The Role of Nutrition in COVID-19 Susceptibility and Severity of Disease: A Systematic Review

BACKGROUND

Many nutrients have powerful immunomodulatory actions with the potential to alter susceptibility to coronavirus disease 2019 (COVID-19) infection, progression to symptoms, likelihood of severe disease, and survival.

OBJECTIVE

The aim was to review the latest evidence on how malnutrition across all its forms (under- and overnutrition and micronutrient status) may influence both susceptibility to, and progression of, COVID-19.

METHODS

We synthesized information on 13 nutrition-related components and their potential interactions with COVID-19: overweight, obesity, and diabetes; protein-energy malnutrition; anemia; vitamins A, C, D, and E; PUFAs; iron; selenium; zinc; antioxidants; and nutritional support. For each section we provide: 1) a landscape review of pertinent material; 2) a systematic search of the literature in PubMed and EMBASE databases, including a wide range of preprint servers; and 3) a screen of 6 clinical trial registries. All original research was considered, without restriction to study design, and included if it covered: 1) severe acute respiratory syndrome coronavirus (CoV) 2 (SARS-CoV-2), Middle East respiratory syndrome CoV (MERS-CoV), or SARS-CoV viruses and 2) disease susceptibility or 3) disease progression, and 4) the nutritional component of interest. Searches took place between 16 May and 11 August 2020.

RESULTS

Across the 13 searches, 2732 articles from PubMed and EMBASE, 4164 articles from the preprint servers, and 433 trials were returned. In the final narrative synthesis, we include 22 published articles, 38 preprint articles, and 79 trials.

CONCLUSIONS

Currently there is limited evidence that high-dose supplements of micronutrients will either prevent severe disease or speed up recovery. However, results of clinical trials are eagerly awaited. Given the known impacts of all forms of malnutrition on the immune system, public health strategies to reduce micronutrient deficiencies and undernutrition remain of critical importance. Furthermore, there is strong evidence that prevention of obesity and type 2 diabetes will reduce the risk of serious COVID-19 outcomes. This review is registered at PROSPERO as CRD42020186194.

Omega-3 fatty acids in the psychological and physiological resilience against COVID-19

As the infected cases of COVID-19 reach more than 20 million with more than 778,000 deaths globally, an increase in psychiatric disorders including anxiety and depression has been reported. Scientists globally have been searching for novel therapies and vaccines to fight against COVID-19. Improving innate immunity has been suggested to block progression of COVID-19 at early stages, while omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been shown to have immunomodulation effects. Moreover, n-3 PUFAs have also been shown to improve mood disorders, thus, future research is warranted to test if n-3 PUFAs may have the potential to improve our immunity to counteract both physical and mental impact of COVID-19.

NUTRITION AND HEALTH: COMPANION ANIMAL APPLICATIONS: Functional nutrition in livestock and companion animals to modulate the immune response

Advances in the understanding of how the immune system functions in response to diet have altered the way we think about feeding livestock and companion animals on both the short (weeks/months) and long-term (years) timelines; however, depth of research in each of these species varies. Work dedicated to understanding how immune function can be altered with diet has revealed additional functions of required nutrients such as vitamins D and E, omega-3 polyunsaturated fatty acids (PUFA), and minerals such as zinc, while feed additives such as phytogenics and probiotics add an additional layer of immunomodulating potential to modern diets. For certain nutrients such as vitamin D or omega-3 PUFA, inclusion above currently recommended levels may optimize immune function and reduce inflammation, while for others such as zinc, additional pharmacological supplementation above requirements may inhibit immune function. Also to consider is the potential to over-immunomodulate, where important functions such as clearance of microbial infections may be reduced when supplementation reduces the inflammatory action of the immune system. Continued work in the area of nutritional immunology will further enhance our understanding of the power of nutrition and diet to improve health in both livestock and companion animals. This review collects examples from several species to highlight the work completed to understand how nutrition can be used to alter immune function, intended or not.

A Role for Lipid Mediators in Acute Myeloid Leukemia

In spite of therapeutic improvements in the treatment of different hematologic malignancies, the prognosis of acute myeloid leukemia (AML) treated solely with conventional induction and consolidation chemotherapy remains poor, especially in association with high risk chromosomal or molecular aberrations. Recent discoveries describe the complex interaction of immune effector cells, as well as the role of the bone marrow microenvironment in the development, maintenance and progression of AML. Lipids, and in particular omega-3 as well as omega-6 polyunsaturated fatty acids (PUFAs) have been shown to play a vital role as signaling molecules of immune processes in numerous benign and malignant conditions. While the majority of research in cancer has been focused on the role of lipid mediators in solid tumors, some data are showing their involvement also in hematologic malignancies. There is a considerable amount of evidence that AML cells are targetable by innate and adaptive immune mechanisms, paving the way for immune therapy approaches in AML. In this article we review the current data showing the lipid mediator and lipidome patterns in AML and their potential links to immune mechanisms.

Saving Problematic Mucosae: SPMs in Intestinal Mucosal Inflammation and Repair

The intestinal mucosa serves as a highly selective barrier that allows the absorption of nutrients and water while restricting microbiota access to tissues. This barrier is compromised in inflammatory conditions such as infectious colitis and inflammatory bowel disease (IBD). In response to mucosal injury, there is a temporal recruitment of leukocytes that crosstalk with epithelial cells to orchestrate repair. Specialized pro-resolving mediators (SPMs) play an important role in the resolution of inflammation and epithelial repair. SPMs actively promote resolution of inflammation by contributing to the clearance of neutrophils, stimulating efferocytosis, and promoting epithelial repair. SPMs have potential to serve as targeted therapeutic agents to be used in adjuvant therapy to promote resolution of inflammation and epithelial repair in chronic inflammatory diseases.

Health relevance of the modification of low grade inflammation in ageing (inflammageing) and the role of nutrition

Ageing of the global population has become a public health concern with an important socio-economic dimension. Ageing is characterized by an increase in the concentration of inflammatory markers in the bloodstream, a phenomenon that has been termed "inflammageing". The inflammatory response is beneficial as an acute, transient reaction to harmful conditions, facilitating the defense, repair, turnover and adaptation of many tissues. However, chronic and low grade inflammation is likely to be detrimental for many tissues and for normal functions. We provide an overview of low grade inflammation (LGI) and determine the potential drivers and the effects of the "inflamed" phenotype observed in the elderly. We discuss the role of gut microbiota and immune system crosstalk and the gut-brain axis. Then, we focus on major health complications associated with LGI in the elderly, including mental health and wellbeing, metabolic abnormalities and infections. Finally, we discuss the possibility of manipulating LGI in the elderly by nutritional interventions. We provide an overview of the evidence that exists in the elderly for omega-3 fatty acid, probiotic, prebiotic, antioxidant and polyphenol interventions as a means to influence LGI. We conclude that slowing, controlling or reversing LGI is likely to be an important way to prevent, or reduce the severity of, age-related functional decline and the onset of conditions affecting health and well-being; that there is evidence to support specific dietary interventions as a strategy to control LGI; and that a continued research focus on this field is warranted.

Intravenous fish oil in critically ill and surgical patients - Historical remarks and critical appraisal

The purpose of this review is to explain the historical and clinical background for intravenous fish oil administration, to evaluate its results by using a product specific metaanalysis, and to stimulate further research in the immune-modulatory potential of fish oil. Concerning the immune-modulatory effects of fatty acids, a study revealed that ω-3 as well as ω-6 fatty acids would prolong transplant survival, and only a mixture with an ω-6:ω-3 ratio of 2.1:1 would give immune-neutral results. In 1998, the label of a newly registered fish oil emulsion also acknowledged this immune-neutral ratio in conjunction with ω-6 lipids. Also, two fish oil-supplemented fat emulsions, registered in 2004, used a similar ω-6:ω-3 ratio. Such an immune-neutral ω-6:ω-3 ratio denoted progress for most patients compared to pure ω-6 lipid emulsions. However, this immune-neutrality might on the other hand be responsible for the limited positive clinical results gained so far in critically ill and surgical patients where in most cases significance could only be shown for the pooled effect of numerous trials. Our product specific metaanalysis also did not reveal any differences, neither in infections rates nor in ICU or hospital length of stay. To evaluate the immune-modulatory effect of fish oil administered alone, new dose finding studies, reporting relevant clinical outcome parameters, are required. Precise mechanistic or physiological biomarkers for the indication of such a therapy should also be developed and validated.

High-Fat Diets Containing Different Amounts of n3 and n6 Polyunsaturated Fatty Acids Modulate Inflammatory Cytokine Production in Mice

Dysregulation of adipokines is a hallmark of obesity. Polyunsaturated fatty acids in fish oil may exert anti-inflammatory effects on adipose tissue mitigating the dysregulation of adipokines thereby preventing obesity. This study investigated the effects of high-fat diets containing different amounts of n3 polyunsaturated fatty acids (PUFA) on adiposity and adipokine production in mice. Mice were fed a low-fat or a high-fat diet with 16 or 45 % of energy from corn oil (low n3 PUFA) in comparison with a high-fat diet containing soybean or high-oleic sunflower oil (adequate n3 PUFA) or flaxseed or fish oil (high n3 PUFA) for 11 weeks. High-fat diets, regardless of types of oils, significantly increased body fat mass and body weights compared to the low-fat diet. Adipose fatty acid composition and contents reflected dietary fatty acid profiles. The high-fat fish oil diet significantly increased adiponectin and reduced leptin concentrations in both plasma and adipose tissue; it did not elevate plasma insulin concentration compared to the high-fat corn oil diet. All high-fat diets elevated concentrations of plasminogen activator inhibitor-1 (PAI-1) and monocyte chemoattractant protein-1 (MCP-1) but lowered resistin concentrations in both plasma and adipose tissue. In conclusion, fish oil may be beneficial in improving insulin sensitivity by upregulation of adiponectin and downregulation of leptin production; n3 and n6 PUFA do not play a role at the dietary levels tested in reducing adiposity and production of pro-inflammatory cytokines (leptin, PAI-1, MCP-1 and resistin) and anti-inflammatory cytokine adiponectin.

A treatment study of canine symmetrical onychomadesis (symmetrical lupoid onychodystrophy) comparing fish oil and cyclosporine supplementation in addition to a diet rich in omega-3 fatty acids

BACKGROUND

Treatment of symmetrical onychomadesis (symmetrical lupoid onychodystrophy) is a challenging task for dermatologists. The acute phase is characterized by sloughing of claw plates and loose claws have to be removed and secondary infections treated. The goal of long-term treatment is to allow claws to re-grow with normal quality and to achieve life-long lack of recurrence. The aim of this randomized treatment trial was to see if adding fish oil or cyclosporine to a diet rich in omega-3 could improve the treatment outcome of symmetrical onychomadesis in Gordon and English setters. All dogs were fed Eukanuba Veterinary Diets Dermatosis® exclusively during the six month treatment trial. The treatment outcome was measured as the change in number of healthy claws during treatment, as well as the long-term effect on hunting ability and recurrence of onychomadesis. The hypothesis was that cyclosporine provides a stronger and different immune modulating property than fish oil and therefore would give a better treatment outcome in dogs with symmetrical onychomadesis eating a diet rich in omega-3 fatty acids.

RESULTS

Six Gordon setters and one English setter were treated with 5 mg/kg cyclosporine once daily for six months and seven Gordon setters were treated with 10 ml Dr Baddaky fish oil® once daily for six months. All dogs were evaluated every month and the numbers of healthy claws were recorded.

CONCLUSION

Cyclosporine and fish oil appeared to be equally effective in treating symmetrical onychomadesis when the dog is fed a diet high in omega-3.

ω3-PUFAs exert anti-inflammatory activity in visceral adipocytes from colorectal cancer patients

Objective

The aim of this study was to correlate specific fatty acid profiles of visceral white adipose tissue (WAT) with inflammatory signatures potentially associated with colorectal cancer (CRC).

Methods

Human adipocytes were isolated from biopsies of visceral WAT from 24 subjects subdivided in four groups: normal-weight (BMI 22.0-24.9 Kg/m²) and over-weight/obese (BMI 26.0-40.0 Kg/m²), affected or not by CRC. To define whether obesity and/or CRC affect the inflammatory status of WAT, the activation of the pro-inflammatory STAT3 and the anti-inflammatory PPARγ transcription factors as well as the expression of adiponectin were analyzed by immunoblotting in adipocytes isolated from each group of subjects. Furthermore, to evaluate whether differences in inflammatory WAT environment correlate with specific fatty acid profiles, gas-chromatographic analysis was carried out on WAT collected from all subject categories. Finally, the effect of the ω3 docosahexaenoic acid treatment on the balance between pro- and anti-inflammatory factors in adipocytes was also evaluated.

Results

We provide the first evidence for the existence of a pro-inflammatory environment in WAT of CRC patients, as assessed by the up-regulation of STAT3, and the concomitant decrease of PPARγ and adiponectin with respect to healthy subjects. WAT inflammatory status was independent of obesity degree but correlated with a decreased ω3-/ω6-polyunsaturated fatty acid ratio. These observations suggested that qualitative changes, other than quantitative ones, in WAT fatty acid may influence tissue dysfunctions potentially linked to inflammatory conditions. This hypothesis was further supported by the finding that adipocyte treatment with docosahexaenoic acid restored the equilibrium between STAT3 and PPARγ.

Conclusion

Our results suggest that adipocyte dysfunctions occur in CRC patients creating a pro-inflammatory environment that might influence cancer development. Furthermore, the protective potential of docosahexaenoic acid in re-establishing the equilibrium between pro- and anti-inflammatory factors might represent a useful tool for preventive and therapeutic strategies.

Immunometabolic role of long-chain omega-3 fatty acids in obesity-induced inflammation

Inflammation links obesity with the development of insulin resistance. Macrophages and phagocytic immune cells communicate with metabolic tissues to direct an inflammatory response caused by overnutrition and expanding adipose tissue. Marine-derived omega-3 fatty acids, specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), modulate inflammatory signalling events, providing various anti-inflammatory and cardioprotective benefits. Moreover, EPA and DHA may improve insulin sensitivity by generating proresolving lipid mediators and promoting alternatively activated macrophages. This review will assess the role of EPA and DHA in ameliorating obesity-induced inflammation, evaluating clinical evidence and mechanisms of action. The pathophysiology of insulin resistance resulting from obesity-induced inflammation will be discussed, highlighting the relationship between metabolism and immunity, and in particular, how EPA and DHA work with both systems to modulate immunometabolic complications and chronic disease.

Dietary n-3 LC-PUFA during the perinatal period as a strategy to minimize childhood allergic disease

There has been growing interest in the role of n-3 long-chain polyunsaturated fatty acids (LC-PUFA) in the modulation of the immune response during early childhood and whether this may translate to a reduction in childhood allergic disease. Several randomized controlled trials of n-3 LC-PUFA supplementation have been reported, largely involving children who are at high hereditary risk of developing allergies. These studies relatively consistently indicate that supplementation during pregnancy results in fewer children with atopic eczema in early childhood. On the other hand, supplementation studies confined exclusively to the postnatal period have demonstrated mixed results with one trial showing no effect and the other suggesting a transient effect on symptoms of respiratory disease. In summary, supplementation with n-3 LC-PUFA during the perinatal period and before allergic response is established may be a useful strategy to prevent early childhood allergic disease in children at high hereditary risk. Further work is needed to establish the optimal period of supplementation and whether longer term benefits exist.

Emerging importance of omega-3 fatty acids in the innate immune response: molecular mechanisms and lipidomic strategies for their analysis

The beneficial health properties of dietary omega-3 polyunsaturated fatty acids, particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have long been known and their metabolic dysfunction has been linked to a range of diseases including various inflammatory disorders, cardiovascular diseases, and cancer. However, the molecular mechanisms underlying their health benefits have remained unclear. Recent technological advances in lipidomic analytical strategies have resulted in the discovery of a range of bioactive mediators derived from EPA and DHA that possess potent anti-inflammatory and pro-resolving properties and that may be responsible, at least in part, for the beneficial effects observed. These mediators include resolvins, protectins and maresins, as well as EPA derivatives of classical arachidonic acid derived eicosanoids, such as prostaglandin E3 . The aim of this review is to provide an overview of the biosynthetic pathways and biological properties of these omega-3 mediators, with a particular focus on the emerging importance of the counter-regulatory role of omega-3 and -6 fatty acids in the spatial and temporal regulation of the inflammatory response. It will also provide an insight into a range of lipidomic approaches, which are currently available to analyse these fatty acids and their metabolites in biological matrices.

Atopy risk in infants and children in relation to early exposure to fish, oily fish, or long-chain omega-3 fatty acids: a systematic review

There are two main families of polyunsaturated fatty acids (PUFAs), the n-6 and the n-3 families. It has been suggested that there is a causal relationship between n-6 PUFA intake and allergic disease, and there are biologically plausible mechanisms, involving eicosanoid mediators of the n-6 PUFA arachidonic acid, that could explain this. Fish and fish oils are sources of long-chain n-3 PUFAs and these fatty acids act to oppose the actions of n-6 PUFAs. Thus, it is considered that n-3 PUFAs will protect against atopic sensitization and against the clinical manifestations of atopy. Evidence to examine this has been acquired from epidemiologic studies investigating associations between fish intake in pregnancy, lactation, infancy, and childhood, and atopic outcomes in infants and children and from intervention studies with fish oil supplements in pregnancy, lactation, infancy, and childhood, and atopic outcomes in infants and children. All five epidemiological studies investigating the effect of maternal fish intake during pregnancy on atopic or allergic outcomes in infants/children of those pregnancies concluded protective associations. One study investigating the effects of maternal fish intake during lactation did not observe any significant associations. The evidence from epidemiological studies investigating the effects of fish intake during infancy and childhood on atopic outcomes in those infants or children is inconsistent, although the majority of the studies (nine of 14) showed a protective effect of fish intake during infancy or childhood on atopic outcomes in those infants/children. Fish oil supplementation during pregnancy and lactation or during infancy or childhood results in a higher n-3 PUFA status in the infants or children. Fish oil provision to pregnant women is associated with immunologic changes in cord blood and such changes may persist. Studies performed to date indicate that provision of fish oil during pregnancy may reduce sensitization to common food allergens and reduce prevalence and severity of atopic dermatitis in the first year of life, with a possible persistence until adolescence with a reduction in eczema, hay fever, and asthma. Fish oil provision to infants or children may be associated with immunologic changes in the blood but it is not clear if these are of clinical significance and whether they persist. Fish oil supplementation in infancy may decrease the risk of developing some manifestations of allergic disease, but this benefit may not persist as other factors come into play. It is not clear whether fish oil can be used to treat children with asthma as the two studies conducted to date give divergent results. Further studies of increased long-chain n-3 PUFA provision in during pregnancy, lactation, and infancy are needed to more clearly identify the immunologic and clinical effects in infants and children and to identify protective and therapeutic effects and their persistence.

Acquired resistance to Listeria monocytogenes during a secondary infection in a murine model fed dietary lipids

OBJECTIVE

The ω-3 polyunsaturated fatty acids can suppress immune system functions. This property may cause adverse effects by impairing host resistance to infection. The present study focused on estimating the impact of different dietary lipids on the immune system of mice after a secondary infection with Listeria monocytogenes.

METHODS

BALB/c mice were divided into five dietary groups of olive oil, fish oil, sunflower oil, high-oleic sunflower oil, or low fat that was administered for 8 wk. The mice were immunized with 10(3) colony-forming units. Thirty-eight days later, each mouse was challenged with 10(4) colony-forming units. Mice survival and bacterial clearance from livers and spleens were determined. In addition, cytokine, chemokine, and adhesion molecule productions were quantified from the sera.

RESULTS

Survival percentage in mice fed a fish oil diet was 100% and bacterial numbers from spleen were decreased at 72 h. Interleukin-12, intercellular adhesion molecule-1, and vascular cell adhesion molecule-1 productions were decreased. Levels of tumor necrosis factor-α and interferon-γ were increased, whereas macrophage inflammatory protein-1α (MIP-1α) production was unaltered.

CONCLUSION

Immune defense in mice fed a fish oil diet was improved after secondary exposure, acquiring an adequate resistance. This result could be attributable to an increase of a T-helper type 1 response.

Effect of marine n-3 fatty acids on circulating inflammatory markers in healthy subjects and subjects with cardiovascular risk factors

Objective

The aim of the present paper was to review the literature in order to summarize the effects of marine n-3 fatty acids on circulating inflammatory markers among healthy subjects, subjects with high risk of developing cardiovascular disease (CVD) and in patients with CVD in human intervention studies.

Methods

A systematic literature search in PubMed was performed. Intervention studies describing the effects of marine n-3 fatty acids on circulating inflammatory markers in healthy subjects, subjects with high risk of CVD and patients with CVD were included. The following exclusion criteria were used: (1) interventions assessing inflammatory markers with ex vivo methods (2) interventions with children (3) articles describing animal or cell culture studies. Twenty-two articles were included. Additionally, 13 papers from their literature lists were included based on the same inclusion and exclusion criteria as the literature search.

Results and conclusion

Intervention studies with marine n-3 fatty acids administered from either fish or fish oil demonstrate different results on inflammatory markers. No firm conclusion can be drawn about the effect of marine n-3 fatty acids on circulating inflammatory markers in healthy individuals, individuals with high risk of developing CVD or individuals with CVD related diseases.

Mediators and receptors in the resolution of inflammation: drug targeting opportunities

The active resolution of inflammation is recognized as offering new opportunities to generate novel anti-inflammatory agents. The emerging appreciation of the importance of active resolution in regulation of inflammation also creates an imperative to examine developing and existing agents for their potential to influence these pathways. This themed issue of the British Journal of Pharmacology contains papers that discuss the roles of annexin-1, lipoxins and related lipid products of fish oils as well as other mechanisms involved in active resolution and their receptor targets.

Fish oil in critical illness

PURPOSE OF REVIEW

The aim of this review is to discuss recent advances in the role of n-3 lipids derived from fish oil in clinical nutrition in an intensive care setting.

RECENT FINDINGS

Fish oil supplies n-3 fatty acids which compete with arachidonic acid (n-6) for the conversion to lipid mediators, influence lipid-bound second messenger generation and dependent cellular functions, and are a source for resolvins necessary for the resolution of inflammation. Enteral nutrition with n-3 fatty acids improved ventilation time in patients with acute lung injury and in one study reduced mortality in septic patients. Using a high-dose short-term infusion of fish oil-based lipid emulsion, rapid immunologic changes and effects on the endotoxin-induced stress response may be achieved. Inclusion of n-3 fatty acids in parenteral nutrition improved immunologic parameters and length of stay in surgical patients.

SUMMARY

Inclusion of fish oil in nutrition may influence the immune response and clinical outcomes by balancing the negative effects of n-6 fatty acids. Application as a part of enteral immunonutrition in surgical or acute respiratory distress syndrome patients and in lipid emulsions in surgical patients has beneficial effects. In septic patients, data on enteral use are highly controversial. Prospective data from randomized trials, however, are lacking.

n-3 Fatty acid supplementation and regular moderate exercise: differential effects of a combined intervention on neutrophil function

CVD is associated with a cellular inflammatory/immune response.n-3 PUFA and moderate aerobic exercise independently alter cytokine production and leucocyte function. There is limited evidence for the combined effect of these treatments on immune function, particularly in patients with risk factors for CVD. We hypothesised that exercise would enhance the anti-inflammatory effects ofn-3 PUFA. In a randomised, placebo-controlled study, fifty volunteers were allocated double-blind to consume either sunflower oil (6 g/d, placebo) or DHA-rich fish oil (6 g/d; about 2 gn-3 PUFA; 1·6 g DHA /d) for 12 weeks. Volunteers were further randomised to undertake regular exercise (walking 3 d/week for 45 min at 75 % of maximum heart rate) or maintain their usual physical activity for 12 weeks. Immune functions were assessed in blood taken initially and after 12 weeks. There was no effect on cytokine production by T cells and monocytes. Superoxide anion production from stimulated blood neutrophils was decreased by fish oil (19·5 (sem8·5) %,P = 0·016) but not by exercise, and this change was negatively correlated with the incorporation of DHA into erythrocytes (r–0·385,P = 0·047). Participation in regular exercise maintained neutrophil bactericidal activity, which decreased in non-exercising subjects (2·9 (sem0·7) %,P = 0·013). Neutrophil chemotaxis and adherence were not significantly affected by exercise, oil, or the combination of the two. Thus the combination of moderate exercise and fish-oil supplementation, which reduces cardiovascular risk, may also help to counteract inflammation.

Differential immunomodulation with long-chain n-3 PUFA in health and chronic disease

The balance of intake of n-6 and n-3 PUFA, and consequently their relative incorporation into immune cells, is important in determining the development and severity of immune and inflammatory responses. Some disorders characterised by exaggerated inflammation and excessive formation of inflammatory markers have become among the most important causes of death and disability in man in modern societies. The recognition that long-chain n-3 PUFA have the potential to inhibit (excessive) inflammatory responses has led to a large number of clinical investigations with these fatty acids in inflammatory conditions as well as in healthy subjects. The present review explores the presence of dose-related effects of long-chain n-3 PUFA supplementation on immune markers and differences between healthy subjects and those with inflammatory conditions, because of the important implications for the transfer of information gained from studies with healthy subjects to patient populations, e.g. for establishing dose levels for specific applications. The effects of long-chain n-3 PUFA supplementation on ex vivo lymphocyte proliferation and cytokine production by lymphocytes and monocytes in healthy subjects have been studied in twenty-seven, twenty-five and forty-six treatment cohorts respectively, at intake levels ranging from 0.2 g EPA+DHA/d to 7.0 g EPA+DHA/d. Most studies, particularly those with the highest quality study design, have found no effects on these immune markers. Significant effects on lymphocyte proliferation are decreased responses in seven of eight cohorts, particularly in older subjects. The direction of the significant changes in cytokine production by lymphocytes is inconsistent and only found at supplementation levels > or =2.0 g EPA+DHA/d. Significant changes in inflammatory cytokine production by monocytes are decreases in their production in all instances. Overall, these studies fail to reveal strong dose-response effects of EPA+DHA on the outcomes measured and suggest that healthy subjects are relatively insensitive to immunomodulation with long-chain n-3 PUFA, even at intake levels that substantially raise their concentrations in phospholipids of immune cells. In patients with inflammatory conditions cytokine concentrations or production are influenced by EPA+DHA supplementation in a relatively large number of studies. Some of these studies suggest that local effects at the site of inflammation might be more pronounced than systemic effects and disease-related markers are more sensitive to the immunomodulatory effects, indicating that the presence of inflamed tissue or 'sensitised' immune cells in inflammatory disorders might increase sensitivity to the immunomodulatory effects of long-chain n-3 PUFA. In a substantial number of these studies clinical benefits related to the inflammatory state of the condition have been observed in the absence of significant effects on immune markers of inflammation. This finding suggests that condition-specific clinical end points might be more sensitive markers of modulation by EPA+DHA than cytokines. In general, the direction of immunomodulation in healthy subjects (if any) and in inflammatory conditions is the same, which indicates that studies in healthy subjects are a useful tool to describe the general principles of immunomodulation by n-3 PUFA. However, the extent of the effect might be very different in inflammatory conditions, indicating that studies in healthy subjects are not particularly suitable for establishing dose levels for specific applications in inflammatory conditions. The reviewed studies provide no indications that the immunomodulatory effects of long-chain n-3 PUFA impair immune function or infectious disease resistance. In contrast, in some conditions the immunomodulatory effects of EPA+DHA might improve immune function.

Enteral immunonutrition during sepsis prevents pulmonary dysfunction in a rat model

BACKGROUND

Sepsis often results in severe pulmonary dysfunction. Via the thoracic duct, the lung is the first organ exposed to gut-derived inflammatory mediators released into mesenteric lymph during sepsis.

AIM

To investigate whether an enteral immunonutrition during sepsis improves pulmonary function.

METHODS

Mesenteric lymph was obtained from lymph fistula donor rats after intra peritoneal (i.p.) saline (control lymph) or lipopolysaccharide (sepsis lymph) injection. Sepsis lymph was also collected during enteral immunonutrition with omega-3 enriched, long-chain fatty acids (SMOF lipid). Control, sepsis, or sepsis-SMOF lymph was reinfused into the jugular vein of separate recipient rats. The lungs were then harvested, stained with hematoxylin-eosin, and analyzed for: (1) perpendicular parenchyma thickness of the alveolar wall; (2) myeloperoxidase-positive cells; and (3) terminal deoxynucleotidyl transferase Biotin-dUTP nick end labeling (TUNEL)-positive cells.

RESULTS

Enteral immunonutrition during sepsis reduced the release of TNFalpha into mesenteric lymph by about 4.5-fold within the first 2 h. Infusion of sepsis lymph into recipient rats induced thickening of alveolar walls, inflammatory reaction, and apoptosis. Infusion of sepsis lymph obtained during enteral immunonutrition did not cause anatomical changes, induced only a mild inflammatory reaction, and prevented apoptosis in the lungs of recipient rats.

CONCLUSIONS

Mediators in sepsis lymph induce pulmonary dysfunction such as an increased distance for oxygen transport, inflammatory reaction, and apoptosis. The lung may be protected by an enteral immunonutrition containing long-chain fatty acids.

Immune modulation by parenteral lipid emulsions

Total parenteral nutrition is the final option for nutritional support of patients with severe intestinal failure. Lipid emulsions constitute the main source of fuel calories and fatty acids (FAs) in parenteral nutrition formulations. However, adverse effects on patient outcomes have been attributed to the use of lipids, mostly in relation to impaired immune defenses and altered inflammatory responses. Over the years, this issue has remained in the limelight, also because technical advances have provided no safeguard against the most daunting problems, ie, infectious complications. Nevertheless, numerous investigations have failed to produce a clear picture of the immunologic characteristics of the most commonly used soybean oil-derived lipid emulsions, although their high content of n-6 polyunsaturated FAs (PUFAs) has been considered a drawback because of their proinflammatory potential. This concern initiated the development of emulsions in which part of the n-6 FA component is replaced by less bioactive FAs, such as coconut oil (rich in medium-chain saturated FAs) or olive oil (rich in the n-9 monounsaturated FA oleic acid). Another approach has been to use fish oil (rich in n-3 PUFA), the FAs of which have biological activities different from those of n-6 PUFAs. Recent studies on the modulation of host defenses and inflammation by fish-oil emulsions have yielded consistent data, which indicate that these emulsions may provide a tool to beneficially alter the course of immune-mediated conditions. Although most of these lipids have not yet become available on the US market, this review synthesizes available information on immunologic characteristics of the different lipids that currently can be applied via parenteral nutrition support.

Use of fish oil in parenteral nutrition: Rationale and reality

Excessive or inappropriate inflammation and immunosuppression are components of the response to surgery, trauma, injury and infection in some individuals and can lead, progressively, to sepsis and septic shock. The hyperinflammation is characterised by the production of inflammatory cytokines, arachidonic acid-derived eicosanoids and other inflammatory mediators, while the immunosuppression is characterised by impairment of antigen presentation and of T-helper lymphocyte type-1 responses. Long-chain n-3 fatty acids from fish oil decrease the production of inflammatory cytokines and eicosanoids. They act both directly (by replacing arachidonic acid as an eicosanoid substrate and by inhibiting arachidonic acid metabolism) and indirectly (by altering the expression of inflammatory genes through effects on transcription factor activation). Thus, long-chain n-3 fatty acids are potentially useful anti-inflammatory agents and may be of benefit in patients at risk of hyperinflammation and sepsis. As a consequence, an emerging application for n-3 fatty acids, in which they may be added to parenteral (or enteral) formulas, is in surgical or critically-ill patients. Parenteral nutrition that includes n-3 fatty acids appears to preserve immune function better than standard formulas and appears to diminish the extent of the inflammatory response. Studies to date are suggestive of clinical benefits from these approaches, especially in patients post surgery, although evidence of clinical benefit in patients with sepsis is emerging.

Fatty acids as modulators of the immune response

Research describing fatty acids as modulators of inflammation and immune responses abounds. Many of these studies have focused on one particular group of fatty acids, omega-3. The data from animal studies have shown that these fatty acids can have powerful anti-inflammatory and immunomodulatory activities in a wide array of diseases (e.g., autoimmunity, arthritis, and infection). However, the evidence from human trials is more equivocal. In this review, a historical framework for understanding how and why fatty acids may affect the immune system is provided. Second, highlights of two recent landmark reports from the Agency for Healthcare Research and Quality are presented. These reports critically evaluate the evidence from human clinical trials of omega-3 fatty acids and rheumatoid arthritis, asthma, and a few other immune-mediated diseases. Third, the data from human clinical trials investigating the impact of various bioactive fatty acids on ex vivo and in vivo immune response are reviewed. Limitations in experimental design and immune assays commonly used are discussed. The discordance between expectation and evidence in this field has been a disappointment. Recommendations for improving both animal-based and human studies are provided.

Pre- and post-challenge immuno-haematological changes in Labeo rohita juveniles fed gelatinised or non-gelatinised carbohydrate with n-3 PUFA

The combined effect of dietary carbohydrate type and n-3 PUFA (EPA+DHA) on pre- and post-challenge haemato-immunological responses in Labeo rohita juveniles was studied. Fish were fed for 67days with six different test diets containing either gelatinised (G) or non-gelatinised (NG) corn (43%) with three levels of n-3 PUFA (0.5%, 1.0% and 2.0%). During the pre-challenge period, significantly higher (P<0.05) NBT, serum lysozyme activity, total protein and globulin content was recorded in the NG carbohydrate fed groups. Highest NBT value was recorded in the groups fed with 1.0% n-3 PUFA, whereas the highest serum lysozyme activity (P<0.05) was recorded at either 0.5% or 2.0% n-3 PUFA fed groups in both the pre- and post-challenge period. Feeding of NG corn significantly increased the total leucocyte count, lysozyme activity, A/G ratio and decreased the total erythrocyte count, haemoglobin, serum total protein and globulin content of L. rohita juveniles during the post-challenge period. Similarly, feeding of n-3 PUFA at any level significantly increased the immunological parameters like lysozyme activity or A/G ratio, whereas total leukocyte count increased due to feeding of either 0.5% or 1.0% n-3 PUFA. The NBT and albumin values remained similar in both the pre- and post-challenge period. After challenge with Aeromonas hydrophila, the highest survival was recorded in the NG carbohydrate fed groups, whereas the lowest survival was recorded in the highest level of n-3 PUFA fed group irrespective of dietary carbohydrate type. Thus, a high level of G carbohydrate as well as n-3 PUFA is found to be immunosuppressive in L. rohita juveniles. NG carbohydrate supplemented with 1.0% n-3 PUFA is found to be optimum to enhance the immunity in L. rohita juveniles.

n-3 polyunsaturated fatty acids, inflammation, and inflammatory diseases

Inflammation is part of the normal host response to infection and injury. However, excessive or inappropriate inflammation contributes to a range of acute and chronic human diseases and is characterized by the production of inflammatory cytokines, arachidonic acid-derived eicosanoids (prostaglandins, thromboxanes, leukotrienes, and other oxidized derivatives), other inflammatory agents (e.g., reactive oxygen species), and adhesion molecules. At sufficiently high intakes, long-chain n-3 polyunsaturated fatty acids (PUFAs), as found in oily fish and fish oils, decrease the production of inflammatory eicosanoids, cytokines, and reactive oxygen species and the expression of adhesion molecules. Long-chain n-3 PUFAs act both directly (e.g., by replacing arachidonic acid as an eicosanoid substrate and inhibiting arachidonic acid metabolism) and indirectly (e.g., by altering the expression of inflammatory genes through effects on transcription factor activation). Long-chain n-3 PUFAs also give rise to a family of antiinflammatory mediators termed resolvins. Thus, n-3 PUFAs are potentially potent antiinflammatory agents. As such, they may be of therapeutic use in a variety of acute and chronic inflammatory settings. Evidence of their clinical efficacy is reasonably strong in some settings (e.g., in rheumatoid arthritis) but is weak in others (e.g., in inflammatory bowel diseases and asthma). More, better designed, and larger trials are required to assess the therapeutic potential of long-chain n-3 PUFAs in inflammatory diseases. The precursor n-3 PUFA alpha-linolenic acid does not appear to exert antiinflammatory effects at achievable intakes.

Fish oil in the critically ill: from experimental to clinical data

PURPOSE OF REVIEW

The aim of this paper is to describe recent relevant literature concerning the role of n-3 lipids derived from fish oil in clinical nutrition in an intensive care setting.

RECENT FINDINGS

N-3 fatty acids compete with arachidonic acid for metabolism to lipid mediators and exert profound effects on second mediator generation and dependent cellular functions. In experimental models, dietary and parenteral use of fish oil was shown to protect the gut by increasing its perfusion. In contrast, use of immunonutrition including fish oil in critical ill patients or patients with severe sepsis may exert an excess mortality. Using parenteral fish oil in surgical patients promising data became available. In septic patients, immunologic effects of fish oil-based lipid emulsions have been found and intravenous supplementation with fish oil may have a beneficial impact on mortality and length of stay. For both patient groups, however, prospective data from randomized trials are lacking.

SUMMARY

N-3 lipids exhibit strong immunologic properties. They offer the possibility to counterbalance the negative effects of conventional n-6 fatty acids. Recent studies exhibit positive effects of intravenous use of fish oil on immunologic functions and clinical parameters in surgical and septic patients.

PARENTERAL N-3 FATTY ACIDS MODULATE INFLAMMATORY AND IMMUNE RESPONSE IN RATS UNDERGOING TOTAL GASTRECTOMY

This study investigated the effect of n-3 fatty acid (FA)-containing parenteral nutrition on the circulatory lymphocyte subpopulation, intracellular cytokine and leukocyte adhesion molecule expression, and phagocytic activity in rats undergoing total gastrectomy. Normal rats with internal jugular catheters were assigned to normal control (NC) and two experimental groups and received total parenteral nutrition (TPN). At the same time, a total gastrectomy was performed in the experimental groups, whereas the NC group underwent a sham operation. The TPN solutions were isonitrogenous and identical in nutrient compositions except for differences in fat emulsion contents. The NC and one of the experimental groups received a soybean oil emulsion (SO), and the other experimental group received 50% soybean oil and 50% fish oil emulsion (FO). Half of the rats in each respective group were sacrificed 1 or 3 days after surgery or the sham operation to examine their immune response. The results showed that the FO group had a higher CD4 proportion and CD4/CD8 ratio than those of the SO and NC groups postoperatively. The phagocytic activity of peritoneal macrophages was higher in the FO group than in the NC group, but no difference was found between the SO and NC groups 3 days after surgery. The intracellular interferon (IFN)-gamma distribution in the FO group was higher than that of the SO group on postoperative days. Leukocyte adhesion molecule expressions and peritoneal monocyte chemotactic protein-1 levels were lower in the FO group than in the SO group on postoperative day 3. These results suggest that parenterally infused FO did not result in immunosuppression. In addition, FO administration promotes lymphocyte Th1 cytokine production, enhances peritoneal macrophage phagocytic activity, and reduces leukocyte adhesion molecule expression in rats with total gastrectomy.

The potential interactions between polyunsaturated fatty acids and colonic inflammatory processes

n-3 Polyunsaturated fatty acids (PUFAs) are recognized as having an anti-inflammatory effect, which is initiated and propagated via a number of mechanisms involving the cells of the immune system. These include: eicosanoid profiles, membrane fluidity and lipid rafts, signal transduction, gene expression and antigen presentation. The wide-range of mechanisms of action of n-3 PUFAs offer a number of potential therapeutic tools with which to treat inflammatory diseases. In this review we discuss the molecular, animal model and clinical evidence for manipulation of the immune profile by n-3 PUFAs with respect to inflammatory bowel disease. In addition to providing a potential therapy for inflammatory bowel disease there is also recent evidence that abnormalities in fatty acid profiles, both in the plasma phospholipid membrane and in perinodal adipose tissue, may be a key component in the multi-factorial aetiology of inflammatory bowel disease. Such abnormalities are likely to be the result of a genetic susceptibility to the changing ratios of n-3 : n-6 fatty acids in the western diet. Evidence that the fatty acid components of perinodal adipose are fuelling the pro- or anti-inflammatory bias of the immune response is also reviewed.

Dietary n-3 polyunsaturated fatty acids increase T-lymphocyte phospholipid mass and acyl-CoA binding protein expression

Dietary flaxseed oil, which is enriched in alpha-linolenic acid, and fish oil, which is enriched in EPA and DHA, possess anti-inflammatory properties when compared with safflower oil, which is enriched in linoleic acid. The influence of flaxseed oil and fish oil feeding on lipid metabolism in T-lymphocytes is currently unknown. This study directly compared the effects of feeding safflower oil, flaxseed oil, and fish oil for 8 wk on splenic T-lymphocyte proliferation, phospholipid mass, and acyl-CoA binding protein expression in the rat. The data show that both flaxseed oil and fish oil increased acyl-CoA binding protein expression and phosphatidic acid mass in unstimulated T-lymphocytes when compared with safflower oil feeding. Fish oil feeding increased cardiolipin mass, whereas flaxseed oil had no effect. After stimulation, flaxseed oil and fish oil blunted T-lymphocyte interleukin-2 production and subsequent proliferation, which was associated with the lack of increased acyl-CoA binding protein expression. The results reported show evidence for a novel mechanism by which dietary flaxseed oil and fish oil suppress T-lymphocyte proliferation via changes in acyl-CoA binding protein expression and phospholipid mass.

Does fish oil supplementation in pregnancy reduce the risk of allergic disease in infants?

PURPOSE OF REVIEW

Parallel increases in many inflammatory diseases over the last 40 years suggest that common environmental changes are promoting inflammatory immune responses and/or inhibiting the processes that normally keep these in check. One key change during this period has been declining intakes of anti-inflammatory dietary factors, including omega-3 polyunsaturated fatty acids (n-3 PUFA). As allergic diseases often first manifest in early infancy, prevention strategies need to be targeted early, even in utero. This review will examine recent evidence for the use of fish oil during this early period as a primary prevention strategy for allergic disease.

RECENT FINDINGS

N-3 PUFA have well documented anti-inflammatory effects in vitro and have also been demonstrated to have health benefits in a range of chronic inflammatory diseases, including cardiovascular disease, rheumatoid arthritis and diabetes, supporting their role in modulating inflammation in vivo. Although the effects of fish oil supplementation in established allergic disease are less convincing, there is accumulating evidence that dietary n-3 PUFA may have greater effects before allergic responses are established.

SUMMARY

Supplementation of the maternal diet in pregnancy with n-3 PUFA may provide a non-invasive intervention with significant potential to prevent the development of allergic and possibly other immune-mediated diseases.

Synergistic anti-inflammatory activity of omega-3 lipid and rofecoxib pretreatment on macrophage proinflammatory cytokine production occurs via divergent NF-kappaB activation

Omega-3 lipid pretreatment significantly decreases TNF-alpha production in LPS-stimulated Mphis; however, this response is only a partial inhibition, suggesting that other nonsubstrate- (lipid) dependent mechanisms are involved. The cyclooxygenase (COX)-2 enzyme is principally responsible for lipid metabolism; thus, a selective COX-2 inhibitor (Rofecoxib) would clarify if it is an omega-3 lipid direct effect or a COX-2 enzyme-associated modulated reduction in TNF-alpha. Moreover, potential synergy between omega-3 lipids and selective COX-2 inhibition is postulated.

HYPOTHESIS

Through divergent regulatory mechanisms, omega-3 lipids in combination with Rofecoxib will synergistically decrease the LPS-stimulated Mphi inflammatory response.

METHODS

RAW 264.7 cells were pretreated with omega-3 lipids, Rofecoxib, or combination treatment and then washed and exposed to LPS. Supernatants were collected for ELISA, total proteins were obtained to determine COX-2 protein expression by Western blot, and nuclear extracts were isolated to determine NF-kappaB activation by electromobility shift assay.

RESULTS

TNF-alpha and PGE2 production was significantly decreased with omega-3 and Rofecoxib pretreatment, and with combination treatment a further decrease in TNF-alpha production was observed. COX-2 protein expression was demonstrated to increase in omega-3, Rofecoxib, and combination groups stimulated with LPS. No alteration in NF-kappaB activation was observed with Rofecoxib or combination pretreatment compared with LPS-stimulated control cells. Repletion of prostaglandin (PGE2) in the Mphi model significantly decreased TNF-alpha in all groups.

CONCLUSIONS

Omega-3 lipids and Rofecoxib independently decrease TNF-alpha and PGE2 production in LPS-stimulated Mphi, yet in combination a synergistic reduction in TNF-alpha production is observed. Although the anti-inflammatory effects observed from omega-3 lipids are known to occur partially through decreasing NF-kappaB activation, we demonstrated that Rofecoxib or even a combination of omega-3 and Rofecoxib does not alter NF-kappaB activation, as seen with omega-3 lipids alone. These data support that combination treatment may result in decreased Mphi inflammation, yet this occurs via divergent mechanisms.

The pharmacological effects of novel nutrients on the immune system

The role of novel nutrients that appear to have pharmacological effects on the immune system has been studied over the past 20 years. This area of research has been termed immunonutrition. This paper provides an overview of particular novel nutrients--argtnine, glutamine, omega-3 fatty acids, and nucleotides--and examines some of the evidence for the effects that they may have on immune function. The benefits to particular patient groups are also considered (Box 1).

Impact of polyunsaturated fatty acids on cytoskeletal linkage of L-selectin

Polyunsaturated fatty acid [omega-3 polyunsaturated fatty acids (omega-3PUFAs)] incorporation into cell membranes has been shown to have potent anti-inflammatory activity, though the mechanisms involved are only partially characterized. Here, we show that PUFA enrichment of T cell membranes decreased the overall expression of L-selectin as well as a highly conserved epitope on L-selectin that may serve as a marker for optimal protein function. Additionally, PUFA enrichment inhibited L-selectin cytoskeletal association, which is thought to be important for optimal functional activity. In support of this, PUFA enrichment of gammadelta T cell membranes reduced L-selectin-dependent rolling interactions under conditions mimicking physiological flow. Taken together, these data suggest that the anti-inflammatory activity of omega-3 polyunsaturated fatty acids may be due, in part, to a novel effect on L-selectin, namely PUFA reduction or prevention of cytoskeletal association of L-selectin.

N-3 polyunsaturated fatty acids and allergic disease

PURPOSE OF REVIEW

With escalating rates of allergic disease, it is vital to explore novel causal pathways. This review examines the evidence for a potential role of changing dietary intake of omega-3 polyunsaturated fatty acids in the development, treatment and prevention of allergic diseases.

RECENT FINDINGS

Although it is difficult to determine the contribution of altered (decreased) dietary intake of omega-3 polyunsaturated fatty acids to the recent rise in the incidence of allergic disease, there is growing evidence that these nutrients have antiinflammatory properties and may modulate immune responses. These fatty acids have few side effects, and may be of some benefit in established allergic diseases (such as asthma and atopic dermatitis), although these effects are not strong. Because of this limited efficacy in established disease, the focus has shifted to the potential benefits of these immune modulators in earlier life for disease prevention. Two recent preliminary reports in infants suggest that dietary omega-3 polyunsaturated fatty acid supplements in pregnancy or in the early postnatal period could have immunomodulatory properties and associated clinical effects, although more studies are now needed. Novel synthetic polyunsaturated fatty acids with more potent and selective antiinflammatory effects may also provide safe therapeutic and preventive strategies in the future.

SUMMARY

Dietary factors are important but still under-explored candidates in the search for environmental strategies to reduce the enormous impact of allergic diseases in modernized societies. There is an ongoing need for further research into the role of omega-3 polyunsaturated fatty acids in allergic disease, particularly in early life before atopy is established.

Omega-3 fatty acid lipid emulsion reduces LPS-stimulated macrophage TNF-alpha production

BACKGROUND

Omega-3 (omega-3) fatty acids (FA), specifically eicosapentaenoic acid (EPA), attenuate cytokine-mediated inflammation. Currently, in the United States, there is no commercial source of omega-3 lipid for clinical use. A clinically used European lipid emulsion, Omegaven, has been shown to have beneficial antiinflammatory effects; however, the mechanisms of its action are not well defined. In the present work, this omega-3 FA emulsion has been evaluated in order to define its effects on TNF-alpha production in a model of LPS-stimulated macrophages.

MATERIALS AND METHODS

RAW 264.7 cells (1 x 10(6) cell/well) were incubated with DMEM, Omegaven, or an isoenergetic omega-6 lipid emulsion, Lipovenos for 4 h. Cells were washed and then stimulated with LPS (1 microg/mL) or media alone for 3 h. Plate well supernatants were collected and assayed for TNF-alpha production by ELISA. Statistical analysis was performed by ANOVA and post-hoc analyses; the significance was defined as p < 0.05.

RESULTS

Unstimulated RAW cell TNF-alpha production was similar in all groups and < 60 pg/mL. Lipovenos pretreatment did not alter TNF-alpha production from that of baseline compared to LPS-stimulated cells. Four-hour Omegaven pretreatment significantly reduced TNF-alpha production in LPS-stimulated cells, with a 46% reduction in TNF-alpha from baseline observed.

CONCLUSION

Four-hour omega-3 FA emulsion pretreatment significantly attenuated LPS-stimulated macrophage TNF-alpha production. These data support the contention that antiinflammatory effects of omega-3 FA occur at least in part through the inhibition of macrophage TNF-alpha production in response to endotoxin. Further studies to define the antiinflammatory mechanisms of omega-3 FA on macrophages are warranted. The availability of Omegaven as an experimental treatment and Lipovenos as an equivalent control will be useful for future studies.

Long-chain n-3 fatty acids and inflammation: potential application in surgical and trauma patients

Lipids used in nutritional support of surgical or critically ill patients have been based on soybean oil, which is rich in the n-6 fatty acid linoleic acid (18:2n-6). Linoleic acid is the precursor of arachidonic acid (20:4n-6). In turn, arachidonic acid in cell membrane phospholipids is the substrate for the synthesis of a range of biologically active compounds (eicosanoids) including prostaglandins, thromboxanes, and leukotrienes. These compounds can act as mediators in their own right and can also act as regulators of other processes, such as platelet aggregation, blood clotting, smooth muscle contraction, leukocyte chemotaxis, inflammatory cytokine production, and immune function. There is a view that an excess of n-6 fatty acids should be avoided since this could contribute to a state where physiological processes become dysregulated. One alternative is the use of fish oil. The rationale of this latter approach is that fish oil contains long chain n-3 fatty acids, such as eicosapentaenoic acid. When fish oil is provided, eicosapentaenoic acid is incorporated into cell membrane phospholipids, partly at the expense of arachidonic acid. Thus, there is less arachidonic acid available for eicosanoid synthesis. Hence, fish oil decreases production of prostaglandins like PGE2 and of leukotrienes like LTB4. Thus, n-3 fatty acids can potentially reduce platelet aggregation, blood clotting, smooth muscle contraction, and leukocyte chemotaxis, and can modulate inflammatory cytokine production and immune function. These effects have been demonstrated in cell culture, animal feeding and healthy volunteer studies. Fish oil decreases the host metabolic response and improves survival to endotoxin in laboratory animals. Recently clinical studies performed in various patient groups have indicated benefit from this approach.

Effects of fish oil in parenteral nutrition

OBJECTIVE

Fish oil is a rich source of omega-3 fatty acids (FAs), especially eicosapentaenoic acid and docosahexaenoic acid. The existing data suggest that eicosapentaenoic acid and docosahexaenoic acid are the active agents in fish oil. A number of clinical trials have shown that dietary fish oil supplementation has antiatherogenic properties and immunomodulation effects. Fish oils are not used widely in parenteral nutrition because fish oil emulsions have not been commercially available until very recently. Studies concerning the use of fish oil in parenteral route are rare.

METHODS

We reviewed the effect of parenteral fish oil infusion on lipid metabolism and immune response in normal and disease conditions.

RESULTS

Studies showed that the main effects of parenteral infusion of fish oil are: 1) incorporation of omega-3 FAs into cellular membranes of many cell populations that consequently influence the disease process of some disease conditions, 2) an effect on eicosanoid metabolism leading to a decrease in platelet aggregation and thrombosis, 3) amelioration of the severity of diet-induced hepatic steatosis, 4) less accumulation of lipid peroxidation products in liver tissue, and 5) immunomodulation effects and therapeutic benefits in animal disease models or various disease conditions of humans. Most of these studies suggested that parenteral infusion of omega-3 FAs have clinical beneficial effects comparable to those of dietary administration. However, different effects of omega-3 and omega-6 FAs in some situations has been reported. For example, plasma triacylglycerol levels were not lowered after fish oil infusion in normal or diabetic rats when compared with those of safflower oil or soybean oil infusion. The reason for the difference remain unclear.

CONCLUSION

The metabolic and immunologic effects of parenteral use of omega-3 FAs requires further evaluation, especially in some disease conditions.

Immunonutrition

Nutrition and immunology are interrelated. Several nutrients like arginine, glutamine, omega-3-fatty acids and nucleotides enhance cellular immunity, modulate tumor cell metabolism and improve clinical outcome in stress situations. Glutamine supplementation has been shown to decrease incidence of sepsis and to reduce length of hospital stay in bone marrow transplant patients, low birth weight infants, surgical and multiple trauma patients. Studies with arginine have shown a reduction in infectious complications and lower mortality, however a better understanding of the biology of arginine is needed. Omega-3-fatty acid supplimentation as in fish oil stimulates the immune system. The beneficial effects of immunonutrition in surgical patients has been demonstrated in several studies. It significantly reduces infectious complications and length of hospital stay. In critically ill patients immunonutrition may decrease infectious complications but it is not associated with a mortality advantage. Pediatric experience is limited, but the future is promising.

The role of dietary long-chain n-3 fatty acids in anti-cancer immune defense and R3230AC mammary tumor growth in rats: influence of diet fat composition

We determined if long-chain n-3 fatty acids fed as part of a: (1) high polyunsaturated fat diet (currently recommended by several health agencies) or (2) low polyunsaturated fat diet (representative of that consumed by a large segment of the North American population) improved antitumor immune defense and inhibited tumor growth. Rats were fed one of four semi-purified diets (20% w/w fat) for 21 days pre- and 17 days post- R3230AC mammary tumor implantation. The polyunsaturated to saturated fatty acid (P/S) ratio was either 1 (high P/S diet) or 0.35 (low P/S diet). At each P/S ratio, diets provided long-chain n-3 fatty acids at 0 or 5% w/w of total fat. Long-chain n-3 fatty acids fed in a high P/S diet did not affect tumor growth or host immune responses. In contrast, feeding long-chain n-3 fatty acids in a low P/S diet increased natural killer cell cytotoxicity, splenocyte nitric oxide and interleukin-2 production, and the proportion of activated (CD25+) CD8+ and CD28+ cells, but did not significantly inhibit tumor growth. For both P/S diets, tumor cells from rats fed long-chain n-3 fatty acids had a higher n-3 content and n-3/n-6 ratio in phosphatidylcholine, phosphatidylethanolamine, and phosphatidylinositol. Furthermore, the magnitude of increase in n-3 fatty acid incorporation into tumor phospholipids was greater when fed in a low P/S diet. We demonstrated that the dietary P/S ratio significantly influences the effect of long-chain n-3 fatty acids on host immune responses and n-3 fatty acid incorporation into tumor cells. These findings warrant further consideration when designing dietary recommendations.

Maintenance of NF-kappaB activation in T-lymphocytes and a naive T-cell population in autoimmune-prone (NZB/NZW)F(1) mice by feeding a food-restricted diet enriched with n-3 fatty acids

We have previously shown that feeding a fish oil (FO) supplemented diet in combination with 40% food restriction (FO/FR) has a greater impact on extending life span in lupus-prone (NZB x NZW)F1 mice than either FO ad libitum (FO/AL) or corn oil food restricted (CO/FR) alone. Lupus disease is associated with increased Th-2 (i.e., IL-6 and IL-10) cytokine production and reduced IL-2 production and NF-kappaB activation. We hypothesized that the mechanism of action by which FO/FR increases life span may involve alterations in T-lymphocyte signaling and subsequent cytokine production. To test this hypothesis, we isolated and then stimulated splenic T-lymphocytes ex vivo with anti-CD3 and -CD28 monoclonal antibodies. We report here that CO/FR and FO/FR and to a lesser extent FO/AL offset disease-associated losses in Th-1 cytokine production, CD69 expression, and NF-kappaB activation in splenic T-lymphocytes activated ex vivo. Similarly, CO/FR and FO/FR prevented the disease-dependent rise in Th-2 cytokine production ex vivo and CD69 expression in vivo. In essence, the T-lymphocyte phenotype in the old CO/FR and FO/FR groups was identical to that in the young disease-free mice. Taken together, the data suggest that both CO/FR and FO/FR increase life span, in part, by maintaining a youthful immune phenotype in autoimmune-prone mice. However, FO/FR appears to represent a more potent dietary strategy in delaying disease-associated immune dysregulation than CO/FR.

Polyunsaturated n-3 fatty acids and the development of atopic disease

The relationship between polyunsaturated longchain fatty acids and atopy has been discussed for decades. Higher levels of the essential fatty acids linoleic acid and alpha-linolenic acid and lower levels of their longer metabolites in plasma phospholipids of atopic as compared to nonatopic individuals have been reported by several, but not all, studies. Largely similar findings have been reported in studies of cell membranes from immunological cells from atopics and non-atopics despite differences in methodology, study groups, and definitions of atopy. An imbalance in the metabolism of the n-6 fatty acids, particularly arachidonic acid and dihomo-gamma-linolenic acid, leading to an inappropriate synthesis of prostaglandin (PG) E2 and PGE1 was hypothesized early on but has not been corroborated. The fatty acid composition of human milk is dependent on the time of lactation not only during a breast meal but also the time of the day and the period of lactation. This explains the discrepancies in reported findings regarding the relationship between milk fatty acids and atopic disease in the mother. Prospective studies show disturbances in both the n-6 and n-3 fatty acid composition between milk from atopic and nonatopic mothers. Only the composition of long-chain polyunsaturated n-3 fatty acids was related to atopic development in the children, however. A relationship between lower levels of n-3 fatty acids, particularly eicosapentaenoic acid (20:5 n-3), and early development of atopic disease is hypothesized.

The effects of lipids on the immune response of patients with cancer

The role of diet and certain nutritional factors in the etiology or promotion of various malignant diseases has widely been studied. A link between dietary fat and cancer has long been proposed through various human epidemiologic and experimental data. High fat diets are associated with a high incidence and accelerated development of certain tumors, while there is evidence that dietary w-3 fatty acids have beneficial effects in cancer growth and metastasis. The relation between the different lipid formulations and cancer appears to be mainly related to the influence of specific fatty acids on the synthesis of the immunosuppressive prostaglandin E2. Omega-3 polyunsaturated fatty acids seem to have an anti-tumor effect through their immunomodulating, anti-inflammatory action and direct inhibition of tumor cell proliferation via alteration in prostaglandin E2 production.

Immunonutrition - fact or fad

Suggestions that modifications to the diet may have a beneficial effect on health are not new. recent work demonstrates that nutritional supplements may effect immune function. This review examines the evidence for the effects of these supplements including arginine, glutamine, nucleotides and omega - 3 fatty acids. In particular, clinical trials with patients in multiple organ failure are discussed. The evidence published thus far suggests that immunonutrition, if absorbed in adequate amounts both pre- and post-operatively, reduces septic complications and improves surrogate measures of ourcome, including length of stay and requirements for mechanical ventilation.

n-3 polyunsaturated fatty acids inhibit the antigen-presenting function of human monocytes

Diets rich in n-3 polyunsaturated fatty acids (PUFAs) are associated with suppression of cell-mediated immune responses, but the mechanisms are unclear. We hypothesized that n-3 PUFAs can inhibit the function of human antigen-presenting cells. A prerequisite for this role of blood monocytes is the cell surface expression of major histocompatibility complex (MHC) class II molecules [human leukocyte antigen (HLA)-DR, -DP, and -DQ], aided by the presence of intercellular adhesion molecule-1 (ICAM-1) and leukocyte function associated antigens 1 and 3. We showed previously that the n-3 PUFA eicosapentaenoic acid (EPA) inhibits the expression of HLA-DR on unstimulated human monocytes in vitro, but that docosahexaenoic acid (DHA) enhances its expression. However, both n-3 PUFAs suppress the expression of HLA-DR, HLA-DP, and ICAM-1 on interferon-gamma-activated monocytes. We also established that dietary fish-oil supplementation can inhibit the expression of these surface molecules on circulating human monocytes. We subsequently showed that when EPA and DHA were combined in the same ratio as is commonly found in fish-oil-supplement capsules (3:2), there was no significant effect in vitro on the expression of HLA-DR on unstimulated monocytes, but the expression on activated monocytes remained significantly inhibited. In the same in vitro system, the ability of activated monocytes to present antigen to autologous lymphocytes was significantly reduced after culture with the combined n-3 PUFAs. These findings provide one potential mechanism for the beneficial effect of fish oil in the treatment of rheumatoid arthritis, a disorder associated with elevated expression of MHC class II and adhesion molecules on monocytes present within affected joints.

Effect of oil containing n-3 polyunsaturated fatty acids (PUFA) on the immune response and growth factors in piglets

Oral administration of n-3 polyunsaturated fatty acids (PUFA) to piglets slightly enhances the immune response. As compared to the control, in the experimental piglets the absolute values of monocytes in the peripheral blood were significantly increased (P < 0.05), while the metabolic activity of phagocytes and the number of lymphocytes within the individual subpopulations were slightly higher. The level of growth factors, determined on the basis of somatomedin in the blood serum, was significantly higher in the experimental group (P < 0.05). n-3 PUFA interfere with the synthesis of prostaglandins and influence the metabolism of fatty acids. This finding may contribute to the therapy of inflammatory processes influencing immune and growth factors in piglets.