Preventing cardiometabolic diseases: how soon should we start? - Dr André Marette

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Preventing cardiometabolic diseases: how soon should we start? - Dr André Marette
Preventing cardiometabolic diseases:
how soon should we start?

Dr André Marette
Professor of Medicine
Cardiolody Axis, Laval Hospital
Scientific Director, Institute of Nutrition (INAF)
Laval University
Preventing cardiometabolic diseases: how soon should we start? - Dr André Marette
Declararations
             Funding
               • CIHR, CDA, HSFC, FRQ, CFI, CRIBIQ, CFREF
               • JA DeSève Fondation
               • Pfizer (Chair CIHR/industry)
               • Danone Nutricia
               • Thetis Pharma
               • Fédération des Producteurs Acéricoles du Québec
               • Dairy Farmers of Canada
               • High-bush Blueberry Council
Consultation and honorarium
  • Danone Nutricia
  • Plexus
  • Valbiotis
Preventing cardiometabolic diseases: how soon should we start? - Dr André Marette
Obesity and type 2 Diabetes (T2D) take
         epidemic proportion
Preventing cardiometabolic diseases: how soon should we start? - Dr André Marette
“Obesogenic” food environment
Preventing cardiometabolic diseases: how soon should we start? - Dr André Marette
Diet-related diseases
▪ Poor diet has now surpassed tobacco use as a main risk
  factor for cardiovascular disease in many countries
▪ Diet-related factors dominate cancer and obesity prevention
  recommendations
▪ Prevalence of “severe” obesity is increasing in children
  ▪ Double burden: continuing levels of undernutrition
▪ High-energy nutrient-poor diets exacerbates risk for “adult” diseases
  ▪ Type 2 diabetes
  ▪ Dyslipidemia and NAFLD
  ▪ Hypertension and CVD
  ▪ Metabolic syndrome
▪ Diet-related diseases are preventable and manageable
  ▪ Healthy diet and lifestyle behaviors learned in childhood

       Kumar and Kelly (2017); Institute for Health Metrics and Evaluation (2017); WCRF-AICR (2018)
Preventing cardiometabolic diseases: how soon should we start? - Dr André Marette
When to start prevention?
  The earlier the better!

  First 1000 days of life are critical
  to prevent childhood obesity

  Effective interventions focus on individual
  or family-level behavior change

  Governments need to work to ensure
  children have access to safe and nutritious foods

  Also, need to protect older children from:
     Sophisticated food marketing
     Inducements to be inactive          Blake-Lamb et al. (2016); Lobstein et al. (2015)
Preventing cardiometabolic diseases: how soon should we start? - Dr André Marette
South African food based dietary guidelines:
Fostering healthy diets in childhood and beyond

      Children 3-5 years            > 5 years

Vorster, Badham and Venter (2013)
Preventing cardiometabolic diseases: how soon should we start? - Dr André Marette
Potential benefits of long-term
 dairy consumption
 ▪ Essential nutrient intakes (e.g., Ca and vitamin D) for adequate growth (e.g.,
   prevent stunting)

 ▪ Development and maintenance of a healthy dietary pattern

 ▪ Type 2 diabetes prevention

 ▪ Cardiovascular disease prevention

 ▪ Obesity prevention and weight maintenance

 ▪ Hypertension prevention

 ▪ Metabolic syndrome prevention

van Stuijvenberg et al. (2015); Mozaffarian (2016); Drouin-Chartier et al. (2016);
Yu and Hu (2018); Mozaffarian et al. (2012); Schwingshackl et al. (2017); Kim and Je (2016)
Preventing cardiometabolic diseases: how soon should we start? - Dr André Marette
What about dairy fat?
Preventing cardiometabolic diseases: how soon should we start? - Dr André Marette
Mozaffarian D, et al
N Engl J Med. 2011
364(25):2392-404.
Systematic review of the association between dairy
product consumption and risk of cardiovascular-
related clinical outcomes

Drouin-Chartier et al. Adv Nutr 2016;7:1026–40
Compilation of
                 scientific literature on
About our book   yogurt and its roles in
                  nutrition and health
Yoghurt in science: 100 years of publications
300

250                                                                                   Total = 3375
                                                                                      Probiotic yogurt = 661
                                                                                      Yoghurt consumption = 865
200                                                                                   Yoghurt and weight = 442
                                                                                      Yoghurt and health = 930
150                                                                                   Microbiota and yoghurt = 93

100

50

  0
                                                1999

                                                                                                               1972
      2017
             2014
                    2011
                           2008
                                  2005
                                         2002

                                                       1996
                                                              1993
                                                                     1990
                                                                            1987
                                                                                   1984
                                                                                          1981
                                                                                                 1978
                                                                                                        1975

                                                                                                                      1969
                                                                                                                             1965
                                                                                                                                    1962
                                                                                                                                           1956
                                                                                                                                                  1915
Level of evidence of the effects of yogurt on
            cardiometabolic diseases in adults
                                Type 2                   Cardiovascular   Metabolic
                   Adiposity              Hypertension
                               diabetes                     disease       syndrome

Cross-sectional
                      √           √            √               √             √
    studies

 Prospective
                      √           √            √               √             √
cohort studies

Meta-analyses
 (prospective       None         >3          None             ≥1             ≥1
   cohorts)

Clinical studies     Few        None         None            Few           None
    Level of
                     Poor      Strong†       Poor         Moderate          Poor
   evidence

                      +           +            ?               =             ?
 Conclusions
Fiction: Eating yogurt will make you skinny

            http://www.fitnessmagazine.com/recipes/healthy-eating/nutrition/health-benefits-of-yogurt/
Eating yogurt is likely to contribute to the
                       maintenance of a healthy weight

                                Protein → satiety
 Majority of                    Calcium → weight
                                management
 studies
 demonstrate                                           Need to establish
 a favorable                                           causal relationship:
                                                       randomized
 relationship                    Nutrient dense
                                                         clinical trials
                                 foods → replace
                                 energy dense
                                 nutrient poor
                                   snacks

(Marette et al. Adv Nut 2017)
Evidence is favourable

http://www.webmd.com/diabetes/news/20141125/yogurt-every-day-may-help-keep-diabetes-away#1
Yoghurt vs type 2 diabetes (adults)
1. Strong consistent evidence from multiple meta-analyses of an
   inverse association between yoghurt consumption and type 2
   diabetes risk

2. Daily yoghurt consumption in the context of a healthy diet may
   help prevent type 2 diabetes

3. BUT, no RCT; therefore, cannot determine causal link

4. Mechanisms not identified, is it related to:
    - specific nutrients (e.g. high protein, dairy fat, calcium…)
    - fermentation products and bacteria
    - something about the yogurt matrix, or
    - coincidental (healthy lifestyle and dietary patterns)
What about yoghurt and children’s health?
Yogurt contributes to intake of key nutrients
   at different age groups
                                                               • Excellent source of
% 50
  45
                                                                 iodine, vitamin B12,
  40                                                             phosphorus, calcium,
  35                                                             riboflavin and
  30                                                             thiamin for children
                                                   4-6 yo
  25                                                             and adolescents
  20                                               7-10 yo
  15                                               11-14 yo
                                                               • Source of folate,
  10                                                             magnesium,
                                                   15-18 yo
   5                                                             potassium and
   0                                                             selenium
                                                               • Concentrated source
                                                                 of nutrients for
                                                                 children
 Based on the dietary reference values for children from the
 British Nutrition Foundation and Public Health England        • Excellent vehicle for
 Composition of foods integrated dataset of 100 g of low-fat     vitamin D
 fruit yogurt. (Fernandez et al. 2017)                           fortification
Macronutrient profile of common yoghurts

                                                                                Percent contribution of
                                                                                100 g of commonly
                                                                                consumed yoghurts to
                                                                                the reference nutrient
                                                                                intakes for energy, fat,
                                                                                carbohydrates and
                                                                                protein in children.

                               Children aged 4-6 y

 Fernandez, Fisberg and Marette, 2016

Based on the dietary reference values for children from the British Nutrition
Foundation and Public Health England Composition of foods integrated dataset        Children aged 7-11 y
The associations between yoghurt consumption, diet
quality, and metabolic profiles in children in the USA
           Frequency of yogurt consumption in a cohort of American
                  children 2-18 y (NHANES 2003 and 2006)

                                                          Frequent yogurt consumers
                                 33%                      (at least once a week; median
                                                          = 2/week)
                                                          Infrequent yogurt consumers
                      67%
                                                          (less than once a week;
                                                          median = 1-6/year)

(Zhu et al. 2015)               Variable              N       Difference         P - value
  No differences in adiposity   Body weight           4,370   -0.3 kg            0.65
  indicators between
                                BMI                   4,342   0.1 kg/m2          0.64
  frequent and infrequent
  yoghurt consumers             Waist circumference   4,278   -0.2 cm            0.76
Associations between yoghurt, dairy, calcium, and
vitamin D intake and obesity among U.S. Children
aged 8–18 years: NHANES, 2005–2008
          Frequency of yogurt consumption in a cohort of American
                    children 8-18 y (NHANES 2005-2008)

                                 8%                        Frequent yogurt consumers
                                                           (at least once out of 2 24-h
                                                           dietary recalls)
                                                           Non yogurt consumers (not at
                                                           all mentioned in 24 hour
                           92%
                                                           dietary recalls)

 (Keast, 2015)                   Variable              N      Difference           P - value
 Significantly lower BMI         Body weight           3786   -1.7 kg              NS
 and waist circumference
 in yoghurt consumers            BMI                   3786   -0.7 kg/m2
The associations between yoghurt consumption,
diet quality, and metabolic profiles in children in
the USA
 Differences type 2 diabetes metabolic risk factors
 between frequent and infrequent consumers (children
 2-18 y)
   Variable                                    N        Difference       P - value
   Glucose (mmol/L)                            930      -0.02 mmol/L 0.64
   Insulin (pmol/L)                            913      -13.6 pmol/L
The associations between yogurt consumption,
diet quality, and metabolic profiles in children in
the USA

Differences in blood pressure between frequent and
infrequent yogurt consumers (children 2-18 y)

Variable             N                 Difference            P - value
Systolic             2,868             -0.5 mmHg             0.45
Diastolic            2,868             -1.6 mg/dL            0.11

 No differences in blood pressure profiles between frequent and infrequent
 yogurt consumers

 (Zhu et al. 2015)
What about added sugars?
                                                                        Plain unsweetened yoghurt
                                                                         ranks highly in most nutrient
                                                                         profiling systems and is
                                                                         considered nutrient dense
                                                                        Sweetened yoghurt is less
                                                                         nutrient dense
                                                                        Progress is being made to
                                                                         reduce the sugar content of
                                                                         sweetened dairy products
https://www.elsevier.com/about/press-releases/research-and-journals/techniques-for-reducing-sugar-content-in-dairy-
                                                                                           products-show-promise
http://albertonrecord.co.za/141015/healthy-friday-5-low-fat-foods-that-are-bad-for-you/
What do we know about sweetened yoghurt?
 Yoghurt can be a source of added sugars in certain populations
    Very young children (low diet diversity)
    Spanish population (high yoghurt consumption)

 Consumers of plain yoghurt may add more sugar than what is found in
  already sweetened yoghurt

 Epidemiological studies make no distinction between sweetened,
  artificially-sweetened and unsweetened yoghurt, but
Consistently show favorable associations, despite presence of sugar
(Williams et al. 2017; Ruiz et al. 2017; Cooper et al. 2017; Ste-Eve et al. 2016)
Support for healthfulness of different yogurts

                                       High-fat
                 Non-fat   Low-fat
                                     (eg. whole-
                  (0%)
                                        milk)
  Artificially
                 Mixed      Mixed        NA
 sweetened
Unsweetened        √          √         Mixed

 Sweetened       Mixed        √           X
Bioactive components in fermented dairy
                               Nutrient rich food profile → contributes to
                                intakes of essential nutrients for health
 Source of bioactive lipids and                                         Source of Ca, vitamin
 proteins → di- and tri-peptides,                                                     D and P
 CLA, whey, medium-chain fatty                                               → contribute to
 acids that contribute to                                                        bone health
 protection against
 cardiometabolic risk factors

 Lipids and lactose → energy
 source

                                                                                  High quality
Live cultures→ improve lactose
                                                                             protein→ growth
tolerance, increase concentrations
                                                                             and maintenance
of some nutrients (eg. CLA and
                                                                               of muscle mass
bioactive peptides)

                                Pairs well with other healthy foods → potential for
                                 increased intake of fruits, vegetables and grains
▪ Improved insulin sensitivity and blood glucose control              ▪ Increase satiety and reduce short-term
▪ PPAR agonist                                                          food intake
▪ Enhanced transport of fat soluble vitamins
                                                                          ▪ Reduced appetite sensations
▪ Adipocyte cell differentiation inhibition
▪ Anti-inflammatory                                                       ▪ Increased gastric transit time
▪ Plaque formation inhibition                                         ▪ Enhanced calcium transport
▪ Anti-obesogenic                                                     ▪ Insulintropic
      ▪ Decreased food intake and increased energy
         expenditure
                                                                      ▪ Decrease plasma cholesterol,
      ▪ Increased fat-cell oxidation                                           triglycerides and fatty acids
      ▪ Increased fat cell breakdown                                           ACE inhibitory bioactive
▪ Anti-atherosclerotic
                                                                                          peptides (blood
▪ Anti-hyperlipidemic
                                                             Yoghurt matrix               pressure control)
                                                                                     Improved lactose digestion
                                                                               ▪ Improved nutrient bioavailability
▪ Normalize glucose tolerance and
  insulin secretion                                                               and digestion
▪ Reduced vascular smooth muscle                                          ▪ Increased pH
  intracellular calcium (lower blood pressure)                            ▪ Increased concentration of CLA
▪ Improved energy regulation and lipid storage                               ▪ Release of bioactive peptides
    ▪ Decreased fatty acid synthesis                                  ▪ Increase in lactate : immunomodulation
    ▪ Increased lipolysis                                                   ▪ Maintenance of gut microbiota
▪ Fecal fatty acid excretion                                          ▪ Release of microbial-derived products
▪ Induction of thermogenesis
                                                                          ▪ B vitamins: folate, riboflavin, B12
▪ Calcium-specific appetite control
                                                                          ▪ Amino acids: eg g-aminobutyric acid
                                                                          ▪ Polysaccharides: immune and prebiotic
    Adapted from Fernandez et al. Adv Nutr 2017 (In press)
                                                                             activities
Take home messages
 Yoghurt is nutrient-rich and contributes to intake of key nutrients in
  both adults and children
 Yoghurt consumption is associated with healthy lifestyles and
  dietary patterns
 There is a favourable relationship between yoghurt consumption
  and type 2 diabetes (observational evidence)
 Yoghurt consumption may help with weight management
 Yoghurt intake may help reduce adiposity and improve the
  metabolic profile in children and adolescents
 Positive relationships between yoghurt consumption and
  hypertension, CVD and metabolic syndrome are accumulating
 Recent animal studies suggest that peptides released during
  fermentation can explain some of the benefits of fermented dairy
Students/PDFs/RA
     Noémie Daniel               Collaborators
                                                          Partners
    Lais Rossi Perazza           Université Laval
  Jose Luis M. Gonzalez             Denis Roy
    Michaël Bouchard               Yves Pouliot
                                 Sylvie Gauthier
      Thibault Varin             Patrick Mathieu

     Mélanie Le Barz       Agriculture/Agri-Food Canada
     Geneviève Pilon               Martin Lessard
   Marie-Julie Dubois               Mylène Blais
    Philippe St-Pierre
                             Université de Sherbrooke
      Christine Dion              Claude Asselin
    Christine Dallaire
     Valérie Dumais               TransBioTech
Joanie Dupont-Morissette          Yvan Boutin
Ke a leboga! Siyabonga ! Thank You !
       Enkosi !Dankie ! Merci!
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