do omega-3 fatty acids aid in the prevention of heart disease? jen smith university of california,...
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Do Omega-3 fatty acids aid in the prevention of heart disease?
Jen SmithUniversity of California, San Francisco
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Objectives…..
• Significance of the problem
• What are Omega-3 fatty Acids?
• What are the cardiovascular benefits?
• Review the literature
• Intake recommendations
• Future research
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Significance of the Problem?• In 2006, 631,636 people died of heart disease in the
US. Heart disease caused 26% of deaths—more than one in every four—in the United States.
• Heart disease is the leading cause of death for both men and women. Half of the deaths due to heart disease in 2006 were women.
• In 2010, heart disease will cost the United States $316.4 billion. This total includes the cost of health care services, medications, and lost productivity.
http://www.cdc.gov/heartdisease/facts.htm
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What can we do?
• Diet and exercise is KEY!
• Are we as American’s missing a key component to our diet?
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Omega 3 intake• Dietary intake of omega-3 and omega 6 fatty acids
varies within and between different populations
• NHANES III (the largest database of nutrient consumption of Americans), reports a median intake of EPA+DHA of 0 and <1 g/d of ALA.
• The ratio of omega-6 to Omega-3 intake is estimated to be 20 to 1 in a modern Western diet, compared with that of our Paleolithic ancestor who ate a diet much richer in omega-3’s (estimated ratio of 1:1)
• We need to balance our Omega-3 to 6 ratio
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“Omega-3”
• Three types of naturally occurring fats classified by the number of double bonds present in their fatty acid chains
• ALA, EPA, DHA
• EPA and DHA have been proven most cardioprotective
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COOH
C20:5 ω-3 Eicosapentaenoic(EPA)
H3C
C18:3 ω-3
ω-3 family
-Linolenic• Flaxseed Oil• Canola Oil• Soybean Oil
C22:6 ω-3 Docosahexaenoic(DHA)
COOHH3C
• Oily Fish• Fish Oil Capsules
H3CCOOH
ω-6 family
C20:4 ω-6
C18:2 ω-6 Linoleic
Arachidonic
H3CCOOH
More thrombotic and inflammatory metabolites
• Corn Oil• Safflower Oil• Sunflower Oil
Essential Fatty Acid Families
Less thrombotic and inflammatory metabolites
H3C COOH
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Omega 6 rich foods• Flax seed oil, Flax seeds, Flax seed meal, Hemp seed oil,
Hemp seeds, Grapeseed Oil, Pumpkin seeds, Pumpkin oil
• Sesame oil, Walnut oil, Pine nuts, Pistachio nuts, Sunflower seeds (raw), Olive oil, Olives, Borage oil, Evening primrose oil
• Black currant seed oil, Chestnut oil, Wheatgerm oil
• Corn, safflower, sunflower, soybean and cottonseed oils are also sources of linoleic acid, but are refined and may be nutrient-deficient as sold in stores.
• Chicken
• mayonnaise
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• DHA+EPA-Fish …halibut, herring, mackerel, oysters, salmon, lake trout, sardines and albacore, tuna.
• ALA - plant sources like flaxseed, chia, purslane, lingonberry, and hemp. walnuts, soy beans and tofu
What foods contain Omega-3 Fatty Acids?
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AHA Recommendations for Omega-3 FA Intake
Kris-Etherton PM et al. Circulation 2002;106:2747-2757.
Population Recommendation
Patients without documented CHD
Eat a variety of (preferably oily) fish at least twice a week. Include oils and foods rich in -linolenic acid (flaxseed, canola, and soybean oils; flaxseeds; and walnuts)
Patients with documented CHD
Consume ~1 g of EPA+DHA per day, preferably from oily fish. EPA+DHA supplements could be considered in consultation with the physician
Patients needing triglyceride lowering
2–4 grams of EPA+DHA per day provided as capsules under a physician’s care
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Ways to Get 1 g/d EPA+DHA
• Fish
• 2–3 oz salmon, sardines, mackerel per day
• Dietary Supplements (Fish oil)
• Low Potency: 300 mg EPA+DHA/g(Typical drug store capsules; 3 g/d)
• Mid Potency: 500–700 mg EPA+DHA/g(Mail-order, online, etc; 2 g/d
• Drugs
• High Potency: 850 mg EPA+DHA/g(Omega-3 acid ethyl esters; 1 g/d)
• Cod Liver Oil
• 1 tsp (RDA for vitamin D; 2 RDA for vitamin A)
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Omega-3’s through food or supplements?
• Research has shown omega-3’s may be better absorbed from food than supplements
• The AHA recommends two servings of omega-3 rich fish per week….but for most people it is not practical
• The fish you get from your local store may not be fresh, which could compromise the quality of the oils
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What is fish oil?• oil derived from the tissues of oily fish sold
in the form of a supplement
• Many different brands to choose from
• Risk of toxins
• Look for a “mecury free”’ fish oil supplement
• Reputable companies source their fish from pristine waters. They use deep sea fish which are less likely to ingest pollutants.
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What are the cardiovascular benefits of omega-3?
• Reduction in arrhythmias• Increased heart rate variability• Antithrombotic effects• Improved endothelial reactivity-production of nitric oxide• Anti-inflammatory effects• Slight lowering of blood pressure• Lower triglyceride levels
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Safety?
• Omega-3 intake is very well tolerated by patients through diet or supplements
• Low incidence of side effects•Gastrointestinal complaints• “fishy taste” from fish oil supplements
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Research?
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Greenland Eskimos• First recognized over 45 years ago
• Revealed low incidence of heart disease
• Ironic because at the time a low saturated fat diet was recommended for prevention of hear disease and the Greenland Eskimos were eating a diet very high in saturated animal fat.
• Also contained high amounts of fish
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GISSI-Prevention trial• Large clinical trial 11,712 patients with recent MI • Randomized to either
1. Omega-3 supplements2. Vit E3. Both4. Or none (along with Mediterranean diet)
Results- Omega-3 supplementation reduced all-cause death by 20% and nonfatal MI and stroke by 15%
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DART
• 2033 Welsh men after a recent MI
• Intervention- group randomized to 2 servings of fish per week or given supplements
• Findings-29% reduction in cardiovascular and total mortality in two years
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Physician's Health Study
• Began in 1982-Epidemiological
• 20,000 healthy male physicians
• Lifestyle, coronary risk factors, and diet data collected at entry and lifestyle and diet were collected at 12 months after entry
• Findings: men who consumed one or more fish meals per week had a 50% lower risk of developing sudden cardiac death than men who rarely ate fish (less than one fish meal per month).
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Nurses’ Health Study• Began in 1976
• 80,000 female nurses completed lifestyle and diet questioners
• Followed for 16 years for the development of coronary artery disease
• Findings : compared to women who rarely ate fish (less than one fish meal per month), women who ate fish once a week had a 29% lower risk of developing coronary heart disease.
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Effect of fish-oil supplements of endothelial function
• Study design-Randomized control trial, double-blinded, crossover
• Objective: to examine whether a fish oil supplement offers protection of endothelial function after a high fat meal. (studies have shown that endothelial function is acutely impaired after a high fat meal)
• Sample: 20 healthy volunteers
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Intervention: Given fish oil ( 1 gram)/or placebo after high fat meal ( lactose capsules)
Measure: flow mediated dilation of the brachial artery was done before and after high fat meal in both groups
Results: The main finding was that 1 gram of fish oil was able to preserve endothelial function after a high fat meal
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Medication?• Omacor/Lovaza
• made from omega 3 fish oil-in each 1 gram capsule EPA - approximately 465 mg and DHA approximately 375 mg.
• Used to lower triglycerides
• But……new study suggests taking Lovaza at a very high dose does not decrease the risk of occurrence of A-fib
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Efficacy and Safety of Prescription Omega-3Fatty Acids for the Prevention of Recurrent
Symptomatic Atrial Fibrillation
• Randomized control trial, double blinded
• 663 outpatients with documented symptomatic paroxsysmal or persistent a-fib
• Received placebo or prescription Omega-3 PUFA capsules at 8g/day for the first seven days followed by 4 g/day for a total of 24 weeks
• Results- The Omega-3 group did not have a reduced risk of recurrence of a-fib over 6 months
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Efficacy and Safety of Prescription Omega-3
Fatty Acids for the Prevention of RecurrentSymptomatic Atrial Fibrillation
• Secondary findings-1. Reduction in average ventricular rate during the
first a-fib recurrence2. Reduction in triglyceride levels
• specific patient population
• This trial was based on a majority of patients with paroxysmal a-fib. The study does not support other patient populations with a-fib, such as post-op patients, or patients with advanced heart disease
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Omega-3 index?What do you know about it?
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Omega-3 index: A modifiable risk factor?
• The Omega 3 Index measures the amount of EPA and DHA omega 3s in red blood cells and is expressed as a percent of total fatty acids.
• The results of the Omega 3 Index test are represented by a score that can be used to assess you risk of heart disease, with a score of 4% or less indicating higher risk and a score of 8% or more indicating relatively low risk.
• Could it be a “risk factor” for heart disease??
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Omega-3 Index: A Modifiable Risk Factor?
• Omega-3 Index is responsive to changes in omega-3 FA intake (fish or capsules)
• Correcting the Omega-3 Index is…
• Safe: Highest AHA recommended intake for CHD prevention (1 g/d) is 1/3 of amount the FDA regards as safe for inclusion in the food supply
• Easy: Eat more oily fish or take 1–3 fish oil capsules per day
• Affordable: Standard drug store capsules can provide about 1 g/d for as little as 7¢
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Check your omega 3 levels at home?
• The Gene Smart Omega 3 Index Home Blood Test Kit
• One easy payment of 149.95!
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Gene smart Omega 3 index Home testing kit
• The Gene Smart Omega 3 Index Home Blood Testing Kit measures your Omega 3 index and your Omega 6 to Omega 3 ratio
• More research could be done?
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Pro’s and Con’s to increasing
Omega-3 intake??
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Implications for our practice?
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Conclusion
• Omega 3’s have many cardioprotective effects observed in epidemiological and experimental studies.
• Most Americans do not get the optimal amount of Omega-3’s in their diet
• Omega-3’s are safe, easy, and affordable
• Omega-3 index may soon be classified as a “risk factor” for heart disease.
• Omega-3 index tests are becoming more readily available to monitor the amount of Omega-3 in your blood
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References• References
• Burr, M. L., Gilbert, J. F., Holliday, R. M., Elwood, P.C., Fehily, A. M., Rogers, S., Sweernam, & P.M., Deadman, N. M. (1989). The Lancet, 757-761.
• Breslow, J. L. (2006). n-3 Fatty acids and cardiovascular disease. American Journal of Clinical Nutrition, 83,1477S-82S.
• Corretti, C.M., Anderson, T. J., Benjamin J .E ., Celermajer, D., Charbonneau, F., Creager, M. & Vogel, R. (2002). Guidelines for the Ultrasound Assessment of Endothelial Dependent Flow-Mediated Vasodilation of the Brachial Artery. Journal of the American College of Cardiology, 39, 257-265.
• Defillippis, A.P., Blaha, M.J., & Jacobson, T.A. (2010). Omega-3 Fatty Acids for Cardiovascular disease prevention. Current Treatment Options in Cardiovascular medicine, 12 (4), 365-80.
• Engler, M. & Engler, M.B., (2006). Omega-3 Fatty Acids. Role in Cardiovascular Heath and Disease. Journal of Cardiovascular Nursing, 20 (1), 17-24.
• Engler, M. M., Engler, M. B., Malloy, M.L., Paul S.M., Kulkarni, K. R. & Mietus-Snyder M.L. (2004). Effect of Docosahexaenoic Acid on Lipoprotein Subclasses in Hyperlipidemic Children. The American Journal of Cardiology, 95, 869-871.
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References• Fahs, C.A., Yan, H., Ranadive, S., Rossow, L.M., Agiovlastis, S., Wilund, K.R., & Fernhall, B.
(2010). The effect of acute fish-oil supplementation on endothelial function and arterial stiffness following a high-fat meal. Applied Physiology, Nutrition, and Metabolism, 35(3), 294-302.
• Harris, S.W. (2010). The Omega-3 index: Clinical Utility for Therapeutic Intervention. Current Cardiology Reports, 12, 503-508.
• Harris,W. (2010). Omega-6 and Omega-3 fatty acids: partners in prevention. Current opinion in Clinical Nutrition and Metabolic Care, 13, 125-129.
• Harris, W. & von Schacky, C (2004). The Omega-3 Index: a new risk factor for death from coronary heart disease? Preventative Medicine, 39, 212-220.
• Kowey, P.R., Reiffel, J.A., Ellenbogen, K.A., (2010). Efficacy and safety of prescription omega-3 fatty acids for the prevention of recurrent symptomatic atrial fibrillation. A randomized controlled trial.JAMA, DOI:10.1001. Retrieved from http:jama.ama-assn.org cgicontent/full/jama.2010.1735v1.
• Rizza, S., Tesauro, M., Cardillo C., Galli A., Iantorno, M., Gigli, F.....Lauro, D. (2009). Fish oil supplementation improves endothelial function in normoglycemic offspring of patients with type 2 diabetes. Atherosclerosis, 206, 569-574.
• Sacks, F. M., Stone, P. H., Gibson, C.M. Silverman, D.I., Rosner, B., & Pasternak R. C. (1995). Controlled trial of fish oil for regression of human coronary atherosclerosis. HARP
Research group. Journal of American College of Cardiology, 25 (7), 1492-1498.
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References• Singh, R. B., Niaz, M. A., Sharma, J. P., Kumar, R., Rastogi, V., & Moshiri (1995).
Randomized, Double-Blind, Placebo-controlled Trial of Fish Oil and Mustard Oil in Patients with Suspected Acute Myocardial Infarction: The Indian Experiment of Infarct Survival. Cardiovascular Drugs and Therapy, 11, 485-491.
• Von, S. C., Angerer P., Kothry, W., Theisen, K., & Mudra, H. (1999). The effect of dietary omega-3 fatty acids on coronary atherosclerosis. A randomized, double-blind, placebo- controlled trial. Annuals of internal medicine, 130 (7), 554-62.
• Walser, B., Giordano, R. M., & Stebbins, C. L. (2006). Supplementation with omega-3 polyunsaturated fatty acids augments brachial artery dilation and blood
flow during forearm contraction. European Journal of Physiology, 97, 347-354.