Evidence-based priority setting for dietary policies Ashkan Afshin, - - PowerPoint PPT Presentation

▶
evidence based priority setting for dietary policies
SMART_READER_LITE
LIVE PREVIEW

Evidence-based priority setting for dietary policies Ashkan Afshin, - - PowerPoint PPT Presentation

Feb 19, 2024 139 likes •472 views

Evidence-based priority setting for dietary policies Ashkan Afshin, MD MPH MSc ScD November 17, 2016 Acting Assistant Professor of Global Health Policy 1. Defining optimal nutrition Agenda Setting Formulation 2. Quantifying the burden of

slide-1
SLIDE 1

Evidence-based priority setting for dietary policies

Ashkan Afshin, MD MPH MSc ScD November 17, 2016 Acting Assistant Professor of Global Health

slide-2
SLIDE 2

Policy Formulation Policy Adoption Policy Implementation Policy Evaluation Agenda Setting

  • 1. Defining optimal nutrition
  • 2. Quantifying the burden of disease due to malnutrition
  • 3. Evaluating the effectiveness of policies to improve nutrition
  • 4. Evaluating the cost-effectiveness of nutrition policies
  • 5. Evaluating the political/legal feasibility of nutrition policies
  • 6. Evaluating the intensity of implementation of nutrition policies
  • 7. Evaluating the short/long term effects of nutrition policies
slide-3
SLIDE 3

Policy Formulation Policy Adoption Policy Implementation Policy Evaluation Agenda Setting

  • 1. Defining optimal nutrition
  • 2. Quantifying the burden of disease due to malnutrition
  • 3. Evaluating the effectiveness of policies to improve nutrition
  • 4. Evaluating the cost-effectiveness of nutrition policies
  • 5. Evaluating the political/legal feasibility of nutrition policies
  • 6. Evaluating the intensity of implementation of nutrition policies
  • 7. Evaluating the short/long term effects of nutrition policies
slide-4
SLIDE 4

4

Malnutrition

slide-5
SLIDE 5

5

slide-6
SLIDE 6

1943 1992 2005 2011 1989 2002 2015

slide-7
SLIDE 7

Nutrients Foods Dietary patterns Biological mechanism No biological knowledge Intercorrelations not a problem Statistical Power No food composition data needed Between-food interactions Supplementation Use in dietary advice

Defining diet

7

Absolute Intake Relative Intake Health outcome

Disease endpoints

(CVD, diabetes, cancer)

Intermediate outcomes

(obesity, blood pressure)

slide-8
SLIDE 8

8

Evidence Description

RCTs of disease endpoint Number of independent RCTs evaluating the effect of the risk on the disease endpoint % of independent RCTs showing significant effect in the opposite direction % of independent RCTs showing no effect Prospective observational studies of disease endpoint Number of independent prospective observational studies evaluating the association of the risk with the disease endpoint % of independent prospective observational studies with significant association in the

  • pposite direction

Strength Lower Limit of RR in observational studies> 1.5 (Yes/No) Dose response Evidence of the dose-response relationship between the risk and the outcome(Yes/No) Biologic plausibility Potential biologic mechanism that could explain the effect of the risk on the disease endpoint (Yes/No) Analogy Evidence on the relationship between the risk factor and a disease endpoint from the same category (Yes/No)

slide-9
SLIDE 9

Outcome

RCTs (Number) RCTs with significant effect in the opposite direction (%) RCTs with null findings (%) Prospective observational studies (Number) Prospective observational studies with significant Lower limit of RR > 1.5 Dose-response relationship Biologic plausibility Analogy

Lip and oral cavity cancer

  • 2

Nasopharynx cancer

  • 2

Other pharynx cancer

  • 2

Larynx cancer

  • 2

Oesophageal cancer

  • 5

Tracheal, bronchus, and lung cancer

  • 22

Ischaemic heart disease

  • 9

Ischaemic stroke

  • 9

Hemorrhagic stroke

  • 5

Diabetes mellitus

  • 9

Oesophageal cancer

  • 5

Ischaemic heart disease

  • 9

Ischaemic stroke

  • 8

Hemorrhagic stroke

  • 5

Ischaemic heart disease

  • 7

Ischemic stroke

  • 6

Hemorrhagic stroke

  • 6

Diabetes mellitus

  • 10

Diet low in nuts and seeds Ischaemic heart disease

1 100 6

Diabetes mellitus

1 100 5

Risk Diet low in vegetables Diet low in vegetables Diet low in vegetables Diet low in whole grains Diet low in whole grains Diet low in nuts and seeds Diet low in fruits Diet low in fruits Diet low in fruits Diet low in fruits Diet low in fruits Diet low in vegetables Diet low in fruits Diet low in fruits Diet low in fruits Diet low in fruits Diet low in fruits Diet low in whole grains Diet low in whole grains

Epidemiologic evidence supporting causality between dietary risk-outcome pairs

GBD 2015

slide-10
SLIDE 10

Outcome

RCTs (Number) RCTs with significant effect in the opposite direction (%) RCTs with null findings (%) Prospective observational studies (Number) Prospective observational studies with significant Lower limit of RR > 1.5 Dose-response relationship Biologic plausibility Analogy

Colon and rectum cancer cancer

  • 7

Colon and rectum cancer cancer

  • 8

Diabetes mellitus

  • 9

11

Colon and rectum cancer cancer

  • 9

11

Ischaemic heart disease

  • 5

Diabetes mellitus

  • 8

Body mass index

10 60 22

  • Colon and rectum cancer cancer
  • 15

Diet low in fibre Ischaemic heart disease

  • 12

Colon and rectum cancer cancer

  • 13

Ischaemic heart disease

17 94 16

Ischaemic heart disease

8 75 11

Ischaemic heart disease

  • 4

Systolic blood pressure

45 73

  • Stomach cancer
  • 3

Risk Diet low in fibre Diet low in calcium Diet low in seafood omega-3 fatty acids Diet low in polyunsaturated fatty acids Diet high in trans fatty acids Diet low in milk Diet high in red meats Diet high in red meats Diet high in processed meats Diet high in processed meats Diet high in processed meats Diet high in sugar sweetened beverages Diet high in sodium Diet high in sodium

Epidemiologic evidence supporting causality between dietary risk-outcome pairs

GBD 2015

slide-11
SLIDE 11

Policy Formulation Policy Adoption Policy Implementation Policy Evaluation Agenda Setting

  • 1. Defining optimal nutrition
  • 2. Quantifying the burden of disease due to malnutrition
  • 3. Evaluating the effectiveness of policies to improve nutrition
  • 4. Evaluating the cost-effectiveness of nutrition policies
  • 5. Evaluating the political/legal feasibility of nutrition policies
  • 6. Evaluating the intensity of implementation of nutrition policies
  • 7. Evaluating the short/long term effects of nutrition policies
slide-12
SLIDE 12

12

Comparative Risk Assessment

slide-13
SLIDE 13

Global Nutrient Database

Calcium

Other nutrients Sugars (Glucose, Sucrose, Starch) Protein Vitamins (A, B, D, E, K) Folates Iron Zinc Magnesium Phosphorus Potassium Selenium

GBD 2015

slide-14
SLIDE 14

14 Sex Suboptimal metric Nationally Representativeness Data from FFQ Data from HBS Data from FAO Country level covariate

Diet low in fruits      

  • Diet low in vegetables

     

  • Diet low in whole grains

    

  • Diet low in nuts and seeds

     

  • Diet low in milk

     

  • Diet high in red meat

     

  • Diet high in processed meat

    

  • National availability of red meat and pig meat

Diet high in sugar-sweetened beverages     

  • National availability of sugar

Diet low in fiber      

  • Diet suboptimal in calcium

     

  • Diet low in seafood omega-3 fatty acids

      Landlocked nation (Yes,/No) Diet low in polyunsaturated fatty acids      

  • Diet high in trans fatty acids

    

  • National availability of hydrogenated oil

Diet high in sodium  

  • Standardizing the modelling approach

GBD 2015

slide-15
SLIDE 15

15

Comparative Risk Assessment

slide-16
SLIDE 16

16

Body Mass Index Total Serum Cholesterol Fasting Plasma Glucose Systolic Blood Pressure

Diet low in fruits

   

Diet low in vegetables

   

Diet low in whole grains

  

  • Diet low in nuts and seeds

   

Diet high in red meats

  • Diet high in processed meats

Diet low in fiber

  • Diet low in seafood omega-3 fatty acids

Diet low in polyunsaturated fatty acids

  • Diet high in trans fatty acids

 

  • Age curve of relative risks

GBD 2015

slide-17
SLIDE 17

Measurement Error

17

Subar (2001)

slide-18
SLIDE 18

Publication Bias

18

Nuts & IHD Red meat & Diabetes Processed meat & Diabetes Trans fat & IHD SSBs & Diabetes

slide-19
SLIDE 19

Definition of dietary factors

19

Wang Huang Johnsen Wu Jacobs Jensen Steffen Liu added bran added wheat germ bagels bran breakfast cereals brown rice brown rice flour buckwheat bulgur cooked cereal cooked oatmeal corn meal dumplings corn meal flat cakes corn meal porridge corn meal steamed bread non-white bread

  • ats
  • ther grains

pancakes pizza popcorn psyllium Aune (2016)

slide-20
SLIDE 20

Covariates

20 Age Sex Race Education Merital Status Smoking Alcohol Physical Excerise Engery Fruit and Vegetables SFA Fish/ Seafood PUFA MUFA Trans- FA Red Meat Sucrose Coffee Sodium Soy Dairy BMI Waist/hip Vitamin Supplements Oral Contraceptives HRT Diabetes Hypertension Hypercholesterolemia Mental Stress Menopausal Status Sleep Duration Atkins (2014) Eshak(2011) Eshak (2014) Jacobs(2001) Jensen(2004) Johnsen (2015) Liu (1999) Mink (2007) Muraki (2014) Muraki (2014) Pietinen (1996) Rautiainen (2012) Steffen(2003) Tognon (2014) Wang(2016) Yu (2013)

Whole grains and Ischemic Heart Disease

Aune (2016)

slide-21
SLIDE 21

Correlation between dietary factors

21

Veg Fruit Proc Meat Red Meat Nuts/seeds Whole grains SSB Milk Sodium Omega-3 PUFA SFA Fiber Calcium Veg 1.00 Fruit 0.19 1.00 Proc Meat

  • 0.13 -0.04 1.00

Red Meat

  • 0.02 -0.11 -0.08 1.00

Nuts/seeds 0.10 0.13

  • 0.07 -0.08 1.00

Whole grains 0.08 0.17

  • 0.07 -0.11 0.12

1.00 SSB

  • 0.21 -0.22 0.03

0.07

  • 0.13 -0.18 1.00

Milk

  • 0.04 0.04
  • 0.02 -0.02 -0.03 0.09
  • 0.12 1.00

Sodium 0.29

  • 0.12 0.31

0.08

  • 0.13 -0.03 -0.13 -0.05 1.00

Omega-3 0.12 0.05

  • 0.10 -0.06 0.07

0.03

  • 0.07 -0.04 0.14 1.00

PUFA 0.08

  • 0.03 0.06
  • 0.13 0.21

0.00

  • 0.15 -0.14 0.02 0.07

1.00 SFA

  • 0.14 -0.12 0.18

0.14

  • 0.07 -0.18 -0.14 0.10

0.00 -0.11 0.09 1.00 Fiber 0.61 0.48

  • 0.15 -0.17 0.25

0.44

  • 0.34 0.04

0.07 0.05 0.04

  • 0.25 1.00

Calcium 0.10 0.11 0.02

  • 0.10 0.11

0.16

  • 0.27 0.54

0.11 -0.02 -0.17 0.18 0.23 1.00 NHANES 2011-2012

slide-22
SLIDE 22

RR for CHD per 1 serving (28.4g)/week of nuts

Afshin 2014

Luo 2014 Zhou 2014

slide-23
SLIDE 23

23

Comparative Risk Assessment

slide-24
SLIDE 24

24

GBD 2015 Fruits 200-300 gr/day Vegetables 340-500 gr/day Whole grains 100-150 gr/day Nuts 16-25 gr/day Red meats 18-27 gr/day Processed meats 0-4 gr/day Milk 350-520 gr/day Sugar sweetened beverages 0-5 gr/day Polyunsaturated fatty acids 9-13% of total daily energy Seafood omega-3 fatty acids 200-300 mg/day Trans fatty acids 0-1%E Dietary fiber 19-28 gr/day Dietary calcium 1-1.5 gr/day Sodium 1-5 gr/day

New approach to determine TMREL

Total Fat < 30% E/d Cardiovascular disease Salt <5 g/d | Sodium< 2g/d Cardiovascular disease Free sugars<10% E/d Adiposity

slide-25
SLIDE 25

Reducing intake of free sugars and body fatness Increasing intake of free sugars and body fatness

Adults Children Morenga (BMJ, 2012)

slide-26
SLIDE 26

Isoenergetic exchanges of free sugars with other carbohydrates

Free sugars<10% E/d

Morenga (BMJ, 2012)

slide-27
SLIDE 27

Mente (Lancet 2016)

Sodium excretion and risk of cardiovascular disease

Mozaffarian (NEJM 2014)

Sodium<5 g/d Sodium<2 g/d

slide-28
SLIDE 28

Citation network graph with 269 reports and 2165 citations.

Ludovic Trinquart et al.

  • Int. J. Epidemiol. 2016
slide-29
SLIDE 29

Co-authorship network graph with 643 authors.

Ludovic Trinquart et al.

  • Int. J. Epidemiol. 2016
slide-30
SLIDE 30

Total Fat < 30% E/d

Howard (2006)

slide-31
SLIDE 31

31

Comparative Risk Assessment

slide-32
SLIDE 32

32

Ranking of dietary risks based on the disease burden attributable to them in the most populous countries

GBD 2015

slide-33
SLIDE 33

Acknowledgment

33

1700+ GBD Collaborators