Do Omega-3 fatty acids aid in the prevention of heart disease?

1. Do Omega-3 fatty acids aid in the prevention of heart disease? Jen Smith University of California, San Francisco

2. Objectives….. • Significance of the problem • What are Omega-3 fatty Acids? • What are the cardiovascular benefits? • Review the literature • Intake recommendations • Future research

3. 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

4. What can we do? • Diet and exercise is KEY! • Are we as American’s missing a key component to our diet?

5. 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

6. “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

7. H3C H3C COOH COOH Essential Fatty Acid Families ω-3 family ω-6 family C18:3 ω-3 • -Linolenic • Flaxseed Oil • Canola Oil • Soybean Oil C18:2 ω-6 Linoleic • Corn Oil • Safflower Oil • Sunflower Oil H3C COOH H3C C20:5 ω-3 Eicosapentaenoic (EPA) COOH C20:4 ω-6 Arachidonic H3C COOH C22:6 ω-3 Docosahexaenoic (DHA) Less thrombotic and inflammatory metabolites More thrombotic and inflammatory metabolites • Oily Fish • Fish Oil Capsules

8. 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, Wheatgermoil • 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

9. What foods contain Omega-3 Fatty Acids? • 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

10. AHA Recommendations for Omega-3 FA Intake Kris-Etherton PM et al. Circulation 2002;106:2747-2757.

11. 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)

12. 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

13. 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.

14. 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

15. 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

16. Research?

17. 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

18. GISSI-Prevention trial • Large clinical trial 11,712 patients with recent MI • Randomized to either • Omega-3 supplements • Vit E • Both • Or none (along with Mediterranean diet) Results- Omega-3 supplementation reduced all-cause death by 20% and nonfatal MI and stroke by 15%

19. 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

20. 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).

21. 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.

22. 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

23. 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

24. 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

25. Efficacy and Safety of Prescription Omega-3Fatty Acids for the Prevention of RecurrentSymptomatic 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

26. Efficacy and Safety of Prescription Omega-3Fatty Acids for the Prevention of RecurrentSymptomatic Atrial Fibrillation • Secondary findings- • Reduction in average ventricular rate during the first a-fib recurrence • 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

28. Omega-3 index? What do you know about it?

29. 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??

30. 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¢

31. Check your omega 3 levels at home? • The Gene Smart Omega 3 IndexHome Blood Test Kit • One easy payment of 149.95!

32. 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?

35. Pro’s and Con’s to increasing Omega-3 intake??

36. Implications for our practice?

37. 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

38. 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.

39. 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.

40. 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.