Laupsa-Borge i s/hv
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
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