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What makes a healthy diet a healthy diet

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Ashkan Afshin, Institute for Health Metrics and Evaluation (IHME)
Expert consultation on trade and nutrition
15-16 November 2016, FAO Headquarters, Rome
Ashkan Afshin, Institute for Health Metrics and Evaluation (IHME)
http://www.fao.org/economic/est/est-events-new/tradenutrition/en/

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What makes a healthy diet a healthy diet

  1. 1. What makes a healthy diet a healthy diet? Challenges and opportunities for defining, measuring, and evaluating the health impact of diet at the population level Ashkan Afshin, MD MPH MSc ScD November 15, 2016 Acting Assistant Professor of Global Health
  2. 2. Policy Formulation Policy Adoption Policy Implementation Policy Evaluation Agenda Setting1. Defining optimal nutrition 2. Quantifying the burden of disease due to malnutrition 3. Evaluating the effectiveness of policies to improve nutrition 4. Evaluating the cost-effectiveness of nutrition policies 5. Evaluating the political/legal feasibility of nutrition policies 6. Evaluating the intensity of implementation of nutrition policies 7. Evaluating the short/long term effects of nutrition policies
  3. 3. Policy Formulation Policy Adoption Policy Implementation Policy Evaluation Agenda Setting1. Defining optimal nutrition 2. Quantifying the burden of disease due to malnutrition 3. Evaluating the effectiveness of policies to improve nutrition 4. Evaluating the cost-effectiveness of nutrition policies 5. Evaluating the political/legal feasibility of nutrition policies 6. Evaluating the intensity of implementation of nutrition policies 7. Evaluating the short/long term effects of nutrition policies
  4. 4. 4 Malnutrition
  5. 5. 5 GBD 2015
  6. 6. 1943 1992 2005 2011 1989 2002 2015
  7. 7. Nutrients Foods Dietary patterns Biological mechanism No biological knowledge Intercorrelations not a problem Statistical Power No food composition data needed Between-food interactions Supplementation Use in dietary advice Defining diet 7 Absolute Intake Relative IntakeHealth outcome Disease endpoints (CVD, diabetes, cancer) Intermediate outcomes (obesity, blood pressure)
  8. 8. 8 Evidence Description RCTs of disease endpoint Number of independent RCTs evaluating the effect of the risk on the disease endpoint % of independent RCTs showing significant effect in the opposite direction % of independent RCTs showing no effect Prospective observational studies of disease endpoint Number of independent prospective observational studies evaluating the association of the risk with the disease endpoint % of independent prospective observational studies with significant association in the opposite direction Strength Lower Limit of RR in observational studies> 1.5 (Yes/No) Dose response Evidence of the dose-response relationship between the risk and the outcome(Yes/No) Biologic plausibility Potential biologic mechanism that could explain the effect of the risk on the disease endpoint (Yes/No) Analogy Evidence on the relationship between the risk factor and a disease endpoint from the same category (Yes/No)
  9. 9. Outcome RCTs(Number) RCTswithsignificanteffectin theoppositedirection(%) RCTswithnullfindings(%) Prospectiveobservational studies(Number) Prospectiveobservational studieswithsignificant LowerlimitofRR>1.5 Dose-responserelationship Biologicplausibility Analogy Lip and oral cavity cancer 0 - - 2 0 Nasopharynx cancer 0 - - 2 0 Other pharynx cancer 0 - - 2 0 Larynx cancer 0 - - 2 0 Oesophageal cancer 0 - - 5 0 Tracheal, bronchus, and lung cancer 0 - - 22 0 Ischaemic heart disease 0 - - 9 0 Ischaemic stroke 0 - - 9 0 Hemorrhagic stroke 0 - - 5 0 Diabetes mellitus 0 - - 9 0 Oesophageal cancer 0 - - 5 0 Ischaemic heart disease 0 - - 9 0 Ischaemic stroke 0 - - 8 0 Hemorrhagic stroke 0 - - 5 0 Ischaemic heart disease 0 - - 7 0 Ischemic stroke 0 - - 6 0 Hemorrhagic stroke 0 - - 6 0 Diabetes mellitus 0 - - 10 0 Diet low in nuts and seeds Ischaemic heart disease 1 0 100 6 0 Diabetes mellitus 1 0 100 5 0 Risk Diet low in vegetables Diet low in vegetables Diet low in vegetables Diet low in whole grains Diet low in whole grains Diet low in nuts and seeds Diet low in fruits Diet low in fruits Diet low in fruits Diet low in fruits Diet low in fruits Diet low in vegetables Diet low in fruits Diet low in fruits Diet low in fruits Diet low in fruits Diet low in fruits Diet low in whole grains Diet low in whole grains Epidemiologic evidence supporting causality between dietary risk-outcome pairs GBD 2015
  10. 10. Outcome RCTs(Number) RCTswithsignificanteffectin theoppositedirection(%) RCTswithnullfindings(%) Prospectiveobservational studies(Number) Prospectiveobservational studieswithsignificant LowerlimitofRR>1.5 Dose-responserelationship Biologicplausibility Analogy Colon and rectum cancer cancer 0 - - 7 0 Colon and rectum cancer cancer 0 - - 8 0 Diabetes mellitus 0 - - 9 11 Colon and rectum cancer cancer 0 - - 9 11 Ischaemic heart disease 0 - - 5 0 Diabetes mellitus 0 - - 8 0 Body mass index 10 0 60 22 0 - - Colon and rectum cancer cancer 0 - - 15 0 Diet low in fibre Ischaemic heart disease 0 - - 12 0 Colon and rectum cancer cancer 0 - - 13 0 Ischaemic heart disease 17 0 94 16 0 Ischaemic heart disease 8 0 75 11 0 Ischaemic heart disease 0 - - 4 0 Systolic blood pressure 45 0 73 - - - - Stomach cancer 0 - - 3 0 Risk Diet low in fibre Diet low in calcium Diet low in seafood omega-3 fatty acids Diet low in polyunsaturated fatty acids Diet high in trans fatty acids Diet low in milk Diet high in red meats Diet high in red meats Diet high in processed meats Diet high in processed meats Diet high in processed meats Diet high in sugar sweetened beverages Diet high in sodium Diet high in sodium Epidemiologic evidence supporting causality between dietary risk-outcome pairs GBD 2015
  11. 11. Policy Formulation Policy Adoption Policy Implementation Policy Evaluation Agenda Setting1. Defining optimal nutrition 2. Quantifying the burden of disease due to malnutrition 3. Evaluating the effectiveness of policies to improve nutrition 4. Evaluating the cost-effectiveness of nutrition policies 5. Evaluating the political/legal feasibility of nutrition policies 6. Evaluating the intensity of implementation of nutrition policies 7. Evaluating the short/long term effects of nutrition policies
  12. 12. 12 ComparativeRiskAssessment
  13. 13. Measurement Error 13 Subar (2001)
  14. 14. Publication Bias 14 Nuts & IHD Red meat & Diabetes Processed meat & Diabetes Trans fat & IHD SSBs & Diabetes
  15. 15. Definition of dietary factors 15 Wang Huang Johnsen Wu Jacobs Jensen Steffen Liu added bran added wheat germ bagels bran breakfast cereals brown rice brown rice flour buckwheat bulgur cooked cereal cooked oatmeal corn meal dumplings corn meal flat cakes corn meal porridge corn meal steamed bread non-white bread oats other grains pancakes pizza popcorn psyllium Aune (2016)
  16. 16. Covariates 16 Age Sex Race Education MeritalStatus Smoking Alcohol PhysicalExcerise Engery FruitandVegetables SFA Fish/Seafood PUFA MUFA Trans-FA RedMeat Sucrose Coffee Sodium Soy Dairy BMI Waist/hip VitaminSupplements OralContraceptives HRT Diabetes Hypertension Hypercholesterolemia MentalStress MenopausalStatus SleepDuration Atkins (2014) Eshak(2011) Eshak (2014) Jacobs(2001) Jensen(2004) Johnsen (2015) Liu (1999) Mink (2007) Muraki (2014) Muraki (2014) Pietinen (1996) Rautiainen (2012) Steffen(2003) Tognon (2014) Wang(2016) Yu (2013) Whole grains and Ischemic Heart Disease Aune (2016)
  17. 17. Correlation between dietary factors 17 Veg Fruit ProcMeat RedMeat Nuts/seeds Wholegrains SSB Milk Sodium Omega-3 PUFA SFA Fiber Calcium Veg 1.00 Fruit 0.19 1.00 Proc Meat -0.13 -0.04 1.00 Red Meat -0.02 -0.11 -0.08 1.00 Nuts/seeds 0.10 0.13 -0.07 -0.08 1.00 Whole grains 0.08 0.17 -0.07 -0.11 0.12 1.00 SSB -0.21 -0.22 0.03 0.07 -0.13 -0.18 1.00 Milk -0.04 0.04 -0.02 -0.02 -0.03 0.09 -0.12 1.00 Sodium 0.29 -0.12 0.31 0.08 -0.13 -0.03 -0.13 -0.05 1.00 Omega-3 0.12 0.05 -0.10 -0.06 0.07 0.03 -0.07 -0.04 0.14 1.00 PUFA 0.08 -0.03 0.06 -0.13 0.21 0.00 -0.15 -0.14 0.02 0.07 1.00 SFA -0.14 -0.12 0.18 0.14 -0.07 -0.18 -0.14 0.10 0.00 -0.11 0.09 1.00 Fiber 0.61 0.48 -0.15 -0.17 0.25 0.44 -0.34 0.04 0.07 0.05 0.04 -0.25 1.00 Calcium 0.10 0.11 0.02 -0.10 0.11 0.16 -0.27 0.54 0.11 -0.02 -0.17 0.18 0.23 1.00 NHANES 2011-2012
  18. 18. RR for CHD per 1 serving (28.4g)/week of nuts Afshin (AJCN, 2014) Luo (AJCN, 2014) Zhou (AJCN, 2014)
  19. 19. 19 ComparativeRiskAssessment
  20. 20. 20 GBD 2015 Fruits 200-300 gr/day Vegetables 340-500 gr/day Whole grains 100-150 gr/day Nuts 16-25 gr/day Red meats 18-27 gr/day Processed meats 0-4 gr/day Milk 350-520 gr/day Sugar sweetened beverages 0-5 gr/day Polyunsaturated fatty acids 9-13% of total daily energy Seafood omega-3 fatty acids 200-300 mg/day Trans fatty acids 0-1%E Dietary fiber 19-28 gr/day Dietary calcium 1-1.5 gr/day New approach to determine TMREL
  21. 21. Healthy diet fact sheet (WHO) 21 Free sugars<10% E/d Salt <5 g/d | Sodium< 2g/d Total Fat < 30% E/d Adiposity Cardiovascular disease Cardiovascular disease
  22. 22. Mente (Lancet 2016) Sodium excretion and risk of cardiovascular disease Mozaffarian (NEJM 2014) Sodium<5 g/d Sodium<2 g/d
  23. 23. Citation network graph with 269 reports and 2165 citations. Ludovic Trinquart et al. Int. J. Epidemiol. 2016
  24. 24. Co-authorship network graph with 643 authors. Ludovic Trinquart et al. Int. J. Epidemiol. 2016
  25. 25. Reducing intake of free sugars and body fatness Increasing intake of free sugars and body fatness Adults Children Morenga (BMJ, 2012)
  26. 26. Isoenergetic exchanges of free sugars with other carbohydrates Free sugars<10% E/d Morenga (BMJ, 2012)
  27. 27. Total Fat < 30% E/d Howard (2006)
  28. 28. 28 ComparativeRiskAssessment
  29. 29. Acknowledgment 29 1700+ GBD Collaborators

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