Transcript The Anti-Inflammatory Diet and Cardiovascular Disease

The Anti-Inflammatory Diet and
Cardiovascular Disease
Michael Brown MD, PhD
Inflammation:
A common final pathway
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Cardiovascular disease
Cancer
Neurodegenerative disease
Autoimmune disease
DM
Obesity
What is Inflammation?
• Complex orchestration of proinflammatory and anti-inflammatory
events
• Mediated by eicosanoids
– Prostaglandins, thromboxanes,
leukotrienes,
– Hydroxylated fatty acids, lipoxins,
prostamides, isoprostanoids
• Silent inflammation vs. painful
inflammation
Phases of inflammation
• Initiating event-
• Pro-inflammatory attack
response/cellular destruction
• Anti-inflammatory healing
response/Cellular rejuvenation
Omega 6 Fatty Acid
Omega 3 Fatty Acids
(Linoleic Acid)
(alpha-linolenic acid)
Δ6-Desaturase
Gamma-linolenic acid
Eicosapentaenoic Acid
(GLA)
Evening Primrose Oil
Borage Oil
Black Current Oil
Δ5-Desaturase
Arachidonic Acid
(EPA)
COX
Lipoxygenase
Prostaglandins
PGE1, PGE3
Cyclo-oxygenase
(COX)
Less Inflammatory
Leukotrienes
(Favorable)
Lipoxygenase
Docosahexaenoic acid
(DHA)
Prostaglandins (PGE2)
(Inflammatory)
Leukotrienes
Arachidonic Acid
(in cell membrane)
Phospholipase A-2
Steroids
Free AA
Aspirin
Cyclo-oxygenase
Lipoxygenase
NSAIDs
Pathway
Pathway
Colchicine
COX II Inhibitors:
Sulfasalazine
Leukotriene
Inhibitors:
Celebrex, Vioxx, Mobic
Accolate,
Singulair, Zyflo
Prostaglandins
&
Thromboxanes
Leukotrienes
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
• Saturated:
beef and other animal fats, dairy
• Monounsaturated (omega-9):
olive and canola oils
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
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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?
• 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
• 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
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Total long-Chain Omega-3 >60%
Dioxins< 1 ppt
Mercury <10 ppb
PCB’s<30 ppb
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
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Exercise
Quit smoking
Weight loss
Stress management
Vagal nerve stimulation via abdominal
breath work
• Treatment of depression
• Social support
Arachidonic Acid
(in cell membrane)
Onions/
Apples
Quercetin
Turmeric
Curcumin
Rosemary
Phospholipase A-2
Onions/Apples Quercetin
Turmeric Curcumin,
Free AA
Feverfew Perthenolides
Onions/
Cyclo-oxygenase
Lipoxygenase Apples
Ursolic acid
Red Pepper
Capsaicin
Ginger
Prostaglandins
&
Thromboxanes
Quercitin
Pathway
Pathway
Boswellia
Bosellic Acid
Rosemary
Carnosol
Leukotrienes
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?
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
• 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
• 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
• 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
• 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
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
• 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…
• Glycemic Index (rate of absorption of
glucose)
• Glycemic Load (ratio between GI and
CHO content)
• www.glycemicindex.com
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
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Whole grains
Fruits
Vegetables
Legumes
Or…mixing high GI/GL foods with those
with lower GI/GL
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 TOMATOES
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
•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
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
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
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Almonds
Pistachios
Sesame Seeds
Peanuts
Pumpkin and Sunflower Seeds
Macadamia Nuts
Pecans
Hazelnuts
Cashews
10 Foods to Avoid
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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
• 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