Welcome to today’s webinar… Omega 3 in Cardiovascular Disease Prevention New Evidence on an Old Intervention Deanne Wooden Nutrition Manager, Heart Foundation

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QCRA-Heart Foundation (QLD) Secondary Prevention in Cardiology Symposium 2015 Friday October 16 th 8am-4pm Russell Strong Auditorium, Princess Alexandra Hospital, Woolloongabba Qld For more details or to register - see ACRA Events page:

Welcome to today’s webinar… Omega 3 in Cardiovascular Disease Prevention New Evidence on an Old Intervention Deanne Wooden Nutrition Manager, Heart Foundation

©2014 National Heart Foundation of Australia Omega-3 polyunsaturated fatty acids and cardiovascular health Released: April 2015

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 8 Released: April 2015 Background Development Evidence Recommendations Other Considerations Key messages Dissemination Questions Overview

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 9 Released: April 2015 What is dietary fat? Dietary fat SaturatedUnsaturated Trans PolyunsaturatedMonounsaturated n-6 PUFAn-3 PUFA Plant n-3Marine n-3 Dietary cholesterol Sterols Phytosterols

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 10 Released: April 2015 n-3 (omega-3) fats are a type of polyunsaturated fat Marine & animal source EPA & DHA: cold water oily fish like Aust. & Atlantic salmon, blue- eye trevalla, blue mackerel, herring, canned sardines, canned salmon and some varieties of canned tuna. DPA: beef, lamb and veal converted to EPA & DHA DHA: found in eggs + also some DPA Plant source ALA: canola and soybean based fats & oils, nuts (esp. walnuts) & freshly ground flax seeds (linseed), and chia seeds. Background

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 11 Released: April 2015 Nutrient Reference Values (2006) 1 EPA + DPA + DHA610 mg/day for men & 430 mg/day for women “…it would seem prudent to encourage increased consumption to the 90th percentile” Australian Dietary Guidelines (2013) 2 “ Satisfactory evidence that the consumption of at least two serves a week of fish is associated with a reduced risk of mortality from cardiovascular disease, and with reduced incidence of cardiovascular disease, and reduced risk of stroke. (Grade C) ” “Weak evidence that consumption of LCPUFA is associated with reduced mortality from cardiovascular disease (Grade D)” Australian Guide to Healthy Eating (2013) 2 “Enjoy lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans. (1) NHMRC. Nutrient Reference Vales for Australia and NZ including Recommended Dietary Intakes, NHMRC September (2) NHMRC. Australian Dietary Guidelines, NHMRC February Accessed from: Existing Australian Guidelines

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 12 Released: April 2015 Fish, fish oils, and n-3 polyunsaturated fatty acids and cardiovascular health (2008) 1 “Consume about 500 mg per day of combined docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) through a combination of the following: - two or three serves (150 g serve) of oily fish per week - fish oil capsules or liquid - food and drink enriched with marine n-3 polyunsaturated fatty acid (n-3 PUFA). Dietary fats (1999) 2 “… at least 2 serves of fish (preferably oily fish) per week” “ both plant and marine omega-3 should be consumed since it is possible that (each)…protect against CHD by different mechanisms” “plant omega-3 intake should be at least 2g per day.” (1) NHFA (2008) Fish, fish oils, and n-3 polyunsaturated fatty acids and cardiovascular health (2008), Melbourne. (2) NHFA (1999) A review of the relationship between dietary fat and cardiovascular disease. Australian Journal of Nutrition and Dietetics, 56:4. Heart Foundation recommendations

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 13 Released: April 2015 Recent meta-analyses reporting neutral effect on cardiovascular outcomes. Kotwal S, Jun M, Sullivan D, Perkovic V, Neal B. Omega 3 fatty acids and cardiovascular outcomes: Systematic review and meta ‐ analysis. Circulation: Cardiovascular Quality and Outcomes.2012;5(6):808 ‐ 818. Rizos EC, Ntzani EE, Bika E, Kostapanos MS, Elisaf MS. Association between omega ‐ 3 fatty acid supplementation and risk of major cardiovascular disease events: a systematic review and meta ‐ analysis. JAMA.2012;308(10):1024 ‐ Kwak SM, Myung SK, Lee YJ, Seo HG. Efficacy of omega ‐ 3 fatty acid supplements (eicosapentaenoic acid and docosahexaenoic acid) in the secondary prevention of cardiovascular disease: a meta ‐ analysis of randomized, double ‐ blind, placebo ‐ controlled trials. Archives of Internal Medicine.2012;172:E1 ‐ E9 Although it remains possible that fish oil supplements will produce health benefits…the size of these gains are probably smaller than previously believed, and both physician and patient expectations may need to be reset. 1 (1) Kotwal et al Why the update?

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 14 Released: April 2015 Recent guidelines advising a step away from specific omega-3 recommendations ESC (2013) Guidelines on the management of stable coronary artery disease: In general, when following the rules for a healthy diet, no dietary supplements are needed. Omega-3 consumption, mainly from fish, is potentially associated with beneficial effects…but not all trials have sown reduction in CV events. Thus current recommendations are to increase omega-3 intake through fish consumption, rather than from supplements. National Institute of Clinical Excellence (2013) Secondary prevention of cardiovascular disease and (2010) Primary prevention of cardiovascular disease: Advise people to eat a Mediterranean-style diet, Do not offer or advise people to use the following to prevent another MI: omega-3 fatty acid capsules; omega-3 fatty acid supplemented foods; If people choose to take omega-3 fatty acid capsules or eat omega-3 fatty acid supplemented foods, healthcare professionals should be aware that there is no evidence of harm. 'People at high risk of or with cardiovascular disease should be advised to consume at least two portions of fish per week, including a portion of oily fish' 'People should not routinely be recommended to take omega-3 fatty acid supplements for the primary prevention of cardiovascular disease'. (1) European Society of Cardiology (2013) Guidelines on the management of stable coronary artery disease (2) National Institute of Clinical Excellence 2010 & 2013 Why the update?

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 15 Released: April 2015 Scientific Literature , update to comprehensive 2008 paper Healthy eating messages and resources Peer review Heart Lung Circulation Summary of evidence paper Position statement w/ recommendations Expert Working Group NHMRC Evidence Levels & Grades Rapid review omega-3 content, mercury, sustainability Conclusions & Recommendations FNAC & CIC CVHAC Nat Brd

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 16 Released: April 2015 Development Expert Working Group: Prof Paul Nestel (Chair), Prof Peter Clifton, A/Prof D Colquhoun, Dr Trevor Mori, Prof Manny Noakes, Clin A/Prof David Sullivan Heart Foundation Members: Ms Beth Thomas, Mrs Melanie Chisholm, Dr Rob Grenfell (until September 2014), Ms E Nixon (until May 2014) Heart Foundation governance & approval: Food and Nutrition Advisory Committee Clinical Issues Committee National Cardiovascular Health Advisory Committee National Board of Heart Foundation Peer reviewed publication: Heart, Lung and Circulation Journal

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 17 Released: April 2015 What we did... Eight Research Questions 1.Are omega-3 LCPUFA supplements effective in the primary prevention of coronary heart disease? 2.Is the reported consumption of omega-3 LCPUFA from fish, or dietary patterns high in omega-3 LCPUFA (measured through plasma or red blood cell LCPUFA) associated with lower incidence of coronary heart disease events in primary prevention? 3.Are omega-3 LCPUFA supplements an effective intervention for the secondary prevention of coronary heart disease? 4.Is the reported consumption of fish, or dietary patterns high in omega-3 LCPUFA (measured through plasma or red blood cell LCPUFA) associated with a lower incidence of coronary heart disease in patients with existing CHD (i.e. secondary prevention)? 5.Are omega-3 LCPUFA supplements effective in the prevention or treatment of heart failure? 6.Is the reported consumption of fish, or dietary patterns high in omega-3 LCPUFA (measured through plasma or red blood cell LCPUFA) associated with lower incidence of heart failure? 7.Are omega-3 LCPUFA supplements an effective intervention for lowering plasma triglycerides in hypertriglyceridaemic patients? 8.Is the intervention with the plant omega-3 fatty acid (alpha-linolenic acid) or its consumption effective in the prevention of coronary heart disease?

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 18 Released: April 2015 What we did...

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 19 Released: April 2015 What we found...

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 20 Released: April 2015 NHMRC Grades for Assessment of Evidence Levels of Evidence

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 21 Released: April 2015 NHMRC Grades for Assessment of Evidence Matrix for Grading Evidence

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 22 Released: April 2015 NHMRC Grades for Assessment of Evidence Matrix for Grading Evidence - example

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 23 Released: April 2015 Adapted from source: NHMRC Grades for Assessment of Evidence Description for grades of evidence

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 24 Released: April 2015 Evidence informed conclusions 1/2

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 25 Released: April 2015 Evidence informed conclusions 2/2

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 26 Released: April 2015 As part of a heart healthy diet based on a variety of foods including plenty of vegetables, legumes, fruit, wholegrain cereal, lean meats and their alternatives, reduced fat milk, cheese and yoghurt and alternatives, nuts, seeds, healthier oils and limiting salt, the following recommendations are made: Primary prevention of coronary heart disease Eat two to three serves of fish ( g), including oily fish, per week to achieve about mg per day of combined docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). Secondary prevention of coronary heart disease Eat two to three serves of fish ( g), including oily fish, per week to achieve about mg per day of combined DHA/EPA. Consider omega-3 LCPUFA supplementation of ≥1000mg combined EPA/DHA as an additional therapy for patients with heart failure. Hypertriglyceridaemia Consider up to 4000 – 5000 mg combined EPA/DHA as the highest dose alone or with a fibrate for moderately sever hypertriglyceridaemia. Alpha-Linolenic Acid Consume at least 1 g per day of alpha-linolenic acid (ALA) from food, consistent with NHMRC recommendations. Heart Foundation recommendations 2015

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 27 Released: April recommendations2015 recommendations To lower their risk of coronary heart disease (CHD), all adult Australians should:  Consume about 500 mg per day of combined docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) through a combination of the following: two or three serves (150 g serve) of oily fish per week fish oil capsules or liquid food and drink enriched with marine n-3 polyunsaturated fatty acid (n-3 PUFA). Adult Australians with documented CHD To lower their risk of further disease progression, Australian adults with documented CHD should:  Consume about 1000 mg per day of combined DHA and EPA through a combination of the following: two or three serves (150 g serve) of oily fish per week fish oil capsules or liquid food and drink enriched with marine n-3 PUFA. Primary prevention of coronary heart disease  Consume between mg per day of combined docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) through the consumption of two to three servings of fish (around g serve), including oily fish, per week. Secondary prevention of coronary heart disease  Consume about mg per day of combined DHA & EPA through the consumption of two to three serves of fish ( g), including oily fish, per week.  Provide omega-3 LCPUFA supplementation as an additional therapy for patients with heart failure.

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 28 Released: April recommendations2015 recommendations Australians with lipid abnormalities For Australians with elevated triglyceride (TG) levels, first-line therapy could be fish oil capsules or liquid and marine n-3 PUFA enriched foods and drink. They should:  start with a dose of 1200 mg per day of DHA and EPA; and if appropriate increase the dose to 4000 mg per day of DHA and EPA and check their response every 3 to 4 weeks when the dose is changed, until target TG levels are reached. Alpha-Linolenic Acid  Consume at least 2 g per day of ALA. Hypertriglyceridaemia  Consider use of supplements to achieve up to 4000 – 5000mg in addition to standard therapy Alpha-Linolenic Acid  Consume at least 1 g per day of alpha-linolenic acid (ALA) consistent with NHMRC recommendations

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 29 Released: April 2015 ~ mg/day DHA and EPA (n-3 marine source) 2-3 serves of oily fish/week (150g serve) At least 1 g/day ALA (n-3 plant source) Observe local safety recommendations Recommendations (detailed) Adult Australians…..

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 30 Released: April 2015 Pregnant, breastfeeding & children As per adult Australians Limit some fish species (FSANZ Guidelines) –High methylmercury: 1 serve per fortnight –Medium methylmercury: 1 serves per week –No recommendation for low methylmercury

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 31 Released: April 2015 Adults with CHD: mg/day DHA and EPA 2-3 serves of oily fish/week (150 g serve) At least 1 g/day ALA Observe local safety recommendations Consider use of omega-3 supplements to achieve 1g/day in those with heart failure Health professionals…..

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 32 Released: April 2015 Adults with elevated triglycerides: As per adult Australians and in addition - –Consider use of supplements to achieve up to 4000 – 5000mg in addition to standard therapy Note, no prescriptive recommendations. Health professionals…..

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 33 Released: April 2015 Risks and cautions Biological Pathogens Viral Bacteria Ciguatera Chemical Pollutant Mercury Dioxin and PCBs Health benefits >>> potential risks

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 34 Released: April 2015 Other considerations Omega-3 content in Australian Foods –EPA & DHA –ALA Chemical Pollutants Mercury Sustainability Australian seafood stocks Canned fish

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 35 Released: April 2015 ALA composition of foods The most up-to-date and highest quality data is from the FSANZ AUSNUT food nutrient database. No significant changes to ALA composition of foods since 2008 review. Best dietary sources of ALA are: walnuts, linseeds/flaxseeds, chia seeds, and oils such as vegetable, canola, soybean and linseed/flaxseed. Given reduction in recommendations for consumption of ALA to 1 g/day, there is now a wider variety of foods that can reasonably meet this level.

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 36 Released: April 2015 EPA and DHA in seafood The most up-to-date and highest quality data is from the FSANZ AUSNUT food nutrient database. There is significant new data on EPA and DHA composition of seafood which has required significant re-categorisation of seafood composition in consumer resources. This reflects variable nature of food composition, improvements in sampling/analytical methods over time, and perhaps changes in composition of foods due to varying environmental conditions and other factors. Given reduction of consumption recommendation to mg/day of EPA and DHA, there is now a wider variety of seafood which can realistically meet this level. Reductions in fatty acid composition of farmed fish (related to reduced use of marine LC omega 3s in fish feed), could have significant implications in future and this should be closely monitored.

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 37 Released: April 2015 Mercury in seafood Heart Foundation recommendations align with FSANZ recommendations to limit the risks of mercury contamination. Heart Foundation consumer resources do not refer to any higher risk species (e.g. Flake, Orange Roughy etc), which also have sustainability concerns. It may be useful to make specific reference to these species in consumer resources to increase awareness of contamination risks and sustainability concerns. –Eg. Flake is commonly sold in takeaway seafood restaurants and many may be unaware that it has a higher risk of mercury contamination (and sustainability issues)

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 38 Released: April 2015 Sustainable seafood choices There is a serious disconnect between current seafood consumption recommendations for health, and sustainability of current seafood supply. Sustainability assessments must include a variety of indicators including fish stocks, fishing practices, by-catch, ecosystem impacts etc, and must cover imported seafood (>70% of seafood consumed in Australia is imported) Current government reports only report on fish stocks (so inadequate as an assessment of sustainability).

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 39 Released: April 2015 Sustainable seafood choices Useful consumer resources on sustainable seafood options include: –Australian Marine Conservation Foundation Sustainable Seafood Guide (online)online –Greenpeace Canned Tuna Guide (online)online Heart Foundation should de-list known overfished species (Gemfish), and link consumers to appropriate resources on sustainable seafood options.

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 40 Released: April 2015 What about supplements? Eating fish is the recommended way to consume essential Omega-3 nutrients for heart health, however supplements will provide people who do not eat fish with some level of marine-sourced Omega-3s. There is no evidence to suggest that Omega-3 supplements are harmful in any way; Omega-3 supplements can play a beneficial role in the treatment of those with high triglycerides and in the secondary prevention of heart disease (specifically heart failure).

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 41 Released: April 2015 Key messages Top line The Heart Foundation recommends all Australians should aim to eat 2-3 serves of fish (including oily fish) per week, which provides about milligrams of Omega-3s (marine source) per day. In addition, the Heart Foundation recommends that all Australians consume at least 1 gram of omega-3 (plant source) every day. And the detail… For heart health, the best available evidence supports including 2-3 serves of fish per week as part of a heart healthy diet. Eating fish is the recommended way to consume essential Omega-3 nutrients for heart health, however supplements will provide people who do not eat fish with some level of marine-sourced Omega-3s. For people with high triglycerides, omega-3s (marine source) can help lower triglycerides. For people with heart failure, your health professional may consider using omega-3s (marine source) in addition to standard medications.

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 42 Released: April 2015 Key messages Making small changes can be as easy as –including a serve of canned salmon or sardines –adding serves of oily fish or seafood (either caught or bought) –Good sources of marine omega-3 include: Atlantic and Australian salmon (fresh or canned), gemfish, blue-eye trevalla, blue mackerel, oysters, arrow squid, canned sardines and some varieties of canned tuna Not eating enough fish or seafood? –Check out our meal plans and recipes for simple ideas. What about supplements? –Eating fish is the recommended way to consume essential Omega-3 nutrients –However supplements will provide people who do not eat fish with some level of marine-sourced Omega-3s. –There is no evidence to suggest that Omega-3 supplements are harmful in any way –Omega-3 supplements can play a beneficial role in the treatment of those with high triglycerides and in the secondary prevention of heart disease (specifically heart failure).

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 43 Released: April 2015 Sneak peek… ……. Down to mg/150 g

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 44 Released: April 2015

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 45 Released: April 2015 Eating Plans Weekly plan 1 = 3 fish serves EPA & DHA =~506 mg /d Weekly plan 4 = 3 fish serves EPA & DHA =~289 mg /d

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 46 Released: April 2015 Coming soon… New position statement…

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 47 Released: April 2015 Coming soon…

©2015 National Heart Foundation of Australia Omega-3 & CVH Slide 48 Released: April 2015 Questions???