Margine or butter

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In this slide deck I present scientific data on the health effect of butter, margarine and vegetable oils.

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  • He didn't tell you that LDL is important for transporting everything critical to make sex hormones, vitamin D, bile salts, fat soluble vitamins. The level of it does not matter, however the particle size matters.SFA increase the size of LDL particle, meaning it can transport more of this cholesterol vital to human life so it is safe and reduces risk of CVD. MUFAs reduces the LDL levels but that is not a risk factor. And PUFA oxidises overall cholesterol levels (which is not advisable saying that we need decent levels to survive). In that case, butter is very healthy
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  • A different perspective on this - http://www.slideshare.net/Zahccc/saturated-fat-vs-carbohydrates-monounsaturated-fat-and-polyunsaturated-fat
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Margine or butter

  1. 1. Butter healthier than margarine? Nope. Evidence refuting butter-is-healthy claims [Updated January 2016] Registered dietitian, M.Sc, MBA Reijo Laatikainen www.pronutritionist.net www.pronutritionistblog.com www.twitter.com/pronutritionist Page 1
  2. 2. Impetus to this slide deck; pro-butter doctors in media • General practioner (GP) John Briffa’s text in Times newspaper and the followed discussion at his blog • Cardiologist Aseem Malhotra’s comment on BBC TV Channel “Butter is healthier than low-fat spreads or margarine” • Diet Doctor’s, GP Andreas Eenfeldt, posts • Finnish doctors, such as Antti Heikkilä’s and Taija Somppi’s, numerous comments in the media • And more … www.pronutritionist.net2
  3. 3. My position • Modern margarines are healthier than butter. However, margarines are not miraculous. Extra virgin olive oils and canola oils are very likely healthier than margarine • Some scientific evidence on dietary fats is controversial • Butter or saturated fat per se have not been shown to be superior to modern vegetable oils or margarines in meta- analyses examining cardiovascular disease, cancer or type 2 diabetes • There is enough scientific evidence to refute the claim ”butter is healthy” • www.pronutritionist.net3
  4. 4. First, some scientific data that is often emphasized by pro-butter doctors www.pronutritionist.net4
  5. 5. Siri-Tarino’s meta-analysis of prospective cohorts: Saturated does not increase the risk of coronary heart disease risk nor does it reduce the risk www.pronutritionist.net Siri-Tarino PW et al. Am J Clin Nutr (January 13, 2010). doi:10.3945/ajcn. 5
  6. 6. Chowdhury’s meta-analysis of prospective, observational studies and randomized, controlled trials. www.pronutritionist.net 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. Ann Intern Med 2014; 160;398-406 6 “Conclusion: Current evidence does not clearly support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats.”
  7. 7. Sydney Diet Heart Study: Cardiac mortality was increased in vegetable oil/margarine group (re-evaluation of the study published originally 1978 ) Page 7 74 % increased risk in PUFA group PUFA Safflower oil/margarine Control Diet, high in SFA Ramsden CE, Zamora D, Leelarthaepin B, Majchrzak-Hong SF, Faurot KR, Suchindran CM, et al. Use of dietary linoleic acid for secondary prevention of coronary heart disease and death: evaluation of recovered data from the Sydney Diet Heart Study and updated meta-analysis. BMJ 2013;346:e8707
  8. 8. Risk of death is not increased nor reduced among butter users. Meta- analysis of prospective cohorts 8 O’Sullivan T et al. Food sources of saturated fat and the association with mortality: a meta-analysis. Am J Public Health. 2013;103:e31-42 1,17* 1,21* 1.01 1.03 0,96** 0 0.2 0.4 0.6 0.8 1 1.2 1.4 Meat Processed meat Milk Cheese Butter *) p<0,001, **) p=0,5 (not significant)
  9. 9. The rest of this slide deck depicts scientific evidence which pro- butter doctors usually dismiss or downplay www.pronutritionist.net9
  10. 10. Point #1 World has changed since 1970s when Sydney Diet Heart Study and many other fat replacement studies were done. www.pronutritionist.net10
  11. 11. 1960 1970 1990 2013 Era of the pivotal fat modification trials Oslo Diet Heart 1958- 1964 MRC Soy 1968 STARS 1992 Minnesota Coronary Survey 1968-1973 LA Veterans 1969 DART 1989 Rose Corn Oil 1965 Margarines per se and use of oils have changed since 1970s *) if not given, the publication date Sydney Diet Heart Study 1966-73
  12. 12. You cannot translate data from 1960’s directly to modern world because margarines per se, use of oils and background diet has changed dramatically www.pronutritionist.net12
  13. 13. Sunflower oil /100 g Corn oil /100 g Soy oil / 100 g Canola oil /100 g Olive oil / 100 g Linoleic acid (omega-6) 62 g 53 g 52 g 22 g 10 g ALA (omega- 3) 0,5 g 1 g 7 g 11 g 0,5 g PUFA 63 g 54 g 59 g 33 g 11 g SFA 11 g 13 g 15 g 6 g 14 g MUFA 22 g 27 g 22 g 60 g 68 g Oils of 1970s have different fatty acid composition Oils losing market share Modern dominating oils
  14. 14. By using canola oil instead of sunflower oil you’ll get >20 times more omega-3 fats. In addition you don’t even get half of the amount of omega-6 linoleic acid www.pronutritionist.net14 In 1970s sunflower, corn, soy and other omega-6 rich oils were used in clinical trials. Canola oil and olive oil are dominating clinical trials today. They also dominate European cuisines
  15. 15. IN ADDITION. MARGARINES ARE WAY BETTER TODAY www.pronutritionist.net15
  16. 16. Modern margarines in UK, or in most European countries, do not commonly contain trans fat. Boy, it was a different story in 1970s www.pronutritionist.net16 21.8 % 0.22% 0.0 % 5.0 % 10.0 % 15.0 % 20.0 % 25.0 % Margarines 1970s* Margarines 2012 (UK)** Median trans fat content of tube margarines/spreads *) Beare-Rogers JL et al. The linoleic acid and trans fatty acids of margarines. Am J Clin Nutr. 1979 Sep;32(9):1805-9. **) Roe M, et al Trans fatty acids in a range of UK processed foods. Food Chem. 2013 Oct 1;140(3):427-31. . ← 1970s vs now →
  17. 17. Median trans fat content of margarines is currently very low. Finland today vs US 1970s 1970s (US*) 2012 (FIN**) Trans fat content of margarines 21.8% 0.34% www.pronutritionist.net17 *) Beare-Rogers JL et al. The linoleic acid and trans fatty acids of margarines. Am J Clin Nutr. 1979 Sep;32(9):1805-9. **) Ritvanen, T., Putkonen, T. , Peltonen, K. A comparative study of the fatty acid composition of dairy products and margarines with reduced or substituted fat content. Food and Nutrition Sciences, Vol. 3, 2012, pp. 1189-1196
  18. 18. Trans fat content of margarines/spreads has plummeted during the last 50 years www.pronutritionist.net18 Source: Ravinder Reddy, American Heart Association. Trans Fat Conference. October 10-11, 2006 Trans fat Saturated fat PUFA Omega-3
  19. 19. Point #2 Meta-analyses of the classic fat replacement trials have shown that combination of omega- 3 fatty acids and omega-6 linoleic acid reduce cardiovascular mortality www.pronutritionist.net19
  20. 20. Meta-analysis: high intake of both linoleic acid AND omega-3 fats reduce cardiovascular deaths by 21 % in randomized trials. www.pronutritionist.net Ramsden CE, Zamora D, Leelarthaepin B, Majchrzak-Hong SF, Faurot KR, Suchindran CM, et al. Use of dietary linoleic acid for secondary prevention of coronary heart disease and death: evaluation of recovered data from the Sydney Diet Heart Study and updated meta-analysis. BMJ 2013;346:e8707.
  21. 21. Supplementing omega-3 fats alone does not reduce cardiac deaths. Meta- analysis • ”Overall, omega-3 PUFA supplementation was not associated with a lower risk of all-cause mortality, cardiac death, sudden death, myocardial infarction, or stroke based on relative and absolute measures of association” www.pronutritionist.net21 Rizos EC, et al. Association between omega-3 fatty acid supplementation and risk of major cardiovascular disease events: a systematic review and meta-analysis. JAMA. 2012 Sep 12;308(10):1024-33
  22. 22. Guidelines recommend increase in both omega-3 fatty acids and omega-6 linoleic acid intake • Dietary recommendations underline the adequate intake of BOTH omega-3 AND omega-6 fatty acids (linoleic acid), exactly in the line with the beneficial outcomes of meta-analysis by Ramsden 2013 • You can increase your intake of omega-3 fatty acids by using canola oil, walnuts and oily fish without fear of increasing too much linoleic acid intake; exactly as the nutrition recommendations tell us to do www.pronutritionist.net22
  23. 23. Point #3 Sydney Diet Heart Study has important limitations (This study is the only randomized study showing increased cardiovascular mortality on vegetable oils/margarine) www.pronutritionist.net23
  24. 24. Lead investigator of Sydney Diet Heart Study, Chris Ramsden: “The really important limitations were; … 2) The median intake of omega-6 linoleic acid was almost 15% of calories. In the United States, consumption of omega-6 linoleic acid has increased from about 2% of calories in the early 20th century to about 7% of calories currently. So in the SDHS [Sydney Diet Heart Study] it ended up approximately twice as much as the average American consumes nowadays.” www.pronutritionist.net24 The PUFA Investigation: An Expert Interview Linda Brookes, MSc, Christopher E. Ramsden, March 18, 2013 www.medscape.com
  25. 25. New systematic review: median global intake of linoleic acid (LA) 5,5 E % www.pronutritionist.net25 Harika RK, Eilander A, Alssema M, Osendarp SJ, Zock PL. Intake of Fatty Acids in General Populations Worldwide Does Not Meet Dietary Recommendations to Prevent Coronary Heart Disease: A Systematic Review of Data from 40 Countries. Ann Nutr Metab. 2013 Oct 29;63(3):229-238
  26. 26. Margarines used at time of Sydney Diet Heart Study contained trans fat 12-65 % of all fatty acids www.pronutritionist.net26 Beare-Rogers JL et al. The linoleic acid and trans fatty acids of margarines. Am J Clin Nutr. 1979 Sep;32(9):1805- 9.
  27. 27. Different realities 1970s vs NOW Omega-6 linoleic acid intake as of total calories Trans fat content of margarines In Sydney Diet Heart Study, ie. 1970s 15% ~20% Now 5.5% <1% (at least in Western Europe) www.pronutritionist.net27
  28. 28. Point #4 Use of either olive oil, margarine or soy oil alone, or as a part of multifactorial intervention has reduced cardiovascular morbidity/mortality www.pronutritionist.net28
  29. 29. In 4 large successful randomized trials, butter and saturated fat reduction has been the key Study Fat given for free to active group Comment Los Angeles Veterans Administration Study Corn, Safflower, sunflower and soy oil (mix) Pure fat replacement study. Combined fatal strokes, amputations and heart attacks reduced by 31%. (p<0,05) Lyon Diet Heart Study Margarine Med Diet Study, ie multifactorial design but only canola oil based margarine given for free. Cardiovascular mortality reduced by 76% (p=0,029) Oslo Diet Heart Study Soy oil (and oily fish occasionally) Multifactorial design but only oil and some oily fish given for free. Fatal heart attacks reduced by 56% (p=0,029) Predimed Olive oil (extra virgin olive oil group) Med Diet Study, ie multifactorial design but only fats given for free. Cardiovascular events reduced by 30% www.pronutritionist.net29
  30. 30. Summary on large randomized CVD trials Favoring saturated fat Draw Favoring vegetable oils and/or margarine Name of the study Sydney Diet Heart Study DART, Minnesota CS, MRC Soy, St Thomas Atherosclerosis , Rose Corn Oil Los Angeles Veterans, Oslo Diet Heart, Lyon Diet Heart, Predimed Number of randomized studies (w/mortality or morbidity end points) 1 5 4 www.pronutritionist.net30
  31. 31. Point #5 Margarine, canola oil and olive oil all induce better total cholesterol/HDL –ratio and apoB levels than butter. This is proven at the level of meta-analysis. If you replace butter with oils/margarine you win. Also if you replace carbohydrates with oils/modern margarine you win. But you lose or have a draw if you replace carbohydrates with butter. www.pronutritionist.net31
  32. 32. Total cholesterol is strong risk factor for ischemic heart disease (IHD) mortality but total cholesterol/HDL – ratio is even stronger www.pronutritionist.net32 Prospective Studies Collaboration,. Blood cholesterol and vascular mortality by age, sex, and blood pressure: a meta- analysis of individual data from 61 prospective studies. Lancet. 2007 Dec 1;370(9602):1829-39. e studies with 55,000 vascular deaths. , Total cholesterol as a risk marker Total cholesterol/HDL as a risk marker
  33. 33. Meta-analysis: Canola oil and even margarine produce clearly better Total Cholesterol/HDL ratios than butter 33 Mensink et al. 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. Canolaoil=
  34. 34. Effects of replacing potatoes with butter or canola oil in an isocaloric situation 34 ?
  35. 35. -9.3 % -0.7 % 0.4 % 2.8 % 6.8 % -12.0 % -10.0 % -8.0 % -6.0 % -4.0 % -2.0 % 0.0 % 2.0 % 4.0 % 6.0 % 8.0 % Carbohydrate Protein* PUFA MUFA SFA Change in macronutrient intake when 10% of daily energy as carbs (boiled potatoes) is replaced by animal fat (butter) Changes in macronutrient intake when butter replaces potatoes 35 *Protein is considered neutral in the following calculations (no data in Mensink). Therefore actual amount of carbs replaced is 9.3 E%-0.7 E%= 8.6 E%. It follows that the ‘replaceable’ fat intake is also reduced by 0.7 E%, and this reduction is splitted to all 3 fatty acid classes in the following calcutions.
  36. 36. Changes in macronutrient intake when canola oil replaces potatoes 36 -9.3 % -0.7 % 2.8 % 6.4 % 0.7 % -12.0 % -10.0 % -8.0 % -6.0 % -4.0 % -2.0 % 0.0 % 2.0 % 4.0 % 6.0 % 8.0 % Carbohydrate Protein PUFA MUFA SFA Change in macronutrient intake when 10% of daily energy as carbs (boiled potatoes) is replaced by canola oil
  37. 37. Change in LDL when potatoes are replaced with butter or canola oil 37 0.1808 -0.0883 -0.15 -0.1 -0.05 0 0.05 0.1 0.15 0.2 Carbs replaced by butter Carbs replaced by canola oil Change in LDL (mmol/L) mmol/L (For mg/DL multiply by 38.67) 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 (calculated from Table 1)
  38. 38. Change in HDL when potatoes are replaced with butter or canola oil 38 0.087 0.0694 0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 0.09 0.1 Carbs replaced by butter Carbs replaced by canola oil Change in HDL (mmol/L) mmol/L (For mg/DL multiply by 38.67) 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 (calculated from Table 1)
  39. 39. Change in total cholesterol:HDL –ratio when potatoes are replaced with butter or canola oil 39 -0.0545 -0.2403 -0.3 -0.25 -0.2 -0.15 -0.1 -0.05 0 Carbs replaced by butter Carbs replaced by canola oil Change in TOT CHOL:HDL -ratio 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 (calculated from Table 1)
  40. 40. Change in apoB when potatoes are replaced with butter or canola oil 40 2.88 -48 -60 -50 -40 -30 -20 -10 0 10 Carbs replaced by butter Carbs replaced by canola oil Change in apoB (mg/L) mg/L 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 (calculated from Table 1)
  41. 41. Point #6 Replacing saturated fat with polyunsaturated fat (PUFA) reduces coronary heart disease mortality in prospective cohorts www.pronutritionist.net41
  42. 42. Pooled analysis of 11 prospective cohorts: “replacing SFAs with PUFAs rather than MUFAs or carbohydrates prevents CHD [Coronary Heart Disease]” Page 42 Jakobsen M et al. Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. Am J Clin Nutr. 2009 May;89(5):1425-32. replace SFA: Saturated fat; PUFA: Polyunsaturated fat, ie. Omega-6 and omega-3 fatty acids
  43. 43. 1.1.2016 43 -21 % -9 % “Comparing the highest to the lowest category, dietary linoleic acid was associated with 21% lower risk of CHD deaths” Farvid MS, Ding M, Pan A, Sun Q, Chiuve SE, Steffen LM, Willett WC, Hu FB.. Dietary Linoleic Acid and Risk of Coronary Heart Disease: A Systematic Review and Meta-Analysis of Prospective Cohort Studies. Circulation. 2014;130(18):1568-1578 “A 5% of energy increment in linoleic acid intake replacing energy from saturated fat intake was associated with a 9% lower risk of CHD events” “A 5% of energy increment in linoleic acid intake replacing energy from saturated fat intake was associated with a 13% lower risk of CHD deaths “ -10 % Meta-analysis of 13 prospective cohorts published between 1992-2011: linoleic acid (prominent PUFA) is associated with reduced risk of CHD.
  44. 44. Point #7 Omega-6 fats are not pro-inflammatory in humans in contrast to common claims by pro- butter doctors www.pronutritionist.net44
  45. 45. Meta-analysis of 15 clinical trials • ” This review clearly demonstrates that virtually no data are available from randomized, controlled intervention studies among healthy, noninfant human beings to show that the addition of LA [linoleic acid] to diets increases markers of inflammation.” • Linoleic acid does not even increase arachidonic acid (AA) levels because conversion to AA is extremely low. Only 0.3- 0.6% of linoleic acid is converted to AA in humans www.pronutritionist.net45 Johnson & Fritsche. Effect of Dietary Linoleic Acid on Markers of Inflammation in Healthy Persons: A Systematic Review of Randomized Controlled Trials. Journal of the Academy of Nutrition and Dietetics 2012; 112: 1029-1041 Rett & Whelan. Increasing dietary linoleic acid does not increase tissue arachidonic acid content in adults consuming Western-type diets: a systematic review. Nutr Metab (Lond). 2011 Jun 10;8:36
  46. 46. Butter and saturated fat per se pose either deleterious or neutral effects on inflammation • Butter induced pro-inflammatory changes versus sunflower oil in clinical trial – Bjermo H, et al. Effects of n-6 PUFAs compared with SFAs on liver fat, lipoproteins, and inflammation in abdominal obesity: a randomized controlled trial. Am J Clin Nutr. 2012 May;95(5):1003-12. • ”Consumption of a saturated fat reduces the anti-inflammatory potential of HDL” – Nicholls SJ, et al. Consumption of saturated fat impairs the anti-inflammatory properties of high-density lipoproteins and endothelial function. Margarine reduces post-prandial inflammation in proportion to butter J Am Coll Cardiol. 2006 Aug 15;48(4):715-20 • Exchanging SFA from butterfat for sunflower oil in a mixed meal decrease postprandial concentrations of IL-6, TNFα, sTNFr-I and -II, and sVCAM-1 in overweight men. – Masson CJ, Mensink RP Exchanging saturated fatty acids for (n-6) polyunsaturated fatty acids in a mixed meal may decrease postprandial lipemia and markers of inflammation and endothelial activity in overweight men.. J Nutr. 2011 May;141(5):816-21.) • Sterol containing margarine and butter produce similar effects on inflammatory markers – Gagliardi AC et al. Effects of margarines and butter consumption on lipid profiles, inflammation markers and lipid transfer to HDL particles in free-living subjects with the metabolic syndrome. Eur J Clin Nutr. 2010 Oct;64(10):1141-9. www.pronutritionist.net46
  47. 47. Point #8 Omega-6 fats are not associated with cancer in contrast to claims by pro-butter doctors. Results from meta-analyses www.pronutritionist.net47
  48. 48. Very high intake of linoleic acid. No increase in cancer risk in clinical trials www.pronutritionist.net48 Zock PL, Katan MB. Linoleic acid intake and cancer risk: a review and meta-analysis. Am J Clin Nutr. 1998 Jul;68(1):142-53.
  49. 49. Meta-analyses by World Cancer Research Fund: Omega-6 fats not linked to cancer. If anything, butter is linked to lung cancer (limited evidence) www.pronutritionist.net49 World Cancer Research Fund / American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR, 2007
  50. 50. Point #9 Lower intake of saturated fat during low carb diet improves parameters of cardiovascular health, when the major source of protein is beef www.pronutritionist.net50
  51. 51. Ronald Krauss with co-workers: lowering SFA content of low carb diet improves cardiovascular risk profile Run in period Low SFA + Low carb diet high in beef High SFA + Low carb diet high in beef TG, mmol/l 1,22 1.0 1.1 LDL, mmol/l 2,87 2.5* 2.86* HDL, mmol/l 1,08 1.04* 1.07* Small LDL, nmol/l 207 187* 222* Medium LDL, “ 284 214* 304* Large LDL, “ 698 655 712 ApoB, g/l 0,74 0.68* 0.73* *) p<0.05 low vs high SFA diets http://twitter.com/pronutritionistPage 51 Mangravite LM, Chiu S, Wojnoonski K, Rawlings RS, Bergeron N, Krauss RM. Changes in atherogenic dyslipidemia induced by carbohydrate restriction in men are dependent on dietary protein source.J Nutr. 2011 Dec;141(12):2180-5 “… reductions in the other lipoprotein-related risk factors, including apoB and small LDL, were greatest following consumption of a Low Carbohydrate Low Saturated Fat Diet”
  52. 52. Point #10 Scientific data in the field of nutrition is almost never perfectly clear due to very complex interplay of nutrients, phytochemicals, cooking methods, biological variation and research methods. You either accept this or deny it. Choice is yours www.pronutritionist.net52
  53. 53. Dietary pattern loaded with butter is likely to be unhealthier than otherwise similar food pattern with vegetables oils or margarine as main edible fat. However, used sparingly, butter is far from poison 53
  54. 54. Wellcome aboard! http://twitter.com/pronutritionist http://www.facebook.com/pronutritionist http://www.pronutritionist.net Reijo Laatikainen, RD, MBA Images bought and licensed from BigStockPhoto. Snapshots from papers and sites refered to. Page 54
  55. 55. 1. Randomized mortality & morbidity trials 2. Prospective cohorts 3. Randomized risk marker studies 4. Cross-sectional and case-control cohorts 5 Ecological & animal studies Strengthofevidence Meta-analyses of 1,2 & 3 Modified from: Micha & Mozaffarian. Lipids. 2010; 45(10): 893–905 and Evidence Analysis Manual. Academy of Nutrition and Dietetics January 2012

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