Hospital Admissions for Myocardial Infarction and Stroke Before and After the Trans-Fatty Acid Restrictions in New York

Proportions of trans fatty acids in erythrocytes of Canadian adults before the prohibition of partially hydrogenated oils in foods: results from the Canadian Health Measures Survey 2012-2015

BACKGROUND

The partially hydrogenated oil (PHO) prohibition came into effect in Canada in September 2018 to reduce the intakes of total trans fatty acids (t-TFAs) and industrially produced TFAs (i-TFAs).

OBJECTIVES

We aimed to estimate the red blood cell (RBC) proportions of t-TFA (primary objective) and total 18:1 TFA (secondary objective) of adults in Canada before the PHO prohibition and to identify the population subgroups at risk of higher TFA intakes.

METHODS

We pooled data from 4025 adult participants of the cross-sectional Canadian Health Measures Survey cycles 3 and 4 (2012-2015). We estimated mean proportions, relative to total fatty acids (FAs), of RBC t-TFA and 18:1 TFA and their associations with sociodemographic, health, and lifestyle characteristics using multiple linear regression models.

RESULTS

The nonadjusted mean RBC proportions of t-TFA and total 18:1 TFA were 0.59% (95% CI: 0.54, 0.63) and 0.27% (95% CI: 0.25, 0.29), respectively. In the adjusted models, the same participant characteristics were associated with t-TFA and 18:1 TFA but differences were generally smaller for 18:1 TFA than for t-TFA. Race, BMI, and alcohol intake were independently associated with RBC t-TFA and 18:1 TFA. Asian and Black participants had lower RBC t-TFA (-0.05% and -0.10% of total FA, respectively) than White participants. Obesity and high risk alcohol drinking were associated with slightly lower (≤0.06%) t-TFA proportions than lower adiposity and alcohol intake concentrations, respectively.

CONCLUSIONS

Pre-PHO prohibition in food in Canada, t-TFA proportions were relatively low compared with a proposed threshold of 1% of total RBC FAs, over which cardiovascular disease risk may be higher. Previous voluntary initiatives to reduce i-TFA in the food supply may explain these relatively low RBC t-TFA concentrations. Some population subgroups had higher baseline RBC TFA than other subgroups, but the physiological implications of these small differences, at relatively low baseline RBC TFA proportions, remain to be determined.

Hospitalisations for cardiovascular and respiratory disease among older adults living near unconventional natural gas development: a difference-in-differences analysis

BACKGROUND

During 2008-15, the Marcellus shale region of the US state of Pennsylvania experienced a boom in unconventional natural gas development (UNGD) or "fracking". However, despite much public debate, little is known about the effects of UNGD on population health in local communities. Among other mechanisms, air pollution from UNGD might affect individuals living nearby through cardiovascular or respiratory disease, and older adults could be particularly susceptible.

METHODS

To study the health impacts of Pennsylvania's fracking boom, we exploited the ban on UNGD in neighbouring New York state. Using 2002-15 Medicare claims, we conducted difference-in-differences analyses over multiple timepoints to estimate the risk of living near UNGD for hospitalisation with acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD) and bronchiectasis, heart failure, ischaemic heart disease, and stroke among older adults (aged ≥65 years).

FINDINGS

Pennsylvania ZIP codes that started UNGD in 2008-10 were associated with more hospitalisations for cardiovascular diseases in 2012-15 than would be expected in the absence of UNGD. Specifically, in 2015, we estimated an additional 11·8, 21·6, and 20·4 hospitalisations for AMI, heart failure, and ischaemic heart disease, respectively, per 1000 Medicare beneficiaries. Hospitalisations increased even as UNGD growth slowed. Results were robust in sensitivity analyses.

INTERPRETATION

Older adults living near UNGD could be at high risk of poor cardiovascular outcomes. Mitigation policies for existing UNGD might be needed to address current and future health risks. Future consideration of UNGD should prioritise local population health.

FUNDING

University of Chicago and Argonne National Laboratories.

Lipids at the Nexus between Cerebrovascular Disease and Vascular Dementia: The Impact of HDL-Cholesterol and Ceramides

Cerebrovascular diseases and the subsequent brain hypoperfusion are at the basis of vascular dementia. Dyslipidemia, marked by an increase in circulating levels of triglycerides and LDL-cholesterol and a parallel decrease in HDL-cholesterol, in turn, is pivotal in promoting atherosclerosis which represents a common feature of cardiovascular and cerebrovascular diseases. In this regard, HDL-cholesterol has traditionally been considered as being protective from a cardiovascular and a cerebrovascular prospective. However, emerging evidence suggests that their quality and functionality play a more prominent role than their circulating levels in shaping cardiovascular health and possibly cognitive function. Furthermore, the quality of lipids embedded in circulating lipoproteins represents another key discriminant in modulating cardiovascular disease, with ceramides being proposed as a novel risk factor for atherosclerosis. This review highlights the role of HDL lipoprotein and ceramides in cerebrovascular diseases and the repercussion on vascular dementia. Additionally, the manuscript provides an up-to-date picture of the impact of saturated and omega-3 fatty acids on HDL circulating levels, functionality and ceramide metabolism.

Different Types of Industry-Produced and Ruminant Trans Fatty Acid Intake and Risk of Type 2 Diabetes: Findings From the NutriNet-Santé Prospective Cohort

OBJECTIVE

The deleterious effects of trans fatty acids (TFAs) on cardiovascular health are well established; however, their impact on type 2 diabetes remains poorly understood. In particular, little is known about the impact of specific TFA types on type 2 diabetes etiology. We aimed to explore the associations between different types of TFAs (total, ruminant, industry produced [iTFAs], and corresponding specific isomers) and risk of type 2 diabetes.

RESEARCH DESIGN AND METHODS

A total of 105,551 participants age >18 years from the French NutriNet-Santé cohort (2009-2021) were included (mean baseline age 42.7 years; SD 14.6 years); 79.2% were women. Dietary intake data, including usual TFA intake, were collected using repeated 24-h dietary records (n = 5.7; SD 3.1). Associations between sex-specific quartile of dietary TFAs and diabetes risk were assessed using multivariable Cox models.

RESULTS

Total TFA intake was associated with higher type 2 diabetes risk (hazard ratio [HR]quartile 4 vs. 1 1.38; 95% CI 1.11-1.73; Ptrend < 0.001; n = 969 incident cases). This association, specifically observed for iTFAs (HR 1.45; 95% CI 1.15-1.83; Ptrend < 0.001), was mainly driven by elaidic acid (HR 1.37; 95% CI 1.09-1.72; Ptrend < 0.001) and linolelaidic acid (HR 1.29; 95% CI 1.04-1.58; Ptrend = 0.07). In contrast, ruminant TFAs were not significantly associated with risk of type 2 diabetes.

CONCLUSIONS

In this large prospective cohort, higher intakes of total and iTFAs were associated with increased type 2 diabetes risk. These findings support the World Health Organization's recommendation to eliminate iTFAs from the food supply worldwide. Consumers should be advised to limit the consumption of food products containing partially hydrogenated oils (main vector of iTFAs). This may contribute to lowering the substantial global burden of type 2 diabetes.

Association between trans fatty acids and COVID-19: A multivariate Mendelian randomization study

Traditional observational studies have suggested a potential association between trans fatty acids (TFAs), which are considered to be health-damaging fatty acids, and coronavirus disease 2019 (COVID-19). However, whether there is a causal relationship between them is currently unclear. We aimed to investigate the causal link between genetically determined TFAs and COVID-19. We performed univariate and multivariate Mendelian randomization (MR) studies using summary statistics from the European Pedigree TFAs (n = 8013), COVID-19 susceptibility (n = 159 840), COVID-19 hospitalization (n = 44 986), and COVID-19 severity (n = 18 152) genome-wide association studies (GWAS). The inverse variance weighted (IVW) method was used as the primary MR analysis, and several other methods were used as supplements. In univariate MR analysis, higher levels of circulating trans, cis-18:2 TFAs were positively associated with a higher COVID-19 hospitalization rate (p < 0.0033; odds ratio [OR] = 1.637; 95% confidence interval [CI]: 1.116-2.401) and COVID-19 severity (p < 0.0033; OR = 2.575; 95% CI: 1.412-4.698). Furthermore, in multivariate MR analysis, trans, cis-18:2 had an independent and significant causal association with a higher COVID-19 hospitalization rate (p = 0.00044; OR = 1.862; 95% CI = 1.316-2.636) and COVID-19 severity (p = 0.0016; OR = 2.268; 95% CI = 1.361-3.779) after the five TFAs were adjusted for each other. Together, our findings provide evidence that trans, cis-18:2 TFAs have an independent and robust causal effect on COVID-19 hospitalization and severity.

Trans-fat labelling information on prepackaged foods and beverages sold in Hong Kong in 2019

OBJECTIVE

To examine the labelling status of trans-fat of pre-packaged foods sold in Hong Kong.

DESIGN

Data from 19 027 items in the 2019 FoodSwitch Hong Kong database were used. Ingredient lists were screened to identify specific (e.g. partially hydrogenated vegetable oil, PHVO) and non-specific trans-fat ingredient indicators (e.g. hydrogenated oil). Trans-fat content was obtained from the on-pack nutrition labels, which was converted into proportion of total fat (%total fat). Descriptive statistics were calculated for trans-fat content and the number of specific, non-specific and total trans-fat ingredients indicators found on the ingredients lists. Comparisons were made between regions using one-way ANOVA and χ2 for continuous and categorical variables, respectively.

SETTING

Cross-sectional audit.

PARTICIPANTS

Not applicable.

RESULTS

A total of 729 items (3·8 % of all products) reported to contain industrially produced trans-fat, with a median of 0·4 g/100 g or 100 ml (interquartile range (IQR): 0·1-0·6) and 1·2 %totalfat (IQR: 0·6-2·9). 'Bread and bakery products' had the highest proportion of items with industrially produced trans-fat (18·9 %). 'Non-alcoholic beverages' had the highest proportion of products of 'false negatives' labelling (e.g. labelled as 0 trans-fat but contains PHVO; 59·3 %). The majority of products with trans-fat indicator originated from Asia (70 %).

CONCLUSIONS

According to the labelling ∼4 % of pre-packaged food and beverages sold in Hong Kong in 2019 contained industrially produced trans-fat, and a third of these had trans-fat >2 %total fat. The ambiguous trans-fat labelling in Hong Kong may not effectively assist consumers in identifying products free from industrially produced trans-fat.

Roles of Cities in Creating Healthful Food Systems

Over the past several decades, cities worldwide have attempted to reconfigure their food systems to improve public health, advance social justice, and promote environmental resilience using diverse municipal policies, often with the support of stakeholder-led governance mechanisms such as food policy councils. This article reviews the roles that cities have played in creating healthful urban food systems and the effects of those policies on public health. It explains that despite wide-ranging policy initiatives, disparities in food insecurity and malnourishment persist. It concludes by describing several promising pathways for urban food policy: engaging in food-focused urban planning to create equitable food environments; treating policies to address inequality and social justice as upstream food policies; considering the effects of new business models such as online food retail in urban food policy making; and using food procurement as a lever to influence regional, national, and global food systems. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

trans-Fatty Acids as an Enhancer of Inflammation and Cell Death: Molecular Basis for Their Pathological Actions

trans-Fatty acids (TFAs) are food-derived fatty acids that possess one or more trans double bonds between carbon atoms. Compelling epidemiological and clinical evidence has demonstrated the association of TFA consumption with various diseases, such as cardiovascular diseases, and neurodegenerative diseases. However, the underlying etiology is poorly understood since the mechanisms of action of TFAs remain to be clarified. Previous studies have shown that single treatment with TFAs induce inflammation and cell death, but to a much lesser extent than saturated fatty acids (SFAs) that are well established as a risk factor for diseases linked with inflammation and cell death, which cannot explain the particularly higher association of TFAs with atherosclerosis than SFAs. In our series of studies, we have established the role of TFAs as an enhancer of inflammation and cell death. We found that pretreatment with TFAs strongly promoted apoptosis induced by either extracellular ATP, one of the damage-associated molecular patterns (DAMPs) leaked from damaged cells, or DNA damaging-agents, including doxorubicin and cisplatin, thorough enhancing activation of the stress-responsive mitogen-activated protein (MAP) kinase p38/c-jun N-terminal kinase (JNK) pathways; pretreatment with SFAs or cis isomers of TFAs had only minor or no effect, suggesting the uniqueness of the pro-apoptotic role of TFAs among fatty acids. Our findings will provide an insight into understanding of the pathogenesis mechanisms, and open up a new avenue for developing prevention strategies and therapies for TFA-related diseases.

A prospective population-based multicentre study on the impact of maternal body mass index on adverse pregnancy outcomes: Focus on normal weight

Background

Maternal body mass index (BMI) below or above the reference interval (18.5–24.9 kg/m²) is associated with adverse pregnancy outcomes. Whether BMI exerts an effect within the reference interval is unclear. Therefore, we assessed the association between adverse pregnancy outcomes and BMI, in particular within the reference interval, in a general unselected pregnant population.

Methods

Data was extracted from a prospective population-based multicentre cohort (Risk Estimation for PrEgnancy Complications to provide Tailored care (RESPECT) study) conducted between December 2012 to January 2014. BMI was studied in categories (I: <18.5, II: 18.5–19.9, III: 20.0–22.9, IV: 23.0–24.9, V: 25.0–27.4, VI: 27.5–29.9, VII: >30.0 kg/m²) and as a continuous variable within the reference interval. Adverse pregnancy outcomes were defined as composite endpoints for maternal, neonatal or any pregnancy complication, and for adverse pregnancy outcomes individually. Linear trends were assessed using linear-by-linear association analysis and (adjusted) relative risks by regression analysis.

Results

The median BMI of the 3671 included women was 23.2 kg/m² (IQR 21.1–26.2). Adverse pregnancy outcomes were reported in 1256 (34.2%). Linear associations were observed between BMI categories and all three composite endpoints, and individually for pregnancy-induced hypertension (PIH), preeclampsia, gestational diabetes mellitus (GDM), large-for-gestational-age (LGA) neonates; but not for small-for-gestational-age neonates and preterm birth. Within the reference interval, BMI was associated with the composite maternal endpoint, PIH, GDM and LGA, with adjusted relative risks of 1.15 (95%CI 1.06–1.26), 1.12 (95%CI 1.00–1.26), 1.31 (95%CI 1.11–1.55) and 1.09 (95%CI 1.01–1.17).

Conclusions

Graded increase in maternal BMI appears to be an indicator of risk for adverse pregnancy outcomes even among women with a BMI within the reference interval. The extent to which BMI directly contributes to the increased risk in this group should be evaluated in order to determine strategies most valuable for promoting safety and long-term health for mothers and their offspring.

The Demise of Artificial Trans Fat: A History of a Public Health Achievement

Policy Points This article describes a strategic combination of research, advocacy, corporate campaigns, communications, grassroots mobilization, legislation, regulatory actions, and litigation against companies and government to secure a national policy to remove artificial trans fat from the US food system. Sharing lessons we learned can help inform policymakers, academics, policy practitioners, and students across disciplines. Some of our lessons are that system change means that all consumers benefit without the need for individual behavior change; research can both identify opportunities to improve health and support policy adoption; policy efforts can serve as public education campaigns; policy campaigns can drive marketplace changes; and engaging forward-thinking companies can diffuse opposition to passing a policy.

CONTEXT

For many decades, partially hydrogenated vegetable oil (PHO), the primary source of artificial trans fat in the American diet, was used widely in processed and restaurant foods. In the early 1990s, studies linked the consumption of artificial trans fat with heart disease. This article details how research and advocacy led to eliminating artificial trans fat from the US food supply.

METHODS

We synthesized published studies of the health impact of trans fat, the legislative history of state and local trans fat bills, the Food and Drug Administration's (FDA) regulatory docket on trans fat labeling and its declaration that PHOs are no longer Generally Recognized as Safe (GRAS), and our own files, which included strategy documents, notes from meetings with the FDA staff, correspondence between advocates and the FDA, fact sheets, press releases, news clips, and other materials.

FINDINGS

This history of trans fat provides insights into policy strategy and advocacy best practices that resulted in the removal of trans fat from food in the United States, preventing an estimated 50,000 premature deaths a year. The lessons we learned are that system change benefits all consumers without the need for individual behavior change; research can both identify opportunities to improve health through policy and support policy adoption; policy campaigns can serve as public education campaigns; policy can drive changes to products and the marketplace; and engaging forward-thinking companies can help diffuse opposition to passing a policy. Securing this policy required the persistence of scientists and health advocates in first discovering the risks and then using the science to secure policies to mitigate the identified harm.

CONCLUSIONS

An understanding of the tactics used to help attain the targeted policies and how challenges were addressed (such as through communications, leveraging an expanding research base and expert reports, showing that a national policy was feasible through voluntary corporate changes and state and local policy, and litigation against companies and government agencies) may provide a model for scientists, students, advocates, and policymakers. We hope this account will inform efforts to address other public health challenges, such as the current threats of excessive exposure to sodium and added sugars, which persist in the US food system.

Association of Nut Consumption with Risk of Stroke and Cardiovascular Disease: The Million Veteran Program

Cardiovascular disease (CVD), including stroke and coronary artery disease (CAD), is the major cause of mortality for Americans. Nuts have been shown to improve a variety of cardiovascular disease risk factors. This study aimed to test the hypothesis that nut consumption is inversely associated with risk of incidence of stroke, CAD, and CVD mortality in the prospective Million Veterans Program (MVP). A total of 179,827 MVP participants enrolled between 2011 and 2018 were free of CVD prior to assessment of nut consumption via the food frequency questionnaire. Incident stroke and CVD events were ascertained from the Veterans Affairs electronic medical health records and the National Death Index. We used the Cox regression model to compute multivariable adjusted hazard ratios. Over the 3.5-year median follow-up, 3362 new cases of ischemic stroke were identified. When compared with participants who rarely or never consumed nuts, those consuming nuts ≥ 5 times per week were 19% less likely to experience a stroke (95% CI: 8% to 28%); 22% less likely to suffer from CAD (95% CI: 16% to 28%); and 24% less likely to die from CVD (95% CI: 7% to 37%). Consumption of peanut butter was not associated with risk of stroke. Increased dietary intake of nuts, but not peanut butter, was associated with a lower risk of stroke, CAD, and CVD death.

Chinese Guideline on the Primary Prevention of Cardiovascular Diseases

Abstract

Cardiovascular disease is the leading cause of mortality in China. Primary prevention of cardiovascular disease with a focus on lifestyle intervention and risk factor control has been shown to effectively delay or prevent the occurrence of cardiovascular events. To promote a healthy lifestyle and enhance the detection, diagnosis, and treatment of cardiovascular risk factors such as hypertension, dyslipidemia, and diabetes, and to improve the overall capacity of primary prevention of cardiovascular disease, the Chinese Society of Cardiology of Chinese Medical Association has collaborated with multiple societies to summarize and evaluate the latest evidence with reference to relevant guidelines and subsequently to develop recommendations for primary cardiovascular disease prevention in Chinese adults. The guideline consists of 10 sections: introduction, methodology for developing the guideline, epidemiology of cardiovascular disease in China and challenges in primary prevention, general recommendations for primary prevention, assessment of cardiovascular risk, lifestyle intervention, blood pressure control, lipid management, management of type 2 diabetes, and use of aspirin. The promulgation and implementation of this guideline will play a key role in promoting the practice of primary prevention for cardiovascular disease in China.

Dietary Sources of Plasma trans Fatty Acids among Adults in the United States: NHANES 2009-2010

BACKGROUND

Intake of trans fatty acids (TFAs) increases LDL cholesterol, decreases HDL cholesterol, and increases the risk of heart disease morbidity and mortality. Many food products potentially contain industrially produced or ruminant TFAs. However, little is known about the dietary sources of plasma TFA concentrations.

OBJECTIVE

The objective of this study was to examine associations between foods consumed and plasma TFA concentrations using 24-h dietary recall data and plasma TFA measures among adults aged ≥20 y who participated in the NHANES 2009-2010 in the United States.

METHODS

Over 4400 food products in the dietary interview data were categorized into 32 food and beverage groups/subgroups. Four major plasma TFAs (palmitelaidic acid, elaidic acid, vaccenic acid, linolelaidic acid) and the sum of the 4 TFAs (sumTFAs) were analyzed using GC-MS. Multivariable linear regression analyses were conducted to identify associations of plasma TFAs with all 32 food and beverage groups/subgroups, controlling for the potential confounding effects of 11 demographic, socioeconomic, behavioral, lifestyle, and health-related variables.

RESULTS

Consumption of the following food groups/subgroups was significantly associated with elevated plasma TFA concentrations: cream substitutes (P < 0.001 for palmitelaidic acid, elaidic acid, vaccenic acid, and sumTFAs); cakes, cookies, pastries, and pies (P < 0.001 for elaidic acid, vaccenic acid, and sumTFAs; P < 0.05 for linolelaidic acid); milk and milk desserts (P < 0.01 for palmitelaidic acid and vaccenic acid; P < 0.05 for linolelaidic acid and sumTFAs); beef/veal, lamb/goat, and venison/deer (P < 0.01 for vaccenic acid; P < 0.05 for sumTFAs); and butters (P < 0.001 for palmitelaidic acid and vaccenic acid; P < 0.05 for sumTFAs).

CONCLUSIONS

The findings suggest that the above 5 food groups/subgroups could be the main dietary sources of plasma TFAs among adults in the United States in 2009-2010.

[Molecular Mechanisms Underlying Toxic Actions of trans-Fatty Acids and Prevention of Related Diseases]

trans-Fatty acids (TFAs), including elaidic acid and linoelaidic acid, are unsaturated fatty acids that contain one or more carbon-carbon double bonds in trans configuration. TFAs are not synthesized in the human body, but are taken into the body from various foods, which are mainly produced during industrial food manufacturing. Recent epidemiological studies have revealed that TFA consumption is a major risk factor for various disorders, such as atherosclerosis, cardiovascular diseases, allergic diseases, and dementia. However, the underlying pathogenic mechanisms of TFA-related disorders and the specific molecular targets evoking TFA toxicity are largely unknown. To elucidate the molecular mechanisms by which TFAs cause the cytotoxicity, we focused on cell death and inflammation, which are the main and common pathogenesis of the TFA-related diseases, and analyzed the effects of TFAs on cellular responses to various stimulations inducing cell death and inflammation. This review provides recent progress in our studies on the molecular mechanisms causing toxic actions of TFAs, which lead to diverse TFA-related disorders.

Trans Fat Free by 2023-A Building Block of the COVID-19 Response

COVID-19 has brought to center stage the most important health issue of our era, largely ignored by policymakers and the public to date: non-communicable diseases (NCDs), the cause of 71% of deaths per year worldwide. People living with NCDs, and particularly those living with cardiovascular disease (CVD), are at higher risk of severe symptoms and death from COVID-19. As a result, the urgent need for policy measures to protect cardiovascular health is more apparent than ever. One example of "low-hanging fruit" in the prevention of CVD is the elimination of industrially-produced trans fatty acids (iTFA). Their removal from the global food supply could prevent up to 17 million deaths by 2040 and would be the first time an NCD risk factor has been eliminated.

Associations of Serum Nonesterified Fatty Acids With Coronary Heart Disease Mortality and Nonfatal Myocardial Infarction: The CHS (Cardiovascular Health Study) Cohort

Background

Significant associations have been reported between serum total nonesterified fatty acid (NEFA) concentrations and coronary heart disease (CHD) mortality and incident nonfatal myocardial infarction (MI) in some prospective cohort studies. Little is known about whether individual or subclasses (saturated, polyunsaturated [n‐6 and n‐3], and trans fatty acids) of serum NEFAs relate to CHD mortality and nonfatal MI.

Methods and Results

CHS (Cardiovascular Health Study) participants (N=1681) who had no history of MI, angina, or revascularization or were free of MI at baseline (1996–1997) were included. NEFAs were quantified using gas chromatography. Cox regression analysis was used to evaluate associations of 5 subclasses and individual NEFAs with CHD composite (CHD mortality and nonfatal MI), CHD mortality, and incident nonfatal MI. During a median follow‐up of 11.7 years, 266 cases of CHD death and 271 cases of nonfatal MI occurred. In the fully adjusted model, no significant associations were identified between individual NEFA and CHD composite. Exploratory analyses indicated that lauric acid (12:0) was negatively associated (hazard ratio [HR], 0.76; 95% CI, 0.59–0.98; P=0.0328) and dihomo‐γ‐linolenic acid (20:3n‐6) was positively associated with CHD mortality (HR, 1.34; 95% CI, 1.02–1.76; P=0.0351). Elaidic acid (18:1n‐7t) was positively associated with incident nonfatal MI (HR, 1.46; 95% CI, 1.01–2.12; P=0.0445). No significant associations were observed for NEFA subclass and any outcomes.

Conclusions

In CHS participants, 2 NEFAs, dihomo‐γ‐linolenic and elaidic acids, were positively associated with CHD mortality and nonfatal MI, respectively, suggesting potential susceptibility biomarkers for risks of CHD mortality and nonfatal MI.

Healthy Eating Policy Strategies in Community Health Improvement Plans: A Cross-Sectional Survey of US Local Health Departments

CONTEXT

Policies (eg, regulations, taxes, and zoning ordinances) can increase opportunities for healthy eating. Community Health Improvement Plans (CHIP) may foster collaboration and local health department (LHD) engagement in policy decision making to improve local food environments. Limited research describes what policies supportive of healthy food environments are included in CHIPs nationally and relationships between LHD characteristics and participation in plans including such policies.

OBJECTIVES

To determine the proportion of US LHDs who participated in development of a CHIP containing healthy eating policy strategies and assess the association between LHD characteristics and inclusion of any healthy eating policy strategy in a CHIP.

DESIGN

A cross-sectional national probability survey.

PARTICIPANTS

Of the 209 US LHDs (serving populations <500 000) (response rate: 30.2%), 176 LHDs with complete data on CHIP status, outcomes, and covariates were eligible for analysis.

MAIN OUTCOME MEASURES

Thirteen healthy eating policy strategies were organized into 3 categories: increasing availability/identification of healthy foods, reducing access to unhealthy foods, and improving school food environments. Strategies and categories were identified from literature and public health recommendations.

RESULTS

In total, 32.2% of LHDs reported inclusion of 1 or more healthy eating policy strategies in a CHIP. The proportion of departments reporting specific strategies ranged from 20.8% for school district policies to 1.1% for sugar-sweetened beverage taxes. Local health departments serving 25 000 to 49 999 residents (odds ratio [OR]: 5.00; 95% confidence interval [CI]: 1.71-14.63), 100 000 to 499 999 residents (OR: 3.66; 95% CI: 1.12-11.95), pursuing national accreditation (OR: 4.46; 95% CI: 1.83-10.83), or accredited (OR: 3.22; 95% CI: 1.08-9.63) were more likely to include 1 or more healthy eating policy strategies in a CHIP than smaller LHDs (<25 000) and LHDs not seeking accreditation, respectively, after adjusting for covariates.

CONCLUSIONS

Few LHDs serving less than 500 000 residents reported CHIPs that included a policy-based approach to improve food environments, indicating room for improvement. Population size served and accreditation may affect LHD policy engagement to enhance local food environments.

Current Activities Centered on Healthy Living and Recommendations for the Future: A Position Statement from the HL-PIVOT Network

We continue to increase our cognizance and recognition of the importance of healthy living (HL) behaviors and HL medicine (HLM) to prevent and treat chronic disease. The continually unfolding events precipitated by the coronavirus disease 2019 (COVID-19) pandemic have further highlighted the importance of HL behaviors, as indicated by the characteristics of those who have been hospitalized and died from this viral infection. There has already been recognition that leading a healthy lifestyle, prior to the COVID-19 pandemic, may have a substantial protective effect in those who become infected with the virus. Now more than ever, HL behaviors and HLM are essential and must be promoted with a renewed vigor across the globe. In response to the rapidly evolving world since the beginning of the COVID-19 pandemic, and the clear need to change lifestyle behaviors to promote human resilience and quality of life, the HL for Pandemic Event Protection (HL-PIVOT) network was established. The 4 major areas of focus for the network are: (1) knowledge discovery and dissemination; (2) education; (3) policy; (4) implementation. This HL-PIVOT network position statement provides a current synopsis of the major focus areas of the network, including leading research in the field of HL behaviors and HLM, examples of best practices in education, policy, and implementation, and recommendations for the future.

What is the impact of food reformulation on individuals' behaviour, nutrient intakes and health status? A systematic review of empirical evidence

Food reformulation aimed at improving the nutritional properties of food products has long been viewed as a promising public health strategy to tackle poor nutrition and obesity. This paper presents a review of the empirical evidence (i.e., modelling studies were excluded) on the impact of food reformulation on food choices, nutrient intakes and health status, based on a systematic search of Medline, Embase, Global Health and sources of grey literature. Fifty-nine studies (in 35 papers) were included in the review. Most studies examined food choices (n = 27) and dietary intakes (n = 26). The nutrients most frequently studied were sodium (n = 32) and trans fatty acids (TFA, n = 13). Reformulated products were generally accepted and purchased by consumers, which led to improved nutrient intakes in 73% of studies. We also conducted two meta-analyses showing, respectively, a -0.57 g/day (95%CI, -0.89 to -0.25) reduction in salt intake and an effect size for TFA intake reduction of -1.2 (95% CI, -1.79 to -0.61). Only six studies examined effects on health outcomes, with studies on TFA reformulation showing overall improvement in cardiovascular risk factors. For other nutrients, it remains unclear whether observed improvements in food choices or nutrient intakes may have led to an improvement in health outcomes.

Assessment of trans-fatty acid content in a sample of foods from the Slovenian food supply using a sales-weighting approach

OBJECTIVE

Consumption of trans-fatty acids (TFA) is a well-established risk factor for CVD morbidity and mortality. Our objective was to investigate TFA levels in Slovenian food supply.

DESIGN

Cross-sectional study.

SETTING

Selected foods (n 282) were purchased in Slovenia (2016), and the TFA content was determined. The sample included pre-packed foods with/without declared partially hydrogenated vegetable oils (PHO), as well as non-pre-packed foods. A sales-weighting approach was used to ponder different market shares of the products.

RESULTS

While the majority of the investigated samples had low levels of TFA, up to 6·8 g of TFA per 100 g of food was observed in certain foods. Within pre-packed foods (n 207), the highest proportion of samples with high TFA levels was found among cookies with labelled PHO: 69 % (n 18) would exceed European Union regulatory TFA limit (2 g industrial TFA per 100 g of fats), which will be implemented in April 2021. Among the investigated non-pre-packed foods (n 75), only croissants contained notable TFA levels (mean 0·90 (sd 0·97); maximum 3·3 g/100 g), with about half of the samples exceeding 2 g TFA per 100 g of fats.

CONCLUSIONS

In 2016, some foods in Slovenian food supply still contained notable amounts of TFA. Foods with listed PHO as an ingredient were usually higher in TFA as compared with foods not labelled to contain PHO. Biscuits were identified as the most concerning category of pre-packed foods, while croissants contained highest levels of TFA within non-pre-packed foods.

Serum nonesterified fatty acids have utility as dietary biomarkers of fat intake from fish, fish oil, and dairy in women

Nutritional studies rely on various biological specimens for FA determination, yet it is unclear how levels of serum NEFAs correlate with other circulating lipid pools. Here, we used a high-throughput method (<4 min/sample) based on multisegment injection-nonaqueous capillary electrophoresis-mass spectrometry (MSI-NACE-MS) to investigate whether specific serum NEFAs have utility as biomarkers of dietary fat intake in women. We first identified circulating NEFAs correlated with long-term/habitual food intake among pregnant women with contrasting dietary patterns (n = 50). Acute changes in serum NEFA trajectories were also studied in nonpregnant women (n = 18) following high-dose (5 g/day) fish oil (FO) supplementation or isoenergetic sunflower oil placebo over 56 days. In the cross-sectional study, serum ω-3 FAs correlated with self-reported total ω-3 daily intake, notably EPA as its NEFA (r = 0.46; P = 0.001), whereas pentadecanoic acid was associated with full-fat dairy intake (r = 0.43; P = 0.002), outcomes consistent with results from total FA serum hydrolysates. In the intervention cohort, serum ω-3 NEFAs increased 2.5-fold from baseline within 28 days following FO supplementation, and this increase was most pronounced for EPA (P = 0.0004). Unlike for DHA, circulating EPA as its NEFA also strongly correlated to EPA concentrations measured from erythrocyte phospholipid hydrolysates (r = 0.66; P = 4.6 × 10-10) and was better suited to detect dietary nonadherence. We conclude that MSI-NACE-MS offers a rapid method to quantify serum NEFAs and objectively monitor dietary fat intake in women that is complementary to food-frequency questionnaires.

Using natural experiments to improve public health evidence: a review of context and utility for obesity prevention

Background

Natural experiments are increasingly valued as a way to assess the health impact of health and non-health interventions when planned controlled experimental research designs may be infeasible or inappropriate to implement. This study sought to investigate the value of natural experiments by exploring how they have been used in practice. The study focused on obesity prevention research as one complex programme area for applying natural experiment studies.

Methods

A literature search sought obesity prevention research from January 1997 to December 2017 and identified 46 population health studies that self-described as a natural experiment.

Results

The majority of studies identified were published in the last 5 years, illustrating a more recent adoption of such opportunities. The majority of studies were evaluations of the impact of policies (n = 19), such as assessing changes to food labelling, food advertising or taxation on diet and obesity outcomes, or were built environment interventions (n = 17), such as the impact of built infrastructure on physical activity or access to healthy food. Research designs included quasi-experimental, pre-experimental and non-experimental methods. Few studies applied rigorous research designs to establish stronger causal inference, such as multiple pre/post measures, time series designs or comparison of change against an unexposed group. In general, researchers employed techniques to enhance the study utility but often were limited in the use of more rigorous study designs by ethical considerations and/or the particular context of the intervention.

Conclusion

Greater recognition of the utility and versatility of natural experiments in generating evidence for complex health issues like obesity prevention is needed. This review suggests that natural experiments may be underutilised as an approach for providing evidence of the effects of interventions, particularly for evaluating health outcomes of interventions when unexpected opportunities to gather evidence arise.

Mechanisms of Action of trans Fatty Acids

Human studies have established a positive association between the intake of industrial trans fatty acids and the development of cardiovascular diseases, leading several countries to enact laws that restrict the presence of industrial trans fatty acids in food products. However, trans fatty acids cannot be completely eliminated from the human diet since they are also naturally present in meat and dairy products of ruminant animals. Moreover, bans on industrial trans fatty acids have not yet been instituted in all countries. The epidemiological evidence against trans fatty acids by far overshadows mechanistic insights that may explain how trans fatty acids achieve their damaging effects. This review focuses on the mechanisms that underlie the deleterious effects of trans fatty acids by juxtaposing effects of trans fatty acids against those of cis-unsaturated fatty acids and saturated fatty acids (SFAs). This review also carefully explores the argument that ruminant trans fatty acids have differential effects from industrial trans fatty acids. Overall, in vivo and in vitro studies demonstrate that industrial trans fatty acids promote inflammation and endoplasmic reticulum (ER) stress, although to a lesser degree than SFAs, whereas cis-unsaturated fatty acids are protective against ER stress and inflammation. Additionally, industrial trans fatty acids promote fat storage in the liver at the expense of adipose tissue compared with cis-unsaturated fatty acids and SFAs. In cultured hepatocytes and adipocytes, industrial trans fatty acids, but not cis-unsaturated fatty acids or SFAs, stimulate the cholesterol synthesis pathway by activating sterol regulatory element binding protein (SREBP) 2-mediated gene regulation. Interestingly, although industrial and ruminant trans fatty acids show similar effects on human plasma lipoproteins, in preclinical models, only industrial trans fatty acids promote inflammation, ER stress, and cholesterol synthesis. Overall, clearer insight into the molecular mechanisms of action of trans fatty acids may create new therapeutic windows for the treatment of diseases characterized by disrupted lipid metabolism.

Plant-Based Diets for Personal, Population, and Planetary Health

Worldwide, the burden of morbidity and mortality from diet-related chronic diseases is increasing, driven by poor diet quality and overconsumption of calories. At the same time, the global food production system is draining our planet's resources, jeopardizing the environment and future food security. Personal, population, and planetary health are closely intertwined and will all continue to be vulnerable to these threats unless action is taken. Fortunately, shifting current global dietary patterns towards high-quality, plant-based diets could alleviate these health and environmental burdens. Compared with typical Western diets with high amounts of animal products, healthy plant-based diets are not only more sustainable, but have also been associated with lower risk of chronic diseases such as obesity, type 2 diabetes, cardiovascular disease, and some cancers. For personalized disease management and prevention, precision nutrition has the potential to offer more effective approaches tailored to individual characteristics such as the genome, metabolome, and microbiome. However, this area of research is in the early stages and is not yet ready for widespread clinical use. Therefore, it must not overshadow public health nutrition strategies, which have the power to improve health and sustainability on a larger scale. If widely implemented, interventions and policy changes that shift the globe towards healthy plant-based dietary patterns could be instrumental in ensuring future personal, population, and planetary health.

Global Surveillance of trans-Fatty Acids

Trans-fatty acid (TFA) intake can increase the risk of coronary heart disease (CHD) morbidity and mortality and all-cause mortality. Industrially produced TFAs and ruminant TFAs are the major sources in foods. TFA intake and TFA-attributed CHD mortality vary widely worldwide. Excessive TFA intake is a health threat in high-income countries; however, it is also a threat in low- and middle-income countries (LMICs). Data on TFA intake are scarce in many LMICs and an urgent need exists to monitor TFAs globally. We reviewed global TFA intake and TFA-attributed CHD mortality and current progress toward policy or regulation on elimination of industrially produced TFAs in foods worldwide. Human biological tissues can be used as biomarkers of TFAs because they reflect actual intake from various foods. Measuring blood TFA levels is a direct and reliable method to quantify TFA intake.

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Geriatrics Society, the American Society of Preventive Cardiology, and the Preventive Cardiovascular Nurses Association

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

1. The most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life.

2. A team-based care approach is an effective strategy for the prevention of cardiovascular disease. Clinicians should evaluate the social determinants of health that affect individuals to inform treatment decisions.

3. Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician–patient risk discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin. The presence or absence of additional risk-enhancing factors can help guide decisions about preventive interventions in select individuals, as can coronary artery calcium scanning.

4. All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, processed meats, refined carbohydrates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss.

5. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity.

6. For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and achieving exercise recommendations are crucial. If medication is indicated, metformin is first-line therapy, followed by consideration of a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist.

7. All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit.

8. Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit.

9. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion.

10. Nonpharmacological interventions are recommended for all adults with elevated blood pressure or hypertension. For those requiring pharmacological therapy, the target blood pressure should generally be <130/80 mm Hg.

Probabilistic Quantitative Assessment of Coronary Heart Disease Risk From Dietary Exposure to Industrially Produced Trans-Fatty Acids in Partially Hydrogenated Oils

We conducted a probabilistic evaluation of changes in coronary heart disease (CHD) risk and public health burdens from industrially produced trans-fatty acids (IP-TFAs) exposure from the uses of partially hydrogenated oils in food. Our analyses used four quantitative methods based on human studies considering the uncertainty associated with risk parameters for CHD and IP-TFA daily dietary exposure of 0.05% of energy. Method 1 used experimental controlled feeding trial data for changes in low-density lipoprotein cholesterol; Method 2 used changes in both low-density lipoprotein cholesterol and high-density lipoprotein cholesterol; Method 3 used changes in a combination of three emerging CHD risk factor biomarkers; and method 4 used prospective observational studies of CHD cases associated with long-term dietary exposure of trans-fatty acids. We estimated mean percent changes in CHD risk and annual CHD cases in U.S. adults, with lower and upper 95% uncertainty intervals. Our results show that consuming 0.05% of energy from IP-TFA, instead of cis-monounsaturated fatty acids, can cause annual mean increases in CHD cases of 814 (510–1151, method 1), 1502 (990–2043, method 2), or 6877 (3611–10 694, method 4) in U.S. adults. Results for method 3 were intermediate between those for methods 2 and 4. Sensitivity analyses using alternate risk parameters or an alternate exposure scenario resulted in minor changes in public health burden estimates. The results demonstrate that IP-TFA exposure as low as 0.05% of energy from partially hydrogenated oil uses in food can cause substantial public health burdens in the United States from increased CHD risk.

Global Improvement in Dietary Quality Could Lead to Substantial Reduction in Premature Death

BACKGROUND

The preventable premature mortality achievable by improvement in dietary quality at a global level is unclear.

OBJECTIVE

The aim of this study was to assess dietary quality globally, and to quantify the potential global impact of improving dietary quality on population health.

METHODS

We applied the Alternate Healthy Eating Index (AHEI, potential range 0-100) to a global dietary database to assess dietary quality among adults in 190 countries/territories. The relation of AHEI score to risks of major chronic disease was estimated from 2 large cohorts of men and women for whom many repeated dietary assessments during up to 30 years were available. We calculated the preventable premature deaths achievable by shifting from current national diets to a reference healthy diet.

RESULTS

The global mean AHEI score in 2017 was 49.5 for males and 50.5 for females. Large differences between current and target intakes existed for whole grains, sodium, long-chain n-3 polyunsaturated fats, polyunsaturated fats, and fruits. From 1990 to 2017, the global mean AHEI score increased modestly from 45.4 to 50.0. Diet quality varied substantially across the world. Coastal Mediterranean nations, the Caribbean region, and Eastern Asia (except China and Mongolia) had a higher AHEI score, whereas Central Asia, the South Pacific, and Eastern and Northern Europe had a lower score. An improvement in dietary quality from the current global diet to the reference healthy diet could prevent >11 million premature deaths, ∼24% of total deaths in 2017. These included 1.6 million cancer deaths, 3.9 million coronary artery disease deaths, 1.0 million stroke deaths, 1.7 million respiratory disease deaths, 0.4 million neurodegenerative disease deaths, 0.5 million kidney disease deaths, 0.6 million diabetes deaths, and 1.2 million digestive disease deaths.

CONCLUSIONS

Global dietary quality is slowly improving, but remains far from optimal and varies across countries. Improvements in dietary quality have the potential to reduce mortality rates substantially.

Comparison of Dietary Patterns, Perceptions of Health, and Perceived Barriers to a Heart Healthy Diet Before and After Coronary Artery Angiography

Poor dietary patterns are associated with coronary artery disease (CAD) and cardiovascular events. The aim of this study was to determine whether reported dietary patterns change after undergoing invasive coronary angiography. Participants without a history of coronary revascularization were prospectively enrolled before undergoing coronary angiography at a tertiary center between February 2015 and February 2017. Enrolled participants completed the Rate Your Plate (RYP) survey at baseline (before angiography), 1-month, and 6-month follow-ups. RYP scores range from 24 to 72 (higher scores indicate healthier dietary patterns) are presented as median (interquartile range), and are compared from baseline to follow-up using a nonparametric related-sample test. No dietary guidance was given outside of usual care. Of the 400 participants, 326 (82%) completed at least 1 follow-up survey with no differences in baseline characteristics of participants who had at least 1 versus no follow-up survey. The median RYP score significantly improved from baseline (53 [47 to 57]) to 1-month (58 [52 to 62]) and 6-month (59 [54 to 63]) follow-ups (p <0.001). Angiography demonstrated severe CAD in 125 (38%) and normal or nonobstructive CAD in 201 (62%) participants. RYP scores significantly improved over time in both groups (p <0.001), but the percent change in RYP score over time was greater in participants with versus without severe CAD (13.9% [5.8 to 22.5] vs 9.6% [4.8 to 19.1], p = 0.03). In conclusion, self-reported dietary patterns improved after invasive coronary angiography, particularly in the subset with CAD. Future studies to determine how best to utilize the periprocedural period to further improve dietary patterns in this population are warranted.

Impact of a Municipal Policy Restricting Trans Fatty Acid Use in New York City Restaurants on Serum Trans Fatty Acid Levels in Adults

OBJECTIVES

To estimate the impact of the 2006 policy restricting use of trans fatty acids (TFAs) in New York City restaurants on change in serum TFA concentrations in New York City adults.

METHODS

Two cross-sectional population-based New York City Health and Nutrition Examination Surveys conducted in 2004 (n = 212) and 2013-2014 (n = 247) provided estimates of serum TFA exposure and average frequency of weekly restaurant meals. We estimated the geometric mean of the sum of serum TFAs by year and restaurant meal frequency by using linear regression.

RESULTS

Among those who ate less than 1 restaurant meal per week, geometric mean of the sum of serum TFAs declined 51.1% (95% confidence interval [CI] = 42.7, 58.3)-from 44.6 (95% CI = 39.7, 50.1) to 21.8 (95% CI = 19.3, 24.5) micromoles per liter. The decline in the geometric mean was greater (P for interaction = .04) among those who ate 4 or more restaurant meals per week: 61.6% (95% CI = 55.8, 66.7) or from 54.6 (95% CI = 49.3, 60.5) to 21.0 (95% CI = 18.9, 23.3) micromoles per liter.

CONCLUSIONS

New York City adult serum TFA concentrations declined between 2004 and 2014. The indication of greater decline in serum TFAs among those eating restaurant meals more frequently suggests that the municipal restriction on TFA use was effective in reducing TFA exposure. Public Health Implications. Local policies focused on restaurants can promote nutritional improvements.

Industrially produced trans fat in popular foods in 15 countries of the former Soviet Union from 2015 to 2016: a market basket investigation

OBJECTIVE

To minimise the intake of industrially produced trans fat (I-TF) and decrease the risk of coronary heart disease, several countries have implemented a legislative restriction on I-TF in foods. The objective of this study was to investigate the presence of I-TF in biscuits/cakes/wafers in 15 countries of the former Soviet Union that all have a high coronary mortality rate compared with countries in Western Europe.

METHODS

Three large supermarkets in 15 capitals were visited in 2015 or 2016. Prepackaged biscuits/cakes/wafers were bought if the list of ingredients disclosed that the product contained more than 15 g of fat per 100 g of product and if partially hydrogenated fat or a similar term, including margarine, refined fat or confectionery fat, were mentioned. Samples of the foods were subsequently analysed for total fat and TF.

RESULTS

Some 994 products contained more than 2% total fat as I-TF (illegal in Denmark). In Armenia, 91 different products had a mean value (SD) of 21 (11)% fat as I-TF. In Estonia, there were eight products with 14 (10)% fat as I-TF. The other 13 countries had values between those of Armenia and Estonia. In several countries, a major portion of the products was imported from Russia and Ukraine. The mean shelf life (SD) of 673 packages was 218 (75) days. The % TF in the fat of the products produced in Russia and in Ukraine in relation to the date of production both declined by approximately 10% points during the 2-year collection period.

CONCLUSIONS

The findings suggest that I-TF is used in popular foods in all 15 countries of the former Soviet Union. Therefore, these findings indicate a possible way for some reduction of the high coronary mortality rate in these countries.

More sugar? No, thank you! The elusive nature of low carbohydrate diets

In the past decades, dietary guidelines focused on reducing saturated fat as the primary strategy for cardiovascular disease prevention, neglecting the many other potential effects of diet on health, in particular the harmful effects of sugar. A greater intake of soft drinks (sugar-sweetened beverages), for example, is associated with a 44% increased prevalence of metabolic syndrome, a higher risk of obesity, and a 26% increased risk of developing diabetes mellitus. Carbohydrates comprise around 55% of the typical western diet, ranging from 200 to 350 g/day in relation to a person's overall caloric intake. For long-term weight gain, food rich in refined grains, starches, and sugar appear to be major culprits. Low-carbohydrate diets restrict daily carbohydrates between 20 and 50 g, as in clinical ketogenic diets. The results of controlled trials show that people on ketogenic diets (a diet with no more than 50 g carbohydrates/day) tend to lose more weight than people on low-fat diets. Moreover, there is no good evidence for recommending low-fat diets, as low-carbohydrate diets lead to significantly greater weight loss (1.15 kg) than did low-fat interventions. However, the magnitude of such a benefit is small. As the quality of ingested carbohydrates seems more important than the quantity for health outcomes, people with metabolic disorders should avoid or substantially reduce low-fiber, rapidly digested, refined grains, starches, and added sugars. So, the consumption of the right carbohydrates (high-fiber, slowly digested, and whole grains), in a moderately lower amount (between 40 and 50% of daily energy content), is compatible with a state of good health and may represent a scientifically-based and palatable choice for people with metabolic disorders.

Perspective: Are Large, Simple Trials the Solution for Nutrition Research?

Nutritional research and policies have been criticized for relying on observational evidence, using self-report diet assessment methods, and supposedly being unable to present a consensus on what constitutes a healthy diet. In particular, it is often asserted that for progress to occur in nutrition science, large, simple trials, which have worked well in evaluating the efficacy of drugs, need to replace most observational research and small trials in nutrition. However, this idea is infeasible, and is unlikely to advance nutritional sciences or improve policies. This article addresses some commonly held and unfounded "myths" surrounding dietary assessments, effect sizes, and confounding, demonstrating how carefully conducted observational studies can provide reliable and reproducible evidence on diet and health. Also, there is a strong consensus among nutritional researchers and practitioners about the basic elements of a healthy diet. To move forward, we should continue to improve study design and diet assessment methodologies, reduce measurement errors, and leverage new technologies. Advances in the field lie in coalescing evidence from multiple study designs, methodologies, and technologies, and translating what we already know into policy and practice, so we can improve diet quality and enhance health in an equitable and sustainable manner across the world.

Blood Fatty Acid Profiles: New Biomarkers for Cardiometabolic Disease Risk

PURPOSE OF REVIEW

Fatty acid (FA) profiles in different blood compartments are reflections of both diet and metabolism, and some FA levels are related to disease risk.

RECENT FINDINGS

Perhaps the most studied FA-disease relationship is between long-chain omega-3 polyunsaturated fatty acids [eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)] and cardiovascular disease (CVD). Despite null results from recent large omega-3 FA supplementation trials, new research continues to support past studies showing that blood levels of EPA + DHA are inversely related to risk for total mortality and fatal CVD events. But blood levels of other FAs may also be useful markers of risk for a variety of diseases. The essential omega-6 FA linoleic acid is inversely associated with risk for developing type 2 diabetes (T2D), whereas risk for T2D is directly related to biomarkers of de novo lipogenesis (palmitic and palmitoleic acids). Levels of industrially produced trans FAs have been linked to higher risk for CVD. Thus, blood levels of several individual FAs are emerging as modifiable biomarkers for risk of major chronic diseases.