PRESENTATION - 1 › bundles › dfcdairy... · Paleo Diet Principals INCLUDED EXCLUDED Meats&and/or&game,preferably grass@fed Processed foods&of&any&kind Fish,preferably wild Processed&oils&(corn,sunflower,etc.)

PRESENTATION - 1

Making Sense of Trendy Diets & SuperfoodsJ ENN IFER SYGO, M.SC . , RD, C LEVELAND CL IN IC CANADA

AUTHOR , UNMASK ING SUPERFOODS (HARPERCOLL INS CANADA , 2014 )

NUTR IT ION IST, TORONTO MAPLE LEAFS AND ATHLET ICS CANADA

Financial Interest Disclosure (over the past 24 months)

Commercial Interest Relationship

Dairy Farmers of Canada SpeakerAlberta Milk SpeakerNestle Speaker

Paleo Diet Overview‣Aka Paleolithic, caveman, Stone Age, hunter-‐gatherer diet‣Paleo period: 2.5 million years ago with start of use of stone tools; ended 10,000 years ago with advent of agriculture, domestication of animals‣Premise: our genomes have not changed (significantly) in ~500 generations since this time; thus, we are better adapted to the diet and lifestyle of the Paleo period than now‣Most searched diet on google, 2013-‐2014

Paleo Popularity

What did hunter-‐gatherers eat?1 Estimated macronutrient intakes (vs.typical Western): Protein: 25-‐29% of calories (15%) Fat: 30-‐39% (30%) Carbohydrates: 39-‐40 (55%)

Estimated fat intakes: Saturated: 11.4-‐12.0% (~10%) Monounsaturated fats: 5.6-‐18.5%(~10%)

Polyunsaturated fats: 8.6-‐15.2 (~10%) Omega-‐3 : omega-‐6: ~1:1 or even 2:1(1:20)

Paleo Diet Premise

1Kuipers et al, Br J Nutr. 2010;104:1666.

Paleo Diet PrincipalsINCLUDED EXCLUDED

Meats and/or game, preferably grass-‐fed Processed foods of any kind

Fish, preferably wild Processed oils (corn, sunflower, etc.)

Eggs Added sugar

Fruits (whole/unprocessed) Added salt

Vegetables (whole/unprocessed) Grains of all kinds, including ancient

Fatty fruits (olives, avocadoes, coconut) Cereals and pseudocereals

Nuts (not peanuts) Dairy, including goat’s milk

Seeds Beans, lentils, pulses/legumes

Also: some oils, e.g. olive, macadamia nut Alcohol (more than 3 drinks/week)

1Cordain L. “Ancestral fire production: implication for contemporary Paleo diets.” Retrieved from: thepaleodiet.com Accessed May 13, 2014.

NB: Controlled use of fire began 75,000-‐100,000 years ago vs. 2 million years our genus has existed; ie. if we need fire to cook it, it isn’t truly Paleo1

AUTHOR POPULATION INTERVENTION CONTROL OUTCOMEO’Dea et al (1980)

13 healthy AustralianAborigines

3 month Paleo diet None Improved insulin response to CHO; no change in glucose among non-‐diabetics

O’Dea et al (1984)

10 AustralianAborigines w/ type 2 DM

7 wks Paleo diet None 10% wt loss; fasting blood sugar,insulin levels, triglycerides (TG) improved

Osterdahl et al (2008)

14 healthysubjects

3 wk Paleo diet None Decreased weight, waist circumference (WC), systolic BP

Frassetto et al (2009)

9 nonobese, sedentary, healthy

10 d. Eucaloric Paleodiet

None Total cholesterol (-‐0.8 mmol/L), LDL chol (-‐0.7 mmol/L), TG (-‐0.3 mmol/L) all improved

Paleo Diet: Evidence

AUTHOR POPULATION INTERVENTION CONTROL OUTCOME

Lindeberg et al (2007); Jonsson et al (2010)

29 pts w/ ischemic HD & IGT or T2DM

12 wk Paleo diet (randomized)

12 wks Mediter-‐ranean diet (low fat dairy, margarines)

Paleo diet: OGTT decr. independent of wt loss vs. Med diet; Paleo diet consumed 1380 kcal vs. 1809 kcal/d

Jonsson et al (2009)

13 T2DM 3 month Paleo(cross-‐over)

Diabetes diet Paleo: Wt (-‐3 kg; p=0.01), WC (-‐4 cm; p=0.02), A1c (-‐0.4%; p=0.01), TG (-‐0.4 mmol/L; p=0.003), DBP (-‐4 mmHg; p=0.03), HDL (+0.08 mmol/L, p=0.03) vs. Diabetes diet

Mellberg et al (2014)

70 obese, post-‐menopausal women

2 year ad libitumPaleo

Nordic Nutrition Rec’s

Paleo: Fat mass (-‐1.9 kg; p <0.001) and WC (-‐7.4 cm, p<0.001) vs. NNR at 6/12 but not 2 y

Boers et al (2014)

34 w/ at least 2 characteristics of MET-‐S

2 wk Paleo diet (randomized; isocaloric vs. baseline)

Dutch Health Council diet

Paleo: SBP (-‐9.1 mmHg; p=0.015) DBP (-‐5.2 mmHg; p=0.038), T-‐chol (-‐0.52 mmol/L; p=0.037), TG (-‐0.89 mmol/L; p=0.001), HDL (+0.15 mmol/L; p=0.013), wt (-‐1.32 kg; p=0.012) vs. control

Pastore et al (2015)

20 hyperlipidemicadults

4 months Paleo diet (not randomized)

4 months AHA heart healthy

T-‐chol, LDL, TG all decr. (p < 0.001), HDL incr. (p < 0.001) vs. AHA diet

Paleo Diet: RCTs

Mellberg 2014: Paleo vs. Nordic Nutr Rec

Manheimer et al (2015): meta-analysisPaleolithic nutrition resulted in greater short-‐term improvements than did the control diets (random-‐effects model) for:

WC (mean difference: -‐2.38 cm; 95% CI: -‐4.73, -‐0.04 cm)

TG (-‐0.40 mmol/L; 95% CI: -‐0.76, -‐0.04 mmol/L)

SBP (-‐3.64 mm Hg; 95% CI: -‐7.36, 0.08 mm Hg)

DBP (-‐2.48 mm Hg; 95% CI: -‐4.98, 0.02 mm Hg)

HDL cholesterol (0.12 mmol/L; 95% CI: -‐0.03, 0.28 mmol/L)

FBG (-‐0.16 mmol/L; 95% CI: -‐0.44, 0.11 mmol/L)

Paleo Diet: Nutrient ConcernsPotentially unnecessary exclusion of dairy, whole(intact) grains, and legumes, despite numerous studies suggesting benefitsDid lactase persistence provide evolutionary advantage?1

Many/most antinutrients in legumes destroyed duringcooking2

Evidence of grain consumption ~30,000 years or more2

Low calcium intake (Mellberg, 2011)

1Wilt TJ, et al. Lactose Intolerance. Evidence Reports/Technology Assessments, No. 192. Rockville (MD): Agency for Healthcare Research and Quality (US); 2010 Feb.

2United States Federal Department of Agriculture. Bad Bug Book: A Handbook of Foodborne Pathogenic Microorganisms and Natural Toxins. 2013: 252.

3Lippi M. PNAS. 2015;112:12075-‐12080.

Paleo Diet: Practical ConcernsChallenges for travel, lifestyle, family, etc.Incomplete information given in passing, or in bite-‐sized chunks (“all meat diet”)Food security, cost1,2, and access to Paleo-‐type foodsAdherence2; feelings of failure“Dieting mindset”; potential for disordered eating

1Metzgar M. Nutr Res. 2011;31:444-‐51.2Genoni A, et al. Nutrients. 2016 Aug 6;8:8.

4 weeks on Paleo diet vs. Australian Guide to Healthy Eating: consumption of discretionary foods

Genoni A, et al. Nutrients. 2016 Aug 6;8:8.

Paleo Diet for Clients: “Meeting Halfway”Expand Paleo to include yogurt, kefir, orcheese, intact grains (e.g. quinoa), pulses, according to tolerance and preferenceEat some non-‐Paleo foods for pleasureEmphasize evidence-‐basedrecommendations for performance vs. theory and hypothesis (PEN pathway)

Gluten-FreeVariations: Wheat-‐freeGluten-‐freeGrain-‐free

Gluten-Free Diets Popular trend among celebrities, athletes 41% of surveyed athletes follow a GF diet, at least in part1

Implications for active individuals, children, non-‐athletes who follow sport?

What do we know about benefit of GF diet for those without celiac disease?

1Lis DM, et al. IJSSEM. 2015;25:37.

Recreational; 121; 41%

Recreationally competative; 9;

3%Provincial/Stat

e; 26; 9%

National; 60; 21%

International; 33; 11%

World/Olympic qualifier; 21;

7%

World/Olympic medallist; 18;

6%

Professional; 5; 2%

①Practical Application Practitioners awareness of athlete-‐type likely to adopt a GFD

Better understanding of GFD followers beliefs, experiences and sources of information to tailor “messaging” and consulting approaches.

online; 28,6%

RD/nutritionist ; 16,8%

trainer/coach ; 26,0%

naturopath; 7,4%

other athletes; 17,3%

other celiacs, nothing; 3,5%

medical professional 0,3%

Sources of GFD information GFD>50 athlete levels

Results7 days of a GF diet in non-‐celiac athletes resulted in:1

No effect on endurance performance

No effect on GI symptoms

No effect on markers of intestinal injury

No effects on inflammatory markers (IL-‐1B, IL-‐6, IL-‐8, IL-‐10, IL-‐15, TNF-‐A)

No effect on self-‐reported markers of well-‐being

1Lis D, et al. Med Sci Sports Exerc. 2015;47:2563.

And What About those Superfoods?Claim: goji, noni, acai are all superfruits with incrediblecapacity to prevent and treat disease, weight, increase energy, etc.

Reality: most of these claims are baseless, with very fewhuman trials to date, and almost none of good quality

Most of the evidence is based on ORAC, anunsubstantiated concept (higher ORAC = more powerful antioxidant)

At the end of the day, readily accessible, local fruits andvegetables likely have a similar effect on disease prevention

The Bottom LineRespect the beliefs of othersBut also be prepared to discuss evidence-‐based alternativesRealize don’t need to be “all” or “nothing”Be aware of placebo effect (lactose intolerance)“VEER Back” (Validate, Empathize, provide an Evidence-‐Based alternative, give Resources, put the ball Back in their court)

Paleo might not be for everyone…

Thank you!

[email protected]

www.jennifersygo.com

@JenniferSygo

www.clevelandclinic.ca

ReferencesBoers I. Lipids Health Dis. 2014;13:160.

Eaton SB. N Engl J Med. 1985; 312:283-‐289.

Lindeberg S. Diabetologia. 2007;50:1795.

Jönsson T. Nutr Metab (Lond). 2010;7:85.

Jönsson T. Cardiovasc Diabetol. 2009;8:35.

Jönsson T. Nutr J. 2013;29:105.

Manheimer EW. Am J Clin Nutr. 2015;102:922.

Mellberg C. Eur J Clin Nutr. 2014;68:350.

Pastore RL. Nutr Res. 2015;35:474.

Spreadbury I. Diabetes Metab Syndr Obes. 2012;5:175.

PRESENTATION - 2

Saturated fat and cardiovascular disease:

Then and now

Andrew J.W. Samis BSc(Hon), MSc, MD, PhD, FCCP, FRCSC, FACS

Assistant Professor, Department of Surgery, Queen’s University,Kingston, Ontario, Canada

Physician Stroke Champion, Quinte Health Care, Belleville, OntarioAttending Staff: Kingston General Hospital, Belleville General Hospital

Disclosure• I have received financial support from theCanadian Institutes of Health Research and thePSI Foundation for research in an areasunrelated to topics in this talk

• I have received speaking honoraria from theHeart and Stroke Foundation, the LungAssociation, the Dairy Farmers of Canada, andOntario Pork in the past

• I have no financial relationship with amanufacturer of any product or class of productsdiscussed in this presentation, as well as with thecommercial supporters of this activity

Mitigating Potential Bias• As a speaker I had complete control over thecontent of this presentation

• There has been no influence from any sponsorsof this event on the content

• The information and recommendations containedin this presentation are evidence-based andconsistent with published studies

FAT

?Confusion

June 2014March1984

Objectives• To understand the history of dietaryguidelines advising lowering total dietaryfat and saturated fat

• To review some of the evidence relating tospecific dietary components andcardiovascular disease

• To discuss what we should tell ourpatients about a healthy diet andcardiovascular risk from an evidenced-based perspective

The History of the Vilification of Fat

-Cartoon Artwork - Clipartpand.com free clipart

CCH

HH HC

H

H

CH

HCH

HCH

HCH

H

CH

HCH

H

CO

OH

CCH

H

HCH

HCH

HCH

HCH

H

CH

HCH

H

CO

OH

CCH

H

H

HCH

HCH

HCH

H

CH

HCH

H

CO

OH

History of the Vilification of Fat• 1904 – The term atherosclerosis is introduced by German Pathologist Dr. Felix Marchand (1846-1928) at the University of Leipzig suggests it is responsible for most obstructive processes in the arteries. From the Greek "athere" meaning gruel, and "skleros", meaning hard1

• 1908 – Dr. Alexander Ignatowskiof the Imperial Medical Academy in St. Petersburg Russia fed rabbits full-fat milk, eggs, and meat and they developed yellow cobblestoning of the aorta which resembled atherosclerotic plaque2. This formulated the idea that something in the diet was clogging the arteries.

1. Marchand, F. 1904. “Ueber Atherosclerosis” Verhandlungen der Kongresse fur Innere Medizin. 21 Kongresse.2. Ignatowski A. Changes in parenchymatous organs and in the aorta of rabbits under the influence of animal protein [in Russian]. Izvestia Imperatorskoi Voenno-Medicinskoi

Akademii (St. Petersburg) 1908;;18:231–44.

• 1913 – Russian pathologist Dr. Nikolaj Anitschkow (1885-1964) has just finished his PhD at the Imperial Medical Academy in St. Petersburg. He became interested in the work of Dr. Ignatowski.

• Over the next thirty years Dr. Anitschkow and his team determine that the material in the meat and eggs that produces the lesions is called cholesterol, and if rabbits are fed purified cholesterol instead of meat and eggs they develop even bigger plaques1,2.

• These experiments became widely known, and replicated in sheep, cows, horses. His conclusion: “cholesterol in diet (eg. eggs, red meat) causes heart disease”

• But these animals are strict herbivores and not evolved to eat meat. Less well known parallel experiments on dogs and rats (natural meat eaters) failed to produce lesions. And the cholesterol levels in the blood of those original rabbits fed pure cholesterol was more than five times what is seen your average person today3.

1. Anitschkow N, Chalatow S. Ueber experimentelle Cholester- insteatose und ihre Bedeutung fuer die Entstehung einiger pathologischer Prozesse. Zentrbl Allg Pathol Pathol Anat 1913;24:1-9. 2. Anitschkow N, Chatatow S. (translated by Mary Z. PeliasJ). 1983. Classics in arteriosclerosis research: On experimental cholesterin steatosis and its significance in the origin of some pathological processes by N. Anitschkow and S. Chalatow, 1913. Arteriosclerosis 1983;3: 178-82.3. Shull K, Mann, GV, Andrus SB, and Stare FJ. 1954. Response of Dogs to Cholesterol Feeding. American Journal of Physiology Published 28 February 1954 Vol. 176 no. 475-482

• 1950/51 – Dr. John Gofman (1918-2007) ofthe University of California proves thatatherosclerotic plaques actually containcholesterol in 1950, and in 1951 using highspeed centrifuges of meat-fed rabbitsdiscovers HDL and LDL cholesterol. He washonoured with the title of "Father of ClinicalLipidology" by the Journal of Clinical Lipidologyin 2007 at the time of his passing.

• 1937 - The Norwegian physician Dr. CarlMüller (1886-1983) discovers a condition calledFamilial Hypercholesterolemia. He associatedthe physical signs, the high cholesterol levels inthe blood, and autosomal dominant inheritance.These individuals developed atheroscleroticdisease at young age. We now know this is amutation of the LDL receptor. This is furtherused as evidence that cholesterol consumptioncauses atherosclerotic disease1.

1. Carl Müller. 1939, Nutrition classics. Archives of Internal Medicine, Volume 64, October 1939: Angina pectoris in hereditary xanthomatosis. Nutr Rev. 1987 Apr;;45(4):113-52. Gofman, J.W., DeLalla, O., Galzier, F., Freeman, M.K., Lindgren, F.T., Nichols, A.V., Strisower, B., Tamplin, A.R. The serum lipoprotein transport system in health, metabolic disorders,

atherosclerosis and coronary artery disease. Plasma. 1955;;2:413–484.

Lipid Hypothesis1951…..

• Cholesterol we eat is like “biological rust” and clogs arteries like “hot grease down a cold drain”

• Eating cholesterol the cause of atherosclerosis

1908

1913 1937

slide art from clipartpanda.com and istockphoto.com

1940

1950

• 1950’s-1960’s: Ancel Keys: Biologist and pathologist at the University of Minnesota.Heart disease had quickly become an epidemic, and everyone was looking for answers. He formulated the “diet-heart hypothesis”, and stated with great persuasion that dietary fat was the cause of atherosclerotic disease, as well as obesity. He also advocated for the Mediterranean diet. The studies of that day are not of the standard of today and have many flaws. In fact his hypothesis was formulated without any real evidence by todays standards2.

• 1950-1955: the field of lipid study took off with the use of gas-liquid chromatography. Pioneered by Dr. Pete Ahrens at Rockefeller University, he initially showed that the consumption of saturated fats raised serum cholesterol. However as his research continued he showed a much more varied response of serum cholesterol to saturate fat consumption, and was critical of those claiming evidence for benefits of a low fat diet1.

1. Ahrens E. H. Jr.. 1984. After 40 years of cholesterol-watching. J. Lipid Res. 25: 1442–14492. Jason Andrade, MD, FRCPC, Aneez Mohamed, MD, FRCPC, Jiri Frohlich, MD, FRCPC, Andrew Ignaszewski, MD, FRCPC. 2009. Ancel Keys and the lipid hypothesis: From early

breakthroughs to current management of dyslipidemiaIssue: BCMJ, Vol. 51, No. 2, March 2009, page(s) 66-72

• In the late 1950’s the American Heart Associationformed a nutrition committee to makerecommendations. It did not support the diet-hearthypothesis of Keys, stating that “the evidence doesnot stand up under critical examination” Thischanged in 1961 when Keys became a member ofthe committee, and the diet-heart hypothesisbecame “the best scientific evidence available atthe time”

• Keys published the seven countries study(1947-1958) which showed that in the countriesanalyzed dietary fat seemed to mirror rates ofcardiovascular disease (USA, Finland,Yugoslavia, Japan, Netherlands, Italy, Greece).There was immediate criticism of the study, anda subsequent Keys had selected six countriesout of 21 for which data were available. Analysisof the full dataset made the analysis between fatintake and heart disease less clear, and currentanalyses have shown an opposite effect.

Keys A (ed). Coronary heart disease in seven countries. Circulation 1970;;41(4S1):1-198.

• The advice to reduce fat in human diet to reduce the risk of heartattacks and strokes has been a corner stone of world wide dietaryguidelines for over 60 years

Adult Nutritional Guidelines 1961

• Circulation 1961:

• “ The reduction or control of fat consumption under medicalsupervision, with reasonable substitution of poly-unsaturated forstaturated fats, is recommended as a possible means of preventingatherosclerosis and decreasing the risk of heart attacks andstrokes”

• “ More complete information must be obtained before finalconclusions are reached”

Dietary fat and its relation to heart attacks and strokes. Report by the Central Committee for Medical and Community Program of the American Heart Association. JAMA. 1961 Feb 4;;175:389-91.

• By 1969 there was still no clear evidence that the diet-heart hypothesis wasin fact correct. In fact, Dr. Pete Ahrens, at that time the chair Diet-HeartReview Panel of the National Heart Institute said “it is not known whetherdietary manipulation has any effect whatsoever on coronary heart disease”

• By the 1970’s, each step in the chain from fat to cholesterol to heart diseasehad been demonstrated in isolation. However the chain as a whole hadnever been proven, that is, it had never been proven that eating high levels ofsaturated fat would increase cardiovascular disease.

• Also in the mid 1970’s, the low fat diethypothesis became political, when SenatorGeorge McGovern’s bipartisan committee onNutrition and Human Needs advocated for thereduction in dietary fat after hearing from avariety of people including non scientists andfood industry personnel.

Dietary Goals for the United States. Prepared by the staff of the select committee on nutrition and human needs. Feb 1977. US. Government Printing Office Washington D.C .

“Dietary Goals for the United States”‘The McGovern Report’

Select Committee on Nutrition and Human NeedsUnited States Senate - February 1977

• The director of the National Heart Lungand Blood Institute Dr. Robert Levy saidthat “no one knew if eating less fat wouldprevent heart attacks”, and Dr. PeteAhrens said that “advising Americans toeat less fat on the strength of suchmarginal evidence was equivalent toconducting a nutritional experiment withthe American public as subjects”.

• The McGovern Report urged the public to cut saturated fat from their diet,but was challenged by a number of scientists in the Congressional hearingswho stated that the findings were not based on sufficient evidence.

• One scientist, Dr. Robert Olson said “I plead in my report and will pleadagain orally here for more research on the problem before we makeannouncements to the American public.” Senator McGovern replied:“Senators don’t have the luxury that the research scientist does of waitinguntil every last shred of evidence is in.”

• Concluded that even though dietary recommendations calling for the public to reduce total fat and saturated fat in their diet were introduced at the cost of $200M USD and $56M GBP, there was no supporting evidence from the seven RCTs that existed at the time

• 2015 Authors Zoe Harcombe et al. publish paper in journal Open Heart which conducts a meta-analysis of RCTs available:• in 1977 when the “Select Committee on Nutrition and Human Needs” published dietary recommendations for Americans

• In 1983 when the UK “National Advisory Committee on Nutritional Education” published dietary recommendations for the British Public

Dietary interventions and all deaths Dietary interventions and heart deaths

Favours Low Fat Diet Favours Control Diet Favours Low Fat Diet Favours Control Diet

Harcombe Z, Baker JS, Cooper SM, et al. Evidence from randomised controlled trials did not support the introduction of dietary fat guidelines in 1977 and 1983: a systematic review and meta-analysis. Open Heart 2015;;2:e000196

Every 5 years, the U.S. Departments of Agriculture (USDA) and Health and Human Services (HHS) must jointly publish a report containing nutritional and dietary information and guidelines for the general public

“Dietary Goals for the United States”‘The McGovern Report’ 1977

1990 National Nutrition Monitoring & Related Research Act

Dietary Guidelines for AmericansUnited States Department of AgricultureCenter for Nutrition Policy and Promotion

2000-2005

1980-1985

1990-1995

2010-20151985-1990

1995-20002005-2010

2015-2020

Canada’s Official Food Rules 1942

Canada’s Food Guide 1961

Eating Well With Canada’s Food Guide 2007

Canada’s Food Rules 1944

Canadian Council on Nutrition

Nutrition Division of the Federal Government

Canada’s Food Guide to Healthy Eating 1992

1982 new section titled “moderation” included which recommends “foods with limited amounts of fat”

1977 the term “meat” is replaced with “cooked lean meat” and serving of carbohydrates increased

Canada’s Food Rules 1949



1992 now suggests leaner meats, meat alternatives, and no more mention of cheese

• 1984 National Institutes of Health advocates the restriction of fat intake.

• 1988-1999 US Surgeon General’s Office commits to writing the definitive report on dietary fat, calling it “the most unwholesome part of the American Diet”. There was four project officers in 10 years, finally halting the project after 11 years. The associate director of the office of prevention at the NIH said “the report was initiated with a preconceived opinion of the conclusions, but the science behind these opinions was not holding up”

• 1970-2000 The production of low fat products became big business – 15,000 products introduced. A food science research industry arose to create palatable non-fat substitutes. The low fat message spread by what Gary Taubes calls “societal osmosis” - continually reinforced by physicians, dieticians, health organizations, journalists, and consumer advocacy groups.

Gary Taubes. 2001.The Soft Science of Dietary Fat. Science 30 Mar 2001:Vol. 291, Issue 5513, pp. 2536-2545

• 2001 After hundreds of millions ofdollars spent on trials, still no clearevidence that the consumption ofsaturated fats above the levelsrecommended in the guidelines wouldlead to an increase in untimely death

• 1984 AHA president tells TimeMagazine “if everyone went alongwe will have atherosclerosisconquered by 2000”

• 1970-2000 Americans dropped fatfrom 40% total calories to 34% - nochange in the incidence of heartdisease

• 1980-2000 Obesity rate goes from14% to 22%

• Despite changing and evolving evidence, not one US government agencychanged its dietary guidelines from 1961-2014

Adult Nutritional Guidelines 2006

AHA 2006 Diet and Lifestyle Recommendations for Cardiovascular Disease Risk Reduction

• Balance calorie intake and physical activity to achieve or maintain a healthy body weight• Consume a diet rich in vegetables and fruits• Choose whole-grain, high-fiber foods• Consume fish, especially oily fish, at least twice a week• Limit your intake of saturated fat to 7% of energy, trans fat to 1% of energy, and cholesterol to300 mg/d by

• Choosing lean meats and vegetable alternatives• Selecting fat-free (skim), 1% fat, and low-fat dairy products• Minimizing intake of partially hydrogenated fats

• Minimize intake of beverages and foods with added sugars• Choose and prepare foods with little or no salt• If you consume alcohol, do so in moderation• When you eat food prepared outside of home, follow the AHA diet and lifestyle recommendations

Diet and Lifestyle Recommendations Revision 2006. A Scientific Statement From the American Heart Association Nutrition Committee. Alice H. Lichtenstein et al., Circulation. 2006;;114:82-96. Originally published July 3, 2006

DEMANDEVIDENCE

ANDTHINK

CRITICALLY

Dietary Cholesterol

Total Dietary Fat

Unsaturated vs Saturated Fat

Dairy Saturated Fat

EggsButter

Image copyright NutrientsReview.com

Dietary Cholesterol

• The concept has been discredited since the 1950’s when studies showedeven high doses of cholesterol, equivalent to 150 egg yolks a day, had onlytrivial effect on serum cholesterol in most people1. Studies continue to showthis, but only now have guidelines caught up with scientific evidence.

• Eating excess cholesterol is not related to CVD, yet many people retain thisfalse impression from the McGovern Report.

Dietary Cholesterol

• Cholesterol is found only in animals and is essential for animallife. It allows animal cell membranes to bend and change shape,and comprises about 30% of our cell membranes.

• Cholesterol is important for making many hormones (cortisol,aldosterone, progesterone, estrogen, testosterone) and helpsabsorb vitamins A, D, E, and K. Cholesterol is vital for brainfunction including memory, and is an antioxidant.

1. Keys, A., and others: Diet and Serum Cholesterol in Man: Lack of Effect of Dietary Cholesterol, J. Nutrition 59:39-56 (May) 1956.

Dietary Cholesterol

• That’s why foods high in cholesterol have very little impact on blood cholesterol. In70% of the population, eating foods rich in cholesterol causes no change in bloodcholesterol or a tiny increase. In 30% of people these foods do cause a rise in bloodcholesterol, but research has never shown a clear link between this rise in dietarycholesterol and the risk for heart disease.

• A 68 kg (150 lb) human body has about 35,000 mg of cholesterol, mostly in thecell membranes. Daily requirements are about 1300 mg. The average person(U.S.) eats about 307 mg/day in food, so the body must make 1,000 mg. Sincewe need cholesterol to live and need 1300 mg per day, if we eat foods rich incholesterol like eggs, butter and meat, our bodies make less. If we limit foodshigh in cholesterol, our bodies make more.

• Too low cholesterol is associated with an increase in conditions such as cancer,hemorrhagic stroke, depression, anxiety, preterm birth, and low birth weight babies

Dietary Cholesterol• Because of the lack of scientific evidence between dietary cholesterol and CVD, countries began rescinding their guidelines capping dietary cholesterol (which started with the McGovern Report in 1977). The UK and most other European nations rescinded their advisories years ago.

McDonald, BE, Canadian experience: why Canada decided against an upper limit for cholesterol. J Am Coll Nutr. 2004 Dec;;23(6 Suppl):616S-620S.

• Canada officially has never had an upper limit for dietary cholesterol. In the final report of a national “Consensus Conference on Cholesterol" in 1988 there was no recommendation an upper limit for dietary cholesterol.

• The 1990 "Nutrition Recommendations: The Report of the Scientific Review Committee” publication by Health Canada also did not place an upper limit on dietary cholesterol

• This lack of a “cap” in Canada came from an understanding by Canadian Health Authorities that blood cholesterol was not linked to dietary cholesterol, and that there was extensive data showing no relationship between dietary cholesterol and cardiovascular mortality.

• Until 2015 the US continued to recommend a cap of 300 mg/day (as per the1977 McGovern Report) and the FDA continued to allow “cholesterol-free” onfood packaging giving the illusion of an important health concern. Thisoccurred even though there was no clear scientific evidence.

Dietary Cholesterol

• In 2015, the US Dietary Guidelines AdvisoryCommittee (DGAC) finally acknowledged theresearch and changed after 50 years ofwarnings about dietary cholesterol. Now"cholesterol is not considered a nutrient ofconcern for overconsumption” and the US isin line with other Western countries

• Ancel Keys himself, up until his death in 2004, expressed that he did notbelieve that dietary cholesterol was associated with CVD.

Total Dietary Fat

-Artwork Clipartpand.com free clipart

- National Center for Health Statistics. Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. Hyattsville, MD. 2016 Table 56- Kennedy ET1, Bowman SA, Powell R.Dietary-fat intake in the US population. Am Coll Nutr. 1999 Jun;;18(3):207-12.

2012

32.9%

Percent kcal from Total Dietary Fat U.S. Population

41.4%

1977

Total Dietary Fat

Does decreasing your total dietary fat intake reduce:• your overall chance of death• your chance of death from heart attack,

stroke• the chance of having a heart attack,

stroke, angina, heart surgery

The Key Question

Question 1: Does Decreasing Dietary Fat Reduce the Rate of Dying or

Cardiovascular Disease

• Hooper L, Summerbell CD, Thompson R, Sills D, Roberts FG, Moore HJ, Davey Smith G. Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD002137. DOI: 10.1002/14651858.CD002137.pub3.

• The Cochrane Database did an initial systematic review of studies looking at reduced or modified dietary fat for preventing cardiovascular disease in 2001, and updated it in 2011, 2012, and 2015

• In the 2012 update they assessed the effect of reduction and/or modification of overall dietary fats on mortality, cardiovascular mortality, cardiovascular morbidity and individual outcomes including myocardial infarction, stroke and cancer diagnoses in randomised clinical trials of at least 6 months duration

Cochrane Database 2012

• Results in terms of overall fat in diet:– No effect of reducing dietary fat on total mortality(RR 0.98, 95% CI 0.93 to 1.04, 71,790 participants)

– No effect of reducing dietary fat on cardiovascular mortality(RR 0.94, 95% CI 0.85 to 1.04, 65,978 participants)

– There are “no clear health benefits” of reducing the totalamount of fat we eat. This included overall death rates,cardiovascular death rates, incidences of heart attacks, angina,strokes, sudden cardiovascular death and the need for heartsurgery.


stroke• the chance of having a heart attack,


Total Dietary FatThe Key Question


stroke • the chance of having a heart attack,


Total Dietary FatThe Key Question


-Artwork Clipartpand.com free clipart

Does eating more unsaturated fats and less saturated fats reduce:• your overall chance of death• your chance of death from heart

attack, stroke• the chance of having a heart attack,


Unsaturated vs Saturated FatThe Key Question





32.9%

PUFASFA

MUFA

U.S. Population

Total Dietary Fat

Total Fat Intake = 32.9% of Total Calories

U.S. Population2012 Data

PUFA23%

(8% total calories)SFA33%

(11% total calories)

MUFA44%

(14% total calories)

- National Center for Health Statistics. Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. Hyattsville, MD. 2016


PUFA23% SFA

33%

MUFA44%



PUFA23% SFA

33%

MUFA44%



PUFA23% SFA

33%

MUFA44%


32.9%

State of the Literature 1950-1990

Fat and SFA should be reduced in diet to prevent heart attack and stroke and obesity

Fat and SFA not related to heart attack and stroke

State of the Literature 1990-2000



Poor quality evidence

State of the Literature 2016



NewNew

NewNew

Old

Old

Old

New

State of the Literature 2016



New

Old

Old

Old NewNew

NewNew

Studies SFA & CVD Finding

Wang et al. 2016 SFAs and Trans Fats associated with increased all cause mortality, and MUFAs and PUFAs associated with less all cause mortality.

Hooper et al. 2015 Replacing SFAs with PUFAs reduced CVD events by 17% in a large meta-analysis of RCTs, but not overall or CVD mortality. No effect if SFAs replaced with protein or carbs

de Souza et al 2015 SFAs not associated with all cause mortality, CVD, CHD, stroke, or DM2. Trans fats associated with all cause mortality, total CHD and CHD mortality, probably because of increased industrial trans fats

Harcombe et al 2015 Meta-analysis of RCTs available at the time the US and UK government issued their dietary fat guidelines (1977 and 1983) showed no evidence from RCTs at the time of issuing of guidelines

Chowdhury et al. 2014 No evidence to support reducing dietary SFAs in a very large meta-analysis, but heavily criticized

Ramsden et al. 2013 Replacing SFAs with a common PUFA increased death and CVD

de Oliveira 2012 higher intake of dairy SFAs associated with lower CVD risk, a higher intake of meat SFAs was associated with greater CVD risk

Mozaffarian 2010 19% reduction in coronary heart disease events by replacing SFAs with PUFAs

Siri-Tarino 2010 No significant evidence that dietary SFAs associated with an increased risk of CHD or CVD

Danaei 2009 Intervention studies replacing SFA with PUFA showed an insignificant relative risk (1.01-1.04) for IHD

Mente 2009 Insignificant effect of replacing SFA with PUFA

SFA→UFA ↓CVD SFA→UFA =CVD SFA→UFA ↑CVD

1 Wang DD, Li Y, Chiuve SE, Stampfer MJ, Manson JE, Rimm EB, Willett WC, Hu FB. Association of Specific Dietary Fats With Total and Cause-Specific Mortality. JAMA Intern Med. 2016;;176(8):1134-1145. doi:10.1001/jamainternmed.2016.24172 Timothy J A Key, Margaret Thorogood, Paul N Appleby, Michael L Burr. Dietary habits and mortality in 11000 vegetarians and health consciouspeople:resultsofa 17year followup BMJ 1996;;313:775-9

Wang et al 20161 Chowdhury et al 2014 Ramsden et al 2016

ChowdhuryR,WarnakulaS,KunutsorS,etal. Association of dietary, circulating, and supplement fatty acids with coronary risk: a systematic review and meta-analysis. Ann Intern Med. 2014;;160(6): 398-406.

RamsdenCE,ZamoraD,LeelarthaepinB,etal. Use of dietary linoleic acid for secondary prevention of coronary heart disease and death: evaluation of recovereddatafromtheSydneyDietHeartStudy and updated meta-analysis. BMJ. 2013;;346:e8707.

Finding: • Trans fat ↑ mortality• SFA ↑ mortality• MUFA ↓ mortality• PUFA ↓ mortality

Criticism: • Observational• Poor quality data• Contrary to RCTs• Heath Awarenessconfounder2

Finding:• Replacing SFAs witha common PUFAincreased death andCVD

Criticism: • Small study (n=221)• Short duration (39months)

• People with knownCVD

• Omega-3 may havebeen reduced

Finding: • Trans fat ↑ coronarydisease

• SFA no effect• MUFA no effect• PUFA no effect

Criticism: • Did not specify whatSFA was beingsubstituted with

• Did not differentiatebetween MUFA frommeat and on meat


attack, stroke • the chance of having a heart attack,



The Key Question





Dairy Saturated Fat

Dairy SFA and CVDStudy Finding

Alexander et al. 2016 Meta-analysis of dairy intake and CVD, CHD and stroke by using prospective cohort studies. Trend toward less CVD and CHD with increase in dairy consumption but not statistically significant, but significant for stroke (not focussed on SFAs)

Qin et al 2015 Dairy consumption reduced overall risk of CVD and stroke. No association with CHD. Stroke was reduced low-fat dairy and cheese and CHD risk was significantly lowered by cheese consumption

Hu et al. 2014 Meta-analysis of prospective cohort studies of dairy foods and risk of stroke finding that dairy consumption reduces risk of stroke (not focussed on SFAs)

de Oliveira 2012 Higher intake of dairy saturated fat was associated with lower CVD risk, a higher intake of meat SF was associated with greater CVD risk

Kratz et al 2012 Review of observational studies. High fat dairy consumption associated with a decrease in obesity, and did not show an effect on CVD or diabetes.

Rosell et al 2006 Intakes of whole milk and cheese was inversely associated with weight gain as measured by BMI.

The Dairy Paradox

Why? …

• ? Satiety - full fat diary produces post consumption satiety and less food consumption in the hours that follow.

• ? Dairy Fatty Acids - direct effect on weight homeostasis in the body from dairy fatty acids

• ? Low Fat = High Sugar - many low fat products replace the fat with sugar which will cause weight gain over full fat products

The Dairy Paradox - consumption of higher fat dairy decreases the risk of obesity and possibly decreases cardiovascular risk

ButterButter

Does decreasing or eliminating your consumption of butter:• your overall chance of death• your chance of getting any kind of CVD,

heart attack specifically, or strokespecifically

The Key Question

Butter

Butter

• Changing viewsexpressed in the press(eg. New York TimesMarch 2014 and TimeMagazine June 2014

Why all the fuss about butter? …

• Controversy around whether saturated fat is truly a risk forCVD, and utility of focusing on one macronutrient like fat

• People really like butter and just want someone to sayit’s ok

• Emerging evidence suggesting benefits of dairy fat

Butter

Pimpin, L, Wu, J.H.Y., Haskelberg, H., Del Bobbo, L., and Mozaffarian, D. 2016. Is butter back? A systematic review and Meta-Analysis of Butter Consumption and Risk of Cardovascular Disease, Diabetes, and Total Mortality. PLoS ONE 11(6) e0158118.doi:10137/journal.pone.0158118Y

• Meta-analysis of butter consumption, CVD, Diabetes, and Total Mortalityacross 9 publications and 636,151 unique participants. All cohort studies, noRCTs.

• Butter consumption weakly associated with all cause mortality (RR 1.01,95% CI 1.00-1.03). Essentially each average consumption of one moretablespoon of butter per day was associated with a 1% increase in all causemortality.

• Butter consumption was not significantly associated with any CVD (RR1.00, 95% CI 0.98-1.02)

• Butter consumption was not significantly associated with coronary heartdisease (RR 0.99, 95% CI 0.96-1.03)

• Butter consumption was not significantly associated with stroke (RR 1.01,95% CI 0.98-1.03)

• Butter consumption was inversely associated with the incidence ofdiabetes (RR 0.96, 95% CI 0.93-0.99)

June 29, 2016 Pimpin, et al.

OR

OR

Butter Margerine

Eggs

Does decreasing or eliminating your consumption of eggs:• the chance of having a heart attack or

stroke

The Key Question

Eggs

• Meta-analysis of egg consumption and coronary artery disease and stroke

• Eight articles with 17 reports (9 coronary heart disease, 8 stroke) were eligible for inclusion in the meta-analysis (3  081  269 person years and 5847 incident cases for coronary heart disease, and 4  148  095 person years and 7579 incident cases for stroke)..

• Conclusion – Eggs have no risk of CVD. Higher consumption of eggs (up to one egg per day) is not associated with increased risk of coronary heart disease or stroke.

• The increased risk of coronary heart disease among diabetic patients and reduced risk of hemorrhagic stroke associated with higher egg consumption in subgroup analyses warrant further studies.

January 2013 Rong, et al.

Eggs

Rong Ying, Chen Li, Zhu Tingting, Song Yadong, Yu Miao, Shan Zhilei et al. Egg consumption and risk of coronary heart disease and stroke: dose-response meta-analysis of prospective cohort studies BMJ 2013;; 346:e8539

Summary: Dietary Fat

• Saturated fat has been demonized since 1950’s, but public policy andguidelines were created before any evidenced-based science was clear.

• The current evidence as of 2016 with respect to dietary fat andcardiovascular disease indicates that:– The consumption of trans fats increases CVD– There is no reduction in CVD by reducing overall fat– The literature is unclear if reducing saturated fat has an impact on CVD

• Replacing saturated fat with refined carbohydrates does not reduce CVD• Replacing saturated fat with unsaturated fat may: 1) reduce CVD, 2) have no effecton CVD, 3) increase CVD

• There may be a decrease in CVD from some dairy saturated fat– There is no increase in CVD from eating cholesterol rich foods, includingeggs and butter

Summary: Dietary Fat

• People were advised to reduce fat intake to 30% of energy and saturated fat to 10% starting in the 1960’s, 70’s, 80’s and 90’s. And they did, with US fat consumption declining from 41.4% to 32.9% in the past 30 years.

• The advice to reduce fat is associated temporally with the epidemic of obesity, and many postulate this has occurred because people are replacing saturated fat with processed carbohydrates like sugar and flour

Obesity Rates

OECD Obesity Update 2012 www.oecd.org/health/fitnotfat

Obesity Rates

OECD Obesity Update 2012 www.oecd.org/health/fitnotfat

Onset of public health advice to eat low fat diet

• Outdated. Was likely scientifically accurate inearly 2000’s, but the science has moved on• Villifies saturated fats and overestimates thelink to cardiovascular disease• Emphasizes nutrients rather than a wholefood approach• Fails to distinguish between whole fruit andfruit juice• Fails to address warnings about trans fat andprocessed food within the body of thedocument, adding at the end• Does not address eating behaviours• Criticism reaching the lay press underminingcredibility, article in Chatelaine Aug 2016

Criticism of Canada’s Food Guide 2007

Development : April 2015Launch: September 29, 2015

To access the complete position paper: EN: http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.9314923/k.E0FA/Saturated_fat_heart_disease_and_stroke.htmFR: http://www.fmcoeur.com/site/c.ntJXJ8MMIqE/b.9314925/k.4CA7/Les_gras_satur233s_les_maladies_du_c339ur_et_l8217AVC.htm

To access the complete position paper: EN: http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.9314923/k.E0FA/Saturated_fat_heart_disease_and_stroke.htmFR: http://www.fmcoeur.com/site/c.ntJXJ8MMIqE/b.9314925/k.4CA7/Les_gras_satur233s_les_maladies_du_c339ur_et_l8217AVC.htm

• Variety of protein sources including beans, nuts, low fat dairy*• Eat fewer highly processed foods like confectionaries, sugary drinks, processed meats, and snack foods

• Plan healthy snacks including 1-2 servings of fruit and veg at every snack• Quench you thirst with water. Avoid soft drinks, fruit drinks, 100% fruit juice, and ready-to-drink sweetened coffees and teas

• Choose healthy portion sizes• Prepare meals at home with natural/whole and minimally processed foods

– Develop and teach the skills to cook from scratch– By from shops and markets selling fresh minimally processed food– Reduce the amount of sugar, salt and solid fats* in preparation– If eating in a restaurant choose places with freshly made dishes

• Promote healthy food in workplaces, schools, sports environments, faith centres, and community centres

Recommendations for Canadians:

• Consume natural/whole minimally processed foods• Half you plate with fresh fruit and vegetables• Whole grains *

So what do well tell our patients

Avoid Processed Food

• Shift away from focussing on isolatedmacronutrient like saturated fat for determining therisk of cardiovascular disease

• Shift towards food-based paradigms

So what do well tell our patients


Shop for food every 1-2 days – more likely to buy fresh, more likely to experiment with new fruits and veg

Cook from fresh ingredients

Go to restaurants that prepare food from fresh

Shop from the periphery of the store – fresh items around the edges, processed food in the middle


Periphery Middle

Quench your thirst with water – avoid sugar sweetened beverages such as soft drinks, sport drinks, fruit drinks and juices

½ to ¾ of your plate fresh fruit & veg – the amount of fresh fruit and veg you consume directly relates to your CVD risk. Consider both cooked and raw. Cut up fruit as part of your meal. Five or more different small servings for variety. You don’t need starch with every meal


The One Unifying Message

Evidence-based and ties together all the literature relating diet and CVD

Inclusive, embraces all “diets” (ancestral/paleo;; plant-based;; Mediterranean;; etc)

Reduces sugars Reduces trans fat

Encourages Healthy Snacking

Addresses Eating Behaviour

Avoids fast food

Reduces Sodium

Reduces deli meats

Reduces flours

Increases fresh fruit and veg

Removes sugar sweetened beverages

“our cardiovascular system is the victim of convenience eating”


Questions

PRESENTATION - 3

Dairy Products and Cardiometabolic Health

Jean-Philippe Drouin-ChartierRD PhD(c)

Institute of Nutrition and Functional FoodsUniversité Laval

Research directors• Dr Patrick Couture, MD PhD FRCP(C)• Dr Benoît Lamarche, PhD FAHADoctoral scholarships• Canadian Institute of Health Research • Fonds de recherche du Québec -‐ Santé

Disclosures

Funding of research projects• CIHR, Merck Frosst, Kaneka Corporation, DairyFarmers of Canada, Dairy Research Cluster, DairyResearch Consortium

Funding of work presented today• Dairy Research Consortium and the Chair ofNutrition at Laval University

Personal funding previously received• Speaker Honoria, Dairy Farmers of Canada (2016)

Disclosures

Introduction

Saturated fatty acids

↑ LDL-‐C ↑ Cardiovascular disease risk

Introduction

Introduction

Questions

1. Is dairy consumption beneficially, neutrally or detrimentally associated with cardiovascular health?

2. Is the recommendation on reduced/low-fatdairy food consumption, vs regular/high-fatdairy, evidence-based?

Our Approach1. Evaluation of epidemiological evidence

2. Evaluation of clinical evidence

AssociationDairy productsCardiovascular and cardiometabolic

health

Dairy productsCardiovascular and cardiometabolic

healthImpact

Epidemiological Evidence

Associations between dairy product consumption and cardiovascular-related clinical outcomes

Epidemiological Evidence - Our Approach

Prospective cohort studies

Case-controlstudies

Cross-sectional studies

Meta-analysis

Quality Meta-analysis

Meta-analysisMeta-analysis

Meta-analysis

Systematic review of

meta-analyses

1. Systematic review of meta-analyses of prospectivecohort studies (PRISMA method)

DP vs cardiovascular disease, coronary artery disease, stroke, hypertension, metabolic syndrome, type 2 diabetes

2. Evaluation of meta-analysis quality (MOOSE method):Low (<60%), moderate (60-80%), high quality (≥80%)

3. Evaluation of the association between dairy consumptionand the risk of cardiovascular-related clinical outcomes:

Favourable (↓ risk), neutral, unfavourable (↑ risk), uncertain4. Evaluation of the quality of the evidence (GRADE

method)

Epidemiological Evidence - Our Approach

References Quality (%) Funding sourceElwood et al., 2004 53 University of Wales College of Medicine and Bristol University, Food Standards AgencyElwood et al., 2008 54 No fundingElwood et al., 2010 54 No fundingSoedamah-Muthu et al., 2011 74 Dutch Dairy Association (unrestricted)Tong et al., 2011 60 National Natural Science Foundation of ChinaBendsen et al., 2011 80 Arla Food AmbaRalston et al., 2012 69 National Health and Medical research Council of AustraliaSoedamah-Muthu et al., 2012 71 Dutch Dairy Association (unrestricted), Global Dairy PlatformAune et al., 2013 69 Liaison Committee between the Central Norway Regional Health Authority and the

Norwegian University of Science and TechnologyGao et al., 2013 80 National Natural Science Foundation of ChinaO'Sullivan et al., 2013 83 National Health and Medical research Council of AustraliaChen et al., 2014 54 National Institutes of HealthChowdhury et al., 2014 100 British Heart Foundation, Medical Research Council, Cambridge National Institute for

Health Research Biomedical Research Centre, Gates CambridgeHu et al., 2014 71 Not indicatedQin et al., 2015 64 Nestec Ltd. (Nestlé R&D (China) Ltd)De Souza et al., 2015 77 World Health OrganizationLarsson et al., 2015 66 Young Scholars Award Grant from the Strategic Research Area in Epidemiology,

Karolinska InstitutetChen et al., 2015 67 Yili Innovation Center, Inner Mongolia Yili Industrial Group Co., Ltd. Kim and Je, 2015 67 Basic Science research Program of the National Research Foundation of Korea,

Ministry of Science, ICT and Future PlanningAlexander et al., 2016 67 Dairy Research InstituteGijsberg et al., 2016 73 Wageningen University

Identified Meta-analyses (n=21)

Epidemiological EvidenceHigh vs Low Dairy Intake

Neutral

Favourable

Unfavourable

Legend



CVD CHD Stroke HypertensionMetabolicsyndrome

Type 2 diabetes

Total dairy NeutralModerate

NeutralHigh

FavorableModerate

FavorableHigh

FavorableModerate

FavorableModerate

High-fat UncertainVery low

NeutralHigh

NeutralModerate

NeutralModerate

UncertainVery low

NeutralModerate

Low-fat UncertainVery low

NeutralHigh

FavorableModerate

FavorableModerate

UncertainVery low

FavorableHigh


« High-fat » dairy

« Low-fat » dairy

Whole milk (3%) Cheese (>30%)

Skim milk (0-1%)Fat-free yogurt (0%)

Low-fat cheese (15-20%)

Fat (%)

CVD CHD Stroke HypertensionMetabolicsyndrome

Type 2 diabetes

Milk UncertainVery low

NeutralModerate

NeutralModerate

FavorableModerate

FavorableModerate

NeutralModerate

Cheese NeutralHigh

NeutralModerate

FavorableModerate

NeutralHigh

UncertainVery low

FavorableModerate

Yogurt NeutralModerate

NeutralModerate

NeutralModerate

NeutralModerate

UncertainVery low

FavorableHigh


Milk and yogurt (0-3%) Cheese (>30% + sodium)

Fat (%)

Clinical Evidence

Impact of dairy food consumption on cardiometabolic risk factors

Clinical Evidence

↑ Cardiovasculardiseaserisk

↑ Endothelial dysfunction

↑ Insulin resistance

↑ ApoB

Small, dense LDLs

↓ HDL-‐C

↑ Blood pressure

↑ TG↑ LDL-‐C

↑ Inflammation

Clinical Evidence - Our Approach

Endothelial dysfunctionInsulin resistance

ApoBsmall, dense LDLsHDL-‐C

Blood pressure

TG

LDL-‐C

Inflammation

Dairyproducts

Dairy-‐containing dietvs

Dairy-‐free diet

High-‐fat dairyvs

Low-‐fat dairy

Review of meta-analyses of randomized controlled trials

Meta-analyses of randomized controlled trials

Clinical Evidence - Our Approach

Identified meta-analyses (n=2)Benatar et al. 2013De Goede et al. 2014

Identified randomized controlled trials(n=45)Abdullah, 2015Alonso, 2009Appel, 1997Ballard, 2013Baran, 1990Barr, 2000Beavers, 2010Benatar, 2013Chiu, 2016Craddick, 2003Crichton, 2012Drouin-Chartier, 2015

Drouin-Chartier, 2014Hidaka, 2012Hilpert, 2009Hjersted, 2011Hoppe, 2009Hoppe, 2004Hussi, 1981Jones, 2013Kynast-Gales, 1992Labonté, 2013Labonté, 2014Maki, 2013

Nestel, 2005Nestel, 2012Nestel, 2013Pal, 2010Palacios, 2011Raziani, 2016Rideout, 2013Sadrzadeh-Yeganek, 2010Schlienger, 2014Schmid, 2015Serra, 2012

Stancliffe, 2011Steinmetz, 1994Thorning, 2015Turner, 2014Turner, 2015Van Loan, 2011Van Meijl, 2010Van Meijl, 2011Van Meijl, 2013Wennersberg, 2009Zemel, 2005

Dairy-containing vs Dairy-free Diet

Total dairy High-fat Low-fat Milk Cheese Yogurt

LDL-C ↔ ↔ ↔HDL-C Mixed Mixed ↔Fasting TGs ↔ ↔ ↔ Mixed ↔ ↔Post-prandial TGs Undetermined Undetermined Undetermined ↔ ↔ Undetermined

LDL size Undetermined ↔ Mixed ↔ Undetermined Undetermined

Apo B Undetermined ↔ ↔ ↔ ↔ Undetermined

Non-HDL-C Undetermined ↔ ↔ Undetermined Undetermined Undetermined

C ratios Undetermined Undetermined Undetermined ↔ ↔ ↓

Legend: no impact, reported in ≥1 meta-analysis Undetermined: no study

↓↔↑: Reported in <3 RCTs, needs to be interpreted with caution

Mixed: mixed results among available RCTs

Dairy-Containing vs Dairy-Free Diet

Total dairy High-fat Low-fat Milk Cheese Yogurt

Inflammation ↔ Undetermined Undetermined

Blood pressure ↔ Undetermined Undetermined

Insulinresistance ? Undetermined ? ↔ ↔ Undetermined

Endothelialfunction ↔ Undetermined ↔ ↔ Undetermined undetermined







High-Fat vs Low-Fat Dairy

Total high fat vs total low fat

Whole vs low-fat milk

Regular vs low-fat cheese

Whole vs low-fat yogurt

LDL-C ↔ ↑ ↔ UndeterminedHDL-C ↔ ↔ ↔ UndeterminedFasting TGs ↓ ? ↔ UndeterminedPost-prandial TGs Undetermined Undetermined Undetermined UndeterminedLDL size ↑ ↓ Undetermined UndeterminedApo B ↔ ↔ Undetermined UndeterminedNon-HDL-C ↔ Undetermined Undetermined UndeterminedC ratios Undetermined ↔ ↔ Undetermined

High-Fat vs Low-Fat Dairy

Total high fat vs total low fat

Whole vs low-fat milk

Regular vs low-fat cheese

Whole vs low-fat yogurt

Inflammation ↔ Undetermined ↔ Undetermined

Blood pressure ↔ Undetermined Undetermined Undetermined

Insulinresistance Undetermined Undetermined ↔ Undetermined

Endothelialfunction Undetermined Undetermined Undetermined Undetermined




Conclusions

Is dairy consumption beneficially, neutrally or detrimentally associated with cardiovascular

health?

ConclusionsEpidemiological evidence:

Clinical evidence:

Dairy products ↑ risk of cardiovascular/ cardiometabolic disease

Dairy productscardiovascular/ cardiometabolic risk factors

Dairy products risk of coronary artery disease

Dairy products ↓ risk of type 2 diabetes and hypertension

Conclusions

Is dairy consumption beneficially, neutrally or detrimentally associated with cardiovascular

health?

Neutral or beneficial

Conclusions

Is the recommendation on reduced/low-fat dairy food consumption, vs regular/high-fat dairy,

evidence-based?

ConclusionsEpidemiological evidence:

Low-fat dairy

High-fat dairy

Milk

Cheese

↓ risk of stroke, hypertension and type 2 diabetes

risk of stroke, hypertension and type 2 diabetes↓ risk of hypertension and metabolic syndrome↓ risk of stroke and type 2 diabetes

ConclusionsClinical evidence:

Low-fat dairyMilk

High-fat dairyCheese

Low-fat dairy High-fat dairy

Cardiometabolic risk factors



Conclusions

Is the recommendation on reduced/low-fat dairy food consumption, vs regular/high-fat dairy,

evidence-based?

No…

Conclusions• Undetermined epidemiological evidence

• Skim vs whole milk• Low-fat vs regular cheese• Skim vs whole yogurt

• Uncertain epidemiological evidence• Milk vs CVD• Cheese, yogurt vs metabolic syndrome

• Undetermined/mixed clinical impact• Skim vs whole milk• Low-fat vs regular cheese• Skim vs whole yogurt

vs risk of cardiovascular and cardiometabolic disease

vs cardiometabolic risk factors

Conclusions• Substantial evidence support the inclusion of dairy products as part of a healthy diet (vs risk of type 2 diabetes and hypertension)

• The review of dietary recommendations should take into account the absence of detrimental association and impact of dairy products on cardiovascular health.

Conclusions

For more detailsJean-Philippe Drouin-Chartier, Didier Brassard, Maude Tessier-Grenier, Julie-Anne Côté, Marie-Ève Labonté, Sophie Desroches, Patrick Couture, Benoît Lamarche. Systematic review of the association between dairy consumption and risk of cardiovascular-related clinical outcomes.Advances in Nutrition

Jean-Philippe Drouin-Chartier, Julie-Anne Côté, Marie-Ève Labonté, Didier Brassard, Maude Tessier-Grenier, Sophie Desroches, Patrick Couture, Benoît Lamarche. Comprehensive review of the impact of dairy foods and dairy fat on cardiometabolic risk. Advances in Nutrition

AcknowledgmentsResearch group- Dr Benoît Lamarche, PhD FAHA- Dr Patrick Couture, MD PhD

FRCP(C)- Dre Sophie Desroches, RD PhD- Dre Marie-Ève Labonté, RD PhD- Julie-Anne Côté, RD PhD(c)- Didier Brassard, RD MSc(c)- Maude Tessier-Grenier, RD MSc(c)

Funding agencies- Dairy Research Consortium- Chair of nutrition

ReferencesMethods:Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS medicine

2009;;6(7):e1000097.Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB. Meta-analysis of observational studies in

epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000;;283(15):2008-12.Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ. GRADE: an emerging consensus on rating quality of evidence and

strength of recommendations. BMJ 2008;;336(7650):924-6.Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, Schunemann HJ. What is "quality of evidence" and why is it important to clinicians? Bmj

2008;;336(7651):995-8. Balshem H, Helfand M, Schunemann HJ, Oxman AD, Kunz R, Brozek J, Vist GE, Falck-Ytter Y, Meerpohl J, Norris S, et al. GRADE guidelines: 3. Rating the quality

of evidence. Journal of clinical epidemiology 2011;;64(4):401-6. Meta-analyses of prospective cohort studies:Elwood PC, Pickering JE, Hughes J, Fehily AM, Ness AR. Milk drinking, ischaemic heart disease and ischaemic stroke II. Evidence from cohort studies. European

journal of clinical nutrition 2004;;58(5):718-24. Elwood PC, Givens DI, Beswick AD, Fehily AM, Pickering JE, Gallacher J. The survival advantage of milk and dairy consumption: an overview of evidence from

cohort studies of vascular diseases, diabetes and cancer. J Am Coll Nutr 2008;;27(6):723S-34S.Elwood PC, Pickering JE, Givens DI, Gallacher JE. The consumption of milk and dairy foods and the incidence of vascular disease and diabetes: an overview of the

evidence. Lipids 2010;;45(10):925-39. Soedamah-Muthu SS, Ding EL, Al-Delaimy WK, Hu FB, Engberink MF, Willett WC, Geleijnse JM. Milk and dairy consumption and incidence of cardiovascular

diseases and all-cause mortality: dose-response meta-analysis of prospective cohort studies. Am J Clin Nutr 2011;;93(1):158-71. Tong X, Dong JY, Wu ZW, Li W, Qin LQ. Dairy consumption and risk of type 2 diabetes mellitus: a meta-analysis of cohort studies. European journal of clinical

nutrition 2011;;65(9):1027-31.Bendsen NT, Christensen R, Bartels EM, Astrup A. Consumption of industrial and ruminant trans fatty acids and risk of coronary heart disease: a systematic review

and meta-analysis of cohort studies. European journal of clinical nutrition 2011;;65(7):773-83.Ralston RA, Lee JH, Truby H, Palermo CE, Walker KZ. A systematic review and meta-analysis of elevated blood pressure and consumption of dairy foods. J Hum

Hypertens 2012;;26(1):3-13.Soedamah-Muthu SS, Verberne LD, Ding EL, Engberink MF, Geleijnse JM. Dairy consumption and incidence of hypertension: a dose-response meta-analysis of

prospective cohort studies. Hypertension 2012;;60(5):1131-7. Aune D, Norat T, Romundstad P, Vatten LJ. Dairy products and the risk of type 2 diabetes: a systematic review and dose-response meta-analysis of cohort studies.

Am J Clin Nutr 2013;;98(4):1066-83. Gao D, Ning N, Wang C, Wang Y, Li Q, Meng Z, Liu Y, Li Q. Dairy products consumption and risk of type 2 diabetes: systematic review and dose-response meta-

analysis. PLoS One 2013;;8(9):e73965.O'Sullivan TA, Hafekost K, Mitrou F, Lawrence D. Food sources of saturated fat and the association with mortality: a meta-analysis. Am J Public Health

2013;;103(9):e31-42.Chen M, Sun Q, Giovannucci E, Mozaffarian D, Manson JE, Willett WC, Hu FB. Dairy consumption and risk of type 2 diabetes: 3 cohorts of US adults and an

updated meta-analysis. BMC Med 2014;;12:215.

ReferencesChowdhury R, Warnakula S, Kunutsor S, Crowe F, Ward HA, Johnson L, Franco OH, Butterworth AS, Forouhi NG, Thompson SG, et al. Association of dietary,

circulating, and supplement fatty acids with coronary risk: a systematic review and meta-analysis. Ann Intern Med 2014;;160(6):398-406.Hu D, Huang J, Wang Y, Zhang D, Qu Y. Dairy foods and risk of stroke: a meta-analysis of prospective cohort studies. Nutr Metab Cardiovasc Dis 2014;;24(5):460-

9.Qin LQ, Xu JY, Han SF, Zhang ZL, Zhao YY, Szeto IM. Dairy consumption and risk of cardiovascular disease: an updated meta-analysis of prospective cohort

studies. Asia Pacific journal of clinical nutrition 2015;;24(1):90-100. de Souza RJ, Mente A, Maroleanu A, Cozma AI, Ha V, Kishibe T, Uleryk E, Budylowski P, Schünemann H, Beyene J, et al. Intake of saturated and trans

unsaturated fatty acids and risk of all cause mortality, cardiovascular disease, and type 2 diabetes: systematic review and meta-analysis of observational studies. BMJ 2015;;351:h3978.

Larsson SC, Crippa A, Orsini N, Wolk A, Michaelsson K. Milk Consumption and Mortality from All Causes, Cardiovascular Disease, and Cancer: A Systematic Review and Meta-Analysis. Nutrients 2015;;7(9):7749-63. doi: 10.3390/nu7095363.

Chen GC, Szeto IM, Chen LH, Han SF, Li YJ, van Hekezen R, Qin LQ. Dairy products consumption and metabolic syndrome in adults: systematic review and meta-analysis of observational studies. Scientific reports 2015;;5:14606.

Kim Y, Je Y. Dairy consumption and risk of metabolic syndrome: a meta-analysis. Diabet Med 2016;;33(4):428-40.Alexander DD, Bylsma LC, Vargas AJ, Cohen SS, Doucette A, Mohamed M, Irvin SR, Miller PE, Watson H, Fryzek JP. Dairy consumption and CVD: a systematic

review and meta-analysis. Br J Nutr 2016;;115(4):737-50.Gijsbers L, Ding EL, Malik VS, de Goede J, Geleijnse JM, Soedamah-Muthu SS. Consumption of dairy foods and diabetes incidence: a dose-response meta-

analysis of observational studies. Am J Clin Nutr 2016;;103(4):1111-24.Prospective cohort study:Michaelsson K, Wolk A, Langenskiold S, Basu S, Warensjo Lemming E, Melhus H, Byberg L. Milk intake and risk of mortality and fractures in women and men:

cohort studies. BMJ 2014;;349:g6015.Meta-analyses of clinical trialsBenatar JR, Sidhu K, Stewart RA. Effects of high and low fat dairy food on cardio-metabolic risk factors: a meta-analysis of randomized studies. PLoS One

2013;;8(10):e76480. doi: 10.1371/journal.pone.0076480de Goede J, Geleijnse JM, Ding EL, Soedamah-Muthu SS. Effect of cheese consumption on blood lipids: a systematic review and meta-analysis of randomized

controlled trials. Nutr Rev 2015;;73(5):259-75. doi: 10.1093/nutrit/nuu060. Labonte ME, Couture P, Richard C, Desroches S, Lamarche B. Impact of dairy products on biomarkers of inflammation: a systematic review of randomized

controlled nutritional intervention studies in overweight and obese adults. Am J Clin Nutr 2013;;97(4):706-17. Clinical trials:Abdullah MM, Cyr A, Lepine MC, Labonte ME, Couture P, Jones PJ, Lamarche B. Recommended dairy product intake modulates circulating fatty acid profile in

healthy adults: a multi-centre cross-over study. Br J Nutr 2015:1-10. Barr SI, McCarron DA, Heaney RP, Dawson-Hughes B, Berga SL, Stern JS, Oparil S. Effects of increased consumption of fluid milk on energy and nutrient intake,

body weight, and cardiovascular risk factors in healthy older adults. J Am Diet Assoc 2000;;100(7):810-7. Beavers KM, Serra MC, Beavers DP, Hudson GM, Willoughby DS. The lipid-lowering effects of 4 weeks of daily soymilk or dairy milk ingestion in a postmenopausal

female population. J Med Food 2010;;13(3):650-6.

ReferencesDrouin-Chartier JP, Gagnon J, Labonte ME, Desroches S, Charest A, Grenier G, Dodin S, Lemieux S, Couture P, Lamarche B. Impact of milk consumption on

cardiometabolic risk in postmenopausal women with abdominal obesity. Nutr J 2015;;14:12. Thorning TK, Raziani F, Bendsen NT, Astrup A, Tholstrup T, Raben A. Diets with high-fat cheese, high-fat meat, or carbohydrate on cardiovascular risk markers in

overweight postmenopausal women: a randomized crossover trial. Am J Clin Nutr 2015. Sadrzadeh-Yeganeh H, Elmadfa I, Djazayery A, Jalali M, Heshmat R, Chamary M. The effects of probiotic and conventional yoghurt on lipid profile in women. Br J

Nutr 2010;;103(12):1778-83. Chiu S, Bergeron N, Williams PT, Bray GA, Sutherland B, Krauss RM. Comparison of the DASH (Dietary Approaches to Stop Hypertension) diet and a higher-fat

DASH diet on blood pressure and lipids and lipoproteins: a randomized controlled trial. Am J Clin Nutr 2016;;103(2):341-7. Steinmetz KA, Childs MT, Stimson C, Kushi LH, McGovern PG, Potter JD, Yamanaka WK. Effect of consumption of whole milk and skim milk on blood lipid profiles

in healthy men. Am J Clin Nutr 1994;;59(3):612-8.Nestel PJ, Chronopulos A, Cehun M. Dairy fat in cheese raises LDL cholesterol less than that in butter in mildly hypercholesterolaemic subjects. European journal of

clinical nutrition 2005;;59(9):1059-63.Baran D, Sorensen A, Grimes J, Lew R, Karellas A, Johnson B, Roche J. Dietary modification with dairy products for preventing vertebral bone loss in

premenopausal women: a three-year prospective study. J Clin Endocrinol Metab 1990;;70(1):264-70. Wennersberg MH, Smedman A, Turpeinen AM, Retterstol K, Tengblad S, Lipre E, Aro A, Mutanen P, Seljeflot I, Basu S, et al. Dairy products and metabolic effects

in overweight men and women: results from a 6-mo intervention study. Am J Clin Nutr 2009;;90(4):960-8. van Meijl LE, Mensink RP. Low-fat dairy consumption reduces systolic blood pressure, but does not improve other metabolic risk parameters in overweight and

obese subjects. Nutr Metab Cardiovasc Dis 2011;;21(5):355-61.Palacios C, Bertran JJ, Rios RE, Soltero S. No effects of low and high consumption of dairy products and calcium supplements on body composition and serum

lipids in Puerto Rican obese adults. Nutrition 2011;;27(5):520-5.Crichton GE, Howe PR, Buckley JD, Coates AM, Murphy KJ. Dairy consumption and cardiometabolic health: outcomes of a 12-month crossover trial. Nutr Metab

(Lond) 2012;;9:19. Benatar JR, Jones E, White H, Stewart RA. A randomized trial evaluating the effects of change in dairy food consumption on cardio-metabolic risk factors. European

journal of preventive cardiology 2013. Hussi E, Miettinen TA, Ollus A, Kostiainen E, Ehnholm C, Haglund B, Huttunen JK, Manninen V. Lack of serum cholesterol-lowering effect of skimmed milk and

butter milk under controlled conditions. Atherosclerosis 1981;;39(2):267-72.Hidaka H, Takiwaki M, Yamashita M, Kawasaki K, Sugano M, Honda T. Consumption of nonfat milk results in a less atherogenic lipoprotein profile: a pilot study.

Annals of nutrition & metabolism 2012;;61(2):111-6. van Meijl LE, Mensink RP. Effects of milk and milk constituents on postprandial lipid and glucose metabolism in overweight and obese men. Br J Nutr

2013;;110(3):413-9. Nordestgaard BG, Benn M, Schnohr P, Tybjaerg-Hansen A. Nonfasting triglycerides and risk of myocardial infarction, ischemic heart disease, and death in men and

women. JAMA 2007;;298(3):299-308. van Meijl LE, Mensink RP. Effects of low-fat dairy consumption on markers of low-grade systemic inflammation and endothelial function in overweight and obese

subjects: an intervention study. Br J Nutr 2010;;104(10):1523-7.

ReferencesVan Loan MD, Keim NL, Adams SH, Souza E, Woodhouse LR, Thomas A, Witbracht M, Gertz ER, Piccolo B, Bremer AA, et al. Dairy Foods in a Moderate Energy

Restricted Diet Do Not Enhance Central Fat, Weight, and Intra-Abdominal Adipose Tissue Losses nor Reduce Adipocyte Size or Inflammatory Markers in Overweight and Obese Adults: A Controlled Feeding Study. J Obes 2011;;2011:989657.

Labonte ME, Cyr A, Abdullah MM, Lepine MC, Vohl MC, Jones P, Couture P, Lamarche B. Dairy product consumption has no impact on biomarkers of inflammation among men and women with low-grade systemic inflammation. The Journal of nutrition 2014;;144

Jones KW, Eller LK, Parnell JA, Doyle-Baker PK, Edwards AL, Reimer RA. Effect of a dairy- and calcium-rich diet on weight loss and appetite during energy restriction in overweight and obese adults: a randomized trial. European journal of clinical nutrition 2013;;67(4):371-6.

Serra MC, Beavers KM, Beavers DP, Willoughby DS. Effects of 28 days of dairy or soy ingestion on skeletal markers of inflammation and proteolysis in post-menopausal women. Nutr Health 2012;;21(2):117-30.

Schmid A, Petry N, Walther B, Butikofer U, Luginbuhl W, Gille D, Chollet M, McTernan PG, Gijs MA, Vionnet N, et al. Inflammatory and metabolic responses to high-fat meals with and without dairy products in men. Br J Nutr 2015;;113(12):1853-61.

Nestel PJ, Mellett N, Pally S, Wong G, Barlow CK, Croft K, Mori TA, Meikle PJ. Effects of low-fat or full-fat fermented and non-fermented dairy foods on selected cardiovascular biomarkers in overweight adults. Br J Nutr 2013;;110(12):2242-9.

Turner KM, Keogh JB, Clifton PM. Dairy consumption and insulin sensitivity: A systematic review of short- and long-term intervention studies. Nutr MetabCardiovasc Dis 2014.

Rideout TC, Marinangeli CP, Martin H, Browne RW, Rempel CB. Consumption of low-fat dairy foods for 6 months improves insulin resistance without adversely affecting lipids or bodyweight in healthy adults: a randomized free-living cross-over study. Nutr J 2013;;12:56.

Zemel MB, Richards J, Milstead A, Campbell P. Effects of calcium and dairy on body composition and weight loss in African-American adults. Obes Res 2005;;13(7):1218-25.

Stancliffe RA, Thorpe T, Zemel MB. Dairy attentuates oxidative and inflammatory stress in metabolic syndrome. Am J Clin Nutr 2011;;94(2):422-30.Pal S, Ellis V, Dhaliwal S. Effects of whey protein isolate on body composition, lipids, insulin and glucose in overweight and obese individuals. Br J Nutr

2010;;104(5):716-23. Hoppe C, Kristensen M, Boiesen M, Kudsk J, Fleischer Michaelsen K, Molgaard C. Short-term effects of replacing milk with cola beverages on insulin-like growth

factor-I and insulin-glucose metabolism: a 10 d interventional study in young men. Br J Nutr 2009;;102(7):1047-51. Hoppe C, Molgaard C, Juul A, Michaelsen KF. High intakes of skimmed milk, but not meat, increase serum IGF-I and IGFBP-3 in eight-year-old boys. European

journal of clinical nutrition 2004;;58(9):1211-6. Turner KM, Keogh JB, Clifton PM. Red meat, dairy, and insulin sensitivity: a randomized crossover intervention study. Am J Clin Nutr 2015. doi:

10.3945/ajcn.114.104976.Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler JA, Windhauser MM, et al. A clinical trial of the effects of dietary

patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997;;336(16):1117-24. Kynast-Gales SA, Massey LK. Effects of dietary calcium from dairy products on ambulatory blood pressure in hypertensive men. J Am Diet Assoc

1992;;92(12):1497-501.Hilpert KF, West SG, Bagshaw DM, Fishell V, Barnhart L, Lefevre M, Most MM, Zemel MB, Chow M, Hinderliter AL, et al. Effects of dairy products on intracellular

calcium and blood pressure in adults with essential hypertension. J Am Coll Nutr 2009;;28(2):142-9.

ReferencesDrouin-Chartier JP, Gigleux I, Tremblay AJ, Poirier L, Lamarche B, Couture P. Impact of dairy consumption on essential hypertension: a clinical study. Nutr J

2014;;13(1):83.Maki KC, Rains TM, Schild AL, Dicklin MR, Park KM, Lawless AL, Kelley KM. Effects of low-fat dairy intake on blood pressure, endothelial function, and lipoprotein

lipids in subjects with prehypertension or stage 1 hypertension. Vasc Health Risk Manag 2013;;9:369-79.Alonso A, Zozaya C, Vazquez Z, Alfredo Martinez J, Martinez-Gonzalez MA. The effect of low-fat versus whole-fat dairy product intake on blood pressure and

weight in young normotensive adults. Journal of human nutrition and dietetics : the official journal of the British Dietetic Association 2009;;22(4):336-42. Hjerpsted J, Leedo E, Tholstrup T. Cheese intake in large amounts lowers LDL-cholesterol concentrations compared with butter intake of equal fat content. Am J

Clin Nutr 2011;;94(6):1479-84. Schlienger JL, Paillard F, Lecerf JM, Romon M, Bonhomme C, Schmitt B, Donazzolo Y, Defoort C, Mallmann C, Le Ruyet P, et al. Effect on blood lipids of two daily

servings of Camembert cheese. An intervention trial in mildly hypercholesterolemic subjects. Int J Food Sci Nutr 2014:1-6.Ballard KD, Mah E, Guo Y, Pei R, Volek JS, Bruno RS. Low-fat milk ingestion prevents postprandial hyperglycemia-mediated impairments in vascular endothelial

function in obese individuals with metabolic syndrome. The Journal of nutrition 2013;;143(10):1602-10.Nestel PJ, Pally S, MacIntosh GL, Greeve MA, Middleton S, Jowett J, Meikle PJ. Circulating inflammatory and atherogenic biomarkers are not increased following

single meals of dairy foods. European journal of clinical nutrition 2012;;66(1):25-31.

PRESENTATION - 4

THE DASH DIET: A MODEL FOR HEALTHY EATINGNathalie Bergeron, PhDTouro University California and Children’s Hospital Oakland Research Institute

November 2016

Disclosures• Dairy Research Institute – Investigator initiatedresearch grant• NIH -‐ Investigator initiated research grant

Dairy Farmers of Canada 2

Outline

• DASH Diet and Cardiometabolic Health• Original DASH trial• OMNI heart• DASH diet with lean beef• DASH diet with lean pork

• Saturated fat, dairy fat and CVD risk

• DASH diet with full-‐fat dairy

• Summary and Conclusions


U.S. Dietary guidelines 2015

• A major feature of the new dietary guidelines is therecommendation to shift toward healthy dietarypatterns rather than focusing on single nutrients.

• Healthy US-‐style eating pattern (DASH-‐like)•Mediterranean-‐style eating pattern• Vegetarian eating pattern


• Tested in a large clinical trial in the 90s for blood pressure ¯• Most widely prescribed dietary intervention for prevention and management of hypertension & CVD risk• Endorsed by:• 2015 Dietary Guidelines for Americans• 2013 AHA/ACC Guideline on Lifestyle Management to ReduceCVD Risk• US guidelines for treatment of high blood pressure

Appel et al. N Engl J Med 1997; 336:1117-‐24

DASH dietEmphasizes fruits, vegetables & low-‐fat dairy

Includes whole grains, fish, poultry

Limits sweets, sugary beverages, red meat

Low in sugar/refined CHOs, SFA, cholesterol, sodium


Karanja et al. J Am Diet Assoc 1999; 99:S19-‐S27

DASH – Food group servings/d Dairy Farmers of Canada 6

Food group Control Fruit & Vegetable DASH Grains 9.1 7 7.7

Fruits & juices 1.6 5.2 5.2

Vegetables 2 3.3 4.4

Meats, poultry, fish

Red meat 1.5 1.8 0.5

Poultry 0.8 0.4 0.6

Fish 0.2 0.3 0.5

Dairy

Low-‐fat 0.1 0 2

Regular fat 0.4 0.3 0.7

Nuts, seeds, legumes

Nuts & seeds 0 0.6 0.5

Legumes 0 0 0.1* 2100 Kcal level


DASH Nutrient Targets


Nutrient targets* Control Fruit & Vegetable DASH

Total fat, % kcal 37 37 27SFA, % kcal 16 16 6

CHO, % kcal 48 48 55Protein, % kcal 15 15 18Potassium, mg/d 1700 4700 4700Magnesium, mg/d 165 500 500Calcium, mg/d 450 450 1240Sodium, mg/d 3,000 -‐ 3,500

* 2100 Kcal level


Control, ‘Western-‐like’ diet

Combination (DASH) diet

Control, ‘Western-‐like’ diet

Combination (DASH) diet

DASH diet reduces blood pressure


Fruits & Vegetables diet

Fruits & Vegetables diet

Mean change m

mol/l

-‐0.5

-‐0.4

-‐0.3

-‐0.2

-‐0.1

0

0.1

0.2

TC LDL-‐C HDL-‐C TG

DASH diet ¯ cholesterol compared to a control, Western diet

Obarzanek et al. Am J Clin Nutr., 2001;;74:80–9


Control DASH(% Kcal)

Total fat 36 27

SFA 14 6

CHO 51 55

Protein 14 18

The Optimal Macronutrient Intake Trial to Prevent Heart Disease –

OmniHeart


Appel et al. JAMA 2005:294:2455-2464

OmniHeart: 3 Modified DASH diets

• Tested 3 variations of DASH diet pattern on blood pressure &plasma lipids• Involved partially substituting carbohydrate with protein & unsaturated fat

Appel et al. JAMA 2005:294:2455-2464


Carbohydrate Protein Unsaturated fatTotal fat 27 27 37

SFA 6 6 6MUFA 13 13 21PUFA 8 8 10

CHO 58 48 48

Protein 15 25(~50% plant protein)

15

OmniHeart –Mean Changes in Blood Pressure, from Baseline Diet

-‐12,9

-‐16,1 -‐15,8

-‐20

-‐15

-‐10

-‐5

0Carbohydrate Protein Unsaturated

Chan

ge SBP, m

m Hg


P < 0.01P < 0.05

Appel et al. JAMA 2005:294:2455-2464

OmniHeart –Mean Changes in Lipid Variables, from Baseline Diet

Appel et al. JAMA 2005:294:2455-2464

Lipids (mg/dL) Carbohydrate Protein Unsaturated

LDL-‐C -‐11.6 -‐14.2* -‐13.1

Triglycerides 0.1 -‐16.4*,† -‐9.3*

HDL-‐C -‐1.4 -‐2.6 † -‐0.3


* P<0.05, vs. CHO diet† P<0.05 vs. CHO diet & Unsaturated fat diet

Beef in an Optimal Lean Diet –BOLD study


Roussell et al. Am J Clin Nutr 2012;;95:9-16

Roussell et al. J Hum Hypertension 2014;;28, 600–605

DASH Diet with Lean Beef• Tested effect of DASH-like diet with lean beef on BP & plasma lipids• All diets low in SFA, vs. Healthy American diet• Involved partially substituting poultry, pork & fish with lean beef (BOLD);; plus vegetable protein (BOLD+)

Roussell et al. Am J Clin Nutr 2012;;95:9-16


Healthy American DASH BOLD

(DASH w/lean beef)

BOLD+(DASH w/lean beef & vegetable protein)

Total fat 33 27 28 29SFA 12 6 6 6

MUFA 11 9 11 12PUFA 7 8 7 7

CHO 50 55 54 45Protein 17 18 19 27


DASH Diet w/Lean Beef – Effect on Blood Pressure

0

20

40

60

80

100

120

140

Systolic blood pressure Diastolic blood pressure

mm Hg HAD

DASH

BOLD

BOLD+



*

* P<0.05 vs. HAD

DASH with Lean Beef –Mean % change in lipids from Healthy American Diet

• Incorporating lean beef in low SFA DASH-‐like diets (BOLD; BOLD+) elicits favorable lipid effects, comparable to DASH


Roussell et al. Am J Clin Nutr. 2012;;95:9-16

DASH – Lean Pork


Sayer et al. Am J Clin Nutr. 2015;;102:302-8

DASH Diet with Lean Pork• Tested whether including lean pork into a DASH-like diet would retain blood pressure benefits in individuals with elevated BP

Sayer et al. Am J Clin Nutr. 2015;;102:302-8


% kcal Pre-‐diet DASH – Pork DASH -‐ Chicken & Fish

Total fat 38 25 27SFA 13 8 8

CHO 47 58 55

Protein 15 1755% pork

1855% chicken/fish

45% dairy, veg, beef 45% dairy, veg, beef

Variable Pre-‐diet DASH – Pork DASH -‐ Chicken & Fish

Systolic BP (mm Hg) 130 122* 123*Diastolic BP (mm Hg) 85 79* 78*

* P<0.05 vs. pre-‐diet

DASH & DASH-‐like diet patterns -‐ Summary

• Original DASH trial• DASH diet emphasizing fruits, vegetables, low-‐fat dairy, wholegrains, fish & poultry ¯ blood pressure & LDL-‐C

• OMNI trial• Partial substitution of CHO with protein or unsaturated fat in aDASH-‐like diet further ¯ systolic & diastolic blood pressure• Partial substitution of CHO for protein ¯ LDL-‐C (and HDL-‐C)• Partial substitution of CHO for unsaturated fat HDL-‐C• Partial substitution of CHO for protein or unsaturated fat ¯ TG


DASH & DASH-‐like diet patterns – Summary (2)

• DASH lean beef/lean pork trials:• Incorporating lean beef (BOLD+) or lean pork in low SFA DASH-‐like diet retained blood pressure ¯ effects of DASH diet

• Incorporating lean beef (BOLD; BOLD+) in low SFA DASH-‐like diet elicited comparable ¯ in total-‐C, LDL-‐C and HDL-‐C vs. DASH diet


DASH diet –meta-‐analysis of BP effects• Meta-‐analysis of dietary patterns and BP effects• 24 trials (N=23,858 participants)

• DASH diet had largest effect on SBP (-‐7.62 mm Hg) & DBP (-‐4.22 mm Hg)


Gay et al. Hypertension 2016;;67

SBP

DBP

Dairy and Blood Pressure


Machin DR et al. Am J Clin Nutr. 2014;;100:80-87

49 individuals with elevated BP participated in randomized trialSystolic BP: 135 ± 1; Diastolic BP: 80 ± 1 mm Hg

Does addition of dairy to usual diet improve BP ?

DAIRY

4 servings of nonfat dairy

CONTROL

Fruit juice, applesauce and fruit cups

DAIRY

4 servings of nonfat dairy

CONTROL

Fruit juice, applesauce and fruit cups

Baseline

4 weeks 4 weeks

2 weeks


Solitary inclusion of dairy foods improved resting BP


* P < 0.05 vs. before dairy† P < 0.05 vs. after the no-‐dairy condition

* P < 0.05 vs. week 0† P < 0.05 vs. no-‐dairy condition

Do benefits of DASH diet on CVD risk markers require limitation to non-‐fat dairy foods?

•Rationale:• Benefits of dairy foods on BP are felt to depend on mineral content • Traditional dietary recommendations emphasize restriction of saturated fat

•But:• DASH dietary patterns have never been tested with full-‐fat vs. low-‐fat dairy foods

Saturated fat and CVD risk

• Dietary guidelines recommend limiting foods rich insaturated fat, including full fat dairy, primarily due totheir ability to raise LDL-‐C.

• However, recent meta-‐analyses show no associationof saturated fat intake per se with increased CVD risk.

Siri-Tarino et al. Am J Clin Nutr 2010;; 91:535–46Chowdhury et al, Ann Intern Med. 2014;;160:398-406de Souza et al. BMJ 2015;;351:h3978 doi: 10.1136/bmj.h3978

Is LDL cholesterol the most meaningful lipid predictor of CVD risk?

St-Pierre et al., ATVB 2005;;25:553 N = 2072 men; follow-‐up 13 years

Levels of small but not large LDL particles are independently associated with CHD risk in Quebec Cardiovascular Study


What is the effect of dairy fat on LDL subclass concentrations?

SFA derived from dairy large LDL particles


Krauss et al. AJCN 2006;;83:1025Siri-Tarino et al. AJCN 2010;;91:502–9

l 8% SFA kcalo 15% SFA kcal, primarily from dairy

15% SFA

Dairy fat and cardiovascular risk• Saturated fats from dairy sources are relatively rich inmyristic (14:0) and lauric (12:0) acids, the most potentLDL-‐C (& HDL-‐C) raising saturated fatty acids

• However, higher dairy fat intake has not beensignificantly associated with increased CVD risk• This may be due in part to the preferential effect of dairy faton large vs. small LDL particles

Is limitation of dairy fat intake required to achieve the cardiovascular benefit of the DASH dietary pattern?

High Fat DASH Study

• We replaced non-‐ and low-‐fat dairy in the DASH dietary patternwith full fat dairy products, while moderately reducingcarbohydrates

Western Diet

Std DASHDiet

HF DASH Diet

40 men &women

w/elevated DBP

Randomized diet order

3wk 3wk 3wk2wk 2wk

washout washout

Chiu et al, Am J Clin Nutr 2016;;103:341–7

Study population• 22 and older (men and women)• BMI < 35 kg/m2

• SBP <160 mmHg, DBP 80-‐95 mmHg (elevated BP)• Generally healthy• Not taking medication or supplements known to affect bloodpressure or lipid metabolism

National High Blood Pressure Education Program

Classification of Blood Pressure (BP)Category SBP, mmHg DBP, mmHgNormal <120 and <80Prehypertension 120-‐139 or 80-‐89Hypertension, stage 1 140-‐159 or 90-‐99Hypertension, stage 2 ≥ 160 or ≥ 100

Hypotheses:Modification of the DASH diet by reducing carbohydrate, primarily from simple sugars and glycemic starches, and allowing for greater total and saturated fat will:

1) Improve lipid risk factors

2) Result in comparable reductions in blood pressure


‘Modified’DASH Diet• The higher-‐fat DASH diet had more SFA (full fat dairy) and lesssugar (juices/glycemic starches)

Values based on a 2100kcal diet. Cholesterol < 300mg/d. Composition calculated by NDS software and adjusted after chemical analysis (Covance)


Control Standard DASH Higher-‐fat DASH

Total fat, % kcal 38 27 40SFA, % kcal 16 8 14

CHO, % kcal 47 55 43Protein, % kcal 14 17 18Potassium, mg/d 1906 4575 4631Magnesium, mg/d 193 469 465Calcium, mg/d 429 1278 1324Sodium, mg/d 3052 2752 2720

‘Modified’DASH Diet – Food servings


Control Standard DASH Higher-‐fat DASH

Grains, svg/d 5.8 5.0 5.2Fruit & juices, cups/d 0.9 3.3 1.4Vegetables, cups/d 1.9 3.7 5.0Beef, oz/d 2.3 1.6 1.9Poultry, oz/d 3.5 2.0 2.1Fish, oz/d 0.7 0.9 0.7Nuts and legumes, oz/d 0 1.9 2.4Low-‐fat dairy, cups/d 0 2.6 0Full-‐fat dairy, cups/d 0.7 0 2.5Sugar, tsp/d 20.4 2.4 0.4Fats, tsp/d 10.1 6.7 11.9

Dietary Compliance

0

20

40

60

80

100

Western DASH Higher-‐fat DASH

P <0.0001 P <0.0001

Urin

ary po

tassium, m

mol


Blood pressure

110

115

120

125

130

135

Clinic Home AM Home PM70

72

74

76

78

80

82

84

86

88

Clinic Home AM Home PM

mmHg

Systolic BP Diastolic BP

***

****

** **

***

****

Control/WesternDASHHigher fat DASH

*p < 0.05, **p <0.001 vs. Control diet. No differences b/w DASH diets


Standard DASH diet ¯ cholesterol vs. Control diet

-‐15

-‐10

-‐5

0

5

10

15

20

25

30

% Cha

nge from

Western Diet

LDLIDL

v sm sm med large sm med lg

VLDL

* * * **

*p<0.05


Higher fat DASH diet ¯ TG and VLDL particles, and did not significantly raise LDL-‐C or apoB vs. DASH

Trig

VLDL lg

VLDL med

VLDL smLDL lg

LDL med

LDL smLDL-C

ApoB

-15

-10

-5

0

5

10

15

% ∆

from

sta

ndar

d D

ASH

* **

NS

LDL pk diameter0.0

0.5

1.0

1.5

2.0

2.5

∆ fr

om s

tand

ard

DA

SH (n

m)

*

*

Chiu, AJCN, 2016Trend for high fat DASH diet to larger LDL and ¯ smaller LDL

-‐8-‐6-‐4-‐202468

1012

% Cha

nge from

DAS

H

Comparison with previous studies

-‐20

-‐15

-‐10

-‐5

0

5

10

15

20

25

30

chan

ge g/l

High

Carb ®

Lower Carb

large medium small very smalllarge medium small very

small

Higher fat DASH~12% Carb replacement with

SFA/MUFA

Previous Dairy studies~20% Carb replacement with

SFA/PUFA

P=0.09


Summary & Conclusions• DASH diet is the most widely recommended diet for overall health

• The standard DASH diet ¯ total and LDL-‐C, but also ¯ HDL-‐C and hasno benefit on TGs

• Modification of DASH diet to allow for more liberal total & SFA intake,in conjunction with moderate carbohydrate intake, resulted in similarbenefits to BP and no deleterious effects on lipid risk factors

• Would allow for more flexibility in food choices when followingDASH diet• Limitation of SFA has been reported to be a barrier to adoption ofthe DASH dietary pattern

• The higher fat DASH diet may be an effective alternative to thestandard DASH diet for cardiometabolic health


DAIRY RESEARCH INSTITUTE®

NATIONAL DAIRY FOODS RESEARCH CENTERS

RESEARCH AND APPLICATIONS RESOURCESDairy Research Centers Applications Labs Facilities and Equipment Technical Training and Short Courses Technical Assistance

®

Acknowledgements

Ronald Krauss, MDSally Chiu, PhD

Cholesterol Research Center (CRC)Megan BennettBarbara SutherlandCRC Staff

CORE labSarah King, PhD Staff

Paul Williams, PhD

UCSF-‐ CTSI BionutritionCewin ChaoMonique SchloetterViva Tai

Ethnic Health Institute at Alta Bates

Quesgen Systems, Inc


Documents

PRESENTATION - 1 › bundles › dfcdairy... · Paleo Diet Principals INCLUDED EXCLUDED Meats&and/or&game,preferably grass@fed Processed foods&of&any&kind Fish,preferably wild Processed&oils&(corn,sunflower,etc.)