The Anti-Inflammatory Diet and Cardiovascular Disease: The Anti-Inflammatory Diet and Cardiovascular Disease Victor S. Sierpina, MD W.D. and Laura Nell Nicholson Family Professor of Integrative Medicine Associate Professor UTMB Family Medicine


Inflammation:A common final pathway: Inflammation: A common final pathway Cardiovascular disease Cancer Neurodegenerative disease Autoimmune disease DM Obesity


What is Inflammation?: What is Inflammation? Complex orchestration of pro-inflammatory and anti-inflammatory events Mediated by eicosanoids Prostaglandins, thromboxanes, leukotrienes, Hydroxylated fatty acids, lipoxins, prostamides, isoprostanoids Silent inflammation vs. painful inflammation


Phases of inflammation: Phases of inflammation Initiating event- Pro-inflammatory attack response/cellular destruction Anti-inflammatory healing response/Cellular rejuvenation


Slide6: Omega 6 Fatty Acid (Linoleic Acid) Omega 3 Fatty Acids (alpha-linolenic acid) Δ6-Desaturase Gamma-linolenic acid (GLA) Evening Primrose Oil Borage Oil Black Current Oil Arachidonic Acid Leukotrienes Prostaglandins (PGE2) (Inflammatory) Lipoxygenase Cyclo-oxygenase (COX) Eicosapentaenoic Acid (EPA) Prostaglandins PGE1, PGE3 (Favorable) Less Inflammatory Leukotrienes Lipoxygenase Docosahexaenoic acid (DHA) COX Δ5-Desaturase


Slide7: Arachidonic Acid (in cell membrane) Free AA Phospholipase A-2 Cyclo-oxygenase Pathway Lipoxygenase Pathway Prostaglandins & Thromboxanes Leukotrienes Steroids Aspirin NSAIDs COX II Inhibitors: Celebrex, Vioxx, Mobic Colchicine Sulfasalazine Leukotriene Inhibitors: Accolate, Singulair, Zyflo


FAT IS GOOD!!: FAT IS GOOD!! Depending on what kind…. Omega 3 fatty acids (fish oils-EPA, DHA; plant sources -ALA) Mono-unsaturated fats (canola and olive oils) Decreased fat consumption since the 1960’s associated with obesity epidemic—CHO intake has increased dramatically Glycemic index/glycemic load


Types of fats: Types of fats Saturated: beef and other animal fats, dairy Monounsaturated (omega-9): olive and canola oils


Polyunsaturated fats (essential FA’s):: Polyunsaturated fats (essential FA’s): Omega-6: Linoleic acid (LA)--vegetable oils, seeds, nuts Gamma Linolenic Acid (GLA)--borage and primrose oil Arachidonic Acid(AA)--meat products — Omega-3: Alpha Linolenic Acid (ALA)--legumes, leafy vegetables, flax, flaxseed and canola oils) Eicosopentanoic acid (EPA)-fish oil Docosahexanoic acid (DHA)--fish oil, breast milk


Avoid or Reduce: Avoid or Reduce Trans-fatty acids BAD! Omega-6 fatty acids Margarine Corn oil, cottonseed oil, grapeseed oil, peanut oil, safflower oil, sesame oil, soybean oil, sunflower oil, partially hydrogenated oils Any product with long shelf life (crackers, pastries, chips)


How much Omega-3 fats do you need?: How much Omega-3 fats do you need? Strive for Omega 6: Omega-3 ratio of 4:1 (usual SAD (Standard American Diet) 16:1 Maintenance 2.5 g/d Improve hear function 5 g/d Treat chronic pain 7.5 g/d Treat neurological disease >10g/d Sears, The Anti-Inflammation Zone, 2005


Types of Fish Oil: Types of Fish Oil Fish Contamination with PCB, dioxin, and Hg Higher in AA than fish oil Crude fish oil High contamination Health food grade Still some contamination with PCB’s and dioxins Ultra-Refined EPA/DHA Concentrates Removal of PCB’s and other toxins Can be used in high doses (“weapons grade”)


Requirements for an Ultra-refined EPA/DHA concentrate: Requirements for an Ultra-refined EPA/DHA concentrate Total long-Chain Omega-3 >60% Dioxins< 1 ppt Mercury <10 ppb PCB’s<30 ppb


What is an anti-inflammatory diet?: What is an anti-inflammatory diet? Lose fat Eat small meals Have some protein at every meal but reduce red meat and dairy (Avoid charred, overcooked foods) Cold water fish (salmon, mackerel, sardines, herring) Eat primarily fruits and vegetables Leafy green vegetables, nuts, flaxseeds or oil Take your fish oil


Anti-inflammatory Lifestyle: Anti-inflammatory Lifestyle Exercise Quit smoking Weight loss Stress management Vagal nerve stimulation via abdominal breath work Treatment of depression Social support


Slide20: Arachidonic Acid (in cell membrane) Free AA Phospholipase A-2 Cyclo-oxygenase Pathway Lipoxygenase Pathway Prostaglandins & Thromboxanes Leukotrienes Onions/Apples Quercetin Turmeric Curcumin, Feverfew Perthenolides Onions/ Apples Quercetin Turmeric Curcumin Rosemary Ursolic acid Red Pepper Capsaicin Ginger Onions/Apples Quercitin Boswellia Bosellic Acid Rosemary Carnosol


Mediterranean Diet : Mediterranean Diet More tolerable than low fat diets and associated with improved long term weight loss (McManus 2001) Risk reduction of death from CAD = 0.67 compared to usual AHA diet (Trichopoulou et al, 2003)


Something fishy?: Something fishy?


American Heart Association Recommendations: American Heart Association Recommendations ·   Healthy individuals should take two servings of fish(salmon, sardines, tuna, mackerel, trout) weekly along with flaxseed, canola, and soybean oil ·  Patients with CHD should consume higher doses, 1 g/d of EPA + DHA, which may require fish oil supplementation Utilize complex carbohydrates, higher in fiber and lower in glycemic load to reduce risk of CHD AHA Recommendations: Intake of omega-3 fatty acids. Women’s Health in Primary Care. 2003.6(1): 25-26 (Consensus opinion) Hu F, Willett W.Optimal diets for prevention of coronary heart disease. JAMA. 2002;288:2569-2578 {Systematic review}        


Indications from other studies: Indications from other studies Eating fish as little as once a week reduces the risk of sudden death in men Eating fish twice a week reduces CHD risk in women Fish intake reduces Alzheimer’s risk Harper, Beyond the Mediterranean Diet: the Role of Omega-3 Fatty Acids in the Prevention of CAD, Prev Cardiol, 2003 Morris, Consumption of fish and n-3 fatty acids and risk of Alzheimer dz,. Arch Neurol, 2003


How intake of Omega-3 Fatty Acids is helpful: How intake of Omega-3 Fatty Acids is helpful Stabilization of atherosclerotic plaques Reduction of inflammation by mediation prostaglandin synthesis pathway Improved ratio of omega-3 to omega 6 FA reduces arachidonic acid and pro-inflammatory, pro-platelet aggregatory cytokines Enhances PGE1 and PGE 3 and less inflammatory leukotrienes(see diagram) Thies F, et al. Association of n-3 polyunsaturated fatty acids with stability of atherosclerotic plaque: RCT, Lancet, 2003;361:477-85 Harper, Beyond the Mediterranean Diet: the Role of Omega-3 Fatty Acids in the Prevention of CAD, Prev Cardiol, 2003;6(3):134-46


Fish Oil for secondary prevention: Fish Oil for secondary prevention 240 pts with suspected Acute MI 2 gms fish oil vs. placebo After 1 year, 54% reduction in serious ventricular arrhythmia, 30% total reduction in cardiac events Singh, Cardiovasc Drugs Ther 1997


GISSI: GISSI More than 11,000 patients on 1 gm fish oil/d < 3mos post MI 20% reduction in total mortality 10% reduction in recurrent MI 40% reduction in sudden death Lancet 1999;354


AHRQ report : AHRQ report Overall, the evidence from the primary and secondary prevention studies supports the hypothesis that consumption of omega-3 fatty acids,fish, and fish oil reduces all-cause mortality. Reduction was observed in CVD outcomes such as sudden death, cardiac death (coronary or MI) and MI although the evidence is strongest for fish or fish oil.


AHRQ study: AHRQ study Most studies show very low cardiovascular mortality in populations with high fish consumption Strongest, most consistent effect of omega-3 fatty acids was reduction in triglycerides from 10-33%


A word about…: A word about… Glycemic Index (rate of absorption of glucose) Glycemic Load (ratio between GI and CHO content) www.glycemicindex.com


High Glycemic/Load Foods Increase: : High Glycemic/Load Foods Increase: Inflammation Risks of heart disease, diabetes Examples include: White bread, glucose (GI= 100) Potatoes, white rice Pastries, white flour Sweets, carbonated soft drinks


Lower GI/GL reduces risk: Lower GI/GL reduces risk Whole grains Fruits Vegetables Legumes Or…mixing high GI/GL foods with those with lower GI/GL


Superfoods to decrease inflammation: Superfoods to decrease inflammation BEANS Pinto, navy, Great Northern, lima, garbanzo(chickpeas), black beans, lentils, green beans, sugar snap peas, and green peas BLUEBERRIES Purple grapes, cranberries, boysenberries, raspberries, strawberries, currants, blackberries, cherries, and all other varieties of fresh, frozen, or dried berries BROCCOLI Brussel sprouts, cabbage, kale, turnips, cauliflower, collards, bok choy, mustard green, Swiss chard OATS Wheat germ, ground flaxseed, brown rice, barley, wheat, buckwheat, rye, millet, bulgur, wheat, amaranth, quinoa, triticale, kamut, yellow corn, wild rice, spelt, couscous ORANGES Lemons, white, and pink grapefruit, kumquats, tangerines, limes PUMPKIN Carrots, butternut squash, sweet potatoes, orange bell peppers


Superfoods to decrease inflammation: Superfoods to decrease inflammation SALMON Alaskan halibut, canned albacore tuna, sardines, herring, trout, sea bass, oysters, and clams SOY Tofu, soymilk, soy nuts, edamame, tempeh, miso   SPINACH Kale, collard, Swiss chard, mustard greens, turnip greens, bok choy, romaine lettuce, orange bell peppers TEA – GREEN OR BLACK TOMATOES Red watermelon, pink grapefruit, Japanese persimmons, red-fleshed papaya, strawberry, guava TURKEY Skinless chicken breast WALNUTS Almonds, pistachios, sesame seeds, peanuts, pumpkin, and sunflower seeds, macadamia nuts, pecans, hazelnuts cashews YOGURT Kefir


Slide38:   SUPERFOOD #7: WILD SALMON   Lowers the risk of heart disease and cancer. The more omega-3 fish oils you eat; the lower your blood pressure In one study eating the oil in fish cut cancer incidence by over 60% 4x weekly  risk for and progression of AMD Studies suggest that fish consumption is associated with a lower risk for depression, violent behavior, Alzheimer’s disease, Attention Deficit Disorder, Atrial fibrillation. SPF nutrients TRY TO EAT Wild salmon, halibut, sardines, etc.  2 to 4 times per week


Slide39:   SUPERFOOD #13: WALNUTS A handful a day can cut your risk of cardiovascular event by as much as 51% Two tablespoons of peanut butter 5 times/week cuts risk of type II diabetes by 20% Along with tea, the easiest way to improve your heath  Risk/progression of AMD SPF nutrients TRY TO EAT a handful of nuts, five times a week * Skip the salt and added oils


WALNUT SIDEKICKS: WALNUT SIDEKICKS Almonds Pistachios Sesame Seeds Peanuts Pumpkin and Sunflower Seeds Macadamia Nuts Pecans Hazelnuts Cashews


10 Foods to Avoid: 10 Foods to Avoid Donuts White Bread Bread with < 3 grams fiber/ slice Soda Stick Margarines White Pasta Full Fat Dairy Movie Theatre Popcorn Luncheon Meats Sugar Coated Cereal


References: References Rakel D, Rindfleisch A. Inflammation: nutritional, botanical, and mind-body influences. South Med J 2005;8(3):303-310 Liu S, Willett W, Stampfer M, et al. A prospective study of dietary glycemic load, carbohydrate intake, and risk of coronary heart disease in US women. Am J Clin Nutr 2000;71:1455-1461 Ascherio A, Katan, M, et al. Trans fatty acids and coronary heart disease. NEJM 1999;340;1994-1998