Banning flavoured vaping liquids? A very bad idea.

Banning flavoured vaping liquids? A very bad idea.

OVERVIEW

  • In response to the increase in the number of young vapers, Health Canada recently proposed to ban most flavouring ingredients in vaping liquids.
  • Data collected in San Francisco, where a ban on the sale of flavoured vaping liquids has been in effect since 2018, shows a significant increase in the number of young people who have smoked cigarettes after the introduction of this measure, which raises serious doubts about the effectiveness of this approach.
  • In addition, the ban on vaping flavours will deprive several thousand adult smokers of the best tool available to quit smoking, as documented by several recent clinical studies.
  • The plan to eliminate vaping flavours from the market therefore seems ill-advised and we believe that its application should at the very least be delayed pending a better determination of its impact on smoking rates, both among young people and adults.

Health Canada recently sought comments on proposed regulations to ban most flavouring ingredients in vaping liquids, with the exception of a limited number of ingredients to impart tobacco or mint/menthol flavour.

This proposal is based on four assumptions:

  • There is apparently a “vaping epidemic” among young Canadians.
  • Flavoured liquids are believed to be one of the main factors contributing to the rapid increase in vaping among young people.
  • Vapers will develop a nicotine addiction and start smoking cigarettes. In other words, vaping would be a stepping stone to tobacco, what is colloquially called the “gateway effect”.
  • As a result, eliminating flavours from vaping liquids will discourage e-cigarette use and thus help prevent youth smoking.

The goal of protecting young people from tobacco is obviously laudable, but a careful examination of the data accumulated over the past few years raises several doubts about the effectiveness of banning flavoured vaping liquids to achieve this. In addition, this project completely ignores the potentially devastating effect of such a ban on adults who use flavoured electronic cigarettes to quit smoking. Before eliminating vaping flavours from the current market, we believe it is important to take a step back and examine the potential negative impacts of this ban, both among young people and adult smokers.

Youth smoking is at an all-time low. First of all, it is important to mention that we have made spectacular progress in the fight against youth smoking. Surprisingly, very little is said about it, but the number of high school students who smoke cigarettes regularly is currently at an all-time low, with only 3% of young smokers aged 15–19 in 2020 in Canada, compared to more than 30% in the late 1990s. A similar phenomenon is observed in most industrialized countries: in New York, for example, there are only 2.4% of smokers in high school compared to 27% in 2000. In concrete terms, this means that over the last 20 years, we have reduced the proportion of young smokers by 90%, which is phenomenal.

Of course, we may wish to reduce this number even further, but we must nevertheless admit that the efforts of recent years in the fight against tobacco have borne fruit and that we have collectively succeeded in making smoking a marginal and old-fashioned behaviour, rejected by the vast majority of young people. Given that more than 90% of adult smokers started smoking as teenagers, this means that the next generation of adults will be overwhelmingly non-smokers and consequently much less affected by the health problems caused by smoking (especially lung cancer) than previous generations. The current status quo therefore represents an unprecedented victory in the fight against tobacco.

Few young people vape regularly and those who do are smokers or ex-smokers. The number of young people who vape has actually increased in recent years. The latest statistics show that in 2019, around 41% of 16–19 year-olds had tried these products at least once, compared to 29% in 2017. On the other hand, it should absolutely be mentioned that this number of vapers is artificially inflated by including young people who have only experimented with electronic cigarettes on a few occasions. When we restrict the analysis to those who use e-cigarettes at least 20 times per month, the data is much less spectacular, with 5.7% regular vapers (see our article on this). In addition, the vast majority of these regular vapers are smokers or ex-smokers, with barely 1% who have never smoked cigarettes. Strictly speaking, there is therefore no vaping epidemic, especially since the latest US data indicates that the proportion of young vapers has decreased by 50% in the last two years, which could indicate that vaping is much more of a passing fad than a lasting transformation in the habits of young people.

Could this vaping among young people, even if it does not reach truly epidemic proportions, still erase this progress and lead to an upsurge in youth smoking? Tobacco control organizations seem to think so and that is why they want to eliminate flavours from vaping liquids to make e-cigarettes less appealing to young people. In other words, it is a question here of making electronic cigarettes “ugly” to reduce their attractiveness and social acceptability and thus prevent exposure to a nicotine-based product from causing young people to turn to tobacco (gateway effect).

This fear of a stepping stone to tobacco is in a way similar to the old mentality of the war on drugs. At the time (towards the end of the 1960s), it was believed that drug users were irremediably attracted by increasingly dangerous products. According to this belief, a cannabis smoker was at a very high risk of becoming a heroin addict, as if people who were attracted to one drug were unable to control themselves and were doomed to always want to go further, even if it meant destroying themselves. We now know that these fears were completely unwarranted and that just because people enjoy the effects of a recreational drug does not mean that they will become irrational. The legalization of cannabis reflects this change in perception of soft drugs.

The same reasoning can be applied to vaping: why would a young person who likes vaping decide to “go further” and turn to a source of nicotine known to be harmful, less appetizing, more expensive, and completely rejected by society like cigarettes? The data accumulated in recent years indicate that this is indeed unlikely and that far from being a stepping stone to tobacco, electronic cigarettes could instead represent a substitute for traditional cigarettes.

Vaping does not lead to smoking. First of all, it should be pointed out that the hypothesis of the gateway effect is completely incompatible with the current situation of youth smoking. Even though electronic cigarettes have been available for several years, the reality is that the proportion of young people who smoke tobacco cigarettes continues to decrease year after year. The arrival of the “pod mod” type electronic cigarettes (Juul, for example), which are even more efficient in terms of nicotine absorption, did not affect this downward trend in smoking among young people and, on the contrary, even accelerated it. In other words, the “vaping epidemic” among young people, so much decried by anti-tobacco organizations, has not led to an increase, but rather a marked decrease in youth smoking, something that would obviously be impossible if vaping led young people to smoke cigarettes.

The claim that vaping is a gateway to tobacco is based on a misinterpretation of studies that have addressed this issue. These studies show that electronic cigarette use is indeed associated with an increased risk of cigarette smoking, which may seemingly validate the existence of a gateway effect. In reality, however, it is impossible to establish a direct cause and effect link between the two behaviours due to what is called “common liabilities”: young people attracted by nicotine will experiment with several forms available, without this meaning that trying one will push them toward another.

In practice, studies show unequivocally that the vast majority of vapers are smokers or ex-smokers, with less than 1% of regular vapers who have never smoked. This suggests that if there is a gateway effect, it is rather in the opposite direction (and positive in terms of reducing tobacco damage), i.e. from cigarettes to vaping.

Vaping is a substitute for smoking. Like it or not, nicotine has long been a recreational drug that attracts significant numbers of young people. For a long time, tobacco was the only available source of this drug, and it is for this reason that rates of youth smoking reached worrying highs until the early 2000s. However, this is no longer the case today, at least in industrialized countries. The electronic cigarette now competes directly with tobacco and represents in practice a much more attractive alternative for nicotine users.

In addition to a better taste (because of the flavours added to vaping liquids) and being devoid of the defects of smoked tobacco (the smell, in particular), a marked advantage of the electronic cigarette is that it is a lot less harmful to health than traditional cigarettes. While the combustion of tobacco generates several thousand highly toxic and carcinogenic compounds that dramatically increase the risk of developing a host of pathologies, in particular cardiovascular disease and lung cancer, the amount of most of these compounds is reduced by 99% in the vapour emanating from electronic cigarette devices (see our article on this subject). According to several major scholarly associations (Public Health England, Académie française de médecine, National Academies of Science, Engineering and Medicine of the United States), electronic cigarettes are at least 20 times less harmful than smoked tobacco.

Vaping therefore has several competitive advantages over smoked tobacco, and it is for this reason that this new technology is establishing itself as a substitute for tobacco cigarettes among nicotine users. Economic analyses also confirm this role of substitution, since an increase in the tax on one of the products (tobacco or electronic cigarettes) leads to a decrease in the consumption of the taxed product for the benefit of the other. For example, one study showed that an increase in the tax on electronic cigarettes was associated with a reduction in vaping and a parallel increase in the sale of tobacco cigarettes. Conversely, an equivalent increase in the tobacco tax leads to an increase in the number of vapers. The two products are therefore substitutes from an economic point of view, which is why a decrease in the competitiveness of the electronic cigarette due to a higher price results in an increase in smoking. It has been estimated that for each cartridge (pod) of vaping liquid that is not purchased due to a tax increase, an additional 6 packs of tobacco cigarettes will be sold. Since a ban on flavoured vaping liquids will also decrease the competitiveness of e-cigarettes, there is concern that a similar phenomenon could occur (see next sections).

Overall, these observations suggest that the electronic cigarette can in a way be considered as a disruptive technology, i.e. an innovation that has the potential to compete with tobacco and even possibly replace it as the main source of nicotine consumed by the population (e.g. digital cameras that have eliminated film cameras).

This is very interesting, since there is usually no going back when one technology supplants another. To take a simple example, streaming has made DVD movie rental clubs a thing of the past, just as DVDs had previously driven VHS tapes out of the market. It is unthinkable that we will ever go back to these old technologies, just as we can be sure that the dial telephone will never take the place of our current cellphones. The electronic cigarette therefore has the potential to eliminate tobacco cigarettes in the medium and long term, a product which, it should be remembered, is responsible for nearly 8 million premature deaths each year. The multinational tobacco companies are perfectly aware of this evolution of the market and it is for this reason that they are gradually turning away from traditional cigarettes to develop less harmful electronic versions, and even anticipate the outright disappearance of traditional cigarettes in the next 10 to 15 years.

Banning flavours could lead to an increase in youth smoking. The main fear invoked to justify the ban on flavoured vaping liquids, namely a massive migration of young vapers to traditional cigarettes, therefore seems unjustified and one can wonder about the relevance of changing the current status quo. Especially since it is necessary to consider that the ban on flavours could have effects contrary to those sought. Since it appears increasingly obvious that the electronic cigarette is a substitute for tobacco cigarettes, isn’t there a risk that by discouraging vaping we push young vapers who are more addicted to nicotine toward tobacco? As Public Health England recently put it, “If an approach makes e-cigarettes less accessible, less palatable or acceptable, more expensive, less consumer-friendly, or less pharmacologically effective, then it causes harm by perpetuating smoking.

Given that the strategy of banning vaping flavours is fairly recent, it is not yet clear exactly how young people will react to the disappearance of these flavours. On the other hand, the preliminary data are very worrying; a study carried out in the San Francisco area, where a ban on the sale of flavoured vaping liquids has been in effect since 2018, recently showed a significant increase in the number of young people who smoked cigarettes after the introduction of this measure, while the smoking trend continues to decline in other parts of the United States where these flavours have not been prohibited (Figure 1).

Figure 1. Impact of a law banning vaping flavours on youth smoking. From Friedman (2021). Note the increase in the number of teenagers who smoked cigarettes following the implementation of the law banning flavours in 2018 (arrow).

 

A survey of young adults aged 18–34 paints a similar picture: When asked what they would do if vaping flavours were banned, 33.2% responded that they would likely use tobacco cigarettes as a source of nicotine. Therefore, there seems to be a significant proportion of young vapers who could make the jump to tobacco cigarettes in response to the disappearance of vaping flavours, which is obviously the reverse of the desired effect. In our view, if the objective of the project to completely ban flavoured vaping liquids is to prevent an upsurge in youth smoking, these observations should at least cause a delay in the application of this measure while waiting to be able to confirm or not this upward trend. In a sector where two products are in direct competition with each other, any attempt to make one of the two products less attractive (by taxing it or banning flavours, for example) is likely to strongly favour the other. Given the catastrophic health effects of tobacco, this is a huge risk that deserves careful consideration.

Vaping flavours play an important role in smoking cessation. Adult smokers are largely forgotten in the current debate on electronic cigarettes, even though they are by far the main users of these products. There is a lot of talk about the (very hypothetical) dangers of an upsurge in youth smoking caused by vaping, but the huge, clinically proven contribution of e-cigarettes as a smoking cessation aid is completely overlooked. In randomized clinical trials (the standard of excellence for clinical research), it is observed that electronic cigarettes are about twice as effective in leading to smoking cessation than traditional approaches (patches, gum). This is particularly true for heavy smokers, who are very dependent, where an even more impressive success rate is observed for electronic cigarettes, 6 times higher than with standard nicotine substitutes.

There is nothing abstract or theoretical about the effectiveness of electronic cigarettes in promoting smoking cessation: surveys reveal that at least 4.3 million Americans, 2.4 million Britons, and 7.5 million Europeans have quit smoking thanks to these devices, at the same time drastically reducing their risk of dying prematurely. There is therefore no doubt that electronic cigarettes have strongly contributed to the significant decline in adult smoking worldwide, from 23.5% in 2007 to 19% today.

The argument often invoked by opponents of vaping, namely that it is not proven that the electronic cigarette can help with smoking cessation, therefore does not correspond at all to the scientific reality and to that experienced by many ex-smokers for whom this new technology has literally saved their lives.

Flavoured vaping liquids are extremely important in enabling smokers to adopt e-cigarettes. Surveys on this subject show that adults much prefer fruit, dessert and candy flavours to that of tobacco. Flavours are therefore not only appealing to young people, because for a smoker looking to break their addiction to cigarettes, tobacco flavoured vaping liquids are often the last thing sought. Banning flavoured vaping liquids would therefore have the direct consequence of eliminating the main appeal of electronic cigarettes, consequently reducing the number of smokers who could adopt this method to break their addiction to cigarettes. In our opinion, this is a huge collateral damage to the proposed flavour prohibition, since the acceptability of a substitute for cigarettes is essential for quitting. In fact, a recent study showed that adult smokers who started vaping flavoured liquids (fruit, candy, chocolate, etc.) were more likely to be able to quit smoking than those who used tobacco flavours.

For all of these reasons, it seems to us that banning vaping flavours is a very bad idea. The effectiveness of this measure in stopping vaping among young people is questionable (flavours are only one of the factors that encourage vaping), and it is certain that it will have negative impacts on adult smokers by eliminating an alternative to tobacco. It should also be mentioned that a decrease in the number of adults who quit smoking has a negative impact on young people, not only because parental smoking is the main risk factor linked to the initiation of smoking in children and adolescents, but also because of the psychological trauma caused by the disease and/or death attributable to smoking in adults around them.

The disagreements over the issue of vaping reflect the evolution of two major schools of thought in the fight against tobacco. On the one hand, there is what we might call “abstentionists” or prohibitionists, for whom the only way to reduce smoking is to abstain completely from any product that contains nicotine, even when it is well documented that these products are much less harmful than smoked tobacco. Seeking to reduce the number of vapers by banning flavours, despite the fact that these products are much less dangerous than tobacco, is a good example of this “all or nothing” approach. In practice, we are no longer talking here only of the fight against tobacco, but rather of a more general fight against nicotine as a recreational drug, even if this drug has no major effects on health as such.

On the other hand, we find the “pragmatists” who are much more interested in concrete results (reduction in tobacco-related illnesses and mortality) than in the means to achieve them. In this approach, cigarettes remain the enemy to be defeated and anything that can reduce the damage caused by the combustion of tobacco is valued, especially when the experimental data clearly show a decrease in toxicity, as is the case for electronic cigarettes. The British are the leaders in this harm reduction approach and the public health agency of this country (Public Health England) strongly encourages all smokers to migrate to electronic cigarettes.

I firmly believe that this pragmatic approach to reducing the harm caused by tobacco is the best. Abstinence is a good virtue in theory, but the reality is that many smokers are extremely addicted to cigarettes and are absolutely unable to quit without a substitute allowing them to absorb an amount of nicotine equivalent to that found in tobacco. I can no longer count the number of my patients who had tried everything, without success, to overcome their addiction to tobacco, until the day they tried e-cigarettes and finally succeeded. A success that has been in many cases a true question of life and death, because there is no doubt that many of them would have died by now if they had not succeeded in quitting smoking. It would be extremely unfortunate if individuals who have to deal with a very heavy tobacco addiction were deprived of the best tool identified so far to quit smoking, namely vaping of flavours other than tobacco.

 

 

 

 

Will cultured meat soon be on our plates?

Will cultured meat soon be on our plates?

OVERVIEW

  • To preserve the planet’s environment and produce enough food to meet growing global demand, experts believe that in the future there will be a need to reduce livestock farming and conventional meat consumption.
  • Cultured meat is presented as a sustainable alternative to farmed meat for those who want to protect the environment but do not want to become vegetarians.
  • For cultured meat to be consumed on a large scale, production techniques and social acceptability will have to make significant progress.

Today there are 7.3 billion human beings on our planet, and it is expected that there will be 9 billion by 2050. The Food and Agriculture Organization (FAO) estimates that in 2050, 70% more food will be required to meet the demand of the growing population. This poses a great challenge because of limited resources and arable land. Meat production (especially beef and pork) is the most resource-intensive, and experts believe it would not be responsible, or even possible, to continue to produce more and more of these foods. Even though meat consumption is declining in developed countries, it is increasing globally because consumers in developing countries are getting richer and meat is seen by the new middle class in these countries as a desirable luxury food.

Among the solutions proposed to get out of this impasse is cultured meat (or lab-grown meat), which is presented as a sustainable alternative to farmed meat for those who want to protect the environment, but who do not wish to become vegetarians. It should be noted that some experts consider that cultured meat poses certain problems and that it would not be a viable alternative to conventional meat (see here and here). We will come back to this a little later in the text.

How is meat grown?
To grow meat, you must first obtain a muscle sample from a live adult animal (by biopsy, under anesthesia) and isolate a subpopulation of cells called “stem” or “satellite” cells. These stem cells participate in muscle regeneration and have the ability to differentiate into muscle cells themselves. The muscle stem cells are then cultured in bioreactors in the presence of a nutrient medium containing growth factors that induce rapid proliferation. The cells are then transformed into muscle cells that form structures called “myotubes” no larger than 0.3 mm in length and mechanically assembled into muscle tissue and ultimately into ground meat or artificial “steak”.

Problematic use of fetal calf serum and growth promoters
The best culture medium for growing cells contains fetal calf serum, obtained from fetal blood after slaughtering a pregnant cow. The procedure usually used (cardiac puncture of the still alive calf fetus) is considered cruel and inhumane by many. This is a problem since large numbers of calves would have to be produced to meet the demand for large-scale meat cultivation, and this use is unacceptable to vegetarians and those who follow a vegan diet or lifestyle. Fortunately, it is now possible, on a laboratory scale, to grow muscle cells without the use of fetal calf serum. However, the serum-free culture will need to be adopted on an industrial scale. To replace fetal calf serum, the industry will need to use growth factors and hormones that will need to be produced on an industrial scale. The use of growth promoters is prohibited in the European Union for conventional meat production; however, you cannot grow meat without using these growth factors and hormones. Overexposure to certain growth promoters can have harmful effects on human health, but this is a subject of debate and several countries approve the supervised use of stimulators in animal production.

From cell to steak
Real muscle (meat) is made up of muscle fibres organized into bundles, blood vessels, nerves, connective tissues, and adipocytes (fat cells). Simply producing animal muscle cells is therefore not enough to recreate meat. This is why in 2013 the first dish prepared from cultivated meat was a simple burger-type patty. Industries that develop cultured meat must now attempt to recreate a 3D structure that will resemble real meat as much as possible, a task that is proving difficult. It’s about recreating the taste experience associated with eating a steak, chicken thigh or shrimp.

Researchers have recently made progress and successfully created small samples of cultured meat that mimic real meat. Using a new approach, a Japanese research group succeeded in growing beef muscle cells in long filaments aligned in a single direction, a structure that closely resembles muscle fibres. When these cultured cells were stimulated by an electric current, the filaments contracted, similar to muscle fibres. Researchers at the University of Tokyo have so far managed to produce pieces of cultured meat weighing a few grams at most. The next challenge will be to successfully produce larger pieces of cultured meat, up to 100 g, and introduce other tissues (blood vessels, fat cells) to mimic meat more convincingly. It should be noted that the culture medium used in this study contained fetal calf serum, an ingredient that cannot be used industrially for ethical and economic reasons, as mentioned above.

Cultured chicken meat
Singapore’s food regulatory agency approved the sale of meat grown by the US company Eat Just in 2020. It was the first time that the sale of cultured meat had been permitted by a state. Eat Just grows chicken meat using a process that does not require antibiotics. This cultured meat is safe because it contains very low levels of bacteria, much less than conventional chicken meat. Cultured chicken meat contains a little more protein, has a more varied amino acid composition, and contains more monounsaturated fat than conventional meat. The muscle cells are grown in 1200-litre bioreactors and then combined with plant ingredients to make chicken nuggets. The Singapore-approved process uses fetal calf serum, but Eat Just plans to use a serum-free culture medium in their future productions.

Estimation of the environmental cost of cultured meat
Cultivated meat production offers many environmental advantages compared to conventional meat, according to a study published in 2011. It would reduce greenhouse gas (GHG) emissions by 78 to 96%, use 7 to 45% less energy and 82 to 96% less water, depending on the type of product. In contrast, a more recent and rigorous study suggests that in the long term, the impact of cultured meat on the environment may be greater than that associated with livestock farming. Cultivated meat production will certainly reduce global warming in the short term since less GHGs will be emitted compared to cattle farming. In the very long term however (i.e., several hundred years), models predict that this would not necessarily be the case, because the main GHG generated by livestock, methane (CH4), does not accumulate in the atmosphere, unlike CO2 which is practically the only GHG generated by cultivated meat. Another study based on data from 15 companies involved in the production of cultured meat concludes that it is less harmful to the environment than the production of beef, but that it has a greater impact on the environment than the production of chicken, pork and plant-based “meat”. In order for the environmental score of cultivated meat to be better than that of conventional products, the industry would have to use only sustainable energy.

Cost of cultured meat
The first cultivated beef burger was produced in 2013 by a Dutch laboratory at an estimated cost of US $416,000. In 2015, the cost of production (on an industrial scale) was reduced to around $12, and it is expected that the price could be the same as conventional meat within ten years. The cultured chicken nuggets produced by Just Eat each cost $63 to produce in 2019, so industries still have some way to go for cultured meat to become affordable enough for consumers to consume on a regular basis.

Cultured meat: an alternative for Canadians?
According to a 2018 Dalhousie University survey of 1,027 Canadians, 32.2% of respondents planned to reduce their meat consumption in the next 6 months. However, cultured meat is not very popular with Canadians as only 18.3% of those consulted said that this new type of “meat” represented an alternative to real meat for them. There is hope, however, as younger consumers (40 and under) seem more likely (34%) to view cultured meat as an alternative.

Will cultured meat one day replace conventional meat on our plates? Although there is still progress to be made before this is possible, both in terms of production and social acceptability, we can hope that the important efforts made will lead to results within a decade. Ideally, for our health and that of the planet, we should reduce our consumption of meat (of all kinds) and eat mainly plants, as is the case with the Mediterranean diet and other traditional diets.

Environmental impacts associated with food production

Environmental impacts associated with food production

OVERVIEW

  • Food production is responsible for about 25% of the greenhouse gases emitted annually, with half of these GHGs coming from animal farming, mainly in the form of methane.
  • The agricultural sector is also an important source of fine particles responsible for air pollution, with the majority of these pollutants coming from ammonia generated by livestock farming.
  • Overall, a reduction in the consumption of animal products, particularly those from cattle farming, is therefore absolutely essential to limit global warming and improve air quality.

The latest report from the Intergovernmental Panel on Climate Change (IPCC) confirms that, if nothing is done, the constant build-up of greenhouse gases (GHG) in the atmosphere will cause temperatures to increase by more than 1.5ºC above pre-industrial levels over the next century, namely the target set by the Paris Agreement to minimize the negative effects of global warming. There is therefore an urgent need to drastically reduce the emission of these gases if we want to prevent the consequences of this warming, already visible today, from becoming out of control and causing an increase in the incidence of extreme climatic events (droughts, heat waves, hurricanes, forest fires), disrupting life on Earth (extinction of species, fall in agricultural yields, increase in infectious diseases, armed conflicts) and increasing the incidence of several diseases linked to excessive heat.

Carbon dioxide and other greenhouse gases
The main greenhouse gas is carbon dioxide (CO2), which now has a concentration of 417 ppm, about twice as much as in pre-industrial times. However, it should be noted that other gases, even if they are present in smaller quantities, also contribute to global warming. These gases, such as methane or certain molecules used for industrial purposes, capture heat in a much greater way than CO2 and therefore have a higher global warming potential (GWP) than CO2. For example, a tonne of methane has a GWP 28 times greater than a tonne of CO2 over a 100-year period, while the GWP of some industrial gases such as sulfur hexafluoride can reach almost 25,000 times that of CO2 (Table 1). In other words, even if many of these gases are present in minute quantities, on the order of a few parts per billion (10-9) or even per trillion (10–12), their emission is several times that of CO2 and therefore significantly contributes to warming.

Table 1. Global warming potential of various greenhouse gases.1 Values are for the year 2018, except for CO2 which is for 2020. Derived from the United States Environmental Protection Agency (EPA).2 Calculated for a 100-year period. From Greenhouse Gas Protocol. *ppm (part per million or 10-6); **ppb (part per billion or 10-9); ***ppt (part per trillion or 10–12).

To calculate this contribution to global greenhouse gas emissions, the method generally used is to convert these emissions into CO2 equivalents (CO2eq) by multiplying their quantity in the atmosphere by their respective GWP. For example, 1 kg of SF6 is equivalent to 23,500 kg (23.5 tonnes) of CO2 (1 kg × 23,500 = 23,500 CO2eq), while it takes 1000 kg of methane to reach an equivalent amount of CO2 (1000 kg × 28 = 28,000 CO2eq). When this method is applied to all gases, it is estimated that 75% of greenhouse gas emissions are in the form of CO2, the remainder coming from methane (17%), nitrous oxide (6%), and various fluorinated gases (2%) (Figure 1).

Figure 1. Distribution of greenhouse gas emissions. Adapted from Ritchie and Roser (2020).


Emissions sources
The use of fossil fuels to support human activities (transport, electricity production, heating, various industrial processes) is the main source of greenhouse gases, accounting for around three quarters of total emissions (Figure 2). This enormous “carbon footprint” implies that the fight against global warming necessarily requires a transition to “cleaner” sources of energy, in particular with regard to transport and electricity production. This is especially true in a country like Canada, where we emit an average of 20 tonnes of CO2eq per person per year, which ranks us, along with the United States and Australia, among the worst producers of GHGs in the world (Quebec, for its part, does better, with about 10 tonnes of CO2eq per person per year).


Figure 2. Contribution of the food sector to the annual production of greenhouse gases. Adapted from Ritchie and Roser (2020).

Another industry that contributes significantly to greenhouse gas emissions, but that we hear much less about, is food production. It is estimated that around 25% of all these gases come from the production and distribution of food, a proportion that rises to 33% when food waste is taken into account. The food sector involved in animal protein production alone is responsible for half of these food-related GHG emissions, mainly due to methane produced by livestock and aquaculture (31%) (see box). Livestock farming also requires large spaces, created in some cases by massive deforestation (in the Amazon, for example), which eliminates huge areas of plants that can sequester COs. Livestock farming also requires large quantities of forage plants and therefore the use of nitrogen fertilizers to accelerate the growth of these plants. The CO2 and nitrous oxide released into the atmosphere during the production of these fertilizers therefore contribute to the GHG generated by livestock.

Where does methane come from?
Methane (CH4) is the end product of the decomposition of organic matter. Methanogenesis is made possible by certain anaerobic microorganisms from the archaea domain (methanogens) which reduce carbon, present in the form of CO2 or certain simple organic acids (acetate, for example), to methane, according to the following reactions:

CO+ 4 H2 → CH4 + 2 H2O

CH3COOH → CH4 + CO2

The methane generated by livestock comes mainly from the fermentation of carbonaceous products inside the digestive system of ruminants. In these animals, the digestion of plant matter generates volatile fatty acids (acetate, propionate, butyrate), which are absorbed by the animal and used as a source of energy, and lead in parallel to the production of methane, about 500 L per day per animal, most of it being released through the mouth of the animal. Globally, livestock is estimated to emit about 3.1 Gt of CO2-eq as methane, which represents almost half of all anthropogenic methane emissions.

Aquaculture is another rapidly expanding form of farming, now accounting for over 60% of the global supply of fish and seafood for human consumption. Although GHG emissions from this sector are still much lower than those associated with livestock, recent measurements nonetheless indicate a sharp increase in its global warming potential, mainly due to an increase in methane production. In these systems, the sediments accumulate food residues used for the growth of fish and seafood as well as the droppings generated by these animals. The transformation of this organic material leads to the production of methane, which can then be diffused into the atmosphere.

Finally, it should be noted that the majority of aquaculture systems are located in Asia, where they are often established in regions previously occupied by mangroves, ecosystems located along the coasts and deltas of tropical regions. The destruction of these mangroves (very often for shrimp farming) is very harmful to global warming, because mangrove forests collectively store around 4 billion tonnes of CO2 and their elimination therefore has a concrete impact on the climate.

A good way to visualize the impact of livestock farming on GHG production is to compare the emissions associated with different foods of animal and plant origin based on the amount of protein in these foods (Figure 3). These comparisons clearly show that products derived from livestock products, beef in particular, represent a much greater source of GHGs than plants. The production of 100 g of beef protein, for example, generates on average 100 times more GHGs than the same amount of protein from nuts or legumes. This is true even for beef produced in the traditional way, i.e., from animals that feed exclusively on grass: these animals grow more slowly and therefore emit methane for a longer period, which cancels out the benefits that could be associated with the sequestration of CO2 by the grass that they eat.

Figure 3. Comparison of GHG levels generated during the production of different protein sources. Based on Poore and Nemecek (2018), as modified by Eikenberry (2018).

These huge differences in GHGs associated with the production of everyday food therefore clearly show that our food choices can have a significant influence on global warming. Since the majority of GHG emissions come from livestock, it is evident that a reduction in the consumption of meat, and animal products as a whole, will have the most positive impact. These benefits can be observed even with a fairly modest reduction in meat intake, as in the Mediterranean diet, or simply by replacing products from ruminants (beef and dairy products) by other sources of animal protein (poultry, pork, fish) (Figure 4). Obviously, a more drastic reduction in meat intake is even more beneficial, whether through the adoption of a flexitarian diet (high intake of plants, but little meat and animal products), vegetarian (no animal products, with the exception of eggs, dairy products and sometimes fish), and vegan (no animal products). This remains true even if the plants consumed come from abroad and sometimes travel long distances, because contrary to popular belief, transport only accounts for a small proportion (less than 10%) of the GHGs associated with a given food.

Figure 4. Potential for mitigation of GHG emissions by different types of diets. Adapted from IPCC (2019).

It is impossible to completely decarbonize food production, especially in a world where there are over 9 billion people to feed daily. On the other hand, there is no doubt that the GHG footprint of food can be significantly reduced by reducing the consumption of products derived from ruminants, such as beef and dairy products. This is extremely important, because the status quo is untenable. According to recent models, even if GHG emissions from fossil fuels ceased immediately, we would still not succeed in reaching the target of a maximum warming of 1.5ºC due to emissions produced by the current food production system.

Another aspect that is often overlooked is how fast and significant this positive impact of a reduction in cattle breeding products can be. Even though methane is a GHG almost 30 times more powerful than CO2, its life in the atmosphere is much shorter, around 10–20 years vs. several thousand years for CO2. Concretely, this means that an immediate drop in methane emissions, for example following a drastic reduction in the consumption of beef and dairy products, can have measurable effects on GHG levels in the following years and therefore represents the fastest and most efficient way to slow global warming.

Pollution from food
In addition to contributing to global GHG emissions, another environmental impact of food production is its contribution to air pollution. This negative impact of the food sector should not be overlooked, because while the influence of global warming caused by GHGs will be felt above all in the medium and longer term, atmospheric pollutants have an immediate effect on health: air pollution is currently the 7th leading cause of premature death worldwide, being directly responsible for around 4 million deaths annually (Figure 5). In some countries, such as the United States, it is estimated that agriculture and livestock are responsible for about 20% of this air pollution-related mortality.

Figure 5. Leading causes of premature mortality worldwide. Note that air pollution is the only risk factor of environmental origin, not related to lifestyle. From GBD 2016 Risk Factors Collaborators (2016).

Fine particles of 2.5 µm and less (PM2.5) are mainly responsible for these negative impacts of air pollution on health. Due to their small size, these particles easily penetrate the lungs to the pulmonary alveoli, where they pass directly to the pulmonary blood vessels and then to all arteries in the body. They then produce an inflammatory reaction and oxidative stress that damage the vascular endothelium, the thin layer of cells that covers the inner walls of the arteries and ensures their proper functioning. The arteries therefore dilate less easily and tend to contract more, which interferes with normal blood circulation. For all these reasons, it is cardiovascular diseases (coronary heart disease and stroke) that represent the main consequence of exposure to fine particles, and alone are responsible for about 80% of all deaths caused by ambient air pollution (Figure 6).

Figure 6. Distribution of premature deaths (in millions) caused by fine particles PM2.5.
Note the predominance of cardiovascular disease as a cause of death linked to air pollution. Adapted from Lelieveld et al. (2015).

Primary and secondary particles
Fine particles can be emitted directly from polluting sources (primary PM2.5) or indirectly, following the combination of several distinct particles present in the atmosphere (secondary PM2.5) (Figure 7). Much of the primary PM2.5 is in the form of carbon soot, produced by the incomplete combustion of fossil fuels (diesel and coal, especially) or biomass (forest fires, for example). Carbon soot is also associated with various organic compounds (polycyclic aromatic hydrocarbons), acids, metals, etc., which contribute to its toxicity after inhalation. These particles can be transported aloft over very long distances and, once deposited, be resuspended in the wind. In urban areas, this resuspension also takes place under the action of road traffic. This turbulence associated with automobile traffic is also responsible for the production of another class of primary PM2.5 called fugitive road dust.

Secondary PM2.5, on the other hand, are formed from precursors such as sulfur dioxide (SO2), nitrogen oxides (NOx), various volatile organic compounds containing carbon (organic carbon) as well as ammonia (NH3). The chemical reactions that govern the interaction between these different volatile substances to form the secondary fine particles are extraordinarily complex, but let us only mention that it is well established that the presence of the ammonium ion (NH4+), derived from ammonia (NH3), neutralizes the negative charge of certain gases and thus promotes their aggregation in the form of fine particles (Figure 7). Consequently, the presence of NH3 in the atmosphere often represents a limiting step in the formation of these secondary fine particles and a reduction in these emissions can therefore have concrete effects on improving air quality.


Figure 7. Schematic representation of the mechanisms of formation of fine particles PM2.5.

It is this important role of ammonia in the formation of secondary fine particles that explains the contribution of the food production sector to air pollution. Agriculture and livestock are in fact responsible for almost all anthropogenic ammonia emissions, a consequence of intensive livestock farming, the spreading of manure and slurry, and the industrial production of nitrogen fertilizers.

An American study clearly illustrates this contribution of agricultural ammonia to the negative impacts of air pollution on health. In this study, the researchers show that of the approximately 18,000 deaths caused annually by pollution derived from the agricultural sector, the vast majority (70%) of these deaths are a consequence of ammonia emissions (and therefore secondary PM2.5), while the emission of primary PM2.5, from plowing, the combustion of agricultural residues, and machinery, is responsible for the rest. Since the vast majority of ammonia emissions come from animal faeces and the use of natural (manure and slurry) or synthetic fertilizers to grow food for these animals, it is not surprising that the production of food from livestock is the main cause of deaths attributable to pollution from agricultural sources (Figure 8).

Figure 8. Distribution of deaths caused annually by PM2.5 from the agricultural sector in the United States. Note that 70% of the mortality is attributable to livestock products, mainly due to the ammonia generated by the animals as well as by the spreading of manure, slurry and synthetic fertilizers for the cultivation of fodder plants (corn, soybeans). From Domingo et al. (2021).

When we compare the impact of different foods for the same quantity of product, we immediately see that the production of red meat is particularly damaging, being responsible for at least 5 times more deaths than that of poultry, 10 times more than that of nuts and seeds, and at least 50 times more than that of other plants such as fruits and vegetables (Figure 9).

Figure 9. Comparison of PM2.5-related mortality by food types. From Domingo et al. (2021).

In short, whether in terms of reducing GHG emissions or health problems associated with atmospheric pollution, all the studies unequivocally show that a reduction in environmental damage caused by food production necessarily involves a reduction in the consumption of products of animal origin, in particular those from cattle farming. A change that is all the more profitable as the reduction in the intake of food of animal origin, combined with an increase in the consumption of plants, is beneficial for health and could prevent about 11 million premature deaths annually, a decrease of 20%.

Choosing the right sources of carbohydrates is essential for preventing cardiovascular disease

Choosing the right sources of carbohydrates is essential for preventing cardiovascular disease

OVERVIEW

  • Recent studies show that people who regularly consume foods containing low-quality carbohydrates (simple sugars, refined flours) have an increased risk of cardiovascular events and premature mortality.
  • Conversely, a high dietary intake of complex carbohydrates, such as resistant starches and dietary fibre, is associated with a lower risk of cardiovascular disease and improved overall health.
  • Favouring the regular consumption of foods rich in complex carbohydrates (whole grains, legumes, nuts, fruits and vegetables) while reducing that of foods containing simple carbohydrates (processed foods, sugary drinks, etc.) is therefore a simple way to improve cardiovascular health.

It is now well established that a good quality diet is essential for the prevention of cardiovascular disease and the maintenance of good health in general. This link is particularly well documented with regard to dietary fat: several epidemiological studies have indeed reported that too high a dietary intake of saturated fat increases LDL cholesterol levels, an important contributor to the development of atherosclerosis, and is associated with an increased risk of cardiovascular disease. As a result, most experts agree that we should limit the intake of foods containing significant amounts of saturated fat, such as red meat, and instead focus on sources of unsaturated fat, such as vegetable oils (especially extra virgin olive oil and those rich in omega-3s such as canola), as well as nuts, certain seeds (flax, chia, hemp) and fish (see our article on this subject). This roughly corresponds to the Mediterranean diet, a diet that has repeatedly been associated with a lower risk of several chronic diseases, especially cardiovascular disease.

On the carbohydrate side, the consensus that has emerged in recent years is to favour sources of complex carbohydrates such as whole grains, legumes and plants in general while reducing the intake of simple carbohydrates from refined flour and added sugars. Following this recommendation, however, can be much more difficult than one might think, as many available food products contain these low-quality carbohydrates, especially the entire range of ultra-processed products, which account for almost half of the calories consumed by the population. It is therefore very important to learn to distinguish between good and bad carbohydrates, especially since these nutrients are the main source of calories consumed daily by the majority of people. To achieve this, we believe it is useful to recall where carbohydrates come from and how industrial processing of foods can affect their properties and impacts on health.

Sugar polymers
All of the carbohydrates in our diet come from, in one way or another, plants. During the photosynthetic reaction, in addition to forming oxygen (O2) from carbon dioxide in the air (CO2), plants also simultaneously transform the energy contained in solar radiation into chemical energy, in the form of sugar:

6 CO2 + 12 H2O + light → C6H12O6 (glucose) + 6 O2 + 6 H2O

In the vast majority of cases, this sugar made by plants does not remain in this simple sugar form, but is rather used to make complex polymers, i.e., chains containing several hundred (and in some cases thousands) sugar molecules chemically bonded to one another. An important consequence of this arrangement is that the sugar contained in these complex carbohydrates is not immediately accessible and must be extracted by digestion before reaching the bloodstream and serving as a source of energy for the body’s cells. This prerequisite helps prevent sugar from entering the blood too rapidly, which would unbalance the control systems responsible for maintaining the concentration of this molecule at levels just sufficient enough to meet the needs of the body. And these levels are much lower than one might think; on average, the blood of a healthy person contains a maximum of 4 to 5 g of sugar in total, or barely the equivalent of a teaspoon. Dietary intake of complex carbohydrates therefore provides enough energy to support our metabolism, while avoiding excessive fluctuations in blood sugar that could lead to health problems.

Figure 1 illustrates the distribution of the two main types of sugar polymers in the plant cell: starches and fibres.

Figure 1. The physicochemical characteristics and physiological impacts of starches and dietary fibres from plant cells. Adapted from Gill et al. (2021).

Starches. Starches are glucose polymers that the plant stores as an energy reserve in granules (amyloplasts) located inside plant cells. This source of dietary carbohydrates has been part of the human diet since the dawn of time, as evidenced by the recent discovery of genes from bacteria specializing in the digestion of starches in the dental plaque of individuals of the genus Homo who lived more than 100,000 years ago. Even today, a very large number of plants commonly eaten are rich in starch, in particular tubers (potatoes, etc.), cereals (wheat, rice, barley, corn, etc.), pseudocereals (quinoa, chia, etc.), legumes, and fruits.

Digestion of the starches present in these plants releases units of glucose into the bloodstream and thus provides the energy necessary to support cell metabolism. However, several factors can influence the degree and speed of digestion of these starches (and the resulting rise in blood sugar). This is particularly the case with “resistant starches” which are not at all (or very little) digested during gastrointestinal transit and therefore remain intact until they reach the colon. Depending on the factors responsible for their resistance to digestion, three main types of these resistant starches (RS) can be identified:

  • RS-1: These starches are physically inaccessible for digestion because they are trapped inside unbroken plant cells, such as whole grains.
  • RS-2: The sensitivity of starches to digestion can also vary considerably depending on the source and the degree of organization of the glucose chains within the granules. For example, the most common form of starch in the plant kingdom is amylopectin (70–80% of total starch), a polymer made up of several branches of glucose chains. This branched structure increases the contact surface with enzymes specialized in the digestion of starches (amylases) and allows better extraction of the glucose units present in the polymer. The other constituent of starch, amylose, has a much more linear structure which reduces the efficiency of enzymes to extract the glucose present in the polymer. As a result, foods with a higher proportion of amylose are more resistant to breakdown, release less glucose, and therefore cause lower blood sugar levels. This is the case, for example, with legumes, which contain up to 50% of their starch in the form of amylose, which is much more than other commonly consumed sources of starches, such as tubers and grains.
  • RS-3: These resistant starches are formed when starch granules are heated and subsequently cooled. The resulting starch crystallization, a phenomenon called retrogradation, creates a rigid structure that protects the starch from digestive enzymes. Pasta salads, potato salads, and sushi rice are all examples of foods containing resistant starches of this type.

An immediate consequence of this resistance of digestion-resistant starches is that these glucose polymers can be considered dietary fibre from a functional point of view. This is important because, as discussed below, the fermentation of fibre by the hundreds of billions of bacteria (microbiota) present in the colon generates several metabolites that play extremely important roles in the maintenance of good health.

Dietary fibre. Fibres are polymers of glucose present in large quantities in the wall of plant cells where they play an important role in maintaining the structure and rigidity of plants. The structure of these fibres makes them completely resistant to digestion and the sugar they contain does not contribute to energy supply. Traditionally, there are two main types of dietary fibre, soluble and insoluble, each with its own physicochemical properties and physiological effects. Everyone has heard of insoluble fibre (in wheat bran, for example), which increases stool volume and speeds up gastrointestinal transit (the famous “regularity”). This mechanical role of insoluble fibres is important, but from a physiological point of view, it is mainly soluble fibres that deserve special attention because of the many positive effects they have on health.

By capturing water, these soluble fibres increase the viscosity of the digestive contents, which helps to reduce the absorption of sugar and dietary fats and thus to avoid excessive increases in blood sugar and blood lipid levels that can contribute to atherosclerosis (LDL cholesterol, triglycerides). The presence of soluble fibre also slows down gastric emptying and can therefore decrease calorie intake by increasing feelings of satiety. Finally, the bacterial community that resides in the colon (the microbiota) loves soluble fibres (and resistant starches), and this bacterial fermentation generates several bioactive substances, in particular the short chain fatty acids (SCFA) acetate, propionate and butyrate. Several studies carried out in recent years have shown that these molecules exert a myriad of positive effects on the body, whether by reducing chronic inflammation, improving insulin resistance, lowering blood pressure and the risk of cardiovascular disease, or promoting the establishment of a diversified microbiota, optimal for colon health (Table 1).

A compilation of many studies carried out in recent years (185 observational studies and 58 randomized trials, which equates to 135 million person-years) indicates that consuming 25 to 30 g of fibre per day seems optimal to benefit from these protective effects, approximately double the current average consumption.

Table 1. Main physiological effects of dietary fibre. Adapted from Barber (2020).

Physiological effectsBeneficial health impacts
MetabolismImproved insulin sensitivity
Reduced risk of type 2 diabetes
Improved blood sugar and lipid profile
Body weight control
Gut microbiotaPromotes a diversified microbiota
Production of short-chain fatty acids
Cardiovascular systemDecrease in chronic inflammation
Reduced risk of cardiovascular events
Reduction of cardiovascular mortality
Digestive systemDecreased risk of colorectal cancer

Overall, we can therefore see that the consumption of complex carbohydrates is optimal for our metabolism, not only because it ensures an adequate supply of energy in the form of sugar, without causing large fluctuations in blood sugar, but also because it provides the intestinal microbiota with the elements necessary for the production of metabolites essential for the prevention of several chronic diseases and for the maintenance of good health in general.

Modern sugars
The situation is quite different, however, for several sources of carbohydrates in modern diets, especially those found in processed industrial foods. Three main problems are associated with processing:

Simple sugars. Simple sugars (glucose, fructose, galactose, etc.) are the molecules responsible for the sweet taste: the interaction of these sugars with receptors present in the tongue sends a signal to the brain warning it of the presence of an energy source. The brain, which alone consumes no less than 120 g of sugar per day, loves sugar and responds positively to this information, which explains our innate attraction to foods with a sweet taste. On the other hand, since the vast majority of carbohydrates produced by plants are in the form of polymers (starches and fibres), simple sugars are actually quite rare in nature, being mainly found in fruits, vegetables such as beets, or even some grasses (sugar cane). It is therefore only with the industrial production of sugar from sugar cane and beets that consumers’ “sweet tooth” could be satisfied on a large scale and that simple sugars became commonly consumed. For example, data collected in the United States shows that between 1820 and 2016, the intake of simple sugars increased from 6 lb (2.7 kg) to 95 lb (43 kg) per person per year, an increase of about 15 times in just under 200 years (Figure 2).

 

 

Figure 2. Consumption of simple sugars in the United States between 1820 and 2016.  From Guyenet (2018).

Our metabolism is obviously not adapted to this very high intake of simple sugars, far beyond what is normally found in nature. Unlike the sugars found in complex carbohydrates, these simple sugars are absorbed very quickly into the bloodstream and cause very rapid and significant increases in blood sugar. Several studies have shown that people who frequently consume foods containing these simple sugars are more likely to suffer from obesity, type 2 diabetes and cardiovascular disease. For example, studies have found that consuming 2 servings of sugary drinks daily was associated with a 35% increase in the risk of coronary heart disease. When the amount of added sugars consumed represents 25% of daily calories, the risk of heart disease nearly triples. Factors that contribute to this detrimental effect of simple sugars on cardiovascular health include increased blood pressure and triglyceride levels, lowered HDL cholesterol, and increased LDL cholesterol (specifically small, very dense LDLs, which are more harmful to the arteries), as well as an increase in inflammation and oxidative stress.

It is therefore necessary to restrict as much as possible the intake of simple sugars, which should not exceed 10% of the daily energy intake according to the World Health Organization. For the average adult who consumes 2,000 calories per day, that’s just 200 calories, or about 12 teaspoons of sugar or the equivalent of a single can of soft drink.

Refined flour.  Cereals are a major source of carbohydrates (and calories) in most food cultures around the world. When they are in whole form, i.e., they retain the outer shell rich in fibre and the germ containing several vitamins and minerals, cereals are a source of complex carbohydrates (starches) of high quality and beneficial to health. This positive impact of whole grains is well illustrated by the reduced risk of coronary heart disease and mortality observed in a large number of population studies. For example, recent meta-analyses have shown that the consumption of about 50 g of whole grains perday is associated with a 22–30% reduction in cardiovascular disease mortality, a 14–18% reduction in cancer-relatedmortality, and a 19–22% reduction in total mortality.

On the other hand, these positive effects are completely eliminated when the grains are refined with modern industrial metal mills to produce the flour used in the manufacture of a very large number of commonly consumed products (breads, pastries, pasta, desserts, etc.). By removing the outer shell of the grain and its germ, this process improves the texture and shelf life of the flour (the unsaturated fatty acids in the germ are sensitive to rancidity), but at the cost of the almost total elimination of fibres and a marked depletion of several nutrients (minerals, vitamins, unsaturated fatty acids, etc.). Refined flours therefore essentially only contain sugar in the form of starch, this sugar being much easier to assimilate due to the absence of fibres that normally slow down the digestion of starch and the absorption of released sugar (Figure 3).

Figure 3. Schematic representation of a whole and refined grain of wheat.

Fibre deficiency. Fortification processes partially compensate for the losses of certain nutrients (e.g., folic acid) that occur during the refining of cereal grains. On the other hand, the loss of fibre during grain refining is irreversible and is directly responsible for one of the most serious modern dietary deficiencies given the many positive effects of fibre on the prevention of several chronic diseases.

Poor-quality carbohydrates
Low-quality carbohydrate sources with a negative impact on health are therefore foods containing a high amount of simple sugars, having a higher content of refined grains than whole grains, or containing a low amount of fibre (or several of these characteristics simultaneously). A common way to describe these poor-quality carbohydrates is to compare the rise in blood sugar they produce to that of pure glucose, called the glycemic index (GI) (see box). The consumption of food with a high glycemic index causes a rapid and dramatic rise in blood sugar levels, which causes the pancreas to secrete a large amount of insulin to get glucose into the cells. This hyperinsulinemia can cause glucose to drop to too low levels, and the resulting hypoglycemia can ironically stimulate appetite, despite ingesting a large amount of sugar a few hours earlier. Conversely, a food with a low glycemic index produces lower, but sustained, blood sugar levels, which reduces the demand for insulin and helps prevent the fluctuations in blood glucose levels often seen with foods with a high glycemic index. Potatoes, breakfast cereals, white bread, and pastries are all examples of high glycemic index foods, while legumes, vegetables, and nuts are conversely foods with a low glycemic index.

Glycemic index and load
The glycemic index (GI) is calculated by comparing the increase in blood sugar levels produced by the absorption of a given food with that of pure glucose. For example, a food that has a glycemic index of 50 (lentils, for example) produces a blood sugar half as important as glucose (which has a glycemic index of 100). As a general rule, values below 50 are considered to correspond to a low GI, while those above 70 are considered high. The glycemic index, however, does not take into account the amount of carbohydrate in foods, so it is often more appropriate to use the concept of glycemic load (GL). For example, although watermelon and breakfast cereals both have high GIs (75), the low-carbohydrate content of melon (11 g per 100 g) equates to a glycemic load of 8, while 26 g of carbohydrates present in breakfast cereals result in a load of 22, which is three times more. GLs ≥ 20 are considered high, intermediate when between 11 and 19, and low when ≤ 10.

PURE study
Results from the PURE (Prospective Urban and Rural Epidemiology) epidemiological study conducted by Canadian cardiologist Salim Yusuf have confirmed the link between low-quality carbohydrates and the risk of cardiovascular disease. In the first of these studies, published in the prestigious New England Journal of Medicine, researchers examined the association between the glycemic index and the total glycemic load of the diet and the incidence of major cardiovascular events (heart attack, stroke, sudden death, heart failure) in more than 130,000 participants aged 35 to 70, spread across all five continents. The study finds that a diet with a high glycemic index is associated with a significant (25%) increase in the risk of having a major cardiovascular event in people without cardiovascular disease, an increase that reaches 51% in those with pre-existing cardiovascular disease (Figure 4). A similar trend is observed for the glycemic load, but in the latter case, the increased risk seems to affect only those with cardiovascular disease at the start of the study.

Figure 4. Comparison of the risk of cardiovascular events according to the glycemic index or the glycemic load of the diet of healthy people (blue) or with a history of cardiovascular disease (red). The median glycemic index values were 76 for quintile 1 and 91 for quintile 5. For glycemic load, the mean values were 136 g of carbohydrates per day for Q1 and 468 g per day for Q5. Note that the increased risk of cardiovascular events associated with a high glycemic index or load is primarily seen in participants with pre-existing cardiovascular disease. From Jenkins et al. (2021).

The impact of the glycemic index appears to be particularly pronounced in overweight people (Figure 5). Thus, while the increase in the risk of major cardiovascular events is 14% in thin people with a BMI less than 25, it reaches 38% in those who are overweight (BMI over 25).

 

Figure 5. Impact of overweight on the increased risk of cardiovascular events related to the glycemic index of the diet. The values shown represent the increased risk of cardiovascular events observed for each category (quintiles 2 to 5) of the glycemic index compared to the category with the lowest index (quintile 1). The median values of the glycemic indices were 76 for quintile 1; 81 for quintile 2; 86 for quintile 3; 89 for quintile 4; and 91 for quintile 5. Taken from Jenkins et al. (2021).

This result is not so surprising, since it has long been known that excess fat disrupts sugar metabolism, especially by producing insulin resistance. A diet with a high glycemic index therefore exacerbates the rise in postprandial blood sugar already in place due to excess weight, which leads to a greater increase in the risk of cardiovascular disease. The message to be drawn from this study is therefore very clear: a diet containing too many easily assimilated sugars, as measured using the glycemic index, is associated with a significant increase in the risk of suffering a major cardiovascular event. The risk of these events is particularly pronounced for people with less than optimal health, either due to the presence of excess fat or pre-existing cardiovascular disease (or both). Reducing the glycemic index of the diet by consuming more foods containing complex carbohydrates (fruits, vegetables, legumes, nuts) and fewer products containing added sugars or refined flour is therefore an essential prerequisite for preventing the development of cardiovascular disease.

Refined flours
Another part of the PURE study looked more specifically at refined flours as a source of easily assimilated sugars that can abnormally increase blood sugar levels and increase the risk of cardiovascular disease. Researchers observed that a high intake (350 g per day, or 7 servings) of products containing refined flours (white bread, breakfast cereals, cookies, crackers, pastries) was associated with a 33% increase in the risk of coronary heart disease, 47% in the risk of stroke, and 27% in the risk of premature death. These observations therefore confirm the negative impact of refined flours on health and the importance of including as much as possible foods containing whole grains in the diet. The preventive potential of this simple dietary change is enormous since the consumption of whole grains remains extremely low, with the majority of the population of industrialized countries consuming less than 1 serving of whole grains daily, well below the recommended minimum (half of all grain products consumed, or about 5 servings per day).

Wholemeal breads are still a great way to boost the whole-grain intake. However, special attention must be paid to the list of ingredients. In Canada, the law allows up to 5% of the grain to be removed when making whole wheat flour, and the part removed contains most of the germ and a fraction of the bran (fibres). This type of bread is superior to white bread, but it is preferable to choose products made from whole-grain flour which contains all the parts of the grain. Note also that multigrain breads (7-14 grains) always contain 80% wheat flour and a maximum of 20% of a mixture of other grains (otherwise the bread does not rise), so the number of grains does not matter, but what does matter is whether the flour is whole wheat or ideally integral, which is not always the case.

In short, a simple way to reduce the risk of cardiovascular events and improve health in general is to replace as much as possible the intake of foods rich in simple sugars and refined flour with plant-based foods containing complex carbohydrates. In addition to carbohydrates, this simple change alone will influence the nature of the proteins and lipids ingested as well as, at the same time, all the phenomena that promote the appearance and progression of atherosclerotic plaques.

Omega-3 fatty acid supplements are ineffective for the prevention of cardiovascular disease

Omega-3 fatty acid supplements are ineffective for the prevention of cardiovascular disease

OVERVIEW

  • The VITAL study in participants who did not have cardiovascular disease and the ASCEND study in diabetic patients did not show a beneficial effect of omega-3 fatty acid supplements on cardiovascular health.
  • The REDUCE-IT study reported a beneficial effect of an omega-3 fatty acid supplement (Vascepa®), while the STRENGTH study reported no effect of another supplement (Epanova®).
  • The divergent results of the REDUCE-IT and STRENGTH studies have raised scientific controversy, mainly about the questionable use of mineral oil as a neutral placebo in the REDUCE-IT study.
  • Overall, the results of the studies lead to the conclusion that omega-3 fatty acid supplements are ineffective in preventing cardiovascular disease, in primary prevention and most likely also in secondary prevention.

Consuming fish on a regular basis (1–2 times per week) is associated with a reduced risk of death from coronary heart disease (see these meta-analyses here and here). In addition, favourable associations between fish consumption and the risks of type 2 diabetes, stroke, dementia, Alzheimer’s disease and cognitive decline have also been identified.

A large number of studies have suggested that it is mainly omega-3 (O-3) fatty acids, a type of very long-chain polyunsaturated fatty acid found in high amounts in several fish species, that are the cause of the positive health effects of eating fish and other seafood. For example, a meta-analysis of 17 prospective studies published in 2021 indicates that the risk of dying prematurely was significantly lower (15–18%) in participants who had the most circulating O-3s, compared to those who had the least. In addition, favourable associations of the same magnitude were observed for cardiovascular and cancer-related mortality.

Since eating fish is associated with better cardiovascular health, why not isolate the “active ingredient”, i.e. the omega-3 fatty acids it contains and make supplements with them? This seemed like a great idea; the same pharmacological approach has been applied successfully to a host of plants, fungi and microorganisms, which has made it possible to create drugs. One such example is aspirin, a derivative of salicylic acid found in the bark of certain tree species, quinine extracted from the cinchona shrub (antimalarial), digitoxin extracted from purple digitalis (treatment of heart problems), paclitaxel from yew (anticancer), etc.

Are marine O-3 supplements just as or even more effective than the whole food from which they are extracted? Several randomized controlled studies (RCTs) have been carried out in recent years to try to prove the effectiveness of O-3s. Meta-analyses of RCTs (see here and here) indicate that O-3 supplements (EPA and DHA) have little or no effect in primary prevention, i.e. on the risk of developing cardiovascular disease or dying prematurely from cardiovascular disease or any other cause. In contrast, data from some studies indicated that O-3 supplements may have beneficial effects in secondary prevention, i.e. in people with cardiovascular disease.

In order to obtain a higher level of evidence, several large, well-planned and controlled studies have been carried out recently: ASCEND, VITAL, STRENGTH and REDUCE-IT. The VITAL study (VITamin D and omegA-3 TriaL) in 25,871 participants who did not have cardiovascular disease and the ASCEND study (A Study of Cardiovascular Events in Diabetes) in 15,480 diabetic patients did not demonstrate any beneficial effects of O-3 supplements on cardiovascular health.

The results of the REDUCE-IT (REDUction of Cardiovascular Events with Icosapent ethyl-Intervention Trial) and STRENGTH (Outcomes Study to Assess STatin Residual Risk Reduction With EpaNova in HiGh CV Risk PatienTs With Hypertriglyceridemia) studies were then published. The results of these studies were eagerly anticipated since they tested the effect of O-3 supplements on major strokes at high doses (3000–4000 mg O-3/day) in patients at risk treated with a statin to lower blood cholesterol, but who had high triglyceride levels.

The results of these two studies are divergent, which has raised scientific controversy. The REDUCE-IT study reported a significant reduction of 25% in the number of cardiovascular events in the group of patients who took daily O-3 supplementation (Vascepa®; ethyl-EPA), compared to the group of patients who took a placebo (mineral oil). The STRENGTH study reported an absence of effect of O-3 supplements (Epanova®; a mixture of EPA and DHA in the form of carboxylic acids) on major cardiovascular events in patients treated with a statin, compared to the group of patients who took a corn oil placebo.

Several hypotheses have been proposed to explain the different results between the two large studies. One of them is that the mineral oil used as a placebo in the REDUCE-IT study may have caused adverse effects that would have led to a false positive effect of the O-3 supplement. Indeed, mineral oil is not a neutral placebo since it caused an average increase of 37% of C-reactive protein (CRP), a marker of systemic inflammation in the control group, as well as a 7.4% increase in LDL cholesterol and 6.7% in apolipoprotein B compared to the group that took Vascepa. These three biomarkers are associated with an increased risk of cardiovascular events.

Two other hypotheses could explain the difference between the two studies. It is possible that the moderately higher plasma levels of EPA obtained in the REDUCE-IT study could be the cause of the beneficial effects seen in this study, or that the DHA used in combination with EPA in the STRENGTH study may have counteracted the beneficial effects of EPA.

To test these two hypotheses, the researchers responsible for the STRENGTH study performed post-hoc analyses of the data collected during their clinical trial. Patients were classified according to their plasma EPA level after 12 months of daily supplementation with O-3. Thus, in the first tertile, patients had an average plasma EPA concentration of 30 µg/mL, those in the second tertile: 90 µg/mL, and those in the third tertile: 151 µg/mL. The mean plasma concentration of EPA in the third tertile (151 µg/mL) is comparable to that reported in the REDUCE-IT study (144 µg/mL). Analyses show that there was no association between the plasma concentration of EPA or DHA and the number of major cardiovascular events. The authors conclude that there is no benefit to taking O-3 supplements for secondary prevention, but they suggest that more studies should be done in the future to compare mineral oil and corn oil as placebos and also to compare different formulations of omega-3 fatty acids.

Overall, the results of recent studies lead to the conclusion that O-3 supplements are ineffective in preventing cardiovascular disease, in primary prevention and most likely also in secondary prevention. It should be noted that, taken in large amounts, O-3 supplements can have unwanted effects. In fact, in both the STRENGTH and REDUCE-IT studies, the incidence of atrial fibrillation was significantly higher with the use of O-3 supplements. In addition, bleeding was more common in patients who took ethyl-EPA (Vascepa®) in the REDUCE-IT study than in patients who took the placebo. It therefore seems safer to eat fish once or twice a week to maintain good health than to take ineffective and expensive supplements.