06.11.15
Spis fett til hjertets begjær
– gamle og nye erkjennelser om fett og hjertehelse fra forskningsfronten
© Johnny Laupsa-Borge
En historie i tre deler
© Johnny Laupsa-Borge
¨ 
Del 1 • FATFUNC-studien ved UiB
bakgrunn
resultater
¤  implikasjoner
¤ 
¤ 
¨ 
Del 2 • Fett og hjertehelse
smakebiter fra forskningsfronten
totalt fettinntak | lavfett vs. høyfett
¤  fettkvalitet | mettet vs. umettet fett
¤ 
¤ 
¨ 
Del 3 • Sunt fettvett
¤ 
¤ 
generelle råd til friske
spesielle råd til syke
Sundvolden • 31. oktober 2015 • ©Johnny Laupsa-Borge
Relevant faglig bakgrunn
Del 1 • FATFUNC-studien ved UiB
tverrfaglig bachelor | master i human ernæring | UiB
– bakgrunn | resultater | implikasjoner
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
2014
2008
2002
1995
1991
1990
Gammel visdom
© Johnny Laupsa-Borge
Epidemi av fedme
og relaterte tilstander
© Johnny Laupsa-Borge
”Ov-etar,
om han ikkje seg sansar,
et seg heilt i hjel.
Mang ein tull,
vert for magen sin,
til lått mellom kloke karar.”
Håvamål
Ng M, Fleming T, Robinson M et al. Global, regional, and national prevalence of overweight and obesity in children and adults
during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 766-81.
1
06.11.15
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 2000, 2010
Prevalence of self-reported obesity among U.S.
adults by state and territory (BRFSS, 2014)
(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)
2000
1990
2010
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates
should not be compared to prevalence estimates before 2011.
7
Ng et al. 2014 | Tall globalt
Overvekt og fedme i Norge
Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic
analysis for the Global Burden of Disease Study 2013
© Johnny Laupsa-Borge
06.11.15
© Johnny Laupsa-Borge
2013
1980
FOREKOMST
Overvekt
2100 mill.
857 mill.
671 mill.
147 mill.
Overvekt | Kvinner
38,0 %
29,8 %
Overvekt | Menn
36,9 %
28,8 %
Fedme
RELATIV ØKNING 1980-2013
Overvekt | Barn
47,1 %
Overvekt | Voksne
27,5 %
Ulset et al. Er fedmeepidemien kommet til Norge? Tidsskrift for den norske legeforening 2007; 127: 34-7
Ng M, Fleming T, Robinson M et al. Global, regional, and national prevalence of overweight and obesity in children and adults during
1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 766-81.
Ng et al. 2014 | Tall fra USA
Ng et al. 2014 | Tall fra Norge
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic
analysis for the Global Burden of Disease Study 2013
2013
Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic
analysis for the Global Burden of Disease Study 2013
1980
2013
OVERVEKT
1980
OVERVEKT
Kvinner
61,9 %
43,9 %
Kvinner
47,3 %
39,0 %
Menn
70,9 %
56,7 %
Menn
58,4 %
48,9 %
FEDME
FEDME
Kvinner
33,9 %
20,9 %
Kvinner
18,0 %
13,5 %
Menn
31,7 %
18,0 %
Menn
19,1 %
14,0 %
Ng M, Fleming T, Robinson M et al. Global, regional, and national prevalence of overweight and obesity in children and adults during
1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 766-81.
Ng M, Fleming T, Robinson M et al. Global, regional, and national prevalence of overweight and obesity in children and adults during
1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 766-81.
2
06.11.15
Fedme og assosierte tilstander
Ektopisk fedme og sykdomsrisiko
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
¨ 
¨ 
Høy BMI og metabolsk friske| Høy BMI og metabolsk syke
Lav BMI og metabolsk friske | Lav BMI og metabolsk syke
Number and Percentage of U.S. Population with Diagnosed Diabetes,
1958-2013!
8
Percentage with Diabetes
© Johnny Laupsa-Borge
25
7
Percentage with Diabetes
6
Number with Diabetes
20
5
15
4
10
3
2
5
1
0
Number with Diabetes (Millions)
Kardiometabolsk syndrom
0
1958 61
64
67
70
73
76
79
82
85
88
91
94
97
00
03
06
09
11
Year
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System
available at http://www.cdc.gov/diabetes/statistics
Age-adjusted Prevalence of Obesity and Diagnosed Diabetes
Among US Adults
Obesity (BMI ≥30 kg/m2)
1994
No Data
<14.0%
2000
14.0%–17.9%
18.0%–21.9%
2013
22.0%–25.9%
Global Burden of Disease Study
© Johnny Laupsa-Borge
Hjerte- og karsykdom medfører flest tapte livsår i Norge
> 26.0%
Diabetes
1994
2000
2013
Kostholdet er viktigste årsaksfaktor
No Data
<4.5%
4.5%–5.9%
6.0%–7.4%
7.5%–8.9%
>9.0%
Lim SS, Vos T, Flaxman AD et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk
factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study
2010. The Lancet 2012; 380: 2224-60.
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://
www.cdc.gov/diabetes/statistics
3
06.11.15
Tapte livsår i Norge
Ledende risikofaktorer
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
DALYs: sum of years lived with disability and years of life lost
Hvorfor …?
© Johnny Laupsa-Borge
Dramatiske kostholdsendringer
– hurtigmatkulturens betydning
© Johnny Laupsa-Borge
Evolusjonært svar
på nye miljøbetingelser
© Johnny Laupsa-Borge
En uheldig kombinasjon
© Johnny Laupsa-Borge
¨ 
¨ 
Mye raffinerte / acellulære karbohydrater
Mye fett og en ubalansert fettsyreprofil
4
06.11.15
Hvis det fortsetter slik, så …
© Johnny Laupsa-Borge
Noe må gjøres …
men hva er mest effektivt?
© Johnny Laupsa-Borge
Diettintervensjoner
Men hvilken diett?
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
¨ 
Mer enn 400 navngitte dietter / kurer.
”Kostholdskrigen”
”Kostholdskrigen”
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
5
06.11.15
Lavfett versus lavkarbo
Mengden og typen karbohydrater
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Det kontroversielle fettet
© Johnny Laupsa-Borge
Ulike anbefalinger
for makronæringsstoffprofil
© Johnny Laupsa-Borge
Karbo
(E%)
Protein
(E%)
Fett
(E%)
Sukker
(E%)
Mettet
fett (E%)
Flerumettet
fett (E%)
USA
45–65
10–35
20–35
(< 10)
< 10
5–10
Norden
45–60
10-20
25–40
< 10
< 10
5–10
Lavfett
≥ 55
15–25
≤ 20/15
< 10
<7
5–10
Lavkarbo
≤ 10
15–25
≥ 65
0
25–35
4–8
¨ 
Trender i nyere ernæringsråd
¤  mindre
¤  mer
fokus på makronæringsstoffprofil
fokus på matvarebaserte råd og kostholdsmønster
Hvorfor så ulikt?
Hvem har rett?
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
6
06.11.15
Ernæringsråd som gjør oss syke?
Men hvor mange følger rådene?
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
¨ 
Syk av lavkarbo?
Kan vi da si at de offisielle ernæringsrådene gjør oss syke?
Manglende forståelse?
– tar både lavfett- og lavkarboforkjemperne feil?
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Hvilke svar gir forskningen?
Kilder til kunnskap om ernæring
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
7
06.11.15
Helhetlig forståelsesramme
Helhet og samspill
– ernæring handler om helhet og samspill
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Systembiologi
Environment
Lifestyle
Diet
Evolusjonært
perspektiv
Metabolic
effects
Clinical
outcomes
?
Biokulturell
forståelse
Dietary fats
Kompleksitet og
individualitet
Kontekst og
interaksjoner
¨ 
¨ 
Cardiometabolic
syndrome
INTERACTIONS
Kompleksitet og individualitet
Kontekst og interaksjoner
External | Dietary determinants
Dietary pattern
Dietary
fats
Metabolic
effects
INTERACTIONS
Macronutrient profile
Food profile
Food quality
Eating behavior
quantity/proportions of
carbohydrate, protein and fat
types/quality of carbohydrate,
protein and fat sources
content of micronutrients,
fibers, phytochemicals, matrix
regularity of meals,
seasonality, sociocultural
Dietary
fats
Metabolic
effects
INTERACTIONS
©Johnny Laupsa-Borge
External | Dietary determinants
External | Dietary determinants
Dietary pattern
Dietary pattern
Macronutrient profile
Food profile
Food quality
Eating behavior
Macronutrient profile
Food profile
Food quality
Eating behavior
quantity/proportions of
carbohydrate, protein and fat
types/quality of carbohydrate,
protein and fat sources
content of micronutrients,
fibers, phytochemicals, matrix
regularity of meals,
seasonality, sociocultural
quantity/proportions of
carbohydrate, protein and fat
types/quality of carbohydrate,
protein and fat sources
content of micronutrients,
fibers, phytochemicals, matrix
regularity of meals,
seasonality, sociocultural
Dietary
fats
Metabolic
effects
INTERACTIONS
Dietary
fats
Vitamins / minerals
nutrients / toxins / metabolites
Metabolome
microbial metabolites
Internal| Metabolic effect modifiers
Metabolic
effects
INTERACTIONS
Sugars
Amino acids
nutrients / toxins / metabolites
Peptides
Fatty acids
Metabolome
Lipid metabolites
One carbon metabolites
ROS
microbial metabolites
Internal| Metabolic effect modifiers
©Johnny Laupsa-Borge
©Johnny Laupsa-Borge
8
06.11.15
External | Dietary determinants
External | Dietary determinants
Dietary pattern
Dietary pattern
Macronutrient profile
Food profile
Food quality
Eating behavior
Macronutrient profile
Food profile
Food quality
Eating behavior
quantity/proportions of
carbohydrate, protein and fat
types/quality of carbohydrate,
protein and fat sources
content of micronutrients,
fibers, phytochemicals, matrix
regularity of meals,
seasonality, sociocultural
quantity/proportions of
carbohydrate, protein and fat
types/quality of carbohydrate,
protein and fat sources
content of micronutrients,
fibers, phytochemicals, matrix
regularity of meals,
seasonality, sociocultural
Dietary
fats
Metabolic
effects
INTERACTIONS
Hormonal response
Vitamins / minerals
Neural response
Sugars
Regulatory proteins
Immune response
Amino acids
nutrients / toxins / metabolites
Peptides
Fatty acids
Cell signaling
Lipid metabolites
Metabolome
Gene expression
One carbon metabolites
ROS
microbial metabolites
Dietary
fats
Metabolic
effects
INTERACTIONS
Hormonal response
Vitamins / minerals
Neural response
Sugars
Amino acids
nutrients / toxins / metabolites
Internal| Metabolic effect modifiers
Immune response
Peptides
Regulatory proteins
Fatty acids
Cell signaling
Lipid metabolites
Metabolome
Gene expression
One carbon metabolites
ROS
microbial metabolites
Internal| Metabolic effect modifiers
epigenetics
External | Dietary determinants
Genotype / Phenotype
genetics / metagenome
environment
©Johnny Laupsa-Borge
©Johnny Laupsa-Borge
Analyser av kostholdsmønster
Dietary pattern
© Johnny Laupsa-Borge
Macronutrient profile
Food profile
Food quality
Eating behavior
quantity/proportions of
carbohydrate, protein and fat
types/quality of carbohydrate,
protein and fat sources
content of micronutrients,
fibers, phytochemicals, matrix
regularity of meals,
seasonality, sociocultural
Dietary
fats
Fat/SFAé +
sugarsé è
inflammation &
glucolipotoxicity è
CVDé
INTERACTIONS
?
Glucose / fructose
Vitamins / minerals
Sugars
Amino acids
nutrients / toxins / metabolites
Peptides
Fatty acids
Lipid metabolites
Metabolome
One carbon metabolites
ROS
microbial metabolites
Internal| Metabolic effect modifiers
epigenetics
Genotype / Phenotype
genetics / metagenome
environment
©Johnny Laupsa-Borge
External | Dietary determinants
FATFUNC-studien ved UiB
Dietary patterns
© Johnny Laupsa-Borge
Healthy Eating Index
Alternate Healthy
Eating Index
Dietary
fats
Mediterranean
diet score
DASH score
INTERACTIONS
Hormonal response
Vitamins / minerals
Neural response
Sugars
Amino acids
nutrients / toxins / metabolites
Immune response
Peptides
CVDê
Regulatory proteins
Fatty acids
Cell signaling
Lipid metabolites
Metabolome
Gene expression
One carbon metabolites
ROS
microbial metabolites
Internal| Metabolic effect modifiers
epigenetics
Genotype / Phenotype
environment
genetics / metagenome
©Johnny Laupsa-Borge
9
06.11.15
Physiological effects of a low-carb, very-high-fat diet
compared with an isocaloric isoproteinic low-fat diet –
results from a randomized controlled trial of obese men
Inkluderte ”menn med mage”
© Johnny Laupsa-Borge
Johnny Laupsa-Borge
Master Thesis in Human Nutrition
Department of Clinical Science • Faculty of Medicine and Dentistry • University of Bergen
Main supervisor: Simon N. Dankel, PhD
Co-supervisors: prof. Gunnar Mellgren, MD PhD & Oddrun Gudbrandsen, PhD
Kliniske tegn / markører
Formål
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Lavfett (HCLF)
ektopisk fedme
høyt midjemål
insulinresistens
høy sdLDL-P
lav HDL-C
Lavkarbo (LCHF)
EFFEKTER PÅ:
KARDIOMETABOLSK
SYNDROM
• kroppsvekt/sammensetning
høyt blodsukker
• risikofaktorer for
kardiometabolsk syndrom
systemisk
inflammasjon
høy TAG
HYPOTESE
Ulik evne til å reversere ektopisk fedme og
sirkulerende markører for kardiometabolsk syndrom
høyt blodtrykk
De eksperimentelle diettene
Kostregistreringer
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
10
06.11.15
Unikt design
Målinger
– god kontroll på en rekke konfundere
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Likt
proteininntak
Bioelektrisk
impedans
Likt inntak av
flerumettet fett
Blodprøver
Urinprøve
(som baseline)
(som baseline)
Likt
energiinntak
(isokalorisk)
Indirekte
kalorimetri
Lik
matvareprofil
CT-skanning og
bildeanalyse
(samme matvarer)
Unikt design
© Johnny Laupsa-Borge
Karbokilder
• blodprøver
4 uker
• blodprøver
8 uker
• blodprøver
12 uker
Proteinkilder
fortrinnsvis komplekse,
cellulære typer
• urinproøve
• urinproøve
• urinproøve
• bioimpedans
• bioimpedans
• bioimpedans
• indirekte kalorimetri
• indirekte kalorimetri
• CT
• CT
unngå sukker og
matvarer tilsatt sukker
mindre brødhvete
mest grønnsaker, bær,
frukt, ris,
surdeigsbrød
Likt kostholdsmønster
kjøtt / innmat
fisk / sjømat
Fettkilder
begrenset inntak av
omega-6-rike
planteoljer
• blodprøver
• urinproøve
• bioimpedans
© Johnny Laupsa-Borge
Moderat
kalorirestriksjon
Lik matvareprofil
– flere tidspunkter med komplementerende målinger
© Johnny Laupsa-Borge
Baseline
Effekter av
karbohydratog fettinntak
per se
egg
ost
belgfrukter
ingen øvre grense for
mettet fett og
kolesterol
mest smør, rømme,
fløte, kokosfett,
olivenolje, rapsolje
Fysisk aktivitet
– ingen endring fra baseline og ingen gruppeforskjeller
© Johnny Laupsa-Borge
11
06.11.15
Takk til våre sponsorer
Kostholdsmønster ved baseline
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Tine ASA
Funksjonell Mat AS
Soma Nordic / Midsona Norge AS
Au Naturel (UK), Inc. Norway
Diett.no / Dietika AS
Resultater fra FATFUNC-studien
Hovedkonklusjon
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
MELDING FRA FOREDRAGSHOLDEREN:
¨  Resultater fra FATFUNC-studien, som ble presentert
muntlig på kongressen, kan ikke gjengis skriftlig i
denne presentasjonen fordi resultatene fremdeles er
under publisering.
¨  Lenke til framtidig publikasjon kunngjøres senere
når artikkelen er tilgjengelig på nettet.
Lavfett (HCLF)
Lavkarbo (LCHF)
Risiko for
kardiometabolsk
syndrom ê
KONKLUSJON
Begge dietter medførte signifikante forbedringer i kroppssammensetning og
risikofaktorer for kardiometabolsk syndrom, men med ulike temporære endringer.
Noen foreløpige konklusjoner
Noen foreløpige konklusjoner
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Antall kalorier betyr noe,
men kvaliteten på dem
betyr enda mer.
Det totale kostholdsmønsteret, herunder
kvaliteten på karbohydrat- og fettkildene,
er overordnet makronæringsstoffprofilen.
12
06.11.15
Noen foreløpige konklusjoner
Noen foreløpige konklusjoner
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
ALTSÅ: vi kan ikke forklare
reduksjonen i kroppsvekt,
ektopisk fettlagring og
kardiometabolsk risiko
bare med kalorirestriksjon.
OG: vi kan ikke forklare
effektene med bare
endringer i kostens
mengde av karbohydrat
og fett i seg selv.
Noen foreløpige konklusjoner
Noen foreløpige konklusjoner
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Endring i insulinnivå og –følsomhet er én av
de metabolske faktorene som henger
sammen med endringer i andre kliniske
variabler og dermed kardiometabolsk risiko.
MEN: endring i insulinresponsen henger ikke
sammen med kostens mengde av
karbohydrat (protein eller fett) i seg selv.
Noen foreløpige konklusjoner
Mulige forklaringer
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Effekten skyldes trolig
endringer i kvaliteten på
karbohydratkildene og
andre aspekter av det
totale kostholdsmønsteret.
Endret
kostholdsmønster
Mer regelmessige
måltider
Mer hjemmelagd
mat av
friske råvarer
Forbedret
karbohydratkvalitet
Mer cellulære /
mindre acellulære
karbohydratkilder
Lite / intet
tilsatt sukker
Mindre brødhvete,
mer av andre korn
Grønnsaker til
hvert måltid
Lavere glykemisk
indeks/belastning
Forbedret
fettkvalitet
Bedre
fettsyreprofil
Redusert
energiinntak
Mer vitaminer og
mineraler
Mer
plantekjemikalier
(antioksidanter …)
Endret mikrobiell
metabolom
?
13
06.11.15
Kliniske implikasjoner
Kliniske implikasjoner
– overføringsverdi til andre populasjoner
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
≈
Vår
populasjon
• fedme
Andre
populasjoner
?
• diabetes type 2
• insulinresistens
¨ 
• etablert HKS
Hvis man vektlegger karbohydratkvalitet
¤  velg
komplekse / lavglykemiske / cellulære kilder
raffinerte / høyglykemiske / acellulære kilder
¤  unngå
Styrker og svakheter
Funn fra andre studier
ved FATFUNC-studien
om lavfett versus lavkarbo
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Styrker
¨ 
¨ 
¨ 
¨ 
¨ 
¨ 
Svakheter
Moderat kalorirestriksjon
Isokalorisk
Likt inntak av protein og
PUFA
Lik matvareprofil og likt
kostholdsmønster
Gode diettdata basert på
et unikt elektronisk verktøy
Omfattende metabolske
data basert på ulike
komplementære målinger
¨ 
Få deltakere
¤ 
¨ 
Kort tidsrom
¤ 
¨ 
bare menn
Ikke-isokalorisk
design
Isokalorisk
design
men vi har data fra 10 mnd.
lavkarbo
≥ lavfett
Behov for flere studier med
ad libitum næringsinntak i
begge grupper
¤  paleolittisk meny
¤  kostholdsmønsteranalyser
¤ 
Mangler ved andre studier
lavkarbo
≈ lavfett
Mer om fett og hjertehelse
om lavfett versus lavkarbo
– en nærmere kikk på andre studier i forskningsfronten
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Ikke-isokalorisk
design
Ulik andel
flerumettete
fettsyrer
Ulik
proteinandel
Ulik
matvareprofil
Stor
kalorirestriksjon
Få deltakere
Dårlig diettetterlevelse
Kort varighet
¨ 
Del 2: Fett og hjertehelse
¤  totaltfett
Mangelfulle
kostholdsdata
Mangelfulle
metabolske
data
| lavfett versus høyfett
| mettet versus umettet fett
¤  fettkvalitet
14
06.11.15
Del 2 • Fett og hjertehelse
Men først pause J
– noen flere smakebiter fra forskningsfronten
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
¨ 
¨ 
¨ 
¨ 
One day I saw a wonderful old
gal sitting on her front step, so I
walked up to her and said, "I
couldn't help noticing how
happy you look! What is your
secret for such a long, happy
life?"
"I smoke ten stogies a day," she
said. "Before I go to bed, I
smoke a nice big joint. All my
life I've eaten only junk food,
and I put away at least a fifth of
Jack Daniels every week. On
weekends I pop pills, and never
do any exercise at all.”
Absolutely amazing, I thought,
and asked, "How old are you?”
”Twenty four,” she replied.
Totalt fettinntak
Lavfettregimet
– lavfett versus høyfett
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Kost-hjertehypotesen
Ancel Keys (1904–2004)
– ”diet-heart hypothesis”
– Six Countries Study (1953) | Seven Countries Study (1970)
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
økt inntak
av (mettet)
fett
økt nivå av
total-C /
LDL-C
økt risiko
for CVD
15
06.11.15
Kritikk av Keys
– Yerushalmy & Hilleboe 1957
© Johnny Laupsa-Borge
¨ 
¨ 
¨ 
Men Keys var ikke den første
© Johnny Laupsa-Borge
Totalt fettinntak – aterosklerose: r = 0,59
Animalsk fett – aterosklerose: r = 0,68
Vegetabilsk fett – aterosklerose: r = -0,47
Walter Kempner (1903–1997)
– risdietten | Rice Diet
© Johnny Laupsa-Borge
Høyfettregimet
© Johnny Laupsa-Borge
Nathan Pritikin (1915–1985)
© Johnny Laupsa-Borge
Minst 150 år
med lavkarbokosthold som medisin
© Johnny Laupsa-Borge
16
06.11.15
Jean-Anthelme Brillat-Savarin
William Banting
– verdens første ”slankeguru”?
(1796–1878)
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Jean-Anthelme Brillat-Savarin (1755–1826)
Physiologie du goût (1825)
Smakens fysiologi (2007)
Vilhjalmur Stefansson
Wolfgang Lutz
(1879–1964)
(1913–2010)
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Jan Kwasniewski
Robert Coleman Atkins
(f. 1937)
(1930–2003)
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
17
06.11.15
Hans H. Bassøe
Sofie Hexeberg
(1922–2004)
(f. 1960)
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Helsemagasinet
Henriette Schönberg Erken
vitenskap og fornuft
(1866–1953)
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Første gang utgitt 1914
Tilbake til forskningsfronten
© Johnny Laupsa-Borge
Skeaff og Miller 2009
Dietary fat and coronary heart disease: summary of evidence from prospective cohort and randomised
controlled trials
© Johnny Laupsa-Borge
Fettinntak og risiko for
koronar hjertesykdom (CHD).
¨  Flere samleanalyser
(metaanalyser) av
befolkningsstudier og kliniske
forsøk (RCT).
¨  Oppsummerer resultatene fra
studier publisert før 2009.
¨ 
Skeaff CM, Miller J. Dietary fat and coronary heart disease: summary of evidence from prospective cohort and randomised
controlled trials. Annals of Nutrition and Metabolism 2009; 55: 173-201.
18
MRC Soya Trial, 1968
Subtotal (I2 = 12.4%, p = 0.335)
CHD event
Finn Mental Hospital (men), 1979
Finn Mental Hospital (women), 1983
STARS, 1992
Oslo, 1966
Veterans’ Administration Trial, 1969
MRC Soya Trial, 1968
DART, 1989
Minnesota Coronary Survey, 1989
London Corn and Olive, 1965
Subtotal (I2 = 44.2%, p = 0.073)
4
4.3
3.7
3.25
5
3.7
4
2
4.5
2
15/199
14/194
1.04 (052, 2.10)
0.84 (0.62, 1.12)
15.00
100.00
8/444
3/372
3/27
34/206
52/424
62/199
132/1,018
131/4,541
15/28
26/478
8/341
9/28
54/206
65/422
74/794
144/1,015
121/4,516
11/26
0.34 (0.16, 0.75)
0.35 (0.09, 1.30)
0.41 (0.12, 1.39)
0.68 (0.46, 1.01)
0.82 (0.58, 1.15)
0.86 (0.64, 1.15)
0.92 (0.74, 1.15)
1.07 (0.84, 1.37)
1.17 (0.62, 2.23)
0.83 (0.69, 1.00)
4.68
1.83
2.14
12.71
14.70
17.08
20.82
19.58
6.46
100.00
06.11.15
0.5 11
0.5
55
Favours intervention
intervention Favours
Favours control
control
Favours
p = 0.867 for CHD death subtotal; p = 0.050 for CHD event subtotal.
STARS = Watts et al. [1992]; Oslo = Leren [1970], 5-year results were used; DART = Burr et al. [1989]; MRC Soya Trial = Medical Research Council [1968];
Minnesota Coronary Survey = Frantz et al. [1989]; Finnish Mental Hospital (men) = Turpeinen [1979]; Finnish Mental Hospital (women) = Miettinen et al.
[1983]; Veterans’ Administration Trial = Dayton and Pearce [1969]; London Corn and Olive = Rose et al. [1965]. Refer to online suppl. table 18 for full study
details.
Fig. 20. Meta-analysis of altered PUFA – SFA modified trials.
Skeaff
og Miller 2009
Howard et al. 2006
Dietary fat and coronary heart disease: summary of evidence from prospective cohort and randomised
controlled trials
Low-fat dietary pattern and risk of cardiovascular disease: The Women's Health Initiative Randomized
Controlled Dietary Modification Trial
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Type of fat
Fatal CHD
CHD events
Total fat
TFA
SFA for CHO
MUFA for SFA
PUFA for SFA
Linoleic
!-linolenic
n–3 LCPUFA
C-NR
Pd
P-NR
C-NR
Cd
P-NR
Cf
Cf
Pf
Cf
Cd = Convincing increase risk; Cf = convincing decrease risk;
C-NR = convincing, no relation; Pd = probable increase risk; Pf =
probable decrease risk; P-NR = probable no relation.
strongly related to dietary¨ patterns,
as a(RCT).
vegetarian
Klinisk such
studie
or Mediterranean diet, which are less influenced by mis¤  40 klinikker i USA
classification. The null results probably reflect the unreli¤  1993–98
ability of the evidence on dietary
fats from cohort studies
that differs markedly from
the 835
reliability
of ecological
¨  48
kvinner
| 50–79 år.
studies or metabolic ward studies of diet and cholesterol.
Oppfølging:
8,1
årpro(median).
One of the exceptions in¨ the
body of evidence
from
spective cohort studies is n–3
LCPUFA intake
or fish
con¨  Kontroll:
29 294
(60
%).
sumption and risk of fatal CHD. The evidence is compre¨  Diettgruppe: 19 541 (40 %).
hensive in number of studies, duration of follow-up, num¤  fettinntak:
≤ 20
E% of
ber of participants and CHD events,
geographic
location
study populations, homogeneity
of association
tri- /
¤  økt
inntak avbetween
grønnsaker
als and absence of evidence for publication
bias. og
Thekorn
obser-(6 p/d)
frukt (5 p/d)
vational evidence is convincing
that a strong inverse assoHoward BV, Van Horn L, Hsia J et al. Low-fat dietary pattern and risk of cardiovascular disease: The Women's Health Initiative
Controlled
Modificationand
Trial. JAMA
ciation exists between n–3Randomized
LCPUFA
or Dietary
fish intake
risk2006; 295: 655-66.
of CHD. The evidence from randomised controlled trials
is concordant, particularly when 2 trials with methodological concerns [Singh et al., 1997; Burr et al., 2003], are excluded from consideration, however, it rests almost entirely on the results from 2 trials (GISSI-P [GISSI-Prevenzione
Investigators, 1999], and DART I [Burr et al., 1989]).
192
Howard
et al. 2006
Ann Nutr Metab 2009;55:173–201
Low-fat dietary pattern and risk of cardiovascular disease: The Women's Health Initiative Randomized
Controlled Dietary Modification Trial
© Johnny Laupsa-Borge
¨ 
¨ 
¨ 
Redusert fettandel og økt
inntak av grønnsaker, frukt og
korn var ikke forbundet med
redusert risiko for CVD
(kardiovaskulære hendelser).
Moderate effekter på
konvensjonelle risikofaktorer.
Hos kvinner med tidligere CVD
(3,4 %) var intervensjonen
assosiert med økt risiko.
Downloaded by:
UIO - Universitetsbibl., i. Oslo
193.157.136.110 - 5/7/2014 9:44:51 PM
Table 4. Summary of the strength of evidence of dietary fat and
CHD
Skeaff/Miller
Kritikk av Howard et al. 2006
© Johnny Laupsa-Borge
¨ 
Høyere fettandel enn målet.
¤  37,8
¨ 
¨ 
è 28,8 E% | -8,2 E%
Økt inntak av raffinert korn.
Metodiske utfordringer.
¤  usikre
¨ 
kostdata fra FFQ
Bare 13 % av de undersøkte
ble inkludert.
¤  mange
ville ikke være med
i sosioøkonomisk status
¤  seleksjonsskjevhet (bias)
¤  forskjeller
Howard BV, Van Horn L, Hsia J et al. Low-fat dietary pattern and risk of cardiovascular disease: The Women's Health Initiative Randomized
Controlled Dietary Modification Trial. JAMA 2006; 295: 655-66.
Conclusions: Over a mean of 8.1 years, a dietary intervention that reduced total fat intake and increased intakes of vegetables, fruits, and
grains did not significantly reduce the risk of CHD, stroke, or CVD in postmenopausal women and achieved only modest effects on CVD risk
factors, suggesting that more focused diet and lifestyle interventions may be needed to improve risk factors and reduce CVD risk.
Mozaffarian D. Low-fat diet and cardiovascular disease. JAMA 2006; 296: 279-81.
Ikke råd om begrenset fettinntak
Ikke råd om begrenset fettinntak
Anderson CM, Appel LJ. Dietary modification and CVD prevention: a matter of fat. JAMA 2006; 295: 693-5.
– ny rapport fra Dietary Guidelines Advisory Committee (USA)
– ny rapport fra Dietary Guidelines Advisory Committee (USA)
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
¨ 
Amerikanske ernæringsråd
revideres og utgis hvert 5. år.
¤  Dietary
| USDA
¨ 
Guidelines for Americans
Råd fra en vitenskapskomite.
¤  Dietary
Guidelines Advisory
Committee (DGAC) | rapport
¨ 
Tidligere råd om fettinntak.
¤  1980:
< 30 E%
25–35 E%
¤  2010: 20–35 E%
¤  2005:
Dietary Guidelines Advisory Committee; Scientific Report of the 2015 Dietary Guidelines Advisory Committee. 2015; http://
www.health.gov /dietaryguidelines/2015-scientific-report/.
Mozaffarian D, Ludwig DS. The 2015 US Dietary Guidelines: lifting the ban on total dietary fat. JAMA 2015; 313: 2421-2.
Dietary Guidelines Advisory Committee; Scientific Report of the 2015 Dietary Guidelines Advisory Committee. 2015; http://
www.health.gov /dietaryguidelines/2015-scientific-report/.
Mozaffarian D, Ludwig DS. The 2015 US Dietary Guidelines: lifting the ban on total dietary fat. JAMA 2015; 313: 2421-2.
19
10
Ikke råd om begrenset fettinntak
06.11.15
Fat and
fatty acids
– ny rapport fra Dietary Guidelines Advisory Committee (USA)
Siste nordiske anbefalinger
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
¨ 
Nye anbefalinger i 2015.
Inntak av kolesterol.
¨ 
Totalt fettinntak.
¨ 
¤  ikke
grunn til bekymring
¤  ingen
grunn til bekymring
¤  ingen øvre grense
n  ikke
¨ 
ved forebygging av fedme
Fokus på matvarebaserte
kostholdsmønster.
Dietary Guidelines Advisory Committee; Scientific Report of the 2015 Dietary Guidelines Advisory Committee. 2015; http://
www.health.gov /dietaryguidelines/2015-scientific-report/.
Mozaffarian D, Ludwig DS. The 2015 US Dietary Guidelines: lifting the ban on total dietary fat. JAMA 2015; 313: 2421-2.
Age
6–11 mo.
12–23 mo.
Adults and
children from 2
years of age
Cis-MUFA
10–25 E%
10–20 E%
10–20 E%*
Cis-PUFA
5–10 E%
5–10 E%
5–10 E%*
≥1 E%
≥1 E%
≥1 E%
- n-3
SFA
<10 E%
<10 E%
<10 E%
TFA
As low as possible
As low as possible
As low as possible
30–45 E%
30–40 E%
25–40 E%
Total fat
Nordic Council of Ministers. Nordic nutrition recommendations 2012: integrating nutrition and physical activity, 5th edition.
*Copenhagen:
Cis-monounsaturated
(cis-MUFA)
and cis-polyunsaturated fat (cis-PUFA) should
Nordic Council of Ministers, 2014.
http://dx.doi.org/10.6027/Nord2014-002
make up a minimum of
2/3 of the total fat intake.
SFA: saturated fatty acids; TFA: trans-fatty acids.
Fatty acids are expressed as triglycerides.
Introduction
Fettkvalitet
– mettet versus umettet fett
© Johnny Laupsa-Borge
Fat provides the body with energy in a concentrated form. In addition to
energy, dietary fats provide essential fatty acids and fat-soluble vitamins.
– fremdeles
kontroversielt
Lipids,
mainly
phospholipids and cholesterol, are included in cell mem© Johnny Laupsa-Borge
branes, and triglycerides are stored in adipose tissue as energy reserves.
Certain fatty acids serve as a source of eicosanoids. In food items, fats are
usually in the form of triglycerides.
Mettet fett
Gjeldende anbefalinger:
Dietary sources and intake
u  < 10 E%
The dietary content of fat and fatty acids in the Nordic countries has
u  bytte ut SFA med PUFA
changed significantly in recent decades. The total fat content decreased
from the 1970s to the 1990s. After being rather stable for several years,
the dietary fat content has again increased in recent years in some Nordic
countries, e.g. in Finland (1). The content of saturated fatty acids (SFA)
has shown a similar trend as total fat, i.e. first it decreased, then levelled
På den ene sida …
– studier som underbygger dagens offisielle anbefalinger
© Johnny Laupsa-Borge
Jakobsen et al. 2009
Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies
© Johnny Laupsa-Borge
¨ 
Samleanalyse (metaanalyse)
av 11 befolkningsstudier.
¤  kohortstudier
¨ 
Fant at risiko for hjerte- og
karsykdom (CVD) ble redusert
ved å erstatte mettet fett
(SFA) med flerumettet fett
(PUFA), men ikke med
karbohydrater.
Jakobsen MU, O'Reilly EJ, Heitmann BL et al. Major types of dietary fat and risk of coronary heart disease: a pooled analysis of
11 cohort studies. The American Journal of Clinical Nutrition 2009; 89: 1425-32.
Conclusion: The associations suggest that replacing SFAs with PUFAs rather than MUFAs or carbohydrates prevents CHD over a
wide range of intakes.
20
06.11.15
Kritikk av Jakobsen et al. 2009
Kritikk av Jakobsen et al. 2009
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
¨ 
1430
Metodiske utfordringer.
JAKOBSEN ET AL
¤  kohortstudier
metaanalyser
Meta-analysis is to¤ 
analysis… | Richard David Feinman
http://feinmantheother.com/2015/08/12/meta-analysis-is-to-an...
This exponential growth suggests that the technique grew by reproducing itself. In other words, it is
popular ¨ 
because it is popular. (It does have obvious advantages. You don’t have to do any
experiments). But does it give any useful information?
another small study may point you to a consistent pattern. As such, it is a last-ditch, hail-Mary kind
of method. Applying it to large studies that have statistically meaningful results, however, doesn’t
make sense, because:
MB.studies
Omega-6 polyunsaturated
fatty acids
and coronary
heart
disease.
The American
Journalanything
of Clinical Nutrition
89:
1. If all Katan
of the
go in the same
direction,
you
are
unlikely
to learn
from2009;
combining
them.1283-4.
In fact, if you come out with a value for the output that is different from the value from the
http://feinmantheother.com/2015/08/12/meta-analysis-is-to-analysis/
individual
studies, in science, you are usually required i to explain why your analysis improved
things. Just saying it is a larger n won’t cut it, especially if it is my study that you are trying to
improve on.
2. In the special case where all the studies show no effect and you come up with a number that is
statistically significant, you are, in essence saying that many wrongs can make a right as described
in a previous blog post on abuse of meta-analyses (http://wp.me/p16vK0-8t). In that post, I
re-iterated the statistical rule that if the 95% CI bar crosses the line for hazard ratio = 1.0 then this
is taken as an indication that there is no significant difference between the two conditions that are
being compared. The example that I gave was the meta-analysis by Jakobsen, et al. on the effects
of SFAs or a replacement on CVD outcomes (Figure 2). Amazingly, in the list of 15 different
studies that she used, all but one cross the hazard ratio = 1.0 line. In other words, only one study
found that keeping SFAs in the diet provides a lower risk than replacement with carbohydrate.
For all the others there was no significant difference. The question is why an analysis was done at
all. What could we hope to find? How could 15 studies that show nothing add up to a new piece
© Johnny Laupsa-Borge
of information?
Most amazing is that some of the studies are more than 20 years old. How could
these have had so little impact on our opinion of saturated fat? Why did we keep believing that it
was bad?
Kritikk av Jakobsen et al. 2009
FIGURE 1. Study-specific and combined hazard ratios and 95% CIs for coronary events (A) (n ¼ 306,244) and coronary deaths (B) (n ¼ 327,660) in the
Pooling Project of Cohort Studies on Diet and Coronary Disease. The model included intake of monounsaturated fatty acids, polyunsaturated fatty acids
Jakobsen MU, O'Reilly
EJ, fatty
Heitmann
BL et al.
Major
types
of asdietary
fat
and
riskintake
of (E%;
coronary
heart
disease:
a pooled
analysis of
(PUFAs), trans
acids, carbohydrates
(CHs),
and protein
expressed
percentages
of total
energy
as continuous
variables),
total energy
intake
(kcal/d; as a continuous variable), smoking (never smokers, former smokers, or current smoker of 1–4, 5–14, 15–24, or "25 cigarettes/d), BMI (in kg/m2;
11 cohort studies.
The American Journal of Clinical Nutrition 2009; 89: 1425-32.
,23, 23 to ,25, 25 to ,27.5, 27.5 to ,30, or "30), physical activity (levels 1–5), highest attained educational level (,high school, high school, or .high
school), alcohol intake (0, 0 to ,5, 5 to ,10, 10 to ,15, 15 to ,30, 30 to ,50, or "50 g/d), history of hypertension (yes or no), and energy-adjusted quintiles
of fiber intake (g/d) and cholesterol intake (mg/d). Age at baseline (y) and the calendar year in which the baseline questionnaire was returned (y) were entered
into the model through the strata statement. Within each study, hazard ratios with 95% CIs for the incidence of a coronary event and of mortality from
coronary heart disease were calculated by using Cox proportional hazards regression with time in study (y) as the time metric. The study-specific logs of
hazard ratios were weighted by the inverse of their variances, and a combined estimate of the hazard ratios was computed by using a random-effects model.
The estimated hazard ratios for PUFAs and CHs can be interpreted as the estimated differences in risk of a 5% lower energy intake from saturated fatty acids
(SFAs) and a concomitant higher energy intake from PUFAs and CHs, respectively. The squares and horizontal lines represent the study-specific hazard ratios
and 95% CIs, respectively. The area of the squares reflects the study-specific weight (inverse of the variance). The diamonds represent the combined hazard
ratios and 95% CI. AHS, Adventis Health Study; ARIC, Atherosclerosis Risk in Communities Study; ATBC, Alpha-Tocopherol and Beta-Carotene Cancer
Prevention Study; FMC, Finnish Mobile Clinic Health Study; GPS, Glostrup Population Study; HPFS, Health Professionals Follow-Up Study; IIHD, Israeli
Ischemic Heart Disease Study; IWHS, Iowa Women’s Health Study; NHSa, Nurses’ Health Study 1980; NHSb, Nurses’ Health Study 1986; VIP, Västerbotten
Intervention Program; WHS, Women’s Health Study.
that suggest that replacing SFAs with PUFAs may have a greater
benefit than replacing SFAs with carbohydrates are in agreement
with previous studies.
Substitution of MUFAs for SFAs decreases plasma LDLcholesterol concentration (25). The indication of an increased
risk of CHD associated with a lower intake of SFAs and a concomitant higher energy intake from MUFAs may be due in part
to intake of TFAs, which is included in the sum of MUFAs.
However, all study-specific HRs of MUFA intake and risk of
CHD were adjusted for TFA intake with the exception of the
study-specific HRs from the AHS, the Glostrup Population Study,
and the IIHD because information on TFA intake was not
Mozaffarian et al. 2010
Effects on coronary heart disease of increasing polyunsaturated fat in place of saturated fat …
¨ 
Metaanalyse av 8 studier
¤  kliniske
Jakobsen MU, O'Reilly EJ, Heitmann BL et al. Major types of dietary fat and risk of coronary heart disease: a pooled analysis of
Figure 2.11Hazard
ratios
and 95%
confidence
intervals
coronary events and deaths in the different
cohort studies.
The American
Journal
of Clinical Nutrition
2009; 89:for
1425-32.
studies in
a meta-analysis from Jakobsen, et al.Major types of dietary fat and risk of coronary heart
https://rdfeinman.files.wordpress.com/2011/10/sfa_jakobsen_sub_ajcn-2_2009.jpg
disease: a pooled analysis of 11 cohort studies. Am J Clin Nutr 2009, 89(5):1425-1432.
available for participants from these cohort studies. Furthermore, in analyses only including participants from the 8 cohort
studies (ARIC, ATBC, FMC, Health Professionals Follow-Up
Study, IWHS, Nurses’ Health Study 1980, Nurses’ Health Study
1986, VIP, and WHS), for whom information on intake of TFAs
was available, adjustment for TFAs did not change the combined
HRs (data not shown). The adjustment for TFAs, however, is
highly probable to have been incomplete because of industrial
modification of the content of TFAs in foods during the time
period of the follow-up of the participants. Other mechanisms
than reduced LDL-cholesterol concentration, however, may be
involved (26). Finally, it should be mentioned that the main
© Johnny Laupsa-Borge
¨ 
(https://rdfeinman.files.wordpress.com/2011/10/sfa_jakobsen_sub_ajcn-2_2009.jpg)
Downloaded from ajcn.nutrition.org at OSLO HEALTH CONSORTIUM on September 9, 2013
De fleste studiene viste ingen
signifikante forskjeller.
Meta-analysis
¨  Samleanalysen ga likevel et
If you have a study that is under-powered, that is, if you only have a small number of subjects and
signifikant
resultat.
you find a degree
of variability
in the outcome, combining the results from your experiment with
studier (RCT)
Fant en reduksjon i
kardiovaskulære hendelser
ved å erstatte SFA med
PUFA.
Mozaffarian D, Micha R, Wallace S. Effects on coronary heart disease of increasing polyunsaturated fat in place of saturated fat:
a systematic review and meta-analysis of randomized controlled trials. PLoS Medicine 2010; 7: e1000252.
Conclusions: These findings provide evidence that consuming PUFA in place of SFA reduces CHD events in RCTs. This suggests that
rather than trying to lower PUFA consumption, a shift toward greater population PUFA consumption in place of SFA would
significantly reduce rates of CHD.
3. Finally, suppose you are doing a meta-analysis on several studies that have very different
outcomes,
showing statistically significant associations in different directions, for example. What
will
3 av
7
17.08.15
12:30
Mozaffarian et al. 2010
Effects on coronary heart disease of increasing polyunsaturated fat in place of saturated fat …
© Johnny Laupsa-Borge
¨ 
15 E% PUFA gjennomsnittlig i
behandlingsgruppene
E% PUFA i kontrollgrupper
¤  anbefalt av IOM: 5–10 E%
Kritikk av Mozaffarian et al. 2010
© Johnny Laupsa-Borge
¨ 
¤  RCT
¤  metaanalyser
¤  5
Relativ risiko for CVD
redusert med 10 % for hver
5 E% økning av PUFA
¨  Studier av lengre varighet
viste større effekt.
¨ 
Mozaffarian D, Micha R, Wallace S. Effects on coronary heart disease of increasing polyunsaturated fat in place of saturated fat:
a systematic review and meta-analysis of randomized controlled trials. PLoS Medicine 2010; 7: e1000252.
Metodiske utfordringer.
¨ 
¨ 
Gamle studier fra 1968-92.
Mangelfullt litteratursøk.
¤  relevante
¨ 
¨ 
studier muligens utelatt
Opplyste ikke om andelen
omega-3 og omega-6.
Mangelfull dokumentasjon av
doserespons.
Hooper L. Meta-analysis of RCTs finds that increasing consumption of polyunsaturated fat as a replacement for saturated fat
reduces the risk of coronary heart disease. Evidence Based Medicine 2010; 15: 108-9.
21
06.11.15
På den andre sida …
– studier som stiller spørsmål ved offisielle anbefalinger
© Johnny Laupsa-Borge
Siri-Tarino et al. 2010
Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease
© Johnny Laupsa-Borge
¨ 
Metaanalyse av 21 studier.
¤  prospektive
¤  347
¨ 
kohortstudier
747 deltakere
Fant ingen signifikant
assosiasjon mellom inntak av
SFA og risiko for CVD.
Siri-Tarino PW, Sun Q, Hu FB et al. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with
cardiovascular disease. The American Journal of Clinical Nutrition 2010; 91: 535-46.
Conclusions: A meta-analysis of prospective epidemiologic studies showed that there is no significant evidence for concluding that
dietary saturated fat is associated with an increased risk of CHD or CVD. More data are needed to elucidate whether CVD risks
are likely to be influenced by the specific nutrients used to replace saturated fat.
Kritikk av Siri-Tarino et al. 2010
© Johnny Laupsa-Borge
¨ 
Schwingshackl og Hoffmann 2014
Dietary fatty acids in the secondary prevention of coronary heart disease …
© Johnny Laupsa-Borge
Bruk av statistiske metoder.
som justerte for
serumkolesterol
¨ 
¤  modell
¨ 
Mangelfull kostregistrering.
¨ 
Metodiske utfordringer.
¤  24-timers
Metaanalyse av 12 studier.
¤  kliniske
¨ 
kostintervju | FFQ
¤  kohortstudier
studier (RCT)
Fant ingen signifikant effekt
av å erstatte SFA med PUFA
hos pasienter med etablert
hjertesykdom.
¤  metaanalyser
¤  heterogenitet
Scarborough P, Rayner M, van Dis I et al. Meta-analysis of effect of saturated fat intake on cardiovascular disease: overadjustment
obscures true associations. The American Journal of Clinical Nutrition 2010; 92: 458-9.
Katan MB, Brouwer IA, Clarke R et al. Saturated fat and heart disease. The American Journal of Clinical Nutrition 2010; 92:
459-60.
Stamler J. Diet-heart: a problematic revisit. The American Journal of Clinical Nutrition 2010; 91: 497-9.
Chowdhury et al. 2014
Schwingshackl L, Hoffmann G. Dietary fatty acids in the secondary prevention of coronary heart disease: a systematic review,
meta-analysis and meta-regression. BMJ Open 2014; 4.
Conclusions: The present systematic review provides no evidence (moderate quality evidence) for the beneficial effects of
reduced/modified fat diets in the secondary prevention of coronary heart disease. Recommending higher intakes of
polyunsaturated fatty acids in replacement of saturated fatty acids was not associated with risk reduction.
Association of dietary, circulating, and supplement fatty acids with coronary risk …
Kritikk av Chowdhury et al. 2014
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
¨ 
Metaanalyse av 72 studier.
¤  27
kliniske studier (RCT)
¤  45 prospektive kohortstudier
¨ 
Fant ikke støtte for å
anbefale lavt inntak av SFA
og høyt inntak PUFA.
Chowdhury R, Warnakula S, Kunutsor S et al. Association of dietary, circulating, and supplement fatty acids with coronary risk: a
systematic review and meta-analysis. Annals of Internal Medicine 2014; 160: 398-406.
Conclusions: Current evidence does not clearly support cardiovascular guidelines that encourage high consumption of
polyunsaturated fatty acids and low consumption of total saturated fats.
Feil rapportering av studie om
omega-3-fettsyrer.
¨  Utelot to viktige studier om
omega-6-fettsyrer.
¨  Tok ikke hensyn til hva mettete
fettsyrer ble erstattet med.
¨  Metaanalyser av studier med
ulikt design er problematisk.
¨  Intern uenighet i gruppa.
¨ 
Chowdhury R, Warnakula S, Kunutsor S et al. Association of dietary, circulating, and supplement fatty acids with coronary risk: a
systematic review and meta-analysis. Annals of Internal Medicine 2014; 160: 398-406.
22
06.11.15
Harcombe et al. 2014
Puaschitz et al. 2015
Evidence from randomised controlled trials did not support the introduction of dietary fat guidelines …
Dietary intake of saturated fat is not associated with risk of coronary events or mortality …
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
¨ 
Metaanalyse av 6 studier
¤  diettstudier
¨ 
¨ 
¨ 
¨ 
(RCT)
Inkluderte 2467 menn
Fant ingen signifikant
sammenheng mellom endring i
fettinntak og dødelighet.
Større kolesterolreduksjon i
behandlingsgruppene resulterte
ikke i signifikante forskjeller i
tilfeller av kardiovaskulær død.
WENBIT-studien.
¤  Western
Norway B-Vitamin
Intervention Trial
¨ 
¨ 
Inkluderte 2412 pasienter.
Fant ingen assosiasjoner
mellom inntak av SFA og
forekomsten av
kardiovaskulære hendelser
eller død hos pasienter med
etablert hjertesykdom (CAD).
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.
Puaschitz NG, Strand E, Norekvål TM et al. Dietary intake of saturated fat is not associated with risk of coronary events or
mortality in patients with established coronary artery disease. The Journal of Nutrition 2015; 145: 299-305.
Conclusions: Dietary recommendations were introduced for 220 million US and 56 million UK citizens by 1983, in the absence of
supporting evidence from RCTs.
Conlusions: There was no association between dietary intake of SFAs and incident coronary events or mortality in patients with
established CAD.
Men likevel …
Rosqvist et al. 2015
– kan et høyt inntak av mettet fett være skadelig?
Potential role of milk fat globule membrane in modulating plasma lipoproteins, gene expression, and
cholesterol metabolism in humans
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
At SFA i normale
mengder ikke øker
risikoen for CVD, betyr
det at store mengder
heller ikke gjør det?
¨  Hvis litt er bra, er da
mye mer enda bedre?
¨ 
¨ 
Klinisk studie (RCT)
¤  8
uker | 57 deltakere | blindet
versus smørolje
¤  ulik matriks | ≈ likt kosthold
¤  fløte
¨ 
Fant signifikante forskjeller i
TC, LDL-C, ikke-HDL-C og apo
B/apo A1.
Rosqvist F, Smedman A, Lindmark-Månsson H et al. Potential role of milk fat globule membrane in modulating plasma lipoproteins,
gene expression, and cholesterol metabolism in humans: a randomized study. The American Journal of Clinical Nutrition 2015; 102:
20-30.
Conclusions: In contrast to milk fat without MFGM, milk fat en- closed by MFGM does not impair the lipoprotein profile. The
mechanism is not clear although suppressed gene expression by MFGM correlated inversely with plasma lipids. The food matrix
should be considered when evaluating cardiovascular aspects of different dairy foods.
Rosqvist et al. 2015
Potential role of milk fat globule membrane in modulating plasma lipoproteins, gene expression, and
cholesterol metabolism in humans
© Johnny Laupsa-Borge
¨ 
Noen effekter av mettete fettsyrer
© Johnny Laupsa-Borge
Forskjell mellom smør fra industrielle smørkanoner og tradisjonelle smørkinner?
23
06.11.15
Foreløpige konklusjoner
Men hva med omega-3/omega-6?
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Del 3 • Sunt fettvett
– noen generelle råd
© Johnny Laupsa-Borge
Funksjonalitet versus optimalitet
© Johnny Laupsa-Borge
Kostråd basert på diettstudier
Evolusjonært perspektiv
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
¨ 
Hva er mennesket blitt best tilpasset å spise?
24
06.11.15
Kosten til jeger- og sankere
Tradisjonelt kosthold
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Andre pattedyrs ernæring
© Johnny Laupsa-Borge
Makronæringsstoffprofil for LCHF
© Johnny Laupsa-Borge
Pattedyrs næringsopptak
0–15 % karbohydrat
15–35 % protein
¨  60–85 % fett
Makronæringsstoffprofil for HCLF
© Johnny Laupsa-Borge
Høykarbo-/lavfettkosthold
45–65 % karbohydrat
15–25 % protein
¨  10–40 % fett
¨ 
¤  55–75
¤  60–70
¤  1–15
% SFA + MUFA
% PUFA
¤  5–10
% SFA + MUFA
% PUFA
Matvareprofil
Komplekse
Lavglykemiske
¨  Cellulære
¨  Fermenterte
¨ 
¨ 
% SFA + MUFA
% PUFA
¨ 
¨ 
Karbohydratkvalitet
¨ 
¤  5–10
5–20 % karbohydrat
15–25 % protein
¨  65–80 % fett
¨ 
© Johnny Laupsa-Borge
¨ 
¤  55–75
Lavkarbo-/høyfettkosthold
25
06.11.15
Feite kostråd til syke
Andre hjertevennlige råd
© Johnny Laupsa-Borge
© Johnny Laupsa-Borge
Takk for oppmerksomheten J
OM FOREDRAGSHOLDEREN
© Johnny Laupsa-Borge
Johnny Laupsa-Borge
Vikjavegen 444 • 5708 VOSS
991 03 109 • [email protected]
Master i human ernæring
Universitetet i Bergen
2012–14 • Masterprosjekt: Fettstudien
Forsker
Haukeland universitetssykehus • hjerteavdelinga
[email protected]
Forskningsjournalist
Helsemagasinet VOF (Vitenskap & fornuft)
[email protected] • www.vof.no
Ernæringsrådgiver
Medisinsk Helsesenter AS
Storøyni 6 • 5730 Ulvik • 56 52 65 05
[email protected] • www.medhelse.no
26