Published on December 16, 2013
Butter healthier than margarine? Nope. Evidence refuting butter-is-healthy claims Registered dietitian, M.Sc, MBA Reijo Laatikainen www.pronutritionist.net www.pronutritionistblog.com www.twitter.com/pronutritionist Page 1
Impetus to this slide deck; pro-butter doctors in media • General practioner (GP) John Briffa’s text in Times newspaper and the followed discussion at his blog • Cardiologist Aseem Malhotra’s comment on BBC TV Channel “Butter is healthier than low-fat spreads or margarine” • Diet Doctor’s, GP Andreas Eenfeldt, posts • Finnish doctor’s like Antti Heikkilä’s, Taija Somppi’s numerous comments in the media • And many more … 2 www.pronutritionist.net
My position • There is enough scientific evidence to refute the claim ”butter is healthy” • Scientific evidence supporting the increased use of margarine and vegetable oils is not equivocal either • Modern margarines are healthier than butter. However, margarines are not miraculous. Extra virgin olive oils and cold pressed canola oils are very likely healthier than margarine 3 www.pronutritionist.net
First, some scientific data that is often emphasized by pro-butter doctors 4 www.pronutritionist.net
Siri-Tarino’s meta-analysis of prospective cohorts: Saturated does not increase the risk of coronary heart disease risk nor does it reduce the risk Siri-Tarino PW et al. Am J Clin Nutr (January 13, 2010). doi:10.3945/ajcn. 5 www.pronutritionist.net
Sydney Diet Heart Study: Cardiac mortality was increased in vegetable oil/margarine group (re-evaluation of the study published originally 1978 ) PUFA Safflower oil/margarine 74 % increased risk in PUFA group Control Diet, high in SFA Ramsden CE, Zamora D, Leelarthaepin B, Majchrzak-Hong SF, Faurot KR, Suchindran CM, et al. Use of dietary linoleic acid for secondary prevention of coronary heart disease and death: evaluation of recovered data from the Sydney Diet Heart Study and updated meta-analysis. BMJ 2013;346:e8707 Page 6
Risk of death is not increased nor reduced among butter users. Metaanalysis of prospective cohorts 1.4 1.2 1.17* 1.21* 1.01 1.03 Milk Cheese 1 0.96** 0.8 0.6 0.4 0.2 0 Meat Processed meat Butter *) p<0.001, **) p=0.5 (not significant) O’Sullivan T et al. Food sources of saturated fat and the association with mortality: a meta-analysis. Am J Public Health. 2013;103:e31-42 7
The rest of this slide deck depicts scientific evidence which probutter doctors usually dismiss or downplay 8 www.pronutritionist.net
Point #1 World has changed since 1970s when Sydney Diet Heart Study and many other fat replacement studies were done. 9 www.pronutritionist.net
Era of the pivotal fat modification trials LA Veterans 1969 Margarines per se and use of oils have changed since 1970s MRC Soy 1968 Minnesota Coronary Survey 1968-1973 DART 1989 Oslo Diet Heart 19581964 Sydney Diet Heart Study 1966-73 STARS 1992 Rose Corn Oil 1965 1960 1970 *) if not given, the publication date 1990 2013
Use of oils has changed since the days of hippies. 11 www.pronutritionist.net
By using canola oil instead of sunflower oil you’ll get >20 times more omega-3 fats. In addition you don’t even get half of the amount of omega-6 linoleic acid In 1970s sunflower, corn, soy and other omega-6 rich oils were used in clinical trials. Canola oil and olive oil are dominating clinical trials today. They also dominate European cuisines 12 www.pronutritionist.net
Oils of 1970s have different fatty acid composition Sunflower oil /100 g Corn oil /100 g Soy oil / 100 g Canola oil /100 g Olive oil / 100 g Linoleic acid (omega-6) 52 g 53 g 52 g 22 g 10 g ALA (omega3) 0,5 g 1g 7g 11 g 0,5 g PUFA 63 g 54 g 59 g 33 g 11 g SFA 11 g 13 g 15 g 6g 14 g MUFA 22 g 27 g 22 g 60 g 68 g Oils of 1970s Modern dominating oils
IN ADDITION. MARGARINES ARE WAY BETTER TODAY 14 www.pronutritionist.net
Modern margarines in UK, or in most European countries, do not commonly contain trans fat. Boy, it was a different story in 1970s Median trans fat content of tube margarines/spreads 25.0 % 21.8 % 20.0 % 15.0 % Margarines 1970s* 10.0 % Margarines 2012 (UK)** 5.0 % 0.22 % 0.0 % Margarines 1970s* Margarines 2012 (UK)** *) Beare-Rogers JL et al. The linoleic acid and trans fatty acids of margarines. Am J Clin Nutr. 1979 Sep;32(9):1805-9. **) Roe M, et al Trans fatty acids in a range of UK processed foods. Food Chem. 2013 Oct 1;140(3):427-31. . 15 www.pronutritionist.net
Median trans fat content of margarines is currently very low. Finnish situation Trans fat content of margarines 1970s (US*) 21.8% (median) 2012 (FIN**) 0.34% (mean) *) Beare-Rogers JL et al. The linoleic acid and trans fatty acids of margarines. Am J Clin Nutr. 1979 Sep;32(9):1805-9. **) Ritvanen, T., Putkonen, T. , Peltonen, K. A comparative study of the fatty acid composition of dairy products and margarines with reduced or substituted fat content. Food and Nutrition Sciences, Vol. 3, 2012, pp. 1189-1196 16 www.pronutritionist.net
Trans fat content of margarines/spreads has plummeted during the last 50 years PUFA Saturated fat Trans fat Omega-3 Source: Ravinder Reddy, American Heart Association. Trans Fat Conference. October 10-11, 2006 17 www.pronutritionist.net
Point #2 Meta-analyses of the classic fat replacement trials have shown that combination of omega3 fatty acids and omega-6 linoleic acid reduce cardiovascular mortality 18 www.pronutritionist.net
Meta-analysis including Sydney Diet Heart Study: high intake of both linoleic acid AND omega-3 fats reduce cardiovascular deaths by 21 % Ramsden CE, Zamora D, Leelarthaepin B, Majchrzak-Hong SF, Faurot KR, Suchindran CM, et al. Use of dietary linoleic acid for secondary prevention of coronary heart disease and death: evaluation of recovered data from the Sydney Diet Heart Study and updated meta-analysis. BMJ 2013;346:e8707. www.pronutritionist.net
Supplementing omega-3 fats alone does not reduce cardiac deaths • ”Overall, omega-3 PUFA supplementation was not associated with a lower risk of all-cause mortality, cardiac death, sudden death, myocardial infarction, or stroke based on relative and absolute measures of association” Rizos EC, et al. Association between omega-3 fatty acid supplementation and risk of major cardiovascular disease events: a systematic review and meta-analysis. JAMA. 2012 Sep 12;308(10):1024-33 20 www.pronutritionist.net
Guidelines recommend increase in both omega-3 fatty acids and omega-6 linoleic acid intake • Dietary recommendations underline the adequate intake of BOTH omega-3 AND omega-6 fatty acids (linoleic acid), exactly in the line with the beneficial outcomes of meta-analysis by Ramsden 2013 • You can increase your intake of omega-3 fatty acids by using canola oil, walnuts and oily fish without fear of increasing too much linoleic acid intake; exactly as the new Nordic nutrition recommendations tell us to do 21 www.pronutritionist.net
Point #3 Sydney Diet Heart Study has important limitations (This study is the only randomized study showing increased cardiovascular mortality on vegetable oils/margarine) 22 www.pronutritionist.net
Lead investigator of Sydney Diet Heart Study, Chris Ramsden: “The really important limitations were; … 2) The median intake of omega-6 linoleic acid was almost 15% of calories. In the United States, consumption of omega-6 linoleic acid has increased from about 2% of calories in the early 20th century to about 7% of calories currently. So in the SDHS [Sydney Diet Heart Study] it ended up approximately twice as much as the average American consumes nowadays.” The PUFA Investigation: An Expert Interview Linda Brookes, MSc, Christopher E. Ramsden, March 18, 2013 www.medscape.com 23 www.pronutritionist.net
New systematic review: median global intake of linoleic acid (LA) 5,5% E Harika RK, Eilander A, Alssema M, Osendarp SJ, Zock PL. Intake of Fatty Acids in General Populations Worldwide Does Not Meet Dietary Recommendations to Prevent Coronary Heart Disease: A Systematic Review of Data from 40 Countries. Ann Nutr Metab. 2013 Oct 29;63(3):229-238 24 www.pronutritionist.net
Margarines used at time of Sydney Diet Heart Study contained trans fat 12-65% of all fatty acids Beare-Rogers JL et al. The linoleic acid and trans fatty acids of margarines. Am J Clin Nutr. 1979 Sep;32(9):18059. 25 www.pronutritionist.net
Different realities 1970s vs NOW Omega-6 linoleic acid intake as of total calories Intake of omega-6 linoleic acid in 15% Sydney Diet Heart Study Intake of omega linoleic acid currently (median worldwide) 26 5.5% www.pronutritionist.net
Point #4 Use of either olive oil, margarine or soy oil alone, or as a part of multifactorial intervention has reduced cardiovascular morbidity/mortality 27 www.pronutritionist.net
In 4 large successful randomized trials, butter and saturated fat reduction has been the key Study Fat given for Comment free to active group Los Angeles Veterans Corn, Safflower, Administration Study sunflower and soy oil (mix) Pure fat replacement study. Combined fatal strokes, amputations and heart attacks reduced by 31 %. (p<0.05) Lyon Diet Heart Study Med Diet Study, ie multifactorial design but only canola oil based margarine given for free. Cardiovascular mortality reduced by 76 % (p=0.029) Margarine Oslo Diet Heart Study Soy oil (and oily fish occasionally) Predimed 28 Multifactorial design but only oil and some oily fish given for free. Fatal heart attacks reduced by 56 % (p=0.029) Med Diet Study, ie multifactorial design but only fats given for free. Cardiovascular events reduced by 30 % Olive oil (extra virgin olive oil group) www.pronutritionist.net
Summary Favoring saturated fat Name of the study Number of randomized studies (w/mortality or morbidity end points) 29 Sydney Diet Heart Study 1 Draw Favoring vegetable oils and/or margarine DART, Los Angeles Minnesota CS, Veterans, Oslo MRC Soy, St Diet Heart, Thomas Lyon Diet Atherosclerosis Heart, , Rose Corn Oil Predimed 5 www.pronutritionist.net 4
Point #5 Margarine, canola oil and olive oil all induce better total cholesterol/HDL –ratio than butter. This is proven at the level of meta-analysis. Total cholesterol/HDL –ratio is very strong indicator of coronary heart disease risk and widely used in clinical practise 30 www.pronutritionist.net
Total cholesterol is strong risk factor for ischemic heart disease (IHD) mortality but total cholesterol/HDL – ratio is even stronger Total cholesterol as a risk marker Total cholesterol/HDL as a risk marker Prospective Studies Collaboration,. Blood cholesterol and vascular mortality by age, sex, and blood pressure: a metaanalysis of individual data from 61 prospective studies. Lancet. 2007 Dec 1;370(9602):1829-39. e studies with 55,000 vascular deaths. , 31 www.pronutritionist.net
Canola oil = Meta-analysis: Canola oil and even margarine produce clearly better Total Cholesterol/HDL ratios than butter Mensink et al. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003 May;77(5):1146-55. 32
Point #6 Replacing saturated fat with polyunsaturated fat (PUFA) reduces coronary heart disease mortality in prospective cohorts 33 www.pronutritionist.net
Pooled analysis of 11 prospective cohorts: “replacing SFAs with PUFAs rather than MUFAs or carbohydrates prevents CHD [Coronary Heart Disease]” replace SFA: Saturated fat; PUFA: Polyunsaturated fat, ie. Omega-6 and omega-3 fatty acids Jakobsen M et al. Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. Am J Clin Nutr. 2009 May;89(5):1425-32. Page 34
Point #7 Omega-6 fats are not pro-inflammatory in humans in contrast to common claims by probutter doctors 35 www.pronutritionist.net
Meta-analysis of 15 clinical trials • ” This review clearly demonstrates that virtually no data are available from randomized, controlled intervention studies among healthy, noninfant human beings to show that the addition of LA [linoleic acid] to diets increases markers of inflammation.” • Linoleic acid does not even increase arachidonic acid (AA) levels because conversion to AA is extremely low. Only 0.30.6% of linoleic acid is converted to AA in humans Johnson & Fritsche. Effect of Dietary Linoleic Acid on Markers of Inflammation in Healthy Persons: A Systematic Review of Randomized Controlled Trials. Journal of the Academy of Nutrition and Dietetics 2012; 112: 1029-1041 Rett & Whelan. Increasing dietary linoleic acid does not increase tissue arachidonic acid content in adults consuming Western-type diets: a systematic review. Nutr Metab (Lond). 2011 Jun 10;8:36 36 www.pronutritionist.net
Butter and saturated fat per se pose either deleterious or neutral effects on inflammation • Butter induced pro-inflammatory changes versus sunflower oil in clinical trial – Bjermo H, et al. Effects of n-6 PUFAs compared with SFAs on liver fat, lipoproteins, and inflammation in abdominal obesity: a randomized controlled trial. Am J Clin Nutr. 2012 May;95(5):1003-12. • ”Consumption of a saturated fat reduces the anti-inflammatory potential of HDL” – • Nicholls SJ, et al. Consumption of saturated fat impairs the anti-inflammatory properties of high-density lipoproteins and endothelial function. Margarine reduces post-prandial inflammation in proportion to butter J Am Coll Cardiol. 2006 Aug 15;48(4):715-20 Exchanging SFA from butterfat for sunflower oil in a mixed meal decrease postprandial concentrations of IL-6, TNFα, sTNFr-I and -II, and sVCAM-1 in overweight men. – Masson CJ, Mensink RP Exchanging saturated fatty acids for (n-6) polyunsaturated fatty acids in a mixed meal may decrease postprandial lipemia and markers of inflammation and endothelial activity in overweight men.. J Nutr. 2011 May;141(5):816-21.) • Sterol containing margarine and butter produce similar effects on inflammatory markers – 37 Gagliardi AC et al. Effects of margarines and butter consumption on lipid profiles, inflammation markers and lipid transfer to HDL particles in free-living subjects with the metabolic syndrome. Eur J Clin Nutr. 2010 Oct;64(10):1141-9. www.pronutritionist.net
Point #8 Omega-6 fats are not associated with cancer in contrast to claims by pro-butter doctors. Results from meta-analyses 38 www.pronutritionist.net
Very high intake of linoleic acid. No increase in cancer risk in clinical trials Zock PL, Katan MB. Linoleic acid intake and cancer risk: a review and meta-analysis. Am J Clin Nutr. 1998 Jul;68(1):142-53. 39 www.pronutritionist.net
Meta-analyses by World Cancer Research Fund: Omega-6 fats not linked to cancer. If anything, butter is linked to lung cancer (limited evidence) World Cancer Research Fund / American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR, 2007 40 www.pronutritionist.net
Point #9 Lower intake of saturated fat during low carb diet improves parameters of cardiovascular health, when the major source of protein is beef 41 www.pronutritionist.net
Ronald Krauss with co-workers: lowering SFA content of low carb diet improves cardiovascular risk profile Run in period Low SFA + Low carb diet high in beef High SFA + Low carb diet high in beef TG, mmol/l 1.22 1.0 1.1 LDL, mmol/l 2.87 2.5* 2.86* HDL, mmol/l 1.08 1.04* 1.07* Small LDL, nmol/l 207 187* 222* Medium LDL, “ 284 214* 304* Large LDL, “ 698 655 712 ApoB, g/l 0.74 0.68* 0.73* *) p<0.05 low vs high SFA diets “… reductions in the other lipoprotein-related risk factors, including apoB and small LDL, were greatest following consumption of a Low Carbohydrate Low Saturated Fat Diet” Mangravite LM, Chiu S, Wojnoonski K, Rawlings RS, Bergeron N, Krauss RM. Changes in atherogenic dyslipidemia induced by carbohydrate restriction in men are dependent on dietary protein source.J Nutr. 2011 Dec;141(12):2180-5 Page 42 http://twitter.com/pronutritionist
Point #10 Scientific data in the field of nutrition is almost never perfectly unequivocal due to very complex interplay of nutrients, phytochemicals, cooking methods, biological variation and research methods. You either accept this or deny it. Choice is yours 43 www.pronutritionist.net
Dietary pattern loaded with butter is likely to be unhealthier than otherwise similar food pattern with vegetables oils or margarine as main edible fat. However, used sparingly, butter is far from poison 44
Wellcome aboard! http://twitter.com/pronutritionist http://www.facebook.com/pronutritionist http://www.pronutritionist.net Reijo Laatikainen, RD, MBA Images bought and licensed from BigStockPhoto. Snapshots from papers and sites refered to. Page 45
Strength of evidence Meta-analyses of 1,2 & 3 Modified from: Micha & Mozaffarian. Lipids. 2010; 45(10): 893–905 and Evidence Analysis Manual. Academy of Nutrition and Dietetics January 2012 1. Randomized mortality & morbidity trials 2. Prospective cohorts 3. Randomized risk marker trials 4. Cross-sectional and case-control cohorts 5 Ecological & animal studies
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