Fat or Low-fat? Anwar T. Merchant ScD, MPH, DMD Department

Fat or Low-fat? Anwar T. Merchant ScD, MPH, DMD Department of Epidemiology and Biostatistics

Do you know? The decline in heart disease in the US from 1981-2000 was Low fat diet reduces heart disease by a. 77% due to new medical treatment, 19% lifestyle, 4% unknown. a. 60% b. 35% due to new medical treatment, 54% lifestyle, 11% unknown c. 47% due to new medical treatment, 44% lifestyle, 9% unknown b. 30% c. 15% d. Not at all

Do you know? What percent of heart disease can be prevented by eating a healthy diet, exercising regularly, and not smoking? a. 54% b. 32% c. 24% What percent of health professionals follow this advice? a. 65% b. 31% c. 13%

Substitute 1% energy from carbohydrate with equivalent saturated fat 0.05 0.04 0.03 0.02 0.01 0 -0.01 -0.02 ΔTotal cholesterol ΔLDL ΔHDL ΔTotal:HDL Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55.

Substitute 1% energy from carbohydrate with equivalent monounsaturated fat 0.02 0.01 0 -0.01 -0.02 -0.03 -0.04 ΔTotal cholesterol ΔLDL ΔHDL ΔTotal:HDL Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55.

Substitute 1% energy from carbohydrate with equivalent polyunsaturated fat 0.02 0.01 0 -0.01 -0.02 -0.03 -0.04 -0.05 ΔTotal cholesterol ΔLDL ΔHDL ΔTotal:HDL Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55.

Estimated Percent Changes in the Risk of Coronary Heart Disease Associated with Isocaloric Substitutions of One Dietary Component for Another. Hu FB et al. N Engl J Med 1997;337:1491-1499.

From: Low-Fat Dietary Pattern and Risk of Cardiovascular Disease: The Women's Health Initiative Randomized Controlled Dietary Modification Trial JAMA. 2006;295(6):655-666. doi:10.1001/jama.295.6.655 Figure Legend: CHD indicates coronary heart disease; CI, confidence interval; HR, hazard ratio; MI, myocardial infarction. Date of download: 4/16/2013 Copyright 2012 American Medical Association. All rights reserved.

PREDIMED study 7447 men and women at high risk of CVD (diabetes or at least 3 risk factors) 3 groups: 2 Mediterranean diets – olive oil and nuts – and control (low-fat diet) Intervention: dietary advice at baseline and quarterly thereafter Midway control group also received dietary advice about low-fat diet at the same frequency No restriction on caloric intake or physical activity

PREDIMED study: diet after 12 months PREDIMED study Mediterranean diet (olive PREDIMED study Mediterranean diet (olive oil)oil) at at 1212 months months 6.3 PREDIMED study Mediterranean diet (nuts) at 12 months 8.2 16.5 21.7 9.3 % energy protein % energy satuated fat % energy monounsaturated fat 16.3 21.6 9.4 38.2 40 % energy protein % energy satuated fat % energy monounsaturated fat % energy carbohydrate % energy polyunsaturated fat % energy carbohydrate % energy polyunsaturated fat PREDIMED study control diet at 12 months 5.9 16.8 19.2 9.5 42.5 % energy protein % energy satuated fat % energy monounsaturated fat % energy carbohydrate % energy polyunsaturated fat Zazpe et al J Am Diet Assoc. 2008 Jul;108(7):1134-44;

Change in % energy Mediterranean (olive oil) vs control 5 4 3 2 1 0 -1 -2 -3 -4 Δ ein t o Pr Δ e at r yd h o rb a C Δ at f al t To Δ d te a ur t Sa t fa t fa d d te te a a ur ur t t sa sa n n u ou lu n o o P M Δ Δ t fa Zazpe et al J Am Diet Assoc. 2008 Jul;108(7):1134-44;

Change in % energy Mediterranean (nut) vs control 6 4 2 0 -2 -4 -6 Δ P ein t ro Δ e at r yd h bo r Ca Δ at la f t To Δ d te a ur t Sa t fa Δ d te a ur t sa n ou n o M t fa Δ ly o P d te a ur t sa n u t fa Zazpe et al J Am Diet Assoc. 2008 Jul;108(7):1134-44;

Effect of intervention at 12 months, PREDIMED % participants with change in risk factors at 12 months, PREDIMED 43.2 *Decreased diastolic BP 51.6 49.8 36.6 *Decreased systolic BP 59.3 58 32.7 *Decreased triglycerides 43.2 *Decreased LDL:DDL 35.8 *Decreased LDL 35.8 49.2 49.2 50.6 47.7 45.5 53.8 Decreased total cholesterol 51.5 41.2 40.9 37.7 Decreased BMI 0 Control 57.3 10 20 Mediterranean (nuts) 30 40 50 60 70 Mediterranean (olive oil) Zazpe et al J Am Diet Assoc. 2008 Jul;108(7):1134-44;

Kaplan–Meier Estimates of the Incidence of Outcome Events in the Total Study Population. Estruch R et al. N Engl J Med 2013;368:1279-1290.

CVD trends in Finland Energy from saturated fat: 22% to 13% Polyunsaturated fat Fruits and vegetables Salt Smoking Vartiainen et al

Fig 2 Summary most adjusted relative risks for saturated fat intake and all cause mortality, CHD mortality, CVD mortality, total CHD, ischemic stroke, and type 2 diabetes. Russell J de Souza et al. BMJ 2015;351:bmj.h3978 2015 by British Medical Journal Publishing Group

Summary