Fish consumption and risk of stroke and its subtypes: accumulative evidence from a meta-analysis of prospective cohort studies

Marine omega-3 fatty acid supplementation and prevention of cardiovascular disease: update on the randomized trial evidence

To date, the VITamin D and OmegA-3 TriaL (VITAL) is the only large-scale randomized trial of marine omega-3 fatty acid (n-3 FA) supplementation for cardiovascular disease (CVD) prevention in a general population unselected for elevated cardiovascular risk. We review the findings of VITAL, as well as results from recent secondary prevention trials and updated meta-analyses of n-3 FA trials in the primary and secondary prevention of CVD. In VITAL, a nationwide sample of 25 871 US adults aged 50 and older, including 5106 African Americans, were randomized in a 2 × 2 factorial design to n-3 FAs (1 g/day; 1.2:1 ratio of eicosapentaenoic to docosahexaenoic acid) and vitamin D3 (2000 IU/day) for a median of 5.3 years. Compared with an olive oil placebo, the n-3 FA intervention did not significantly reduce the primary endpoint of major CVD events [composite of myocardial infarction (MI), stroke, and CVD mortality; hazard ratio (HR) = 0.92 (95% confidence interval 0.80-1.06)] but did significantly reduce total MI [HR = 0.72 (0.59-0.90)], percutaneous coronary intervention [HR = 0.78 (0.63-0.95)], fatal MI [HR = 0.50 (0.26-0.97)], and recurrent (but not first) hospitalization for heart failure [HR = 0.86 (0.74-0.998)]. The intervention neither decreased nor increased risk of atrial fibrillation. African Americans derived the greatest treatment benefit for MI and for recurrent hospitalization for heart failure (P interaction < 0.05 for both outcomes). Meta-analyses that include VITAL and high-risk or secondary prevention n-3 FA trials show coronary, but generally not stroke, risk reduction. More research is needed to determine which individuals may be most likely to derive net benefit. (VITAL clinicaltrials.gov identifier: NCT01169259).

Adolescent girls in aquaculture ecozones at risk of nutrient deficiency in Bangladesh development and validation of an integrated metric

BACKGROUND

This study developed and validated an integrated metric that enhances understanding of linkages between agro-ecological and socio-economic factors that are important for explaining nutritional wellbeing in relation to fish consumption; especially among adolescent girls who are at risk of nutritional deficiency in Bangladesh. Currently, there is no metric that takes account of environmental, cultural and economic contexts when considering fish consumption and dietary health from a policy perspective.

METHODS

The study was designed as a bi-seasonal survey, repeated in the same population of adolescent girls recruited during the dry and wet seasons. Sampling was stratified by five settings (four aqua-agroecological zones and one processing plant community), with 60 girls recruited in each. Associations between candidate predictors (salinity, diet diversity, religion, socio-economic status and women's autonomy score) and dependent variables representing nutritional outcomes (anthropometry, omega-3 index and micronutrient levels) were explored in multivariable regressions. The fitted model with its predictors was validated, and a risk score derived from responses to a few short questions on religion, salinity zone, female autonomy, diet diversity and tilapia consumption.

RESULTS

The omega-3 index showed the clearest distinction between seasons, by salinity and religion. Higher female autonomy, religion (being Hindu rather than Muslim), geographical location (living in a high or mid-saline area), and a higher dietary diversity were the strongest predictors of whole blood omega-3 index. The c-index for the prognostic model was 0.83 and 0.76 in the wet and dry season respectively, indicating good predictive accuracy. There appeared to be a clear trend in risk scores differentiating between those 'chronically at risk' and those 'never at risk'.

CONCLUSIONS

Observational data on different aquaculture-ecozones defined by salinity enabled us to establish linkages between seasonal fish intake, religion, diet diversity, female autonomy and nutritional wellbeing. The purpose of the metric is to reveal these specific linkages in practice. This tool should improve targeting of timely, preventative and cost-effective nutritional interventions to adolescent girls most at-risk from low omega-3 levels in communities where seafood is produced.

Fish consumption in multiple health outcomes: an umbrella review of meta-analyses of observational and clinical studies

Background

Omega-3 polyunsaturated fatty acids are known to be associated with numbers of health benefits, and which can be uptake from fish. The aim of this study was to evaluate the current evidence of associations between consumption of fish and diverse health outcomes. Here, we performed an umbrella review to summarize the breadth, strength, and validity of the evidence derived from meta-analyses and systematic reviews of fish consumption on all health outcomes.

Methods

The methodological quality of the included meta-analyses and the quality of the evidence were assessed by the Assessment of Multiple Systematic Reviews (AMSTAR) and the grading of recommendations, assessment, development, and evaluation (GRADE) tools, respectively. The umbrella review identified 91 meta-analyses with 66 unique health outcomes, of which 32 outcomes were beneficial, 34 showed nonsignificant associations and only one was harmful (myeloid leukemia).

Results

A total of 17 beneficial associations [all-cause mortality, prostate cancer mortality, cardiovascular disease (CVD) mortality, esophageal squamous cell carcinoma (ESCC), glioma, non-Hodgkin lymphoma (NHL), oral cancer, acute coronary syndrome (ACS), cerebrovascular disease, metabolic syndrome, age-related macular degeneration (AMD), inflammatory bowel disease (IBD), Crohn's disease (CD), triglycerides, vitamin D, high-density lipoprotein (HDL)-cholesterol, and multiple sclerosis (MS)], and eight nonsignificant associations [colorectal cancer (CRC) mortality, esophageal adenocarcinoma (EAC), prostate cancer, renal cancer, ovarian cancer, hypertension, ulcerative colitis (UC), and rheumatoid arthritis (RA)] were evaluated as moderate/high quality of evidence. According to dose-response analyses, consumption of fish, especially fatty types, seems generally safe at one-two servings per week and could exert protective effects.

Conclusions

Fish consumption is often associated with a variety of health outcomes, both beneficial and harmless, but only about 34% of the associations were graded as based on a moderate/high quality of evidence, and additional multicenter high quality randomized controlled trials (RCTs) with a large sample size are needed to verify these findings in the future.

Components of a healthy diet and different types of physical activity and risk of atherothrombotic ischemic stroke: A prospective cohort study

Background

Diet and physical activity (PA) are modifiable risk factors thought to influence the risk of ischemic stroke (IS). However, few studies have examined their effect on different subtypes of IS.

Aim

To examine components of overall diet quality and different types of PA in relation to the risk of atherothrombotic IS (aIS).

Materials and methods

The study population included 23,797 participants (mean age 58 years; 63% women) from the Malmö Diet and Cancer Study cohort. Participants were enrolled between 1991 and 1996 and followed until end of 2016 (median follow-up 21.5 years). Incident aIS events were identified using national registries (total cases 1,937). Measures of PA (total, leisure-time, occupational, and domestic) were assessed using a baseline questionnaire and dietary intakes were estimated using a modified diet history method. Overall diet quality was assessed using a diet quality index. Intake of key food groups and beverages associated with overall diet quality were investigated separately. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using multivariable Cox regression models adjusting for confounders.

Results

A high diet quality with high intake of fruit and vegetables, fish and shellfish and low intake of sugar-sweetened beverages and red and processed meat compared to a low diet quality was associated with lower risk of aIS (HR = 0.82, 95% CI = 0.69–0.97; p = 0.015). Leisure-time PA was associated with reduced risk of aIS (HR = 0.95 per SD increase in MET-hours/week, 95% CI = 0.91–0.99; p = 0.028) with null associations observed for total, occupational and domestic PA level. We observed no significant interaction between diet and PA on the risk of aIS. The standardized 20-year risk of aIS among subjects with low leisure-time PA and low diet quality was 8.1% compared to 6.1% among those with high leisure-time PA and high diet quality.

Conclusion

Several components of a healthy diet and being physically active may reduce the risk of aIS, however, the absolute risk reduction observed was modest. A high diet quality seemed to have a risk reducing effect regardless of level of PA suggesting that individuals with a sedentary lifestyle may still gain some positive health benefits through a healthy diet.

Fish and human health: an umbrella review of observational studies

Fish represents one of the most important dietary sources of omega-3 polyunsaturated fatty acids, which are known to be associated with various health benefits. This study aimed to systematically review existing meta-analyses of observational studies exploring the association between fish intake and various health outcomes. A systematic search of electronic databases was conducted to retrieve a total of 63 studies. Evidence was deemed as possible for the association between higher fish intake and decreased risk of the acute coronary syndrome, liver cancer, and depression, and limited for other outcomes (including age-related macular degeneration, Alzheimer's disease, heart failure, all-cause and coronary heart disease mortality, total and ischaemic stroke) due to heterogeneity between results and potential otherwise inexplicable confounding factors. In conclusion, results from epidemiological studies support the mechanistic effects associated with omega-3 fatty acids from high fish consumption, but evidence needs to be further corroborated with more reliable results.

Fishing for health: Neighborhood variation in fish intake, fish quality and association with stroke risk among older adults in the Cardiovascular Health Study

BACKGROUND AND AIMS

Fish consumption has been associated with better health outcomes. Dietary patterns may vary substantially by neighborhood of residence. However, it is unclear if the benefits of a healthy diet are equivalent in different communities. This study examines associations of fish consumption with stroke incidence and stroke risk factors, and whether these differ by neighborhood socioeconomic status (NSES).

METHODS AND RESULTS

We studied 4007 participants in the Cardiovascular Health Study who were 65 years or older and recruited between 1989 and 1990 from 4 US communities. Outcomes included fish consumption type (bakes/broiled vs. fried) and frequency, stroke incidence, and stroke risk factors. Multilevel regressions models were used to estimate fish consumption associations with clinical outcomes. Lower NSES was associated with higher consumption of fried fish (aOR = 1.47, 95% CI: 1.10-1.98) and lower consumption of non-fried fish (0.64, 0.47-0.86). Frequent fried fish (11.9 vs. 9.2 person-years for at least once weekly vs. less than once a month, respectively) and less frequent non-fried fish (17.7 vs. 9.6 person-years for less than once a month vs. at least once weekly, respectively) were independently associated with an increased risk of stroke (p-values < 0.05). However, among those with similar levels of healthy fish consumption, residents with low NSES had less benefit on stroke risk reduction, compared with high NSES.

CONCLUSION

Fish consumption type and frequency both impact stroke risk. Benefits of healthy fish consumption differ by neighborhood socioeconomic status.

Role of diet in stroke incidence: an umbrella review of meta-analyses of prospective observational studies

BACKGROUND

Stroke is one of the major challenges for the global healthcare system, which makes it necessary to explore the relationship between various modifiable factors and stroke risk. Recently, numerous meta-analyses of prospective observational studies have reported that dietary factors played a key role in the occurrence of stroke. However, the conclusions of previous studies have remained controversial and unclear. Accordingly, we conducted an umbrella review synthesizing and recalculating available evidence to assess the certainty of the associations between dietary factors and stroke.

METHODS

Relevant meta-analyses examining the associations between dietary factors and stroke were searched in PubMed and Embase databases up to September 1, 2021. For each eligible meta-analysis, two independent reviewers appraised the methodologic quality using the AMSTAR 2 criteria and estimated the summary effect size, 95% confidence intervals, 95% prediction intervals, heterogeneity between studies, and small-study effects. Moreover, we further assessed the associations between dietary factors and ischemic stroke as well as hemorrhagic stroke. Lastly, a set of pre-specified criteria was applied to qualitatively evaluate the epidemiological credibility of each dietary factor.

RESULTS

Overall, our umbrella review included 122 qualified meta-analyses for qualitative synthesis, involving 71 dietary factors related to food groups, foods, macronutrients, and micronutrients. Using the AMSTAR 2 criteria, 5 studies were assessed as high quality, 4 studies as moderate quality, and 113 studies as low or critically low quality. We identified 34 dietary factors associated with stroke occurrence, 25 dietary factors related to ischemic stroke, and 11 factors related to hemorrhagic stroke. Among them, high/moderate certainty epidemiological evidence demonstrated an inverse association between intake of fruits (RR: 0.90) and vegetables (RR: 0.92) and stroke incidence, but a detrimental association between red meat (RR: 1.12), especially processed red meat consumption (RR:1.17), and stroke incidence. Besides, the evidence of high/moderate certainty suggested that the intake of processed meat, fruits, coffee, tea, magnesium, and dietary fiber was associated with ischemic stroke risk, while consumption of tea, fruits, and vegetables was relevant to hemorrhagic stroke susceptibility.

CONCLUSIONS

Our study has reported that several dietary factors have a significant impact on stroke risk and offered a new insight into the relationship between dietary modification and stroke occurrence. Our results may provide an effective strategy for stroke prevention.

Prepregnancy plant-based diets and the risk of gestational diabetes mellitus: a prospective cohort study of 14,926 women

BACKGROUND

Emerging evidence suggests beneficial impacts of plant-based diets on glucose metabolism among generally healthy individuals. Whether adherence to these diets is related to risk of gestational diabetes mellitus (GDM) is unknown.

OBJECTIVES

We aimed to examine associations between plant-based diets and GDM in a large prospective study.

METHODS

We included 14,926 women from the Nurses' Health Study II (1991-2001), who reported ≥1 singleton pregnancy and without previous GDM before the index pregnancy. Prepregnancy adherence to plant-based diets was measured by an overall plant-based diet index (PDI), healthful plant-based diet index (hPDI), and unhealthful plant-based diet index (uPDI) as assessed by FFQs every 4 y. Incident first-time GDM was ascertained from a self-reported physician diagnosis, which was previously validated by review of medical records. We used log-binomial models with generalized estimating equations to calculate RRs and 95% CIs for associations of PDIs with GDM.

RESULTS

We documented 846 incident GDM cases over the 10-y follow-up among 20,707 pregnancies. Greater adherence to the PDI and hPDI was associated with lower GDM risk. For the PDI, the multivariable-adjusted RR (95% CI) comparing the highest and lowest quintiles (Q5 compared with Q1) was 0.70 (0.56, 0.87) (Ptrend = 0.0004), and for each 10-point increment was 0.80 (0.71, 0.90). For the hPDI, the RR (95% CI) of Q5 compared with Q1 was 0.75 (0.59, 0.94) (Ptrend = 0.009) and for each 10-point increment was 0.86 (0.77, 0.95). After further adjustment for prepregnancy BMI, the associations were attenuated but remained significant: for the PDI, the RR (95% CI) for each 10-point increment was 0.89 (0.79, 1.00) and the corresponding RR (95% CI) was 0.89 (0.80, 0.99) for the hPDI. The uPDI was not associated with GDM.

CONCLUSIONS

Our study suggests that greater prepregnancy adherence to a healthful plant-based diet was associated with lower risk of GDM, whereas an unhealthful plant-based diet was not related to GDM risk.

Anti-Atherogenic Effect of 10% Supplementation of Anchovy (Engraulis encrasicolus) Waste Protein Hydrolysates in ApoE-Deficient Mice

Fish protein consumption exerts beneficial metabolic effects on human health, also correlating with a decreased risk for cardiovascular disease. Fish waste contains high amount of proteins and utilization may offer the opportunity for generating compounds advantageous for human health. Especially, fish waste protein hydrolysates beneficially influence pathways involved in body composition, exerting anti-inflammatory and antioxidant activities, making their potential supplementation in human disorders of increased interest. This study assessed the effect of a 10% (w/w) anchovy waste protein hydrolysate (APH) diet for 12 weeks in reducing atherosclerosis in ApoE^-/- mice, through histological and immunohistochemical methods. In addition, monitoring of plaque development was performed, using high-frequency ultrasound and magnetic resonance imaging. Overall, the APH diet attenuated atherosclerotic plaque development, producing a regression of arterial lesions over time (p < 0.05). Twelve weeks on an APH diet had an anti-obesity effect, improving lipid metabolism and reducing hepatic enzyme activity. A significant reduction in plaque size and lipid content was observed in the aortic sinus of APH-fed mice, compared to the control (p < 0.001), whereas no differences in the extracellular matrix and macrophage recruitment were observed. Supplementation of APH significantly attenuates atherosclerosis in ApoE^-/- mice, exerting a lipid-lowering activity. The opportunity to use fish waste protein hydrolysates as a nutraceutical in atherosclerosis is worthy of future investigations, representing a low cost, sustainable, and nutritional strategy with minimal environmental impact.

Less than half of the European dietary recommendations for fish consumption are satisfied by national seafood supplies

Purpose

To review the seafood dietary recommendations of European countries and compare them to national seafood supplies.

Methods

Current seafood dietary recommendations were collated from national health authorities across Europe. Food balance sheets were downloaded from the FAO, and appropriate conversion factors were applied to each seafood commodity. Average net per capita seafood supplies from 2007 to 2017 were derived from data on imports and production for food from both capture fisheries and aquaculture, accounting for exports.

Results

Both national dietary recommendations and seafood supplies varied considerably throughout Europe. At a national level, on a per capita basis, only 13 out of the 31 of European dietary recommendations for fish consumption were satisfied by national seafood supplies. Most of the countries with coastal access, as well as those with traditional fish-eating cultures, such as France and countries in Northern Europe, had adequate seafood supplies to meet their recommendations. The landlocked countries of Central and Eastern Europe did not have enough seafood supplies to satisfy their recommendations.

Conclusions

Our findings emphasise the need to not only consider consumer health outcomes when developing and advocating dietary recommendations, but also the sustainability of food production systems. As many foods are not necessarily locally sourced but traded as part of global production and distribution systems, it is important to consider greater consistency between national dietary recommendations to facilitate more sustainable marine food systems.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00394-021-02580-6.

Dietary Oily Fish Intake is Inversely Associated with Severity of White Matter Hyperintensities of Presumed Vascular Origin. A Population-Based Study in Frequent Fish Consumers of Amerindian Ancestry

BACKGROUND

Oily fish is a major dietary source of omega-3 polyunsaturated fatty acids and other nutrients that may reduce the expression of cerebral small vessel disease (cSVD) biomarkers, including white matter hyperintensities (WMH) of presumed vascular origin. However, information on this relationship is limited. We aimed to assess the association between oily fish intake and WMH severity in a population of frequent fish consumers.

METHODS

The study included 572 individuals aged ≥60 years living in three neighboring rural villages of coastal Ecuador. Dietary oily fish intake was calculated and all participants received a brain MRI. Logistic regression models, adjusted for demographics, level of education, cardiovascular risk factors and other cSVD biomarkers, were fitted to assess the independent association between amounts of oily fish intake and WMH severity.

RESULTS

Overall, the mean intake of oily fish was 8.5 ± 4.7 servings per week, and 164 individuals (29%) had moderate-to-severe WMH (according to the modified Fazekas scale). A multivariate logistic regression model disclosed a significant inverse association between the amount of oily fish intake and the presence of moderate-to-severe WMH (OR: 0.89; 95% C.I.: 0.85-0.94; p < 0.001). Predictive margins revealed an almost linear inverse relationship between quartiles of oily fish intake and probabilities of WMH severity, which became significant when the 1^st quartile was compared with the 3^rd and 4^th quartiles.

CONCLUSIONS

Increased amounts of oily fish intake are inversely associated with WMH severity. Further studies are warranted to determine whether oily fish intake reduces the risk of cSVD-related cerebrovascular complications.

Prevention of Endothelial Dysfunction and Cardiovascular Disease by n-3 Fatty Acids-Inhibiting Action on Oxidative Stress and Inflammation

BACKGROUND

Prospective cohort studies and randomized controlled trials have shown the protective effect of n-3 fatty acids against cardiovascular disease (CVD). The effect of n-3 fatty acids on vascular endothelial cells indicates their possible role in CVD prevention.

OBJECTIVE

Here, we describe the effect of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) on endothelial dysfunction-caused by inflammation and oxidative stress-and their role in the development of CVD.

METHODS

We reviewed epidemiological studies done on n-3 fatty acids in CVD. The effect of DHA and EPA on vascular endothelial cells was examined with regard to changes in various markers, such as arteriosclerosis, inflammation, and oxidative stress, using cell and animal models.

RESULTS

Epidemiological studies revealed that dietary intake of EPA and DHA was associated with a reduced risk of various CVDs. EPA and DHA inhibited various events involved in arteriosclerosis development by preventing oxidative stress and inflammation associated with endothelial cell damage. In particular, EPA and DHA prevented endothelial cell dysfunction mediated by inflammatory responses and oxidative stress induced by events related to CVD. DHA and EPA also increased eNOS activity and induced nitric oxide production.

CONCLUSION

The effects of DHA and EPA on vascular endothelial cell damage and dysfunction may involve the induction of nitric oxide, in addition to antioxidant and anti-inflammatory effects. n-3 fatty acids inhibit endothelial dysfunction and prevent arteriosclerosis. Therefore, the intake of n-3 fatty acids may prevent CVDs, like myocardial infarction and stroke.

Role of polyunsaturated fatty acids in ischemic stroke - A perspective of specialized pro-resolving mediators

Polyunsaturated fatty acids (PUFAs) have been proposed as beneficial for cardiovascular health. However, results from both epidemiological studies and clinical trials have been inconsistent, whereas most of the animal studies showed promising benefits of PUFAs in the prevention and treatment of ischemic stroke. In recent years, it has become clear that PUFAs are metabolized into various types of bioactive derivatives, including the specialized pro-resolving mediators (SPMs). SPMs exert multiple biofunctions, such as to limit excessive inflammatory responses, regulate lipid metabolism and immune cell functions, decrease production of pro-inflammatory factors, increase anti-inflammatory mediators, as well as to promote tissue repair and homeostasis. Inflammation has been recognised as a key contributor to the pathophysiology of acute ischemic stroke. Owing to their potent pro-resolving actions, SPMs are potential for development of novel anti-stroke therapy. In this review, we will summarize current knowledge of epidemiological studies, basic research and clinical trials concerning PUFAs in stroke prevention and treatment, with special attention to SPMs as the unsung heroes behind PUFAs.

Omega-3 polyunsaturated fatty acids focusing on eicosapentaenoic acid and docosahexaenoic acid in the prevention of cardiovascular diseases: a review of the state-of-the-art

INTRODUCTION

: An epidemiological study of Greenlandic Inuit suggested the importance of omega-3 polyunsaturated fatty acids (PUFAs) in preventing ischemic heart disease. After this landmark study, large-scale epidemiological studies have examined the benefits of omega-3 PUFAs in the prevention of cardiovascular diseases.

AREAS COVERED

: This article reviews studies on omega-3 PUFAs, and identifies issues relevant to cardiovascular risk.

EXPERT OPINION

: Recent studies have focused on the anti-inflammatory effects of omega-3 PUFAs and specialized pro-resolving mediators. High-purity eicosapentaenoic acid (EPA) ethyl ester and EPA/docosahexaenoic acid (DHA) preparations have been developed primarily for the treatment of hypertriglyceridemia. Various trials on the cardiovascular protective effects of omega-3 PUFAs have been reported, but the results have not been consistent. Some issues of the trials have been suggested, such as using low-dose omega-3 PUFAs and not including hypertriglyceridemia in subject selection criteria. REDUCE-IT study that used a high dose of high-purity EPA preparation showed a relative reduction in cardiovascular events, but, the STRENGTH study that used a high dose of EPA/DHA preparation did not support this benefit. This article reviews the roles of omega-3 PUFAs in cardiovascular diseases, including progress in understanding the molecular mechanisms and recent large-scale clinical trials.

Changing dietary approaches to prevent cardiovascular disease

PURPOSE OF REVIEW

We have focused on recent research relevant to effects of dietary patterns and major food groups on cardiovascular outcomes, taking into account guidelines and position statements from expert authorities, with an emphasis on important changes in recommendations, some of which remain controversial.

RECENT FINDINGS

Major findings include: refocusing on qualitative patterns of food consumption replacing quantitative prescriptive advice on nutrients; increasing intake of plant foods; substituting saturated fats with polyunsaturated and monounsaturated oils; reducing salt intake; regular consumption of fish with a focus on omega-3 enrichment; not restricting dairy foods, other than butter and cream, with encouragement of some fermented products; reducing cholesterol intake for those at increased cardiovascular risk and diabetes, allowing 7-eggs weekly; restricting processed meats and allowing moderate lean meat consumption; preference for fiber-rich complex carbohydrates and reduced sugar intake; maintaining healthy bodyweight; and although water is the preferred beverage, allowing moderate alcohol consumption to national guidelines and avoiding alcohol in specific cardiovascular disorders.

SUMMARY

The new approach that focuses on healthier patterns of food intake is more readily understood by health practitioners and translatable to consumers and patients.

Linkages of agroecosystems producing farmed seafood on food security, nutritional status and adolescent health in Bangladesh

This narrative review aims to provide an interdisciplinary perspective on actors that link global aquatic food production systems with fish consumption and nutritional status, with a special focus on adolescent girls in Bangladesh. The writing of this narrative perspective was undertaken within the framework of the Aquatic Food for Health and Nutrition (AQN) project that aimed to develop a metric for assessing the impacts on nutrition and health of agroecosystems producing farmed seafood. Previous studies evaluating links between agricultural ecosystems, aquaculture, food security and human health have systemically ignored the importance of diet and nutrition. Such studies have also ignored the importance of local communities, cultural norms and household composition and behaviours to identify vulnerable groups such as adolescent girls. This narrative review presents our current understanding of the relationships between aquaculture, fish production and consumption patterns, food security, optimal nutrition and health. It also highlights the importance of research into aquaculture food systems, linking aquatic food production systems with nutritional status, health and socioeconomic prosperity, which would help to develop more integrated and relevant food policies.

Effect of vitamin D and/or omega-3 fatty acid supplementation on stroke outcomes: A randomized trial

BACKGROUND AND PURPOSE

Among stroke patients, low serum 25-hydroxyvitamin D predicts poor outcomes. In mice, higher omega-3 (n-3) fatty acid intake diminishes brain damage after stroke. In this study, we tested whether vitamin D or n-3 fatty acids supplementation prior to stroke reduces the risk of functional limitations and physical disability after stroke.

METHODS

We used data from VITAL (the VITamin D and OmegA-3 TriaL) which randomized middle-aged and older men and women without cardiovascular disease to vitamin D₃ (2000 IU/day) and/or marine n-3 fatty acids (1 g/day) and followed them for incident stroke events. Individuals experiencing a non-fatal stroke were mailed questionnaires assessing functional limitations (the physical performance scale adapted from Nagi) and physical disability (the modified Katz Activities of Daily Living and Rosow-Breslau Functional Health scales). We used logistic regression to analyze associations between randomized treatment and limitations on each scale.

RESULTS

A total of 290 individuals experienced their first stroke during the trial, of whom 197 stroke survivors completed the stroke outcomes questionnaire a median of 1.4 years after diagnosis. We observed no associations between randomized treatment to vitamin D and functional limitations (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.52, 1.97) or physical disability (Rosow-Breslau scale: OR 0.92, 95% CI 0.50, 1.67; Katz scale: OR 1.03, 95% CI 0.31, 3.42). Those randomized to n-3 fatty acids had a non-significantly lower risk of functional limitations (OR 0.55, 95% CI 0.28, 1.09) and physical disability (Rosow-Breslau scale: OR 0.56, 95% CI 0.31, 1.02; Katz sclae: OR 0.32, 95% CI 0.50, 1.67).

CONCLUSION

Vitamin D or omega-3 fatty acid supplementation prior to stroke did not result in significantly improved post-stroke outcomes.

Practical Guidance for Food Consumption to Prevent Cardiovascular Disease

This dietary guidance, informed by best contemporary evidence, aims to assist medical practitioners and allied health professionals in advising patients for the primary and secondary prevention of cardiovascular disease (CVD). While differing in some details from other current guidelines, the core messages accord with those published in 2019 by the American College of Cardiology/American Heart Association and the European Society of Cardiology/European Atherosclerosis Society; the National Lipid Association in 2014 and the NH&MRC Australian Dietary Guidelines in 2013. These were assessed through the Appraisal of Guidelines for Research and Evaluation (AGREE II) and the levels of evidence and classes of a recommendation developed using the GRADE system. Recommendations with high levels of evidence include increased consumption of plant based foods comprising mainly complex, fibre enriched carbohydrates (wholegrains, fruits and vegetables) while limiting intake of refined starches; partial replacement of saturated fats with monounsaturated or polyunsaturated fats and oils; reduced salt intake; achievement and maintenance of healthy weight; and low-to-moderate consumption of alcohol. Additional guidance but with moderate levels of evidence includes increased consumption of fish (and fish oils where indicated); reduction in sugar-sweetened beverages and added sugars; avoidance of butter and cream especially in those at increased CVD risk but encouragement of yoghurt; allow moderate consumption of lean meat but limit intake of processed meats; and limit cholesterol-rich foods such as eggs and crustaceans for those at increased CVD risk. Guidance has been formulated qualitatively on food categories of commonly eaten foods while avoiding prescriptive quantitative measures that are less readily translatable. This approach accords with current guidelines such as the American College of Cardiology/American Heart Association 2019 guidelines and is understandable and readily implemented.

The nutritional and cardiovascular health benefits of rapeseed oil-fed farmed salmon in humans are not decreased compared with those of traditionally farmed salmon: a randomized controlled trial

PURPOSE

Farmed fish are increasingly raised on feeds containing vegetable oils, which affects their composition and possibly health properties. We investigated the effects of consuming farmed salmon, raised on different feeding regimes, on nutrient status and health outcomes in healthy subjects.

METHODS

Salmon were grown on feeds containing mainly fish oil (FO) or rapeseed oil (RO), resulting in an eicosapentaenoic acid (EPA) + docosahexaenoic acid (DHA) content of fillets of 2.1 or 0.9 g/100 g, respectively. In a randomized parallel controlled trial, 51 healthy subjects were allocated to consume 2 portions/week of FO salmon (n = 17), RO salmon (n = 17) or no additional salmon (Control, n = 17) as part of their habitual diet, for 18 weeks. We collected blood at 0, 9 and 18 weeks to measure omega-3 index (O3I) in red blood cells, plasma markers of cardiovascular risk, serum 25(OH)-vitamin D₃ (25(OH)D₃) and plasma trace elements.

RESULTS

After 18 weeks, O3I was similarly increased in subjects consuming 2 portions/week of FO or RO salmon compared to control (both p < 0.05). Serum 25(OH)D₃ was significantly higher, whereas plasma triacylglycerols were significantly lower in subjects consuming RO salmon compared to control (both p < 0.05). Heart rate was significantly lower in subjects consuming FO salmon after 9 weeks, compared to control (p < 0.01). Salmon consumption did not affect other markers.

CONCLUSION

Consuming two portions/week of salmon raised on rapeseed oil rather than fish oil increased the O3I and vitamin D status, and decreased plasma triacylglycerols. These outcomes endorse opportunities for developing more sustainable feeds within aquaculture food systems.

CLINICAL TRIAL REGISTRY

This trial was registered at clinicaltrials.gov as NCT01916434.

The associations of major foods and fibre with risks of ischaemic and haemorrhagic stroke: a prospective study of 418 329 participants in the EPIC cohort across nine European countries

AIM

To investigate the associations between major foods and dietary fibre with subtypes of stroke in a large prospective cohort.

METHODS AND RESULTS

We analysed data on 418 329 men and women from nine European countries, with an average of 12.7 years of follow-up. Diet was assessed using validated country-specific questionnaires which asked about habitual intake over the past year, calibrated using 24-h recalls. Multivariable-adjusted Cox regressions were used to estimate hazard ratios (HRs) for ischaemic and haemorrhagic stroke associated with consumption of red and processed meat, poultry, fish, dairy foods, eggs, cereals, fruit and vegetables, legumes, nuts and seeds, and dietary fibre. For ischaemic stroke (4281 cases), lower risks were observed with higher consumption of fruit and vegetables combined (HR; 95% CI per 200 g/day higher intake, 0.87; 0.82-0.93, P-trend < 0.001), dietary fibre (per 10 g/day, 0.77; 0.69-0.86, P-trend < 0.001), milk (per 200 g/day, 0.95; 0.91-0.99, P-trend = 0.02), yogurt (per 100 g/day, 0.91; 0.85-0.97, P-trend = 0.004), and cheese (per 30 g/day, 0.88; 0.81-0.97, P-trend = 0.008), while higher risk was observed with higher red meat consumption which attenuated when adjusted for the other statistically significant foods (per 50 g/day, 1.07; 0.96-1.20, P-trend = 0.20). For haemorrhagic stroke (1430 cases), higher risk was associated with higher egg consumption (per 20 g/day, 1.25; 1.09-1.43, P-trend = 0.002).

CONCLUSION

Risk of ischaemic stroke was inversely associated with consumption of fruit and vegetables, dietary fibre, and dairy foods, while risk of haemorrhagic stroke was positively associated with egg consumption. The apparent differences in the associations highlight the importance of examining ischaemic and haemorrhagic stroke subtypes separately.

The healthiness and sustainability of national and global food based dietary guidelines: modelling study

OBJECTIVE

To analyse the health and environmental implications of adopting national food based dietary guidelines (FBDGs) at a national level and compared with global health and environmental targets.

DESIGN

Modelling study.

SETTING

85 countries.

PARTICIPANTS

Population of 85 countries.

MAIN OUTCOME MEASURES

A graded coding method was developed and used to extract quantitative recommendations from 85 FBDGs. The health and environmental impacts of these guidelines were assessed by using a comparative risk assessment of deaths from chronic diseases and a set of country specific environmental footprints for greenhouse gas emissions, freshwater use, cropland use, and fertiliser application. For comparison, the impacts of adopting the global dietary recommendations of the World Health Organization and the EAT-Lancet Commission on Healthy Diets from Sustainable Food Systems were also analysed. Each guideline's health and sustainability implications were assessed by modelling its adoption at both the national level and globally, and comparing the impacts to global health and environmental targets, including the Action Agenda on Non-Communicable Diseases, the Paris Climate Agreement, the Aichi biodiversity targets related to land use, and the sustainable development goals and planetary boundaries related to freshwater use and fertiliser application.

RESULTS

Adoption of national FBDGs was associated with reductions in premature mortality of 15% on average (95% uncertainty interval 13% to 16%) and mixed changes in environmental resource demand, including a reduction in greenhouse gas emissions of 13% on average (regional range -34% to 35%). When universally adopted globally, most of the national guidelines (83, 98%) were not compatible with at least one of the global health and environmental targets. About a third of the FBDGs (29, 34%) were incompatible with the agenda on non-communicable diseases, and most (57 to 74, 67% to 87%) were incompatible with the Paris Climate Agreement and other environmental targets. In comparison, adoption of the WHO recommendations was associated with similar health and environmental changes, whereas adoption of the EAT-Lancet recommendations was associated with 34% greater reductions in premature mortality, more than three times greater reductions in greenhouse gas emissions, and general attainment of the global health and environmental targets. As an example, the FBDGs of the UK, US, and China were incompatible with the climate change, land use, freshwater, and nitrogen targets, and adopting guidelines in line with the EAT-Lancet recommendation could increase the number of avoided deaths from 78 000 (74 000 to 81 000) to 104 000 (96 000 to 112 000) in the UK, from 480 000 (445 000 to 516 000) to 585 000 (523 000 to 646 000) in the USA, and from 1 149 000 (1 095 000 to 1 204 000) to 1 802 000 (1 664 000 to 1 941 000) in China.

CONCLUSIONS

This analysis suggests that national guidelines could be both healthier and more sustainable. Providing clearer advice on limiting in most contexts the consumption of animal source foods, in particular beef and dairy, was found to have the greatest potential for increasing the environmental sustainability of dietary guidelines, whereas increasing the intake of whole grains, fruits and vegetables, nuts and seeds, and legumes, reducing the intake of red and processed meat, and highlighting the importance of attaining balanced energy intake and weight levels were associated with most of the additional health benefits. The health results were based on observational data and assuming a causal relation between dietary risk factors and health outcomes. The certainty of evidence for these relations is mostly graded as moderate in existing meta-analyses.

Dietary n-3 polyunsaturated fatty acids, fish intake and healthy ageing

BACKGROUND

Seafood consumption and dietary intake of n-3 polyunsaturated fatty acids (PUFA) protect from cardiovascular disease, muscle wasting and mortality; however, their role in delaying unhealthy ageing is uncertain.

METHODS

A prospective cohort study with 1592 community-dwelling individuals aged ≥60 years recruited in 2008-2010, and followed through 2015. Intake of seafood and n-3 PUFA [eicosapentanoic acid (EPA) and docosahexanoic acid (DHA)] was estimated using a validated diet history and food composition tables. Unhealthy ageing was assessed across the domains of physical and cognitive function, mental health, morbidity, self-rated health and vitality.

RESULTS

Higher blue fish consumption was negatively associated with unhealthy ageing in 2015 [multivariate ß (95% confidence interval) per interquartile range (IQR) increase of fish: -0.49 (-0.90; -0.08)] and, specifically, was associated with lower accumulation of functional impairments [-1.00 (-1.71; -0.28)] and morbidities [-0.30 (-0.73; 0.13)]. Individuals with high intakes of EPA (≥0.47 g/day) and DHA (≥0.89 g/day) presented the highest reductions in age-related deficits accumulation: -1.61 (-3.01; -0.22) and -1.34 (-2.76; 0.08), respectively. Intake of EPA and DHA were negatively associated with the accumulation of functional deficits [results per IQR increase: -0.79 (-1.64; -0.06) and -0.84 (-1.67; -0.01), respectively] and morbidities [-0.60 (-1.10; -1.11) and -0.60 (-1.09; -0.11)]. No associations were observed between n-3 PUFA and self-rated or mental health, or between white fish and unhealthy ageing.

CONCLUSIONS

In this cohort of Spanish individuals with elevated intake of fish and a high adherence to the Mediterranean diet, consumption of blue fish and n-3 PUFA had a prospective protective association with deficits accumulation.

Roles for circulating polyunsaturated fatty acids in ischemic stroke and modifiable factors: a Mendelian randomization study

Background

Available data about the effects of circulating polyunsaturated fatty acids (PUFAs) on ischemic stroke (IS) and its main risk factors remains limited and conflicting. Therefore, we conducted Mendelian randomization (MR) to assess whether genetically predicted PUFA affected IS, lipids and blood pressure (BP).

Methods

Genetic instruments associated with IS were derived from ISGC Consortium (n = 29,633), with lipids were derived from GLGC(n = 188,577), with BP were derived from Neale Lab(n = 337,000). The inverse-variance weighted method was the main analysis to estimate the effect of exposure on outcome. Sensitivity analyses included principal components analysis, MR-Egger, weighted median, and weighted mode.

Results

Per SD increases in serum α-linolenic acid (ALA) were associated with lower IS risk, with odd ratio (OR) of 0.867(0.782,0.961), arachidonic acid (AA) were associated with higher IS risk (OR: 1.053(1.014,1.094)). Likewise, Per SD increases in ALA were associated with the lower-level low-density lipoprotein cholesterol(LDL-C), high-density lipoprotein cholesterol (HDL-C), total cholesterol (TC) (β:-0.122(− 0.144, − 0.101), − 0.159(− 0.182, − 0.135), − 0.148(− 0.171, − 0.126), respectively), AA were associated with the higher-level of LDL-C, HDL-C and TC (β:0.045(0.034,0.056), 0.059(0.050,0.067), 0.055(0.046,0.063), respectively). Linoleic acid (LA), eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and docosapentaenoic acid (DPA) had little or no association with IS, lipids or BP at Bonferroni-corrected significance. Different analytic methods supported these findings. The intercept test of MR-Egger implied no pleiotropy.

Conclusions

High-level plasma ALA was protective for IS but AA was the opposite. LA, EPA, DHA, and DPA had no effects on IS.

Dietary habits, lipoprotein metabolism and cardiovascular disease: From individual foods to dietary patterns

Cardiovascular disease (CVD) remains the first cause of mortality in Western countries. Among cardiometabolic risk factors, dyslipidemia, and especially high low-density lipoprotein cholesterol (LDL-C) concentrations, have been extensively linked to the development and progression of atherosclerosis and to CVD events. Recent evidence has shown that the prevention of unhealthy dietary habits and sedentarism is crucial in the management of dyslipidemia. In this sense, a number of scientific societies recommend the adherence to certain healthy dietary patterns (DPs), such as the Mediterranean diet (MedDiet), the Dietary Approaches to Stop Hypertension (DASH), the Portfolio diet, the Vegetarian diet, the Nordic diet and low-carbohydrate diets, as well as increased physical activity between others. This nutritional and lifestyle advice could be adopted by government bodies and implemented in different health programs as a reliable way of providing health-care professionals with efficient tools to manage cardiometabolic risk factors and thus, prevent CVD. In this narrative review, we will discuss recent data about the effects of nutrition on dyslipidemia, mainly focusing on high LDL-C concentrations and other lipid particles related to atherogenic dyslipidemia such as triglycerides (TG) and non-high density lipoprotein cholesterol (non-HDL-C), that are related to CVD. On the other hand, we also comment on other cardiometabolic risk factors such as type 2 diabetes mellitus (T2DM), high blood pressure (HBP), inflammation and endothelial dysfunction. This review includes food groups as well as different healthy DPs.

Effects of an Omega-3 and Vitamin D Supplement on Fatty Acids and Vitamin D Serum Levels in Double-Blinded, Randomized, Controlled Trials in Healthy and Crohn's Disease Populations

Two trials separately measured the bioavailability and impact on inflammation of a supplement taken daily containing 510 mg Docosahexaenoic acid (DHA), 344 mg Eicosapentaenoic acid (EPA), and 1000 IU of vitamin D (25-hydroxyvitamin D; 25(OH)D), for healthy and Crohn’s disease (CD) populations. Both trials were double blinded, randomized, placebo-controlled with cross-over. Participants were randomly allocated to groups A (placebo then supplement) or B (supplement then placebo). Both included a washout. Fatty acid (N-3 PUFAs) and vitamin D serum levels, plasma C-reactive protein (CRP), and stool calprotectin were measured before and after each treatment period. Outcome measures were analyzed using generalized linear mixed models, including terms for treatment, period, and a treatment-by-period interaction. The supplement significantly increased serum levels in healthy and CD groups for EPA (p < 0.001 and p < 0.001, respectively), Docosapentaenoic acid (p < 0.001 and 0.005), DHA (p < 0.001 and 0.006), the omega-3 index (p < 0.001 and 0.001), and (vitamin D (p < 0.001 and 0.027). CRP and calprotectin measures showed no evidence of a treatment effect on inflammation; however, model estimation was imprecise for both outcomes, hence further research is required to elucidate potential inflammation effects. The nutrient supplement increased serum levels of key N-3 PUFAs and vitamin D in both populations, showing the preparation was readily bioavailable.

Hypothetical Lifestyle Strategies in Middle-Aged Women and the Long-Term Risk of Stroke

Supplemental Digital Content is available in the text.

Long-term effect of lifestyle changes on stroke incidence has not been estimated in randomized trials. We used observational data to estimate the incidence of stroke under hypothetical lifestyle strategies in the NHS (Nurses’ Health Study).

Fish Consumption and the Risk of Chronic Disease: An Umbrella Review of Meta-Analyses of Prospective Cohort Studies

We aimed to present a comprehensive review of published meta-analyses of prospective cohort studies on the association of fish consumption and the risk of chronic disease. A systematic search was undertaken in Pubmed and Scopus to October 2019 to find meta-analyses of observational studies evaluating the association of fish consumption and the risk of chronic disease. Retrospective and cross-sectional studies and studies with unadjusted risk estimates were excluded. The summary relative risk (SRR) for each meta-analysis was recalculated by using a random-effects model. The methodological quality of included meta-analyses and the quality of the evidence were assessed by the AMSTAR and NutriGrade tools, respectively. A total of 34 meta-analyses of prospective observational studies, reporting SRRs for 40 different outcomes obtained from 298 primary prospective cohort studies, were included. Moderate-quality evidence suggested that each 100-g/d increment in fish consumption was associated with a lower risk of all-cause mortality (SRR: 0.92; 95% CI: 0.87, 0.97), cardiovascular mortality (SRR: 0.75; 95% CI: 0.65, 0.87), coronary heart disease (SRR: 0.88; 95% CI: 0.79, 0.99), myocardial infarction (SRR: 0.75; 95% CI: 0.65, 0.93), stroke (SRR: 0.86; 95% CI: 0.75, 0.99), heart failure (SRR: 0.80; 95% CI: 0.67, 0.95), depression (SRR: 0.88; 95% CI: 0.79, 0.98), and liver cancer (SRR: 0.65; 95% CI: 0.48, 0.87). For cancers of most sites, there was no significant association and the quality of the evidence was rated low and very low. In conclusion, evidence of moderate quality suggests that fish consumption is associated with a lower risk of cardiovascular disease, depression, and mortality and, therefore, can be considered as a healthy animal-based dietary source of protein. Further research is needed for outcomes for which the quality of the evidence was rated low and very low, considering types of fish consumed, different methods of cooking fish, and all potential confounding variables.

Associations of habitual fish oil supplementation with cardiovascular outcomes and all cause mortality: evidence from a large population based cohort study

OBJECTIVES

To evaluate the associations of habitual fish oil supplementation with cardiovascular disease (CVD) and mortality in a large prospective cohort.

DESIGN

Population based, prospective cohort study.

SETTING

UK Biobank.

PARTICIPANTS

A total of 427 678 men and women aged between 40 and 69 who had no CVD or cancer at baseline were enrolled between 2006 and 2010 and followed up to the end of 2018.

MAIN EXPOSURE

All participants answered questions on the habitual use of supplements, including fish oil.

MAIN OUTCOME MEASURES

All cause mortality, CVD mortality, and CVD events.

RESULTS

At baseline, 133 438 (31.2%) of the 427 678 participants reported habitual use of fish oil supplements. The multivariable adjusted hazard ratios for habitual users of fish oil versus non-users were 0.87 (95% confidence interval 0.83 to 0.90) for all cause mortality, 0.84 (0.78 to 0.91) for CVD mortality, and 0.93 (0.90 to 0.96) for incident CVD events. For CVD events, the association seemed to be stronger among those with prevalent hypertension (P for interaction=0.005).

CONCLUSIONS

Habitual use of fish oil seems to be associated with a lower risk of all cause and CVD mortality and to provide a marginal benefit against CVD events among the general population.

Is There Something Fishy About Fish Oil?

BACKGROUND

Fish is consumed as food worldwide and is considered as a rich source of essential nutrients required for a healthy life. Supplementation with fish oil has been adopted as a solution to prevent or cure many pathophysiological states and diseases by both the professionals and the civil population. The beneficial effects are, however, being questioned, as some controversial results were obtained in clinical and population studies.

METHODS

Critical evaluation of studies regarding known effects of fish oil, both in favour of its consumption and related controversies.

RESULTS

From the literature review, contradictory allegations about the positive action of the fish oil on human health emerged, so that a clear line about its beneficial effect cannot be withdrawn.

CONCLUSION

Scientific results on the application of fish oil should be taken with caution as there is still no standardised approach in testing its effects and there are significantly different baselines in respect to nutritional and other lifestyle habits of different populations.

Vitamin D, Marine n-3 Fatty Acids, and Primary Prevention of Cardiovascular Disease Current Evidence

Whether marine omega-3 fatty acid (n-3 FA) or vitamin D supplementation can prevent cardiovascular disease (CVD) in general populations at usual risk for this outcome is unknown. A major goal of VITAL (Vitamin D and Omega-3 Trial) was to fill this knowledge gap. In this article, we review the results of VITAL, discuss relevant mechanistic studies regarding n-3 FAs, vitamin D, and vascular disease, and summarize recent meta-analyses of the randomized trial evidence on these agents. VITAL was a nationwide, randomized, placebo-controlled, 2×2 factorial trial of marine n-3 FAs (1 g/d) and vitamin D₃ (2000 IU/d) in the primary prevention of CVD and cancer among 25 871 US men aged ≥50 and women aged ≥55 years, including 5106 blacks. Median treatment duration was 5.3 years. Supplemental n-3 FAs did not significantly reduce the primary cardiovascular end point of major CVD events (composite of myocardial infarction, stroke, and CVD mortality; hazard ratio [HR], 0.92 [95% CI, 0.80-1.06]) but were associated with significant reductions in total myocardial infarction (HR, 0.72 [95% CI, 0.59-0.90]), percutaneous coronary intervention (HR, 0.78 [95% CI, 0.63-0.95]), and fatal myocardial infarction (HR, 0.50 [95% CI, 0.26-0.97]) but not stroke or other cardiovascular end points. For major CVD events, a treatment benefit was seen in those with dietary fish intake below the cohort median of 1.5 servings/wk (HR, 0.81 [95% CI, 0.67-0.98]) but not in those above (P interaction=0.045). For myocardial infarction, the greatest risk reductions were in blacks (HR, 0.23 [95% CI, 0.11-0.47]; P interaction by race, 0.001). Vitamin D supplementation did not reduce major CVD events (HR, 0.97 [95% CI, 0.85-1.12]) or other cardiovascular end points. Updated meta-analyses that include VITAL and other recent trials document coronary risk reduction from supplemental marine n-3 FAs but no clear CVD risk reduction from supplemental vitamin D. Additional research is needed to determine which individuals may be most likely to derive net benefit from supplementation. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01169259.

Association between Adherence to the Mediterranean Diet and Physical Fitness with Body Composition Parameters in 1717 European Adolescents: The AdolesHealth Study

Obesity, low levels of physical fitness, and unhealthy eating patterns are responsible for part of the health problems of adolescents today. The current study aimed at examining the association between the adherence to the Mediterranean diet (MD), through each answer to the items of the Adherence to the MD Questionnaire (KIDMED), and physical fitness with body composition parameters (body mass index (BMI), percentage of body fat, and waist circumference) in 1717 European adolescents (N = 900 boys, N = 817 girls). Data of body composition, physical fitness results, and the answers to KIDMED were analyzed by the Student’s t-test. Additionally, the effect size (ES) was calculated and a Chi-square test analyzed the proportion of participants with and without over waist circumference, overfat, and overweight in each KIDMED question. The relative risk of suffering over waist circumference, overfat and overweight in relation to the responses was calculated by Odd-Ratio. Adherence to the MD did not influence the condition of over waist circumference, overfat and overweight, although certain dietary habits were identified as risk factors for their development. Over waist circumference, overfat, and overweight boys and girls presented higher levels of body mass, waist circumference, body fat percentage, and BMI (p < 0.001; ES = 1.73–3.38), as well as lower levels of all the parameters of the physical fitness analyzed (p < 0.001; ES = 0.45–1.08), except the handgrip test. A direct relationship between fitness and over waist circumference, overfat, and overweight was found.

Prevention of Cardiovascular Events with Omega-3 Polyunsaturated Fatty Acids and the Mechanism Involved

An epidemiological study of Greenlandic Inuit suggested that fish oil, or omega-3 polyunsaturated fatty acids (PUFA), was important in preventing atherosclerotic disease. After this landmark study, many large-scale epidemiological studies and meta-analyses have examined the health benefits of omega-3 PUFA as part of a fatty acid-rich diet to demonstrate its beneficial roles in the prevention of cardiovascular diseases. Recent research has also focused attention on the anti-inflammatory effects of omega-3 PUFA and on specialized pro-resolving mediators. Findings of these studies have led to the development of omega-3 PUFA preparations for the treatment of dyslipidemia, including a highly purified eicosapentaenoic acid (EPA)-ethyl ester product (Epadel^®) in Japan and an EPA/docosahexaenoic acid (DHA) preparation (Lotriga^®) in the United States and Europe. Although various large-scale clinical trials on the cardiovascular preventive effect of omega-3 PUFA were conducted and reported, the results were not always consistent. The issues of not targeting subjects with hypertriglyceridemia and using low dose of omega-3 PUFA have been suggested to contribute to the failure of demonstrating the preventive effect of omega-3 PUFA in these clinical trials. Taking into account the above issues, the REDUCE-IT trial evaluated a highly purified EPA preparation at a high dose of 4 g/day in patients with hypertriglyceridemia and high cardiovascular risk, and demonstrated an extraordinary outcome of 25% relative reduction in cardiovascular events. This article reviews studies on omega-3 fatty acids during the last 50 years, including the progress in elucidating molecular mechanisms and recent large-scale clinical studies.

Overview of Meta-Analyses: The Impact of Dietary Lifestyle on Stroke Risk

A stroke is one of the most prevalent cardiovascular diseases worldwide, both in high-income countries and in medium and low-medium income countries. The World Health Organization's (WHO) report on non-communicable diseases (NCDs) indicates that the highest behavioral risk in NCDs is attributable to incorrect nutrition. The objective of our work is to present an overview of meta-analyses that have investigated the impact of different foods and/or drinks in relationship with the risk of stroke events (ischemic/hemorrhagic). The papers to be included in the overview were found in MEDLINE, EMBASE, Scopus, Clinicaltrials.gov, Web of Science, and Cochrane Library and were selected according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow chart. Quality assessment were made according to the AMSTAR 2 scale. This overview shows that all primary studies came from countries with high income levels. This evidence shows that many countries are not represented. Therefore, different lifestyles, ethnic groups, potentially harmful or virtuous eating habits are not reported. It is important to underline how the choose of foods may help reduce the risk of cardiovascular diseases and stroke in particular.

Linking agroecosystems producing farmed seafood with food security and health status to better address the nutritional challenges in Bangladesh

OBJECTIVE

Aquaculture is one of the fastest-growing food production sectors in many low-income and food-deficit countries with aquatic ecozones. Yet its specific impact on nutrition and livelihood in local communities, where commercial and/or export-orientated aquaculture activities are developed, is largely unknown.

DESIGN

The present narrative and argumentative review aims to provide an overview of our current understanding of the connections between aquaculture agroecosystems, local and national fish production, fish consumption patterns and nutrition and health outcomes.

RESULTS

The agroecological dynamic in a coastal-estuarine zone, where the aquatic environment ranges from fully saline to freshwater, is complex, with seasonal and annual fluctuations in freshwater supply creating a variable salinity gradient which impacts on aquatic food production and on food production more generally. The local communities living in these dynamic aquatic ecozones are vulnerable to poverty, poor diet and health, while these ecosystems produce highly valuable and nutritious aquatic foods. Policies addressing the specific challenges of risk management of these communities are limited by the sectoral separation of aquatic food production - the fisheries and aquaculture sector, the broader food sector - and public health institutions.

CONCLUSIONS

Here we provide an argument for the integration of these factors to improve aquaculture value chains to better address the nutritional challenges in Bangladesh.

Fish-derived proteins and their potential to improve human health

Emerging evidence from studies evaluating the effect of lean fish consumption in humans suggests that proteins from fish have several beneficial metabolic effects. Rest, or waste, material from the fishing industry contains high-quality proteins, and utilization of this material offers novel possibilities for the development of protein-containing products that might be beneficial for human consumption. Fish-derived peptides containing bioactive amino acid sequences suggested to beneficially influence pathways involved in body composition, hypertension, lipid profile, and regulation of glucose metabolism are of particular interest, although the results of published studies are conflicting. This review aims to summarize current knowledge from animal studies and clinical interventions in humans evaluating the effects of lean fish, fish proteins, and fish-derived peptides on outcomes related to metabolic health. Fish proteins have a high content of taurine, and animal trials suggest that taurine mediates some of the beneficial effects observed thus far, although the mechanisms by which fish peptides exert their action are not yet elucidated. At this time, the literature is inconsistent, and there is insufficient mechanistic evidence to support a beneficial effect of fish-derived peptides on metabolic health.

[SEA/SEMERGEN consensus document 2019: Dietary recommendations in the prevention of cardiovascular disease]

The current paradigm in the nutrition sciences states that the basic nutritional unit is not the nutrients, but the foods that contain them (oils, nuts, dairy products, eggs, red or processed meats, etc.). These act as a food matrix in which the different nutrients synergistically or antagonistically modulate their effects on the various metabolic pathways determining health and disease. Food is not based on nutrients or isolated foods but on complex mixtures of one and the other that are part of a specific food pattern, a concept that has been targeted as the most pertinent to evaluate the associations between nutrition and health or disease. This document presents a summary of the available evidence on the relationship between different foods and cardiovascular health, and offers simple recommendations to be implemented in the dietary advice offered by the health professional.

National Dietary Guidelines of Greece for children and adolescents: a tool for promoting healthy eating habits

Objective:

Dietary guidelines are an essential policy tool for facilitating optimal dietary patterns and healthy eating behaviours. We report: (i) the methodological approach adopted for developing the National Dietary Guidelines of Greece (NDGGr) for Infants, Children and Adolescents; and (ii) the guidelines for children aged 1–18 years.

Design:

An evidence-based approach was employed to develop food-based recommendations according to the methodologies of the WHO, FAO and European Food Safety Authority. Physical activity recommendations were also compiled. Food education, healthy eating tips and suggestions were also provided.

Setting:

The NDGGr encompass food-based nutritional and physical activity recommendations for promoting healthy dietary patterns and eating behaviours and secondarily to serve as a helpful tool for the prevention of childhood overweight and obesity.

Results:

The NDGGr include food-based recommendations, food education and health promotion messages regarding: (i) fruits; (ii) vegetables; (iii) milk and dairy products; (iv) cereals; (v) red and white meat; (vi) fish and seafood; (vii) eggs; (viii) legumes; (ix) added lipids, olives, and nuts; (x) added sugars and salt; (xi) water and beverages, and (xii) physical activity. A Nutrition Wheel, consisting of the ten most pivotal key messages, was developed to enhance the adoption of optimal dietary patterns and a healthy lifestyle. The NDGGr additionally provide recommendations regarding the optimal frequency and serving sizes of main meals, based on the traditional Greek diet.

Conclusions:

As a policy tool for promoting healthy eating, the NDGGr have been disseminated in public schools across Greece.

SEA/SEMERGEN consensus document 2019: Dietary recommendations in the prevention of cardiovascular disease

The current paradigm in the nutrition sciences states that the basic nutritional unit is not the nutrients, but the foods that contain them (oils, nuts, dairy products, eggs, red or processed meats, etc.). These act as a food matrix in which the different nutrients synergistically or antagonistically modulate their effects on the various metabolic pathways determining health and disease. Food is not based on nutrients or isolated foods but on complex mixtures of one and the other that are part of a specific food pattern, a concept that has been targeted as the most pertinent to evaluate the associations between nutrition and health or disease. This document presents a summary of the available evidence on the relationship between different foods and cardiovascular health, and offers simple recommendations to be implemented in the dietary advice offered by the health professional.

Effects of fatty and lean fish intake on stroke risk: a meta-analysis of prospective cohort studies

BACKGROUND

Fish intake has been postulated to reduce the risk of stroke. However, whether the beneficial effect of fish are mainly linked to fat content, as a source of omega-3 polyunsaturated fatty acids, remains unclear. We conducted a meta-analysis to compare the effect of fatty and lean fish intake on stroke risk.

METHODS

We performed a literature search on four database (PubMed, Embase, Scopus, and Cochrane Library) through February 1, 2018 to identify prospective studies of fatty and lean fish in relation to stroke risk. A random-effects model was used to calculate the summary estimates.

RESULTS

We identified five prospective studies, including 7 comparisons for fatty fish intake and 5 comparisons for lean fish intake. Compared with the highest category of intake with lowest category, the summary relative risk was 0.88 [95% confidence interval (CI), 0.74-1.04] for fatty fish intake and 0.81 (95% CI, 0.67-0.99) for lean fish intake. No heterogeneity across studies and publication bias were observed.

CONCLUSION

Our findings demonstrated that fatty and lean fish intake has beneficial effects on stroke risk, especially lean fish intake. Additional prospective studies are necessary to confirm these observations.

Substitution of Fish for Red Meat or Poultry and Risk of Ischemic Stroke

We investigated the risk of ischemic stroke and its subtypes when red meat or poultry was substituted with fish. A total of 57,053 participants aged 50⁻65 years at baseline were included in the Danish Diet, Cancer and Health study. All participants filled in a food-frequency questionnaire at recruitment. Potential ischemic stroke cases were identified by linkage to the Danish National Patient Register, and all cases were validated and subclassified. Substitutions were investigated as 150 g/week of fish for 150 g/week of red meat or of poultry using multivariable Cox proportional hazard regression models. During 13.5 years of follow-up, 1879 participants developed an ischemic stroke. Replacing red meat or poultry with fish was not associated with the rate of total ischemic stroke, but there was a statistically significant lower rate of large artery atherosclerosis when fish replaced processed (hazard ratio (HR): 0.78; 95% confidence interval (CI): 0.67; 0.90) and unprocessed (HR: 0.87; 95% CI: 0.75; 0.99) red meat. A statistically significant higher rate of cardioembolism was found when poultry was replaced by total fish (HR: 1.42; 95% CI: 1.04; 1.93). When fatty fish replaced unprocessed red meat, a statistically significant lower rate of small-vessel occlusion was found (HR: 0.88; 95% CI: 0.77; 0.99). In conclusion, replacing red meat with fish was not associated with risk of total ischemic stroke but was associated with a lower risk of subtypes of ischemic stroke.

Document of recommendations of the SEA 2018. Lifestyle in cardiovascular prevention

Lifestyle is a complex concept that includes aspects external to ourselves that can modulate and influence our health. The knowledge of the relationship between lifestyle and cardiovascular risk does not attain the level of evidence achieved with clinical trials with drugs, because clinical studies are scarce and mainly of observational nature, albeit based on large cohorts. Nutritional epidemiology has the added difficulty of being based mostly on subjective dietary recall methods to ascertain nutrient and food intake over time, with the additional problems of incomplete data collection, variable measurements of adherence due to seasonal and geographical differences in food composition, and the changing eating behavior that human beings have over time. The purpose of this document is to carry out an updated and hierarchical review of the relationship between lifestyle and cardiovascular disease based on current evidence, paying attention to three aspects that are of great pathogenic importance and are directly modifiable: physical activity, tobacco consumption, and diet. With this, we intend to update the knowledge on this relationship, construct evidence-based recommendations, and provide a simple tool for clinical practice especially directed to health professionals involved in the care of people at cardiovascular risk, defining simple and easy strategies for individuals who receive advice for the primary and secondary prevention of cardiovascular diseases.

Fish consumption and risk of stroke, coronary heart disease, and cardiovascular mortality in a Dutch population with low fish intake

BACKGROUND/OBJECTIVES

Fish consumption of at least 1 portion/week is related to lower cardiovascular disease (CVD) risk. It is uncertain whether a less frequent intake is also beneficial and whether the type of fish matters. We investigated associations of very low intakes of total, fatty, and lean fish, compared with no fish intake, with 18-year incidences of stroke, coronary heart disease (CHD), and CVD mortality.

METHODS

Data were used from 34,033 participants, aged 20-70 years, of the EPIC-Netherlands cohort. Baseline (1993-1997) fish consumption was estimated using a food frequency questionnaire. We compared any fish consumption, <1 portion/week (<100 g) and ≥1 portion/week to non-fish consumption.

RESULTS

During 18 follow-up years, 753 stroke events, 2134 CHD events, and 540 CVD deaths occurred. Among the fish consumers (~92%) median intakes of total, lean, and fatty fish were 57.9, 32.9, and 10.7 g/week, respectively. Any fish consumption compared with non-consumption was not associated with incidences of stroke, CHD, MI, and CVD mortality. Furthermore, consumption of <1 portion/week of total, fatty, or lean fish was not associated with any CVD outcome, as compared with non-consumption. Consumption of ≥1 portion/week of lean fish (HR: 0.70, 95% CI: 0.57-0.86) and of fatty fish (HR: 0.63, 95% CI: 0.39-1.02) were associated with lower incidence of ischaemic stroke.

CONCLUSIONS

Baseline fish consumption of <1 portion/week, regardless of the type of fish, was unrelated to incidences of stroke, CHD, and CVD mortality in this Dutch cohort. Consumption of ≥1 portion/week of fatty or of lean fish reduced the incidence of ischaemic stroke.

Seafood Long-Chain n-3 Polyunsaturated Fatty Acids and Cardiovascular Disease: A Science Advisory From the American Heart Association

Since the 2002 American Heart Association scientific statement "Fish Consumption, Fish Oil, Omega-3 Fatty Acids, and Cardiovascular Disease," evidence from observational and experimental studies and from randomized controlled trials continues to emerge to further substantiate the beneficial effects of seafood long-chain n-3 polyunsaturated fatty acids and cardiovascular disease. A recent American Heart Association science advisory addressed the specific effect of n-3 polyunsaturated fatty acid supplementation on clinical cardiovascular events. This American Heart Association science advisory extends that review and offers further support to include n-3 polyunsaturated fatty acids from seafood consumption. Several potential mechanisms have been investigated, including antiarrhythmic, anti-inflammatory, hematologic, and endothelial, although for most, longer-term dietary trials of seafood are warranted to substantiate the benefit of seafood as a replacement for other important sources of macronutrients. The present science advisory reviews this evidence and makes a suggestion in the context of the 2015-2020 Dietary Guidelines for Americans and in consideration of other constituents of seafood and the impact on sustainability. We conclude that 1 to 2 seafood meals per week be included to reduce the risk of congestive heart failure, coronary heart disease, ischemic stroke, and sudden cardiac death, especially when seafood replaces the intake of less healthy foods.

Reprint of: Marine OMEGA-3 fatty acids in the prevention of cardiovascular disease

Omega-6 (ω6) and omega-3 (ω3) fatty acids are two classes of dietary polyunsaturated fatty acids derived from linoleic acid (18:2ω6) and α-linolenic acid (18:3ω3), respectively. Enzymatic metabolism of linoleic and α-linolenic acids generates arachidonic acid (20:4ω6) and eicosapentaenoic acid (20:5ω3; EPA), respectively, both of which are substrates for enzymes that yield eicosanoids with multiple and varying physiological functions. Further elongation and desaturation of EPA yields the 22-carbon fatty acid docosahexaenoic acid (22:6ω3; DHA). The main dietary source of EPA and DHA for human consumption is fish, especially oily fish. There is considerable evidence that EPA and DHA are protective against cardiovascular disease (heart disease and stroke), particularly in individuals with pre-existing disease. ω3 Fatty acids benefit multiple risk factors including blood pressure, blood vessel function, heart function and blood lipids, and they have antithrombotic, anti-inflammatory and anti-oxidative actions. ω3 Fatty acids do not adversely interact with medications. Supplementation with ω3 fatty acids is recommended in individuals with elevated blood triglyceride levels and patients with coronary heart disease. A practical recommendation for the general population is to increase ω3 fatty acid intake by incorporating fish as part of a healthy diet that includes increased fruits and vegetables, and moderation of salt intake. Health authorities recommend the general population should consume at least two oily fish meals per week.

Diet and primary prevention of stroke: Systematic review and dietary recommendations by the ad hoc Working Group of the Italian Society of Human Nutrition

BACKGROUND AND AIMS

To systematically review the latest evidence on established and emerging nutrition-related risk factors for incidence of and mortality from total, ischemic and haemorrhagic strokes. The present review was conducted in the framework of the work carried out through 2015 and 2016 for the preparation of the Italian Guidelines for the Prevention and Treatment of Stroke, 8th Edition, by ISO-SPREAD (Italian Stroke Organization and the Stroke Prevention and Educational Awareness Diffusion).

METHODS AND RESULTS

Systematic review of articles focused on primary prevention of stroke published between January 2013 to May 2016 through an extensive search of the literature using MEDLINE/PUBMED, EMBASE and the Cochrane Library. Articles were ranked according to the SIGN methodology while the GRADE system was used to establish the strength of recommendations. As a result of our literature search, we examined 87 meta-analyses overall (mainly of prospective studies), a few isolated more recent prospective studies not included in the meta-analyses, and a smaller number of available randomized controlled trials and case-control studies. Based on the analysis of the above articles, 36 Syntheses of the available evidence and 36 Recommendations were eventually prepared. The present document was developed by organizing the available evidence into three individual areas (nutrients, food groups and dietary patterns) to provide a systematic and user-friendly overview of the available evidence on the relationship between nutrition and primary prevention of stroke. Yet analysis of foods and food patterns allowed translating the information about nutrients in a tool more amenable to use in daily life also in the light of the argument that people eat foods rather than nutrients.

CONCLUSIONS

The present literature review and dietary recommendations provide healthcare professionals and all interested readers with a useful overview for the reduction of the risk of total, ischemic and haemorrhagic stroke through dietary modifications.

Stroke and food groups: an overview of systematic reviews and meta-analyses

OBJECTIVE

Numerous systematic reviews of prospective studies on the association of stroke risk with the consumption of various food groups have been published. A review of the evidence across the existing systematic reviews and meta-analyses of prospective studies was conducted to provide an overview of the range and validity of the reported associations of food groups with stroke risk.

DESIGN

The PubMed, EMBASE and Cochrane Library databases were searched for articles published up to September 2015 to identify systematic reviews of prospective studies.

RESULTS

A total of eighteen studies published from 2008 to 2015 were eligible for analysis. Overall, thirteen specific foods were studied for an association with stroke outcome, including nuts, legumes, fruits and vegetables, refined grains, whole grains, dairy products, eggs, chocolate, red and/or processed meat, fish, tea, sugar-sweetened beverages and coffee. Whereas a high consumption of nuts, fruits, vegetables, dairy foods, fish and tea, and moderate consumption of coffee and chocolate demonstrated a protective effect, a high consumption of red and/or processed meat was associated with increased stroke risk. Refined grain, sugar-sweetened beverage, legume, egg and whole grain intake showed no effect on stroke outcome.

CONCLUSIONS

The current overview provided a high level of evidence to support the beneficial effect of specific foods on stroke outcome. Clinicians and policy makers could inform clinical practice and policy based on this overview.

Food groups and risk of coronary heart disease, stroke and heart failure: A systematic review and dose-response meta-analysis of prospective studies

BACKGROUND

Despite growing evidence for food-based dietary patterns' potential to reduce cardiovascular disease risk, knowledge about the amounts of food associated with the greatest change in risk of specific cardiovascular outcomes and about the quality of meta-evidence is limited. Therefore, the aim of this meta-analysis was to synthesize the knowledge about the relation between intake of 12 major food groups (whole grains, refined grains, vegetables, fruits, nuts, legumes, eggs, dairy, fish, red meat, processed meat, and sugar-sweetened beverages [SSB]) and the risk of coronary heart disease (CHD), stroke and heart failure (HF).

METHODS

We conducted a systematic search in PubMed and Embase up to March 2017 for prospective studies. Summary risk ratios (RRs) and 95% confidence intervals (95% CI) were estimated using a random effects model for highest versus lowest intake categories, as well as for linear and non-linear relationships.

RESULTS

Overall, 123 reports were included in the meta-analyses. An inverse association was present for whole grains (RRCHD: 0.95 (95% CI: 0.92-0.98), RRHF: 0.96 (0.95-0.97)), vegetables and fruits (RRCHD: 0.97 (0.96-0.99), and 0.94 (0.90-0.97); RRstroke: 0.92 (0.86-0.98), and 0.90 (0.84-0.97)), nuts (RRCHD: 0.67 (0.43-1.05)), and fish consumption (RRCHD: 0.88 (0.79-0.99), RRstroke: 0.86 (0.75-0.99), and RRHF: 0.80 (0.67-0.95)), while a positive association was present for egg (RRHF: 1.16 (1.03-1.31)), red meat (RRCHD: 1.15 (1.08-1.23), RRstroke: 1.12 (1.06-1.17), RRHF: 1.08 (1.02-1.14)), processed meat (RRCHD: 1.27 (1.09-1.49), RRstroke: 1.17 (1.02-1.34), RRHF: 1.12 (1.05-1.19)), and SSB consumption (RRCHD: 1.17 (1.11-1.23), RRstroke: 1.07 (1.02-1.12), RRHF: 1.08 (1.05-1.12)) in the linear dose-response meta-analysis. There were clear indications for non-linear dose-response relationships between whole grains, fruits, nuts, dairy, and red meat and CHD.

CONCLUSION

An optimal intake of whole grains, vegetables, fruits, nuts, legumes, dairy, fish, red and processed meat, eggs and SSB showed an important lower risk of CHD, stroke, and HF.

Fish intake is associated with lower cardiovascular risk in a Mediterranean population: Prospective results from the Moli-sani study

BACKGROUND AND AIMS

Fish consumption reportedly reduces the risk of heart disease, but the evidence of cardiovascular advantages associated with fish intake within Mediterranean cohorts is limited. The aim of this study was to test the association between fish intake and risk of composite coronary heart disease (CHD) and stroke in a large population-based cohort adhering to Mediterranean Diet.

METHODS AND RESULTS

Prospective analysis on 20,969 subjects free from cardiovascular disease at baseline, enrolled in the Moli-sani study (2005-2010). Food intake was recorded by the Italian version of the EPIC food frequency questionnaire. Hazard ratios were calculated by using multivariable Cox-proportional hazard models. During a median follow-up of 4.3 years, a total of 352 events occurred (n of CHD = 287 and n of stroke = 66). After adjustment for a large panel of covariates, fish intake ≥4 times per week was associated with 40% reduced risk of composite CHD and stroke (HR = 0.60; 95%CI 0.40-0.90), and with 40% lower risk of CHD (HR = 0.60; 95%CI 0.38-0.94) as compared with subjects in the lowest category of intake (<2 times/week). A similar trend of protection was found for stroke risk although results were not significant (HR = 0.62; 95%CI 0.26-1.51). When fish types were considered, protection against the composite outcome and CHD was confined to fatty fish intake.

CONCLUSIONS

Fish intake was associated with reduced risk of composite fatal and non-fatal CHD and stroke in a general Mediterranean population. The favourable association was likely to be driven by fatty fish.