Food, Nutrients and Health: Interim Evidence Update 2018

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Date published: 2019-01-22

The Evidence Review Cycle for Dietary Guidance (ERC) is Health Canada's ongoing systematic approach to gathering, assessing, and analyzing scientific evidence relevant to dietary guidance. This process helps to ensure that dietary guidance from Health Canada on healthy eating, such as Canada's Food Guide, remains scientifically sound, current, relevant, and useful. The ERC examines evidence in three key input areas that inform dietary guidance: Scientific Basis; Relevance in the Canadian Context; and Use of Existing Dietary Guidance (Figure 1). The current Food, Nutrients and Health: Interim Evidence Update 2018 focuses specifically on one of the key areas of the ERC—the Scientific Basis. It aims to:

ensure that dietary guidance from Health Canada is developed using the latest scientific evidence;
maintain credibility in Health Canada's approach to gathering evidence on relationships between food, nutrients and health;
provide an overview of evidence on convincing relationships between food, nutrients and health gathered between July 2015 and November 2018;
summarize the state of the evidence on convincing relationships between food, nutrients and health gathered between January 2006 and November 2018.

Figure 1: Key input areas to inform decisions about dietary guidance. Text description follows. — **Figure 1: Key input areas to inform decisions about dietary guidance**

A brief summary of the methodology for the evidence review process of the scientific basis is described in Annex 1. When developing dietary guidance, Health Canada uses convincing findings that are supported by a well-established evidence base and are unlikely to change in the foreseeable future as new scientific evidence emerges. Annex 2 provides an overview of evidence on convincing relationships between food, nutrients and health gathered between July 2015 and November 2018. Annex 3 summarizes the state of the evidence on convincing relationships between food, nutrients and health gathered between January 2006 and November 2018.

Annex 1: Summary of the Evidence Review Process Methodology

Health Canada used the methodology outlined in the 2015 Evidence Review for Dietary Guidance: Technical Report.^Footnote 1 The outcomes of interest were chronic diseases/conditions of public health concern in Canada—as identified in the 2015 evidence review—specifically: cancer (various types), cardiovascular disease/coronary artery disease (including hypertension, dyslipidemia and stroke), obesity (including adiposity and weight gain), osteoporosis (including bone health and fractures), and type 2 diabetes. The following health outcomes were added to the evidence review process since 2015 based on expert reviewer suggestions:

All-cause mortality
Metabolic syndrome
Oral health

In addition, since 2015, there has been an increase in the overall amount of credible evidence. As a result, recent reports generally provide greater detail on food, nutrients and health relationships (for example, specificity of health outcomes, identification of thresholds in the level of exposure to a food or nutrient, stratification of exposures by demographic variables, etc.). Health Canada has refined its approach to gathering and assessing the evidence to accurately reflect the food, nutrients and health relationships provided in more recent reports.

Annex 2: How has Health Canada's General Understanding of Food, Nutrients and Health Relationships Changed Since 2015?

The 2015 Evidence Review for Dietary Guidance: Technical Report^Footnote 1 included a review of 27 reports ^Footnote 2,^Footnote 3,^Footnote 4,^Footnote 5,^Footnote 6,^Footnote 7,^Footnote 8,^Footnote 9,^Footnote 10,^Footnote 11,^Footnote 12,^Footnote 13,^Footnote 14,^Footnote 15,^Footnote 16,^Footnote 17,^Footnote 18,^Footnote 19,^Footnote 20,^Footnote 21,^Footnote 22,^Footnote 23,^Footnote 24,^Footnote 25,^Footnote 26,^Footnote 27,^Footnote 28 published between January 2006 and July 2015 by federal agencies and leading scientific organizations. Since 2015, an additional 33 reports^Footnote 29,^Footnote 30,^Footnote 31,^Footnote 32,^Footnote 33,^Footnote 34,^Footnote 35,^Footnote 36,^Footnote 37,^Footnote 38,^Footnote 39,^Footnote 40,^Footnote 41,^Footnote 42,^Footnote 43,^Footnote 44,^Footnote 45,^Footnote 46,^Footnote 47,^Footnote 48,^Footnote 49,^Footnote 50,^Footnote 51,^Footnote 52,^Footnote 53,^Footnote 54,^Footnote 55,^Footnote 56,^Footnote 57,^Footnote 58,^Footnote 59,^Footnote 60,^Footnote 61 were reviewed. A total of 47 reports^Footnote 2,^Footnote 4,^Footnote 5,^Footnote 6,^Footnote 7,^Footnote 8,^Footnote 9,^Footnote 10,^Footnote 11,^Footnote 12,^Footnote 13,^Footnote 14,^Footnote 15,^Footnote 24,^Footnote 25,^Footnote 26,^Footnote 27,^Footnote 28,^Footnote 29,^Footnote 30,^Footnote 31,^Footnote 32,^Footnote 33,^Footnote 34,^Footnote 35,^Footnote 36,^Footnote 37,^Footnote 38,^Footnote 39,^Footnote 40,^Footnote 41,^Footnote 42,^Footnote 43,^Footnote 44,^Footnote 45,^Footnote 46,^Footnote 47,^Footnote 48,^Footnote 49,^Footnote 54,^Footnote 55,^Footnote 56,^Footnote 57,^Footnote 58,^Footnote 59,^Footnote 60,^Footnote 61 were retained for this Interim Evidence Update as 13 reports^Footnote 3,^Footnote 16,^Footnote 17,^Footnote 18,^Footnote 19,^Footnote 20,^Footnote 21,^Footnote 22,^Footnote 23,^Footnote 50,^Footnote 51,^Footnote 52,^Footnote 53 published between 2006 and 2015 were superseded by updated reports published since 2015.

Consistent convincing evidence

Most of the convincing evidence reviewed since 2015 re-affirmed Health Canada's understanding of food, nutrients and health relationships. For example the following convincing evidence is consistent with previous convincing evidence captured in the 2015 Evidence Review for Dietary Guidance: Technical Report^Footnote 1:

Alcohol:

Alcohol intake and increased risk of liver, oesophageal (squamous cell carcinoma), mouth, pharynx and larynx, colorectal, and breast (postmenopausal) cancer.^Footnote 36,^Footnote 43,^Footnote 44,^Footnote 47,^Footnote 49

Fats:

Replacement of saturated fat with carbohydrate and improved blood lipid levels.^Footnote 56
Replacement of saturated fat or trans fat with unsaturated fat (polyunsaturated or monounsaturated) and improved blood lipid levels in adults.^Footnote 56,^Footnote 57
Replacement of trans fat with unsaturated fat (polyunsaturated or monounsaturated) and improved blood lipid levels in adults.^Footnote 57

Fibre:

Dietary fibre and improved blood lipid levels.^Footnote 34

Meat and meat alternatives:

Diets high in soy protein and lowered low-density lipoprotein (LDL) cholesterol.^Footnote 32
Processed meat intake and increased risk of colorectal cancer.^Footnote 29,^Footnote 49

Patterns:

Healthy dietary patterns and lowered LDL cholesterol and cardiovascular disease risk.^Footnote 32

Sugars:

Intake of sugar-sweetened drinks and increased risk of weight gain, overweight and obesity.^Footnote 60

New convincing evidence

Some of the convincing evidence reviewed since 2015 added to our understanding of food, nutrients and health relationships. For example, there is new convincing evidence for the following food, nutrients and health relationships:

Carbohydrates:

Diets higher in carbohydrate and lower in fat and/or protein and improved blood lipid levels.^Footnote 34

Fats:

Increased intake of polyunsaturated fat and improved blood lipid levels.^Footnote 31,^Footnote 33,^Footnote 54
Replacement of saturated fat with unsaturated fat (polyunsaturated or monounsaturated) and improved blood lipid levels in children.^Footnote 55
Decreased saturated fat intake in children and improved blood lipid levels, lower blood pressure and lower risk of obesity.^Footnote 55
Replacement of trans fat with carbohydrate and improved blood lipid levels.^Footnote 57

Fibre:

Dietary fibre and decreased risk of colon cancer, cardiovascular diseases and type 2 diabetes.^Footnote 34

Glycemic Index/Load:

Higher glycemic index or glycemic load and increased risk of type 2 diabetes.^Footnote 34

Meat and meat alternatives:

Diets high in nuts and lowered LDL cholesterol.^Footnote 32
Processed meat intake and increased risk of cancer.^Footnote 29

Sugars:

Intake of sugars-containing beverages, including 100% fruit juice, and increased risk of dental decay in children.^Footnote 34
Increased intake of sugars and increased risk of excess energy intake leading to weight gain.^Footnote 34

No longer convincing evidence

Occasionally, some relationships are no longer convincing, which also has important implications for dietary guidance. For example, since 2015, the evidence grade changed from 'convincing' to 'probable' for the following food, nutrients and health relationships:

Fibre:

Dietary fibre (total fibre and fibre found in fruits and vegetables as well as whole grains) and decreased risk of colorectal cancer.^Footnote 49

Meat and meat alternatives:

Red meat intake and increased risk of colorectal cancer.^Footnote 49

Annex 3: Summary of Convincing (strong) Food and Health Relationships and Changes Since 2015
PREDICTOR	OUTCOME (SPECIFIC OUTCOME OR RISK FACTOR)	DIRECTION OF RISK^{Table 1 footnote †},^{Table 1 footnote ††}	SOURCE (# OF FINDINGS)	CHANGES IN CONVINCING EVIDENCE SINCE 2015^{Table 1 footnote },^{Table 1 footnote },^{Table 1 footnote **}
Alcohol
Alcohol	Cancer (Colorectal; Breast - postmenopausal; Oesophageal - squamous cell carcinoma; Liver; Mouth, pharynx, larynx)	Increased	WCRF, 2018^{Table 1 footnote 49} (1); WCRF, 2018^{Table 1 footnote 36} (1); WCRF, 2018^{Table 1 footnote 44} (1); WCRF, 2018^{Table 1 footnote 43} (1); WCRF, 2018^{Table 1 footnote 47} (1)	No change
Alcohol (Moderate drinking)	CVD (CHD)	Decreased	DGAC, 2010^{Table 1 footnote 5} (1)	No change
Carbohydrates
Diets higher in carbohydrate, lower fat	CVD (Blood lipids: TC)	Decreased	SACN, 2015^{Table 1 footnote 34} (1)	New finding
Diets higher in carbohydrates, lower fat & average protein	CVD (Blood lipids: LDL; TC)	Decreased	SACN, 2015^{Table 1 footnote 34} (2)	New finding
Diets higher in carbohydrate, differing in the proportion of fat and protein^{Table 1 footnote a}	CVD (BP: SBP; DBP); CVD (Blood lipids: CRP; NEFA; LDL; HDL)	No effect	SACN, 2015^{Table 1 footnote 34} (11)	New finding
Diets higher in carbohydrate and/or lower fat and average protein^{Table 1 footnote a}	Overweight/Obesity (Body weight; Energy intake)	No effect	SACN, 2015^{Table 1 footnote 34} (2)	New finding
Diets higher in carbohydrate, differing in the proportion of fat and protein^{Table 1 footnote a}	T2D (A1c; Fasting insulin; FBG; OGTT)	No effect	SACN, 2015^{Table 1 footnote 34} (7)	New finding
Total carbohydrate intake	Cancer (Colorectal; Colon; Rectal)	No association	SACN, 2015^{Table 1 footnote 34} (3)	New finding
Dietary Behaviours
Fast food	Overweight/Obesity (Weight gain, overweight, obesity)	Increased	DGAC, 2010^{Table 1 footnote 5} (1)	No change
Dietary patterns
DASH combined with independent lowered sodium intake	CVD (BP: SBP & DBD)	Decreased	ACC/AHA, 2013^{Table 1 footnote 2} (1)	No change
Dietary pattern^{Table 1 footnote b}	CVD	Decreased	DGAC, 2015^{Table 1 footnote 4} (1)	No change
Dietary pattern higher in vegetables, fruits, & whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils, & nuts; & limits intake of sweets, SSBs, & red meats	CVD (Blood lipids: LDL); BP (SBP, DBP)	Decreased	ACC/AHA, 2013^{Table 1 footnote 2} (2)	No change
Mediterranean	CVD	Decreased	CCS, 2016^{Table 1 footnote 32} (1)	No change
Macronutrient profiles that contain 5% to 6% saturated fat, 26% to 27% total fat, 15% to 18% protein, & 55% to 59% carbohydrate	CVD (Blood lipids: LDL)	Decreased	ACC/AHA, 2013^{Table 1 footnote 2} (1)	No change
Steps I and II diets from the US National Cholesterol Education Program	CVD (Blood lipids: LDL)	Decreased	CCS, 2016^{Table 1 footnote 32} (1)	No change
Fats
PUFA (EPA & DHA &/or DPA)	All-cause mortality	No association	AHRQ, 2016^{Table 1 footnote 31} (1)	New finding
PUFA (EPA & DHA &/or DPA)	CVD (Blood lipids: TG; TC:HDL ratio)	Decreased	AHRQ, 2016^{Table 1 footnote 31} (2)	New finding
PUFA (EPA &/or DHA)	CVD (Blood lipids: TG)	Decreased	HC, 2016^{Table 1 footnote 33} (1)	New finding
PUFA (EPA & DHA &/or DPA)	CVD (Blood lipids: LDL; HDL)	Increased	AHRQ, 2016^{Table 1 footnote 31} (2)	New finding
PUFA (EPA & DHA &/or DPA)	CVD (Coronary revascularization; Major adverse CVD event; Sudden cardiac death)	No association	AHRQ, 2016^{Table 1 footnote 31} (3)	New finding
PUFA (EPA & DHA &/or DPA)	CVD (BP: SBP & DBP)	No effect	AHRQ, 2016^{Table 1 footnote 31} (1)	New finding
PUFA (Long-chain omega-3)	All-cause mortality	No effect	WHO, 2018^{Table 1 footnote 54} (1)	New finding
PUFA (Long-chain omega-3)	CVD (Blood lipids: HDL)	No effect	WHO, 2018^{Table 1 footnote 54} (1)	New finding
PUFA (Long-chain omega-3)	CVD (Blood lipids: TG)	Decreased	WHO, 2018^{Table 1 footnote 54} (1)	New finding
PUFA (Long-chain omega-3)	CVD (Cardiovascular events)	No effect	WHO, 2018^{Table 1 footnote 54} (1)	New finding
PUFA (Long-chain omega-3)	Overweight/Obesity (BMI; Body weight)	No effect	WHO, 2018^{Table 1 footnote 54} (2)	New finding
PUFA (Type not specified)	CVD (Blood lipids)	Decreased	DGAC, 2010^{Table 1 footnote 5} (1)	No change
SFA	CVD (Blood lipids: LDL, TC); T2D (Insulin resistance)	Increased	DGAC, 2010^{Table 1 footnote 5} (2)	No change
SFA^{Table 1 footnote c} (Decreased)	CVD (Blood lipids: HDL) – In children	No effect	WHO, 2017^{Table 1 footnote 55} (3)	New finding
SFA (Decreased)	CVD (Blood lipids: LDL)	Decreased	ACC/AHA, 2013^{Table 1 footnote 2} (1)	No change
SFA^{Table 1 footnote c} (Decreased)	CVD (Blood lipids: LDL; TC) – In children	Decreased	WHO, 2017^{Table 1 footnote 55} (6)	New finding
SFA^{Table 1 footnote c} (Decreased)	CVD (BP: DBP) – In children	Decreased	WHO, 2017^{Table 1 footnote 55} (2)	New finding
SFA^{Table 1 footnote c} (Decreased)	Overweight/Obesity (BMI; Body weight) – In children	Decreased	WHO, 2017^{Table 1 footnote 55} (4)	New finding
SFA (Reduction in diet for those with SFA intakes >10% of total energy)	CVD (Blood lipids: Apo-B) – In children	Decreased	WHO, 2017^{Table 1 footnote 55} (1)	New finding
TFA	CVD (CHD risk factors & events)	Increased	FAO, 2010^{Table 1 footnote 6} (1)	No change
TFA (Decreased)	CVD (Blood lipids: LDL)	Decreased	ACC/AHA, 2013^{Table 1 footnote 2} (1)	No change
Replacement of carbohydrate with:
MUFA	CVD (Blood lipids: HDL)	Increased	FAO, 2010^{Table 1 footnote 6} (1)	No change
Replacement of SFA with:
Carbohydrate	CVD (Blood lipids: HDL, LDL)^{Table 1 footnote f}	Decreased	FAO, 2010^{Table 1 footnote 6} (1)	No change
Carbohydrate^{Table 1 footnote c}	CVD (Blood lipids: HDL; LDL;TC; LDL:HDL ratio; ApoA-1; Apo-B)^{Table 1 footnote l}	Decreased	WHO, 2016^{Table 1 footnote 56} (24)	New finding
Carbohydrate^{Table 1 footnote c}	CVD (Blood lipids: TG; TG:HDL ratio)^{Table 1 footnote l}	Increased	WHO, 2016^{Table 1 footnote 56} (8)	New finding
MUFA^{Table 1 footnote d}	CVD (Blood lipids: HDL; LDL;TC; TG; TC:HDL ratio; LDL:HDL ratio; ApoA-1^{Table 1 footnote g}; Apo-B)^{Table 1 footnote e}	Decreased	WHO, 2016^{Table 1 footnote 56} (29)	No change
MUFA	CVD (Blood lipids: LDL, TC:HDL ratio)	Decreased	FAO, 2010^{Table 1 footnote 6} (1)	No change
MUFA^{Table 1 footnote c}	CVD (Blood lipids: LDL; TC; TG) – In children	Decreased	WHO, 2017^{Table 1 footnote 55} (3)	New finding
MUFA	CVD (Blood lipids); T2D (Blood lipids)	Decreased	DGAC, 2010^{Table 1 footnote 5} (2)	No change
PUFA^{Table 1 footnote d} (LA & ALA)	CVD (Blood lipids: HDL; LDL; TC; TG; TC:HDL ratio; LDL:HDL ratio; TG:HDL ratio; ApoA-1, Apo-B)^{Table 1 footnote e}	Decreased	WHO, 2016^{Table 1 footnote 56} (36)	No change
PUFA^{Table 1 footnote c} (Type not specified)	CVD (Blood lipids: HDL) – In children	No effect	WHO, 2017^{Table 1 footnote 55} (1)	New finding
PUFA^{Table 1 footnote c} (Type not specified)	CVD (Blood lipids: LDL; TC) – In children	Decreased	WHO, 2017^{Table 1 footnote 55} (2)	New finding
PUFA (Type not specified)	CVD (CVD events, coronary mortality)	Decreased	DGAC, 2015^{Table 1 footnote 4} (1)	No change
Unsaturated Fatty Acids (PUFA & MUFA from vegetable oils)	CVD (Blood lipids: TC, LDL)	Decreased	HC, 2012^{Table 1 footnote 10} (1)	No change
Unsaturated Fatty Acids, especially PUFA (Type not specified)	CVD (Blood lipids: TC, LDL)	Decreased	DGAC, 2015^{Table 1 footnote 4} (1)	No change
TFA	CVD (Blood lipids: HDL)^{Table 1 footnote h}	Decreased	FAO, 2010^{Table 1 footnote 6} (1)	No change
TFA	CVD (Blood lipids: HDL; LDL;TC; ApoA-1; Apo-B)^{Table 1 footnote i},^{Table 1 footnote j}	Decreased	WHO, 2016^{Table 1 footnote 57} (35)	New finding
TFA^{Table 1 footnote k}	CVD (Blood lipids: TG; TC:HDL ratio; LDL:HDL ratio)^{Table 1 footnote i},^{Table 1 footnote j}	Increased	WHO, 2016^{Table 1 footnote 57} (19)	New finding
Replacement of TFA with:
Carbohydrate^{Table 1 footnote k}	CVD (Blood lipids: Apo-B)^{Table 1 footnote p}	Increased	WHO, 2016^{Table 1 footnote 57} (6)	New finding
Carbohydrate^{Table 1 footnote k}	CVD (Blood lipids: LDL;TC; TC:HDL ratio; LDL:HDL ratio; ApoA-1)^{Table 1 footnote p}	Decreased	WHO, 2016^{Table 1 footnote 57} (35)	New finding
MUFA^{Table 1 footnote k}	CVD (Blood lipids: HDL)^{Table 1 footnote m},^{Table 1 footnote o}	Increased	WHO, 2016^{Table 1 footnote 57} (7)	New finding
MUFA^{Table 1 footnote k}	CVD (Blood lipids: LDL; TC; TG; TC:HDL ratio; LDL:HDL ratio; Apo-B^{Table 1 footnote n})^{Table 1 footnote m}	Decreased	WHO, 2016^{Table 1 footnote 57} (40)	New finding
PUFA^{Table 1 footnote k} (Type not specified)	CVD (Blood lipids: HDL)^{Table 1 footnote m},^{Table 1 footnote o}	Increased	WHO, 2016^{Table 1 footnote 57} (7)	New finding
PUFA^{Table 1 footnote k} (Type not specified)	CVD (Blood lipids: LDL; TC; TG; TC:HDL ratio; LDL:HDL ratio; ApoA-1; Apo-B)^{Table 1 footnote m},^{Table 1 footnote o}	Decreased	WHO, 2016^{Table 1 footnote 57} (49)	New finding
Fibre
Cereal fibre	CVD (Coronary events); T2D	Decreased	SACN, 2015^{Table 1 footnote 34} (2)	New finding
Dietary fibre	Cancer (Colon)	Decreased	SACN, 2015^{Table 1 footnote 34} (1)	New finding
Dietary fibre	CVD (Coronary events; Stroke); T2D	Decreased	SACN, 2015^{Table 1 footnote 34} (3)	New finding
Dietary fibre (From mixed sources)	CVD (Blood lipids: HDL, LDL, TC, TG)	No association	SACN, 2015^{Table 1 footnote 34} (1)	New finding
Diets high in viscous soluble fibre, such as oats	CVD (Blood lipids: LDL)	Decreased	CCS, 2016^{Table 1 footnote 32} (1)	No change
Oat bran or beta-glucan supplementation	CVD (Blood lipids: HDL)	No effect	SACN, 2015^{Table 1 footnote 34} (1)	New finding
Oat bran or beta-glucan supplementation	CVD (Blood lipids: LDL)	Decreased	SACN, 2015^{Table 1 footnote 34} (1)	No change
Oat fibre, barley fibre or β-glucan supplements	Overweight/Obesity (Energy intake)	No effect	SACN, 2015^{Table 1 footnote 34} (1)	New finding
Oat bran or beta-glucan supplementation	T2D (FBG)	No effect	SACN, 2015^{Table 1 footnote 34} (1)	New finding
Single grains (i.e. Beta-glucan oat fibre; Barley grain products; Psyllium fibre); Ground whole flaxseed	CVD (Blood lipids: LDL, TC)	Decreased	HC, 2010^{Table 1 footnote 14} (1); HC, 2012^{Table 1 footnote 11} (1); HC, 2011^{Table 1 footnote 13} (1); HC 2014^{Table 1 footnote 9} (1)	No change
Vegetable or fruit fibre	Cancer (Colorectal); T2D	No association	SACN, 2015^{Table 1 footnote 34} (4)	New finding
Glycemic Index/Load
Glycemic index or glycemic load	Overweight/Obesity (Body weight); Cancer	No association	DGAC, 2010^{Table 1 footnote 5} (2)	No change
Glycemic index or glycemic load (Higher)	T2D	Increased	SACN, 2015^{Table 1 footnote 34} (2)	New finding
Glycemic load	T2D	No association	DGAC, 2010^{Table 1 footnote 5} (1)	No change
Grain Products
Whole grains	CVD (Blood lipids: TC, TG); T2D (FBG; Fasting insulin concentration; Insulin sensitivity)	No effect	SACN, 2015^{Table 1 footnote 34} (4)	New finding
Meat and meat alternatives
Diets high in nuts	CVD (Blood lipids: LDL)	Decreased	CCS, 2016^{Table 1 footnote 32} (1)	New finding
Diets high in soy protein	CVD (Blood lipids: LDL)	Decreased	CCS, 2016^{Table 1 footnote 32} (1)	No change
Processed meat	Cancer (General)^{Table 1 footnote q}	Increased	IARC, 2018^{Table 1 footnote 29} (1)	New finding
Processed meat	Cancer (Colorectal)	Increased	WCRF, 2018^{Table 1 footnote 49} (1)	No change
Soy protein	CVD (Blood lipids: TC, LDL)	Decreased	HC, 2015^{Table 1 footnote 8} (1)	No change
Milk and milk alternatives
Milk & milk products	Overweight/Obesity (Weight control)	No association	DGAC, 2010^{Table 1 footnote 5} (1)	No change
Minerals
Potassium^{Table 1 footnote r},^{Table 1 footnote s}	CVD (Blood lipids: TC)	No effect	WHO, 2012^{Table 1 footnote 27} (2)	No change
Potassium^{Table 1 footnote s}	CVD (BP: Resting SBP)	Decreased	WHO, 2012^{Table 1 footnote 27} (1)	No change
Sodium & salt^{Table 1 footnote t} (Decreased)	CVD (Blood lipids: TC)	No effect	WHO, 2012^{Table 1 footnote 28} (2)	No change
Sodium & salt^{Table 1 footnote t} (Decreased)	CVD (BP: Resting SBP)	Decreased	WHO, 2012^{Table 1 footnote 28} (2);	No change
Sodium & salt (Decreased)	CVD (BP: SBP & DBP)	Decreased	ACC/AHA, 2013^{Table 1 footnote 2} (1); DGAC, 2010^{Table 1 footnote 5} (1); NHMRC, 2011^{Table 1 footnote 15} (1)	No change
Sugars
Added sugars (Food &/or SSBs)	Overweight/Obesity (Obesity); T2D	Increased	DGAC, 2015^{Table 1 footnote 4} (2)	No change
Sugar sweetened drinks	Overweight/Obesity (Weight gain, overweight, obesity)	Increased	WCRF, 2018^{Table 1 footnote 60} (1)	No change
Sugar-sweetened beverages	Overweight/Obesity (Adiposity) — In children	Increased	DGAC, 2010^{Table 1 footnote 5} (1)	No change
Sugars	Overweight/Obesity (Excess energy intake)	Increased	SACN, 2015^{Table 1 footnote 34} (1)	New finding
Sugars-containing beverages (Amount and frequency)	Oral health (Dental caries in deciduous dentition) — In children	Increased	SACN, 2015^{Table 1 footnote 34} (1)	New finding
Sugars-sweetened beverages	Cancer (Colon)	No association	SACN, 2015^{Table 1 footnote 34} (1)	New finding
Supplements
PUFA (Omega-3)	CVD (CVD events)	No effect	CCS, 2016^{Table 1 footnote 32} (1)	New finding
Vegetables and Fruit
Fruit and vegetables	CVD (CHD)	Decreased	HC, 2016^{Table 1 footnote 7} (1)	No change
Abbreviations ACC/AHA: American College of Cardiologists/American Heart Association; AHRQ: Agency for Healthcare Research and Quality; ALA: Alpha-linolenic acid; ApoA-1: Apolipoprotein A-1; Apo-B: Apolipoprotein B; BMI: Body mass index; BP: Blood pressure; CCS: Canadian Cardiovascular Society; CRP: C-Reactive Protein; CVD: Cardiovascular disease; CHD: Coronary heart disease; DASH: Dietary Approaches to Stop Hypertension; DBP: Diastolic blood pressure; DGAC: Dietary Guidelines Advisory Committee (US); DHA: Docosahexaenoic acid; DPA: Docosapentaenoic acid; EPA: Eicosapentaenoic acid; FAO: Food and Agriculture Organization of the United Nations; FBG: Fasting blood glucose; HC: Health Canada; HDL: High Density Lipoprotein; IARC: International Agency for Research on Cancer; LA: Linoleic acid; LDL: Low density lipoprotein; MUFA: Monounsaturated fatty acid; NEFA: Non-esterified fatty acid; OGTT: Oral glucose tolerance test; PUFA: Polyunsaturated fatty acid; RCT: Randomized controlled trial; SACN: Scientific Advisory Council on Nutrition (UK); SFA: Saturated Fatty Acid; SSB: Sugar-Sweetened Beverage; SBP: Systolic blood pressure; T2D: Type 2 Diabetes; TC: Total cholesterol; TFA: Trans Fatty Acid; TG: Triglyceride; WCRF: World Cancer Research Fund/American Institute of Cancer Research; WHO: World Health Organization.
Footnotes Table 1 footnote * Changes are assessed based on 2015 Evidence Review for Dietary Guidance: Technical Report^Footnote 1 Return to Table 1 footnote * referrer Table 1 footnote No change: Convincing findings gathered since 2015 that do not change Health Canada's understanding of food, nutrients and health relationships or previous convincing findings (i.e. gathered between 2006 and 2015) that remain convincing to this date. Return to Table 1 footnote referrer Table 1 footnote * New convincing finding: Convincing findings gathered since 2015 that added to Health Canada's understanding of food, nutrients and health relationships or findings that became convincing since 2015 (for example, the evidence grade changed from probable to convincing). Return to Table 1 footnote * referrer Table 1 footnote † No association: There is convincing evidence (mainly from observational cohort studies) that there is no association between the predictor (i.e. food or nutrient) and the specific outcome or risk factor of interest. Return to Table 1 footnote † referrer Table 1 footnote †† No effect: There is convincing evidence (from RCTs) that there is no effect between the predictor (i.e. food or nutrient) and the specific outcome or risk factor of interest. Return to Table 1 footnote †† referrer Table 1 footnote a Examined effects in diets with various proportions of carbohydrates, fats or proteins. Return to Table 1 footnote a referrer Table 1 footnote b Dietary pattern characterized by higher consumption of vegetables, fruits, whole grains, low-fat dairy, and seafood, and lower consumption of red and processed meats, refined grains, and sugar sweetened foods and beverages. Regular consumption of nuts and legumes and moderate consumption of alcohol also are shown to be components of a beneficial dietary pattern in most studies. Additionally, research that includes specific nutrients in their description of dietary patterns indicate that patterns that are lower in saturated fat, cholesterol, and sodium and richer in fibre, potassium, and unsaturated fats are beneficial for reducing cardiovascular risk. Return to Table 1 footnote b referrer Table 1 footnote c Examined effect of replacement in 3 general population groups: general children population, general children population with intakes >10% of total energy from SFA, and general children population with intakes reduced to <10% of total energy from SFA. Return to Table 1 footnote c referrer Table 1 footnote d Examined effect of replacement in four general population groups: general adult population, general adult population with intakes >10% of total energy from SFA, general adult population with intakes reduced to <10% of total energy from SFA, and general adult population with a starting intake of <10% of total energy from SFA. Return to Table 1 footnote d referrer Table 1 footnote e Effect is the opposite when the unsaturated fatty acid is replaced with SFA in adults with a starting intake of <10% of total energy from SFA. Return to Table 1 footnote e referrer Table 1 footnote f Finding also states no change in TC:HDL ratio. Return to Table 1 footnote f referrer Table 1 footnote g ApoA-1 only convincing for MUFA replaced with SFA in adults with a starting intake of <10% of total energy from SFA. Return to Table 1 footnote g referrer Table 1 footnote h Finding also states increased TC:HDL ratio. Return to Table 1 footnote h referrer Table 1 footnote i Effect is the opposite when TFA is replaced with SFA. Return to Table 1 footnote i referrer Table 1 footnote j Also examined with industrial TFA only and found similar results, with the exception of TG finding not being convincing. Return to Table 1 footnote j referrer Table 1 footnote k Examined effect of replacement in the nine general population groups: reduction in industrial TFA in adults, increase in industrial TFA in adults, reduction in ruminant TFA in adults, increase in ruminant TFA in adults, reduction in TFA in adults, reduction in TFA in adults with intakes >1% of total energy from TFA, reduction in TFA in adults with intakes <1% of total energy from TFA, increase in TFA in adults, increase in TFA in adults with intakes <1% of total energy from TFA. Return to Table 1 footnote k referrer Table 1 footnote l Effect is the opposite when the carbohydrate is replaced with SFA. Return to Table 1 footnote l referrer Table 1 footnote m Effect is the opposite when the unsaturated fatty acid is replaced with TFA. Return to Table 1 footnote m referrer Table 1 footnote n When industrial TFA was examined alone, Apo-B was not convincing. Return to Table 1 footnote n referrer Table 1 footnote o Same findings with just industrial TFA. Return to Table 1 footnote o referrer Table 1 footnote p Effect is the opposite when the carbohydrate is replaced with TFA. Return to Table 1 footnote p referrer Table 1 footnote q This finding is based on evidence demonstrating a causal relationship between the consumption of processed meat and cancer of the colorectum. Return to Table 1 footnote q referrer Table 1 footnote r Examined effect of increased potassium intake relative to a lower intake in adults. Return to Table 1 footnote r referrer Table 1 footnote s Examined effect of an increase in potassium intake to at least 90mmol/day relative to a lower intake in adults. Return to Table 1 footnote s referrer Table 1 footnote t Examined effect of decreased sodium intake relative to a higher intake in adults and the effect of a decrease in sodium intake to <2g/day relative to an intake of ≥2g/day in adults. Return to Table 1 footnote t referrer

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Food, Nutrients and Health: Interim Evidence Update 2018

Annex 1: Summary of the Evidence Review Process Methodology

Annex 2: How has Health Canada's General Understanding of Food, Nutrients and Health Relationships Changed Since 2015?

Consistent convincing evidence

New convincing evidence

No longer convincing evidence

References

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