The Anti-Inflammatory Diet and Cardiovascular Disease

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The Anti-Inflammatory Diet and Cardiovascular
Disease

• Michael Brown MD, PhD

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InflammationA common final pathway

• Cardiovascular disease
• Cancer
• Neurodegenerative disease
• Autoimmune disease
• DM
• Obesity

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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

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Phases of inflammation

• Initiating event-?
• Pro-inflammatory attack response/cellular
  destruction?
• Anti-inflammatory healing response/Cellular
  rejuvenation

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Omega 6 Fatty Acid (Linoleic Acid)
Omega 3 Fatty Acids (alpha-linolenic acid)
?6-Desaturase
Gamma-linolenic acid (GLA) Evening Primrose
Oil Borage Oil Black Current Oil
Eicosapentaenoic Acid (EPA)
COX
Lipoxygenase
?5-Desaturase
Arachidonic Acid
Prostaglandins PGE1, PGE3 (Favorable)
Less Inflammatory Leukotrienes
Cyclo-oxygenase (COX)
Lipoxygenase
Docosahexaenoic acid (DHA)
Prostaglandins (PGE2) (Inflammatory)
Leukotrienes
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Arachidonic Acid (in cell membrane)
Phospholipase A-2
Steroids
Free AA
Colchicine
Cyclo-oxygenase Pathway
Aspirin
Lipoxygenase Pathway
Sulfasalazine
NSAIDs
Leukotriene Inhibitors Accolate,
Singulair, Zyflo
COX II Inhibitors Celebrex, Vioxx, Mobic
Prostaglandins Thromboxanes
Leukotrienes
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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 1960s
  associated with obesity epidemicCHO intake has
  increased dramatically
• Glycemic index/glycemic load

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Types of fats

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

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Polyunsaturated fats (essential FAs)

• 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

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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)

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How much Omega-3 fats do you need?

• Strive for Omega 6 Omega-3 ratio of 41 (usual
  SAD (Standard American Diet) 161
• Maintenance 2.5 g/d
• Improve hear function 5 g/d
• Treat chronic pain 7.5 g/d
• Treat neurological disease gt10g/d
• Sears, The Anti-Inflammation Zone, 2005

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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 PCBs and dioxins
• Ultra-Refined EPA/DHA Concentrates
• Removal of PCBs and other toxins
• Can be used in high doses (weapons grade)

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Requirements for an Ultra-refined EPA/DHA
concentrate

• Total long-Chain Omega-3 gt60
• Dioxinslt 1 ppt
• Mercury lt10 ppb
• PCBslt30 ppb

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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

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Anti-inflammatory Lifestyle

• Exercise
• Quit smoking
• Weight loss
• Stress management
• Vagal nerve stimulation via abdominal breath work
• Treatment of depression
• Social support

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

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Something fishy?
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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. Womens Health in Primary Care. 2003.6(1)
  25-26 (Consensus opinion)
• Hu F, Willett W.Optimal diets for prevention of
  coronary heart disease. JAMA. 20022882569-2578
  Systematic review
•        

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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 Alzheimers 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

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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,
  2003361477-85
• Harper, Beyond the Mediterranean Diet the Role
  of Omega-3 Fatty Acids in the Prevention of CAD,
  Prev Cardiol, 20036(3)134-46

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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

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GISSI

• More than 11,000 patients on 1 gm fish oil/d lt
  3mos post MI
• 20 reduction in total mortality
• 10 reduction in recurrent MI
• 40 reduction in sudden death
• Lancet 1999354

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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.

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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

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A word about

• Glycemic Index (rate of absorption of glucose)
• Glycemic Load (ratio between GI and CHO content)
• www.glycemicindex.com

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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

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Lower GI/GL reduces risk

• Whole grains
• Fruits
• Vegetables
• Legumes
• Ormixing high GI/GL foods with those with lower
  GI/GL

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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

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Superfoods to decrease inflammation

• 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

• SALMON
• Alaskan halibut, canned albacore tuna, sardines,
  herring, trout, sea bass, oysters, and clams
• SOY
• Tofu, soymilk, soy nuts, edamame, tempeh, miso
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• SPINACH
• Kale, collard, Swiss chard, mustard greens,
  turnip greens, bok choy, romaine lettuce, orange
  bell peppers
• TEA GREEN OR BLACK

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  SUPERFOOD 7WILD 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, Alzheimers disease, Attention
  Deficit Disorder, Atrial fibrillation.
• SPF nutrients
• TRY TO EAT Wild salmon, halibut, sardines, etc. 
  2 to 4 times per week

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  SUPERFOOD 13WALNUTS

• 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

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WALNUT SIDEKICKS

• Almonds
• Pistachios
• Sesame Seeds
• Peanuts
• Pumpkin and Sunflower Seeds
• Macadamia Nuts
• Pecans
• Hazelnuts
• Cashews

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10 Foods to Avoid

• Donuts
• White Bread
• Bread with lt 3 grams fiber/ slice
• Soda
• Stick Margarines
• White Pasta
• Full Fat Dairy
• Movie Theatre Popcorn
• Luncheon Meats
• Sugar Coated Cereal

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References

• Rakel D, Rindfleisch A. Inflammation
  nutritional, botanical, and mind-body influences.
  South Med J 20058(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
  2000711455-1461
• Ascherio A, Katan, M, et al. Trans fatty acids
  and coronary heart disease. NEJM
  19993401994-1998