Dr. Dariush Mozaffarian – Translating Nutrition Science into Practice

OmegaMatters: Episode 14

Hosts: Drs. Bill Harris & Kristina Harris Jackson

Guest: Dr. Dariush Mozaffarian

Background and Key Takeaways: Dr. Mozaffarian received his MD at Columbia University in New York City. And he did his Internal Medicine residency at Stanford and a Fellowship in Cardiovascular Medicine at the University of Washington. It was there that he became interested in public health, receiving an MPH and later a doctorate in Public Health from Harvard. In 2006 he joined the faculty at the Harvard Medical School and the School of Public Health. Eight years later moved across town to Tufts University where he’s currently the Dean of the Freedman School of Nutrition Science and Policy. He’s also a Jean Mayer Professor of Nutrition and a Professor of Medicine at Tufts. Almost 20 years ago he published his first paper on omega-3 fatty acids and heart disease. In this episode, Dr. Mozaffarian discusses how he stumbled across omega-3s, the epidemic of poor nutrition, and the potential creation of a National Institute of Nutrition at the NIH.

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Dr. Kristina Harris Jackson: Dr. Mozaffarian received his MD at Columbia University in New York City. And he did his Internal Medicine residency at Stanford and a Fellowship in Cardiovascular Medicine at the University of Washington. It was there that he became interested in public health r- receiving an MPH and later a doctorate in Public Health from Harvard. And in 2006 he joined the faculty at the Harvard Medical School and the School of Public Health. And eight years later moved across town to Tufts University where he’s currently the Dean of the Freedman School of Nutrition Science and Policy. He’s also a Jean Mayer Professor of Nutrition and a Professor of Medicine at Tufts. And almost 20 years ago he published his first paper on Omega-3 fatty acids and heart disease. And it’s this aspect of his career that we want to focus on today.

Dr. Dariush Mozaffarian: A pleasure. Thank you.

Dr. Kristina Harris Jackson: Yeah. So, we’ve already gone into your background. Could you tell us how you got interested in Omega-3 fatty acids?

Dr. Dariush Mozaffarian: Well, you know, for me, I was always interested in what impacted my patient’s health most of all. And it was so clear throughout my training in medical school, in residency, in fellowship, you know, all those years of training, 11 years of training that food was pretty much the biggest factor affecting my patients. You know? If they smoked, probably smoking, but outside that it was really nutrition.

Dr. Dariush Mozaffarian: And yet I wasn’t learning about it at all in medical school, internal medicine residency, or cardiology. So, that was, you know, kind of a big epiphany. And then the second big epiphany was when I started reading about the science myself, so at least I would know enough to help my patients. I realized that the science of the day wasn’t being translated into practice. And so at the time, this was in the 90s at the height of the low fat diet craze where everything was low fat and, you know, after 100 years of Oreos being the top selling cookie in the United States, Entenmann’s, these low fat, like, cardboard tasting things, became the top selling cookie in the United States overnight.

Dr. Dariush Mozaffarian: Even in the 90s the, the dietary guidelines didn’t support low fat diets. They supported high, healthy fat diets. Mediterranean style diets. That was a second epiphany. That, you know, the top cause of first the top cause, of poor health isn’t being taught in healthcare. And then second that, that the science we have isn’t actually being translated into practice. And so those are two things I’ve tried to do in my career; understand the science better and translate it into practice.

Dr. Dariush Mozaffarian:

And, you know, as I mentioned, given what I had learned about fats, you know, one of the most interesting things to me was healthy fats and, and how fats were actually healthy, which had, was not a concept I’d ever heard before. And Omega-3’s are the perfect example of a healthy fat.

Dr. Kristina Harris Jackson: Yeah. Absolutely.

Dr. Bill Harris: Good. Very straightforward. So you really cut your teeth and at Washington, I believe, in epidemiology. You became interested in fat and epidemiology and started out looking at fish and fish intake as it related to outcomes. More recently you’ve gotten more into biomarkers of Omega-3 as it relates to outcomes. Why did you make that transition? Why is that important?

Dr. Dariush Mozaffarian: Well I’ll actually go back a little bit to my original interest. The first thing I wanted to do as a Fellow was to do a randomized control trial of the Mediterranean diet in patients who had survived heart attacks. Do a pilot study of maybe 100 patients, randomized them to a low fat American Heart Association diet, and a Mediterranean diet, and just look at compliance and tolerability for six months. So, I had the funding to do that. Somebody heard me speak from a foundation in Seattle and wanted to fund it. So, I just needed a faculty member to help me do the, be the actual PI (principle investigator) since I was a Fellow.

Dr. Dariush Mozaffarian: So, I went around and talked to 20 or 30 different faculty members at the University of Washington, trying to find somebody to be a PI for this Mediterranean diet trial where we had the protocol and funding. And nobody in medicine was interested in nutrition or Mediterranean diets that I could find. And, I was very lucky in that search to come across David Siscovick, MD, MPH, who was a professor at the University of Washington. And, who you know well, Bill. And David was the first person I talked to. He said, “Look, I don’t have any expertise in Mediterranean diet trials. So, I don’t think I’m the right person for that. But what do you want do in your career? What’s of interest to you? Like, where do you want to be in a few years? What’s your goal?”

Dr. Dariush Mozaffarian: He actually took interest in me as a scientist, as a person, and wanted to help grow my career. And so that’s how I got into working with David and the cardiovascular study was because I found an amazing mentor. And so I just wanna highlight that story, first, just to give kudus to David Siscovick. And also to give kudos to mentors and mentorship. I think for anyone interested in this field you have to find the right mentor.

Dr. Dariush Mozaffarian: To answer your second about biomarkers… focusing on not just dietary self-reported diet, but also biomarkers. I will point out that both are very important and useful. Some people criticize self-reported diet as not providing any useful information. And that’s just not true. There’s plenty of studies that have looked at self-reported diet against a range of other validated tools showing they’re pretty good. They’re not perfect, but they’re pretty good.

Dr. Dariush Mozaffarian: So, you get a lot of information but what you don’t get from self-reported diet is the precision of individual molecules, the objectivity of individual molecules in the bloodstream, and also the integration of diet with metabolism. Because when we eat foods we also have a metabolism, a microbiome or physiology. And so when you look at biomarkers you get that. You get, you know, the specificity of specific molecules, the objectivity where you’re not relying on recall. And this integration of  what we are putting in our mouths and what happens to it when it enters our body in terms of the ultimate levels in our bloodstream. It’s a very powerful way to look at diet-related risk factors like omega-3s, trans fatty acids, molecules produced by the microbiome, many other things, and risk of various diseases.

Dr. Bill Harris: Wow. Do you see a role for measuring omega-3 levels particularly in clinical care?

Dr. Dariush Mozaffarian: I think we need to integrate nutrition into clinical care in a range of ways. My gut feeling when I was in my training has been now confirmed by many quantitative studies that poor nutrition is the top cause of poor health in the United States. And the top cause in the world. exceeding every other cause, including actually tobacco smoking.

Dr. Dariush Mozaffarian: And we’re not measuring or assessing or reporting on the top cause of poor health in healthcare. So, there’s nothing in the healthcare system — doctors don’t learn when they’re learning their SOAP notes (subjective/objective assessment plan), how to assess nutrition. It’s not in the medical record. And so we need to integrate nutrition. That can be done in many ways. One of those should be a short kind of nutrition screener or nutrition vital sign, maybe 10 questions that should be asked at every clinical visit. And there should also be a physical activity vital sign and Kaiser Permanente has actually implemented that. They have a two-question physical activity vital sign that every patient at every clinical visit gets.

Dr. Dariush Mozaffarian: We need a nutrition vital sign. And then I think you need an annual nutrition physical. And that annual nutrition physical should include a more comprehensive dietary assessment, like a food frequency questionnaire or some diet records, and a range of biomarker studies that could be done. Not every biomarker study would need to be done every year on every person, but among biomarkers that should be done at least once, you probably want to know a person’s omega-3 levels, given how predictive those are for a range of diseases.

Dr. Bill Harris: Yeah. Right.

Dr. Kristina Harris Jackson: Yeah.

Dr. Bill Harris: Great.

Dr. Kristina Harris Jackson: And omega-3s are nice from an RD perspective, ’cause food wise they have pretty much one source, which is not the case with most other nutrients actually. So, it’s, it’s pretty easy to capture just asking a couple questions, capture a pretty good idea of what levels are. and kind of going along this practical path, how do we do this practically? we’re kind of interested in what you think about health policy and the current state of omega-3s in the federal nutrition recommendations. And if that’s changing or if that’s really important, actually, to moving it in the clinical space, in the medical space? Are those federal recommendations important for omega-3s specifically?

Dr. Dariush Mozaffarian: Well, one of the striking things about US food policy is there is no unified US food policy. So, there’s no single set of recommendations. There’s actually fractured policies and programs. And so just as two examples, you have the dietary guidelines for Americans, which are put out by the Departments of Health and Human Services and Agriculture jointly every five years. That determines school meals and a range of other things. And then kind of the public guidelines.

Dr. Dariush Mozaffarian: Then you have what’s on the back of packages. The nutrition facts information. That’s not determined by the dietary guidelines. That has nothing to do with the dietary guidelines. That’s determined by the dietary reference intakes, which are set through a totally separate process, often by the Food and Drug Administration in collaboration with the National Academies of Medicine and often with actually multiple governments. And those, in contrast to the dietary guidelines that are updated every five years, don’t have any statutory updating or guidelines. And so back to good ‘ol fats you know, the last time the dietary references intakes, the DRI’s, were updated for fats, carbohydrates, protein, and energy was 2002. 20 years ago.

Dr. Dariush Mozaffarian: So everything we have on the back of the packages, all those percentages are based on at least 20-year-old science, if not 30- and 40-year-old science, In fact, nothing we’ve learned in the last 20 years is actually being passed on to nutrition. I will say that Tufts was involved with Congress a few years ago raising these issues and a congresswoman, Rosa Delario, and congressman, Tim Ryan, instructed the Government Accountability Office, the GAO, which is the US government watch dog, to audit federal food policy around nutrition and diet related chronic disease. And that report came out September of 2021. It’s a terrific report. And what the report concluded is there are, there are 200 different federal policy efforts intending to improve nutrition. They’re fractured and fragmented and, and not harmonized. Two of them I just mentioned. There’s 198 more.

Dr. Dariush Mozaffarian: And that that lack of coordination is causing significant inefficiencies and failure to meet the government’s goals. And the GAO instructed Congress to create or instruct a federal entity to coordinate federal food policy. And so Congress is looking at those recommendations, that audit, and thinking about how to coordinate federal food policy.

Dr. Dariush Mozaffarian: So, that’s the big picture of there is no single federal policy around omega-3s.

Dr. Kristina Harris Jackson: Yeah.

Dr. Dariush Mozaffarian: But, you know, there’s at least two things. There’s the dietary guidelines and there’s the dietary reference intakes, which guides what’s on the back of the package. The dietary guidelines have moved forward every time with evidence recommending fish as part of a healthy diet. The latest dietary guidelines recommend you know, at least two servings per day. But the dietary guidelines can’t set a DRI. They can’t set the percentage intake or gram intake. That’s a separate process. And so that requires the US government usually again to get together with some other governments, particularly Canada, to ask the National Academies of Medicine to set a new DRI. That can cost a couple million dollars, take a couple of years.

Dr. Dariush Mozaffarian: I really think it’s time for that to happen for omega-3s. There’s enough evidence that I think the US government could set a DRI and allow an amount to be on the back of the package. About 10 years ago I worked with the World Health Organization and United Nations Food and Food & Agricultural Organization and we went through an equivalent process. They’re not called DRI’s but we basically set adequate intakes for omega-3s with a scientific panel that was released and published by the UN Food and Agricultural Organization. There we did recommend 250 mg of EPA and DHA for every adult and an appropriate amount for children. And for women who are pregnant or nursing or may become pregnant and nursing, in addition, a minimum of 200 mg of DHA. So, I think that’s a pretty reasonable recommendation that if there were a DRI, you know, maybe it should be mirrored in the United States.

Dr. Kristina Harris Jackson: And what does that translate to in rish intake? That amount?

Dr. Dariush Mozaffarian: Well, so fish, it depends on the fish as you know. There is a thousand-fold difference in omega-3 content between different types of fish. White flaky tend to be the lowest in omega-3s. This includes fish like cod and pollock. They still have more than than most other food, so they’re still a good source, but they tend to be low. And then, you know, trout and bass and shellfish tend to be kind of medium. And then the oily and dark meat fish, like salmon and ahi tuna are high in omega-3s.

Dr. Kristina Harris Jackson: Like herring and sardines, and …

Dr. Dariush Mozaffarian: Herring and sardines tend to be very high. But if you’re eating oily fish, you know, one or two servings a week, one serving a week, even, could get you that.

Dr. Kristina Harris Jackson: Mm-hmm (affirmative).

Dr. Dariush Mozaffarian: If you’re cooking a super white fish, you know, maybe a serving you know, five servings or even a serving a day.

Dr. Kristina Harris Jackson: Yeah. That really matches with the dietary guidelines, too, from what I’ve seen. It was the same.

Dr. Bill Harris: Jumping over more to the clinical side your thoughts about whether like the AHA (American Heart Association) or the ACC (American College of Cardiology) would recommend Omega-3 supplements or, or higher intake of Omega-3 for reducing risk for heart disease?

Dr. Dariush Mozaffarian: Well, I’ve been, you know, fortunate to be part of some American Heart Association statements on omega-3s and on fish and seafood, and the American Heart Association’s dietary guidelines do certainly recommend fish intake.

Dr. Bill Harris: Yeah.

Dr. Dariush Mozaffarian: The challenge with moving toward a strong recommendation for supplements is the clinical trial results of the last 20 years. While there have been several positive trials showing benefits of omega-3s for cardiovascular disease, several haven’t shown benefits for supplements. And, and this is a really perplexing area because, you know, out of about, like, say, 15 or 18 major trials about half have shown benefit and about half haven’t. And, and they’re all reasonably well done in different ways. You can’t find any obvious you know methods, differences, that might explain these results or population differences that might explain the results.

Dr. Dariush Mozaffarian: So, I think it’s still perplexing. But I will say that fish oil supplements are the only supplement, full stop, that have ever been shown to have a hard clinical benefit in a clinical trial. So, Vitamin C, Vitamin E, Vitamin D, I mean, everybody’s on Vitamin D. The vast majority of these vitamins and nutrients have never been shown to have a significant health benefit except maybe in very selective populations who are deficient and truly clinically deficient.

Dr. Dariush Mozaffarian: So, there are some very well done large trials that do show significant benefits of fish oil. So, I don’t know what the American Heart Association or American College of Cardiology will do. I think they will need to see probably more robust and consistent trials. But what I recommend to patients is to eat fish. Two servings per week. Preferably oily or dark meat fish, which is higher in omega-3s. And if you don’t eat fish or if you eat fish but want to be sure to get your omega-3s, it’s perfectly reasonable to take a supplement one once per day. We know very, very well there’s absolutely no harm and it could benefit you.

Dr. Bill Harris: Yeah. Do you see any large trials like STRENGTH or REDUCE-IT in the future?

Dr. Dariush Mozaffarian: Well, you know, these were two large trials were very similar in design and treatments. I mean, one was EPA only and one was EPA and DHA, but I don’t think that explains any differences. And one showed benefits and one didn’t. And it’s perplexing. There’s lots of theoretical reasons for this. The REDUCE-IT trial that showed benefit used a mineral oil placebo and in the placebo group LDL cholesterol went up and CRP went up, which had never been seen in any other trial, suggesting that the mineral oil placebo could have produced some harm.

Dr. Dariush Mozaffarian: On the other hand, even if you account for those changes, it doesn’t look like it would totally explain the benefits. So, probably there still was benefit for REDUCE-IT. I was on the steering committee of the STRENGTH trial. By every indication it should have shown benefit and didn’t. And that could just be just chance, right? We have confidence intervals. We have random chance in science. Maybe just statistically by chance it didn’t show benefit. You know, we can’t exclude that.

Dr. Dariush Mozaffarian: So, I guess the question is, who’s going to step up now and invest?

Dr. Bill Harris: Right.

Dr. Dariush Mozaffarian: Probably no one. But if another agent comes up that’s a different formulation or has something maybe more attractive, I think the market is quite large for you know natural treatments that address residual lipid risk, like high triglyceride levels.

Dr. Bill Harris: Yeah. So, it, it’s either going to be another drug company or it’s going to be the NIH.

Dr. Dariush Mozaffarian: Well, so you’ve opened the perfect door for me to talk about one of our policy advocacy topics, which we’ve been working on for a couple of years is advocating for National Institute of Nutrition at NIH. So, just like nutrition is missing in healthcare the top cause of poor health and is not focused upon in our National Institutes of Health.

Dr. Bill Harris: Mm-hmm (affirmative).

Dr. Dariush Mozaffarian: The National Institutes of Health is the world’s premiere research organization. It’s terrific, has amazing research, and does so much good. And yet it’s 27 centers and institutes, none of which have a core focus on nutrition. So, it’s time for a full institute to have a focus on nutrition. I think if there were an institute with sufficient new funding to have focus on that we could get funding for a major trial like that.

Dr. Bill Harris: Great.

Dr. Kristina Harris Jackson: Wow.

Dr. Bill Harris: And where are we at? Have we got the National Institute for Nutrition established? Is it happening?

Dr. Dariush Mozaffarian: Well, it would take an act of Congress. The last time an institute was put in place was about 20 years ago. And I think it was Senator Tom Harken who did that and he’s very supportive of this effort as well. I’ve spoken to him many times. So, that takes an act of Congress. It needs political will to make it happen. At the same time, NIH has actions they can take to build nutrition research. So two things that have happened at NIH, which NIH could do without Congress, is they’ve created a new office of Nutrition Research in the office of the director at NIH. That was created last year.

Dr. Dariush Mozaffarian: That was really important because there’s a handful of specific offices in the office of the director that then coordinate research across NIH. And so every dollar spent in those offices can have a manyfold benefit in coordinating research across NIH. And so having a new office of nutrition in the office of the director is really important.

Dr. Dariush Mozaffarian: Since it was only created last year, as a new office it didn’t have much of a budget. It had one million dollar budget, which isn’t terrific. The president’s budget, which just came out a couple of weeks ago for next year, they had proposed that that office have a $97 million dollar budget. So, an increase from one million to $97 million. That’s a pretty good increase. And, you know, with $100 million dollar budget the office could have some really significant impact and so if that budget is approved by Congress that would be terrific.

Dr. Dariush Mozaffarian: And then secondly, the NIH released a strategic plan for nutrition research last year, including major funding for precision nutrition. And so I think NIH, to the extent it can without Congress, is definitely listening and understanding the importance of nutrition science.

Dr. Bill Harris: Great. Great. Well, that’s good news.

Dr. Kristina Harris Jackson: What about the Department of Nutrition on the food side, when you get to the research side? ‘Cause we view USDA and FDA that kind of are governing the food side. Do you see a need for that to be streamlined?

Dr. Dariush Mozaffarian: Well, so, I think first the National Institute of Nutrition would have many positives, including that it would be within Health and Human Services. NIH has been Health and Human Services. It would have many positives beyond research. It could coordinate cross agency research, it could coordinate research with USDA, with the Department of Education, with the Department of Defense, with the VA, Health Services, with the CDC, within Human and Health Services, with FDA, within Health and Human Services. All those agencies do nutrition surveillance and research.

Dr. Dariush Mozaffarian: And so the National institute of Nutrition could do that. It could also help create and organize curriculum for health care professionals to learn nutrition in their training. The NIH has a lot of funding and support for nutrition training. They could organize that.

Dr. Dariush Mozaffarian: Third, I mentioned earlier that the dietary guidelines come out of both USDA and Health and Human Services. Health and Human Services doesn’t have a huge budget or staff to be that partner, although they do a great job with, with what they have. The National Institute of Nutrition could be part of a partnership for the dietary guidelines, which would be terrific. And then lastly, the dietary guidelines by statute are for the healthy general population. They’re not for disease populations.

Dr. Kristina Harris Jackson: Mm-hmm (affirmative).

Dr. Dariush Mozaffarian: So, we have no national guidelines for diabetes, we have no national diet for nutrition for diabetes, no national guidelines for hypertension, no national guidelines for obesity. And those patient populations get upset every time the dietary guidelines come out. They say there’s nothing in here for me. That’s by law the dietary guidelines are not for the disease population. Health and Human Services is supposed to do those. It’s supposed to do-

Dr. Kristina Harris Jackson: Hmm.

Dr. Dariush Mozaffarian: The guidelines for the disease population — the National Institute of Nutrition could do that. I think for larger coordination, for broader coordination what we proposed is a new office of the National Director of Food and Nutrition in the White House. This is building on the model and the precedent of the Office of the Director of National Intelligence. And so that was created in 2003, two years after September 11th. When Congress did an inquiry and recognized that one of the reasons there was the terrorist attack, and it went undetected and was able to be to happen was lack of coordination among the federal investments in national security.

Dr. Dariush Mozaffarian: And so they created the office of the Director of National Intelligence to coordinate national security and it’s overwhelmingly been a success. It’s worked really, really well. The office works with the FBI and the CIA and the National Security Council and sits with the Cabinet and, and you know, our investments, our federal investments in food and nutrition far exceed our federal investments in national security by manyfold. And costs of poor nutrition far exceed the cost of wars and other things if you just look at the number of Americans dying every month from poor nutrition. You know? It exceeds all the Americans that died in the Iraq and Afghani war combined.

Dr. Dariush Mozaffarian: So I think there’s clear need to have a similar office that coordinates federal food and nutrition policy.

Dr. Kristina Harris Jackson: Yeah. I think that’s a great idea.

Dr. Bill Harris: Great stuff.

Dr. Kristina Harris Jackson: I support it.

Dr. Bill Harris: Great stuff. Dari, thank you very much. We appreciate your comments and thoughts and look forward to maybe talking to you again.

Dr. Dariush Mozaffarian: Yeah, terrific. And it’s so nice to speak with you, Bill, who has done so much work to advance knowledge and attention on omega-3s. They have pretty incredible physiologic effects on a range of pathways and their potential benefits for cardiovascular disease and other diseases. You really shined a spotlight on that, and I think that, you know, we’re still halfway through the journey, the Omega-3 story, and there’s more to learn.

Dr. Bill Harris: Good. So, there’s something for my daughter to learn, then, huh?

Dr. Dariush Mozaffarian: Perfect.

Dr. Kristina Harris Jackson: Oh boy. (laughs)

Dr. Bill Harris: Thanks, Dari.

Dr. Kristina Harris Jackson: All right. Thank you.

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