saturated Fat
Dietary change (each 5% energy)
RCT’s NONE
RCT’s NONE
14
11/12/2013
8
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
15
“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
16
11/12/2013
9
Austin GL et al. Am J Clin Nutr. 2011 Apr;93(4):836-43
carbohydrates fats
17
“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.
18
11/12/2013
10
La guerre des macronutriments
1970-1980
19
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
11/12/2013
11
Krauss RM. J Nutr 2001; 131: 340S–3S
50 40 30 20 10 %Fat
LDL particle size is responsive to
Dietary CHO
21
Rizzo M & Berneis K. Q J Med 2006; 99:1–14
LDL heterogeneity & plasma TG & HDL
22
11/12/2013
12
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)
23
Popkin BM. Am J Clin Nutr 2006;84:289 –98.
Characteristics of the 5 patterns
of the nutrition transition
24
...Economy,
Household production
Income & assets
Mortality & fertility
Age structure
Residency patterns
11/12/2013
13
Popkin BM. Public Health Nutr. 2002 Feb;5(1A):93-103.
Stages of the nutrition transition
25
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%
26
11/12/2013
14
Wo
lf A
et
al. O
be
sity r
evie
ws (
20
08
) 9
, 1
51
–6
4
1789
27
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)
28
11/12/2013
15
Te Morenga L, et al. BMJ. 2012;346:e7492.
Incident overweight/obesity children (1 or + servings SSB/day vs. none or very little)
29
- 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)
30
11/12/2013
16
31
32
11/12/2013
17
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).
11/12/2013
18
Women Men
Calories 100 150
÷ 4 cal/g 25 37.5 g/d
÷ 4.2 g/tsp 6 9 tsp/d
93 g/d
35
36
11/12/2013
19
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
37
38
11/12/2013
20
http://www.youtube.com/watch?v=RCrE26FYFuQ
40
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."
11/12/2013
21
http://www.coca-colacompany.com/press-center/press-releases/
Here’s How Coke is Buying the Silence of Health Organizations.
For Pocket Change
41
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.
42
11/12/2013
22
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
43
N Engl J Med 2011;364:2392-404 44
11/12/2013
23
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
45
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
46
11/12/2013
24
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.
48
11/12/2013
25
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
11/12/2013
26
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/
51
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
11/12/2013
27
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
53
http://www.youtube.com/watch?v=dBnniua6-oM
Sugar: The Bitter Truth
54
11/12/2013
28
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
55
Hyperinsulinemia drives diet-induced obesity & its complications
Genetic evidence
Mehran AE et al. Cell Metabolism 2012; 16, 723–737 56
11/12/2013
29
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?
58
11/12/2013
30
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
11/12/2013
31
Corkey BE. Banting lecture 2011: hyperinsulinemia: cause or consequence? Diabetes. Jan 2012;61(1):4-13.
(mono-oleoyl-glycerol)
61
Viandes et charcuteries
62
11/12/2013
32
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!"
63
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
11/12/2013
33
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
65
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
11/12/2013
34
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
68
11/12/2013
35
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
69
7. Why We Overeat:
The Toxic Food Environment and Obesity
http://theforum.sph.harvard.edu/events/why-we-overeat/ 70
11/12/2013
36
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/
72
11/12/2013
37
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.
73
? DV
Added?
74
11/12/2013
38
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
11/12/2013
39
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
11/12/2013
40
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
11/12/2013
41
Lucas M et al. Brain Behav Immun. 2013 Oct 1
Nurses’ Health Study
Inflammatory dietary pattern & depression risk
81
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.
11/12/2013
42
Estruch R, Martínez-González MA, et al. N Engl J Med. 2013 Apr 4;368(14):1279-90. 83
84
11/12/2013
43
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
85
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.
86
11/12/2013
44
87
MERCI
Top Related