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 Professor of Medicine Cardiolody Axis, Laval Hospital Scientific Director, Institute of Nutrition (INAF) Laval University
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
Obesity and type 2 Diabetes (T2D) take
epidemic proportion
“Obesogenic” food environment
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)
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)
South African food based dietary guidelines:
Fostering healthy diets in childhood and beyond
Children 3-5 years > 5 years
Vorster, Badham and Venter (2013)
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)
What about dairy fat?
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 healthYoghurt 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
1915Level 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
+ + ? = ?
ConclusionsFiction: 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) fortificationMacronutrient 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 yThe 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 0.76Associations 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/m2The 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 √ XBioactive 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)
activitiesTake 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
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