1.
Following dietary guidelines
is associated with reduced risk of
type 2 diabetes, coronary heart
disease and obesity.
Scientific evidence
[Updated May, 2016]
Registered dietitian, M.Sc, MBA
Reijo Laatikainen
www.twitter.com/pronutritionist
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2.
Why this slide deck?
• Numerous accusations by some representatives of low carb and
“Paleolithic“ diet communities and by some “nutrition authors”
maintain that dietary guidelines have made us fat and sick:
– “Dietary guidelines have caused the obesity epidemic”
– “Dietary guidelines are not based on scientific evidence”
– “Dietary guidelines are the reason for type 2 diabetes epidemic”
– And so forth
• Quite often these accusations are not addressed adequately.
Consequently, many people buy in the claims.
• This deck is about science. What does the high quality data show
about the evidence of dietary guidelines?
2

3.
1. Randomized mortality &
morbidity trials
2. Prospective cohorts
3. Randomized risk
marker studies
4. Cross-sectional and
case-control cohorts
5 Ecological & animal
studies
Strengthofevidence
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
Hierarchy of evidence in nutrition
science

4.
Commonly recommended dietary
patterns have many names and
their quality varies little. All are
rather high in carbs:
DASH
Low GI diet
Prudent diet pattern
High quality diet pattern
Healthy diet pattern
Healthy Eating Index
… and so on.
4

5.
Their claim: This food pyramid is the
root cause of OBESITY EPIDEMIC
”Carbs are bad”
”Carbs are bad”

6.
Dietary macronutrients and long
term weight change
Systematic review by Fogelholm
et al 2013
6

7.
Prudent diet, healthy diet and Med Diet
reduce the risk of weight gain
7
Fogelholm M et al. Dietary macronutrients and food consumption as determinants of long-term
weight change in adult populations: a systematic literature review.Food Nutr Res. 2012;56
Number of studies showing
reduced risk of weight gain in
long term: 4
Number of studies showing
increased risk of weight gain
in long term: zero

8.
Fiber rich carbohydrates associated
with lower body weight and refined
carbs with weight gain
8
Number of studies showing
reduced risk of weight gain in
long term: 13
Number of studies showing
increased risk of weight gain
in long term: zero
Fogelholm M et al. Dietary macronutrients and food consumption as determinants of long-term
weight change in adult populations: a systematic literature review.Food Nutr Res. 2012;56

9.
Meat is associated with weight gain.
Dairy is associated with lower weight
9
Number of studies showing
increased risk of weight gain
in long term: 3
Fogelholm M et al. Dietary macronutrients and food consumption as determinants of long-term
weight change in adult populations: a systematic literature review.Food Nutr Res. 2012;56

10.
No evidence that share of carbs in a
diet is a determinant of weight gain
10
Fogelholm M et al. Dietary macronutrients and food consumption as determinants of long-term
weight change in adult populations: a systematic literature review.Food Nutr Res. 2012;56

11.
Carbs and weight management
Systematic review by Hauner et al
2012
www.pronutritionist.net11

12.
Intake of carbs is not associated with with
risk of obesity.
12
Hauner H et al. Evidence-based guideline of the German Nutrition Society: carbohydrate intake
and prevention of nutrition-related diseases. Ann Nutr Metab. 2012;60 Suppl 1:1-58

13.
Fiber rich carbs are associated with
reduced risk of obesity. Sugary drinks
increase the risk of weight gain
13
Hauner H et al. Evidence-based guideline of the German Nutrition Society: carbohydrate intake
and prevention of nutrition-related diseases. Ann Nutr Metab. 2012;60 Suppl 1:1-58

14.
Their claim: This food pyramid is the
root cause of TYPE 2 DIABETES
EPIDEMIC
”Carbs are bad”
”Carbs are bad”

15.
Type 2 diabetes
Meta-analyses of prospective
cohorts by Esposito et al. 2014,
Alhazmi et al. 2014, Ye et al.2013
and meta-analysis of RCTs by
Gillies et al 2007
Systematic review by Hauner et a.
2012
www.pronutritionist.net15

16.
Healthy dietary pattern is associated with
reduced risk of type 2 diabetes
Page 16
“The results indicated that dietary patterns consisting of healthy foods and/or
nutrient choices and had higher energy contributions from whole grain products,
fruit and vegetables may decrease the risk of type 2 diabetes.”
Alhazmi A., et al. he association between dietary patterns and type 2 diabetes: a systematic
review and meta-analysis of cohort studiesJ Hum Nutr Diet 2014;27:251–260

17.
DASH, Med Diet and healthy dietary pattern
are all associated with reduced risk of type 2
diabetes
Page 17
Esposito et al., Which diet for prevention of type 2 diabetes? A meta-analysis of prospective
studies. Endocrine. 2014 Apr 18
“The results of our study demonstrate that
several healthy diets are equally and
consistently associated with a 20 % reduced
risk of future type 2 diabetes.”

18.
Systematic review of prospective
cohorts and RCTs: whole grains
associated with reduced risk of T2D,
weight gain and CVD
• Cohorts: whole grain users
(48-80 g/day vs ”low users”)
– Relative risk of T2D ↓ by 28
%
– Relative risk of CVD ↓ by 21
%
– Weigh 0,4 kilos less
Page 18
Ye E et al. Greater whole-grain intake is associated with lower risk of type 2 diabetes,
cardiovascular disease, and weight gain. J Nutr. 2012 Jul;142(7):1304-13.

19.
Meta-analysis of RCTs: recommended
diet reduces the risk of type 2 diabetes
19
Gillies et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in
people with impaired glucose tolerance: systematic review and meta-analysis. BMJ
2007;334:29
(The Da Qing IGT and Diabetes Study. Diabetes Care1997; 20: 537-544, Wein et al Aust N Z J Obstet
Gynaecol. 1999;39:162-6., Jarrett et al. 1979)

20.
Share of carbs per se is not associated
with risk of type 2 diabetes.
20
Hauner H et al. Evidence-based guideline of the German Nutrition Society: carbohydrate intake
and prevention of nutrition-related diseases. Ann Nutr Metab. 2012;60 Suppl 1:1-58

21.
Their claim: This food pyramid is the
root cause of ATHEROSCLEROSIS
(through small LDL particles)
”Carbs are bad”
”Carbs are bad”

22.
Recommended dietary pattern and
coronary heart disease
(CHD)
Meta-analysis by Mente et al. 2009
www.pronutritionist.net22

23.
Meta-analysis: risk of coronary heart
disease reduced by “High quality diet”,
Med Diet and low GI/GL diet
Mente A et al. Arch Intern Med. 2009 Apr 13;169(7):659-69.
High quality diet= a dietary pattern characterized by consumption of
foods recommended in dietary guidelines

24.
Pooled analysis of 2 prospective
cohorts. Healthy diets are associated
with reduced risk of cardiovascular,
cancer and all cause death
Sivu 24
Reedy J et al. Higher Diet Quality Is Associated with Decreased Risk of All-Cause, Cardiovascular
Disease, and Cancer Mortality among Older Adults. J Nutr 2014; February 26, online
n = 492 823, 86 419 deaths, 15 years of follow up.
Total
mortality
CVD
mortality
Cancer
mortality
Healthy Eating Index -22% -15% - 24%
Mediterranean diet -27% -20% -20%
DASH diet -17% -14% -20%
Results shown are for males. Results for women in line with men’s results. All presented
results statistically significant

25.
Meta-analysis of 15 cohorts on
recommended diets
Sivu 25
Schwingshackl L, Hoffmann G. Diet quality as assessed by the Healthy Eating Index, the
Alternate Healthy Eating Index, the Dietary Approaches to Stop Hypertension score, and
health outcomes: a systematic review and meta-analysis of cohort studies. J Acad Nutr Diet.
2015 May;115(5):780-800.e5
n = 1,020,642
Diabetes CVD Cancer All cause
mortality
Generally
recommended diets*
-22% -22% - 15% -22%
*) Healthy Eating Index (HEI) or Alternative Healthy Eating Index (AHEI) or DASH diet
Note: people in the cohorts did not follow analysed diets strictly but merely belonged to the
“somewhat adherent” categories. Therefore realeffects for ideal adherence might be even
higher.

26.
Analysis of 304 systematic reviews
and meta-analyses published between
1950-2013*: Dietary guidelines are right
Sivu 26
Fardet A, Boirie Y. Associations between food and beverage groups and major diet-related chronic
diseases: an exhaustive review of pooled/meta-analyses and systematic reviews. Nutr Rev
2014;72(12):741-62
”… these results substantiate certain a priori nutritional
recommendations that are sometimes based on
assumptions about the foods that should be included in
a balanced diet or on characteristics of “healthy” foods”
[review focused on obesity, cancer, type 2 diabetes
and cardiovascular disease]
*) Included study designs 1) interventional study, 2) longitudinal study, 3) case-control study, 4)
cross-sectional study, and 5) ecological study

27.
What they usually DON’T tell: Most
people NEVER followed the pyramid.
Many follow junk food diet (“Western
diet pattern”)
Mostly refined carbs, sugar,
butter, fatty cheese and
processed/red meat

28.
In Nordic countries: only 0,3 % adhere
strictly to recommendations and 9-24 %
of the populations have somewhat
“healthy” diet
28
Nordic monitoring of diet, physical activity and overweight. First collection of data in all Nordic
Countries 2011.

29.
More than 90% of children in US have
poor diet*. Only 0.1% has ideal diet.
29
Mozaffarian D et al. AHA Statistical Update. Heart Disease and Stroke Statistics—2015 Update.
Circulation. 2015;131:00-00.
*) Poor diet: 0-1 dietary goals met
Intermediate diet: 2-3 goals met
Ideal diet: 4-5 goals met.
Dietary goals were:
• Fruits and vegetables: >4.5 cups/d
• Fish: More than two servings/wk
• Fiber-rich whole grains at least 3
servings per/d
• Salt intake less than 3,75 g/d
• Sugar-sweetened beverages:
<450 kcal/wk (~ <1 liter/wk)

30.
More than 65% of adults in US have poor
diet*. Only 0.4-0.6% has ideal diet.
30
Mozaffarian D et al. AHA Statistical Update. Heart Disease and Stroke Statistics—2015 Update.
Circulation. 2015;131:00-00.
*) Poor diet: 0-1 dietary goals met
Intermediate diet: 2-3 goals met
Ideal diet: 4-5 goals met.
Dietary goals were:
• Fruits and vegetables: >4.5 cups/d
• Fish: More than two servings/wk
• Fiber-rich whole grains at least 3
servings per/d
• Salt intake less than 3,75 g/d
• Sugar-sweetened beverages:
<450 kcal/wk (~ <1 liter/wk)

31.
An average person in US eats > 2 times
more refined grains, solid fats and sugars
than recommended and < 50 % of the
recommended fruit & whole grain intake
31
SoFAS: Solid fats and sugar. Source: USDA dietary guidelines, chapter 5

32.
Are our current diets really lower in
fat than ever (as it often claimed by
low carb proponents)?
Case US
Data from NHANES studies
and U.S. Department of Agriculture (USDA)
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33.
NHANES studies 1971-2010
Absolute intake in grams.
Data is based on self-reports which usually
underestimate real intake
33

34.
Intake of fat, carbohydrates and protein (grams/day/person)
NHANES
Ford ES, Dietz WH. Trends in energy intake among adults in the United States:
findings from NHANES. Am J Clin Nutr. 2013 Apr;97(4):848-53.

35.
Data from USDA (1971-2006)
Absolute availability per person in
grams.
Data is based on balance sheets (food
availability) which may overestimate
consumption of all macronutrients due to
incomplete correction of food waste
35

36.
0
100
200
300
400
500
600
gramspercaptia/day Fat, protein and carbohydrate availability in US
(grams/day/person)
USDA
Carbohydrates
Total fat
Source: USDA, http://www.ers.usda.gov/
Protein

37.
Is there any data that supported
the notion of decreased fat intake
in US?
Yes. Only data that supports this notion is data
that is presented as percentage of total energy
intake (E%). But this is misleading because the
increased intake of carbohydrates over the time,
and thus increased intake of total calories, drives
the percentage of fat calories down.
37

38.
NHANES studies 1971-2010
Percentage of energy intake
38

39.
Intake of fat, carbohydrates and protein
(percentage of energy intake/day/person)
NHANES
Ford ES, Dietz WH. Trends in energy intake among adults in the United States:
findings from NHANES. Am J Clin Nutr. 2013 Apr;97(4):848-53.

40.
Conclusion
• There is no decrease in fat intake in US population during the past
four decades.
• Intake of carbohydrates has increased and intake protein has
remained rather stable during the same time period. Therefore the
percentage of total calories from fat has decreased.
• US population has not followed low fat diet but has only increased
carbohydrate intake.
• It’s misleading to claim that US population had followed low fat diet
as it was described in dietary guidelines in 1980s.
• US population has adopted higher carbohydrate intake without any
decrease in fat consumption
40

41.
The real problem: Western crappy diet
is one of the key reasons for obesity
and type 2 diabetes epidemic
I’m indeed loving it

42.
Western diet, the junk food diet, that many
follow is associated with increased risk of
type 2 diabetes in prospective cohorts
Page 42
Alhazmi A., et al. he association between dietary patterns and type 2 diabetes: a systematic
review and meta-analysis of cohort studiesJ Hum Nutr Diet 2014;27:251–260
“By contrast, there was evidence of an increased risk of type 2 diabetes by
comparing the highest and lowest adherence to unhealthy dietary patterns intake
when all studies were pooled (RR = 1.44, 95% CI = 1.33–1.57, P < 0.005) (Fig. 3).

43.
Analysis of 3 cohorts: Western diet is
associated with increased risk of obesity in
prospective cohorts while recommended
food items seem to protect from weight gain
Page 43
Mozaffarian D et al. Changes in diet and lifestyle and long-term weight gain in women and men. NEJM.
2011;364:2392-404.

44.
Conclusion
• Different universally recommended dietary patterns are associated
with reduced risk of weight gain, type 2 diabetes and deaths.
Dietary guidelines are supported by scientific evidence.
• Guidelines have never recommended use of refined carbs, ie. low
fiber grains, cereals and sugar, which clearly are bad for health
• Majority of people do not adhere to dietary guidelines. Substantial
part of western populations follow western diet pattern
characterized with “junk food”.
• Claiming that people receive heart attack or become obese and
diabetic by following dietary guidelines is unfounded
44

45.
A bonus.
Why there is then so much
controversy around the
guidelines?
Let’s give a word to Seth Yoder
@thescienceofnutrition
45

46.
46
Read this text and you know. Worth
your 20 minutes.

47.
Disclaimer
I’m not saying the recommended diet would
be superior or the only way of healthy eating.
There are several variants of healthy diets.
For example, low carb, “Paleolithic” and
vegan diets can be healthy if food choices are
right.
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48.
Wellcome aboard!
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http://www.pronutritionist.net
Reijo Laatikainen, RD, MBA
Images bought and licensed from BigStockPhoto. Snapshots from papers and sites referred to.
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