Nutrition and health: a public health perspective

Nutrition and health: a public health perspective

Prof Dr med Murielle Bochud, PhDDepartment Epidemiology and Systèmes de santé

Unisanté, Université de Lausanne, Lausanne

Brennpunkt Nahrung Conference November 9, 2021, Luzern

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Important megatrends

Globalization Climate change

Urbanization Big data

Why did life expectancy increase during the 20th century(Switzerland and other high income countries)?

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Frieden, Am J Public Health. 2010 Apr;100(4):590-5

1900 1950

50 years

70 years

80 years

2010

Life expectancy

Drinking water availabilityDecrease in infectious diseasesImproved socio-economic conditionsImproved nutritional status

20yr

10yr

Prevention and treatment of cardiovascular risk factors (tobacco, high blood pressure, cholesterol, etc)

https://www.ncbi.nlm.nih.gov/pubmed/20167880

Health determinants are complex and include foodproduction, transformation and transport

Dahlgren, G. and Whitehead, M. (1993) Tackling inequalities in health: what can we learn from what has been tried?

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Nutrition science: historical perspective

Reductionistapproach

Complexsystems-based

approach

Transdisciplinarymodels

197019801990

20002010

Mozaffarian, BMJ 2018; history of modern nutrition science

The determinants of food choices are complex

PMID: 11358343, Appetite 2001

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Lifecourse perspective for nutrition

Fœtal origin of chronic diseases

Importance of the first 1000 days

A growing body of evidence suggests that the paternal diet also influences disease onset in

offspring.

Long-term dietaryexposure is difficulty

to measure

The foodenvironment

constantly changes

Challenges

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Life-long consumption of foods and drugs

60’000-90’000 Kg 20 Kg

Dose-response relationship between fruit and vegetable consumption and all-cause mortality

(meta-analysis including > 550’000 participants)

Wang et al, BMJ 2014;349:g4490

6% and 5% mortality reductionfor each additional dailyportion of fruits and vegetables, respectively.This effects appears to bemainly attribuable to reducedcardiovascular mortality.

Diet and risk of type 2 diabetes(meta-analysis of observational studies)

Schwingshackl et al Eur J Epidemiol (2017) 32:363–375

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BMJ 2020;368:m315

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BMJ 2020;368:m315

• There is a dose-response relation between saltreduction and blood pressure lowering.

• Very short-term trials underestimate the effect of saltreduction on blood pressure.

• Population-wide salt reduction is recommended.

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Relationship between sodium intake and blood pressure

Filippini, Circulation. 2021;143:1542–1567

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J Am Heart Assoc. 2020;9:e015719.

• Dose-response meta-analysis of changes in bloodprssure (mm Hg), according to achieved K excretion levels, using as a reference point a K excretion of 90 mmol/d.

• Low achieved K excretion associated with higher blood pressure levels.

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Impact of dietary Na/K ratio on blood pressure and

cardiovascular disease

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Neal, NEJM 2021 Aug 29

4.7 yearsblood pressure

Na K

Salt substitute

stroke (14%)cardiovascular disease (13%)

all-cause mortality (12%)

600 villages in rural China

(20’995 persons)

K-richsalt

NaCl OR

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Dietary Approaches to Stop Hypertension (DASH diet)

https://www.diabetescarecommunity.ca/wp-content/uploads/2020/06/dash-diet.jpg

DASH emphasizes eating whole grains, fruits, vegetables, fish, poultry, beans, seeds and nuts. The diet is low in saturated fats, fatty red meats, full-fat dairy products, cholesterol and tropical oils. It is also low in sodium, sugars. and sweets.

DASH diet reduces blood pressure(Appel, NEJM 1997;336(16):1117–24; Saneei, Nutr Metab Cardiovasc Dis 2014;24(12): 1253–61; Lopes Hypertension 2003;41(3):422–30; Siervo, Br J Nutr 2015;113(1):1–15; Schwingshackl, Crit Rev Food Sci Nutr. 2019;59(16):2674-2687)

DASH is rich in potassium, calcium, magnesium, fibres and proteins.

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Public health perspective on salt consumption

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Barriers & enablers to out-of-home dietary salt reduction

Michael, Int J Environ Res Public Health. 2021 Jul 30;18(15):8099.PMID: 34360392

• Systematic review including 65 studies• perceived barriers:

• lack of menu and food variabilities• loss of sales due to salt reduction• lack of technical skills for implementing the salt reduction processes for cooking or reformulation• absence of environmental and systemic support for reducing the salt concentration

• enablers:• easy accessibility to salt substitutes• salt intake measurement• educational availability• gradual reduction in the salt levels.

policymakers need to encourage a multisectoralcollaboration for reducing the salt intake in the population.

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Higher production costs, low profit return, and reduced market demand for reduced-sodium salts were key barriers for industry in implementation.

2021

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Efficacy of different dietary patterns on lowering of blood pressure level: an umbrella review

• Review of 50 systematic reviews and meta-analyses of RCTs.• Conclusions:

• Adherence to the DASH, Nordic, and portfolio diets effectively reduced BP.

• Low-salt diets significantly decreased BP levels in normotensive Afro-Caribbean people and in hypertensive patients of all ethnic origins.

Sukhato. Am J Clin Nutr. 2020 Dec 10;112(6):1584-1598

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Nordic diet: high consumption of whole

grains, root vegetables, legumes, berries, fatty fish,

and low consumption of sweets and red meat

Paleolithic diet: lean meat, fish, fruit,

vegetables, nuts and seeds (hunting & gathering)

Portfolio diet: plant-based dietary pattern that

combines recognized cholesterol-lowering foods (e.g., nuts, plant

protein, viscous fiber, and plant sterols)

Sukhato. Am J Clin Nutr. 2020 Dec 10;112(6):1584-1598

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Megatrends in human nutrition

Sustainability Ultrastransformation

Personalized nutrition Food as a medicine

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Dietary patterns and green-house gas emissions (GHG)

Lifecycle GHG emissions (CO2-Ceq) for 22 different food types. The data are based on an analysis of 555 food production systems: a, per kilocalorie; the mean and s.e.m. are shown for each case. GHG, green house gas.

Tilman, Global diets link environmental sustainability and human health. Nature 2014; 515; 518–522

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NOVA classification: degree of food processing

Rico-Campà, BMJ 2019;365:l1949

Ultra-processed

foods

Processedfoods

Processed culinaryingredients

Unprocessed or miniallyprocessed foods

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Ultra-processed foods and all cause mortality: SUN prospective cohort study

Rico-Campà, BMJ 2019;365:l1949

Higher consumption of ultra-processed foods (> 4 servingsdaily) associated with 62% increased all-cause mortality.Each additional serving of ultra-processed food daily increasedmortality by 18%.

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Ultraprocessed food and CVD: NutriNet cohort (France)

Srour, BMJ 2019;365:l1451

Spline plot for linearity assumption of association between proportion ofultra-processed food in diet and risks of overall cardiovascular, coronary heart, andcerebrovascular diseases

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Ultraprocessed food and CVD: NutriNet cohort (France)

Srour, BMJ 2019;365:l1451

Spline plot for linearity assumption of association between proportion ofultra-processed food in diet and risks of overall cardiovascular, coronary heart, andcerebrovascular diseases

In this large prospective cohort (n=105 159), an absolute increment of 10in the percentage of ultra-processed foods in the diet was associated witha >10% increase in the rates of overall cardiovascular, coronary heart, andcerebrovascular diseases.

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Exposure Exposome

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Obesity genetic risk prediction at birth

Khera et al, Cell 2019 Apr 18;177(3):587-596.e9.

• A genetic score can quantify inherited susceptibility to obesity.

• The genetic score effect on weight emerges early in life and increases into adulthood.

• High score is a strong risk factor for severe obesity and associated diseases.

• The score is associated with only minimal differences in birthweight, but clear differences in weight during early childhood and profound differences in weight trajectory and risk of developing severe obesity in subsequent years.

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Personalized nutrition by prediction of glycemic responses

Zeevi, Cell 2015

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Computational diet: when data science meets nutrition sciences

Eetemadi, Front Microbiol 2020; 11(393).

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Trends: food as a medicine

NIH 2020-2030 precision nutrition strategy

Rodgers & Collins, JAMA 2020, viewpoint on precision nutrition

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Conclusions

• Lifelong exposure to diet has a major impact on human health. Early life exposure has an impact on chronic disease risk during adulthood.

• Food production, distribution and consumption has a major environmental impact. Healthy food is usually more sustainable.

• Big data science will improve our understanding of the underlyingmecanisms linking food intake to human health.

• Personalized nutrition and food as a medicine are likely to grow in importance in coming decades.

Documents

Nutrition and health: a public health perspective