Fish in the diet a review. Sara Stanner British Nutrition Foundation

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1 Fish in the diet a review Sara Stanner British Nutrition Foundation

2 BNF who we are, what we do?

3 What the review covers Fish consumption Nutrient composition of fish and factors affecting this Contribution to dietary intakes in UK Contamination of fish and effects on health Link with health outcomes obesity, CVD, type 2 diabetes, cancer, asthma, eczema & atopic conditions, cognitive function, bone health Recommendations for intake Sustainability issues

4 Methodology Definition: Fish finfish and shellfish, marine or freshwater origin, farmed or wild General classification of white (1-2% fat) vs oil-rich fish (5-20% fat)* PubMed search for best evidence *SACN 2004

5 Nutrition claims for selected types of fish in the context of EU nutrition claims legislation Raw fish Tuna Salmon Cod King prawns Protein High in High in High in High in Omega 3 DHA/EPA Source High in Source High in Potassium Source Source Source Phosphorus High in High in Source Source Selenium High in High in High in High in Iodine Source High in Vitamin D High in High in Niacin High in High in Vitamin B6 High in High in Vitamin B12 High in High in High in High in

6 Micronutrients of concern in the UK Low intake Vitamin A Riboflavin Iron Low status Iron Riboflavin Vitamin D Calcium Magnesium Potassium Zinc Selenium Iodine Source: National Diet and Nutrition Survey, Rolling Programme Years 1, 2 and 3, The British Nutrition Foundation

7 Current recommendations DH (England): Eat at least two portions of fish (140g each) per week, one of which should be oily. This does not include shellfish. SACN (2004): endorsed population recommendation - one portion oily fish would provide approximately 0.45g/day LC n-3 PUFA or 3.15g/week but the recommendation is for FISH specifically and a minimum requirement EFSA (2010): proposed Adequate Intake of 0.25g EPA+DHA/day for adults (1.5-2g/wk) (plus mg/d DHA in pregnancy/lactation) But beneficial effects on CVD risk factors mainly observed at intakes above 1g/day NICE (2013): revised their guidelines on the use of omega 3 supplements for people who have had heart attacks and are now not recommending omega 3 supplementation

8 Health claims relating to n-3 PUFA Permitted Article 13(1) health claim for normal function of the heart (not risk reduction) for foods that are a source of EPA/DHA (at least 40mg/100g and per 100kcal) Also: DHA contributes to the maintenance of normal vision; DHA contributes to maintenance of normal brain function Article 14(1) DHA intake contributes to the normal visual development of infants up to 12 months of age DHA maternal intake contributes to the normal brain development of the foetus and breastfed infants DHA maternal intake contributes to the normal development of the eye of the foetus and breastfed infants No permitted Article 13(5) claims relating to n-3 PUFA

9 What does the evidence say?

10 Fish and CHD: cohort studies Significant reduction of CHD mortality by 18% for highest compared to lowest consumption of fish (or LC n-3 PUFA). Skeaff CM & Miller J (2009)

11 Fish and stroke Most recent meta-analysis of 21 cohort studies included 675,048 participants Risk was reduced by 6% when eating 2-4 portions of fish per week compared to 1 serving/wk Reduction in risk reduction was larger (12%) when comparing 5 servings/wk with 1 serving/wk But the risk was only significantly reduced with oily fish not white fish. This may be explained by distinct way the two types are generally prepared data for this sub-analysis came from UK and Sweden, where white fish is typically battered and fried. Source: Chowdhury R, Stevens S, Gorman D et al. (2012)

12 Omega 3 supplements and CVD Only blinded RCTs! 14 studies, participants 70% male, EPA & DHA dose g/d No risk reduction of cardiovascular events in secondary prevention. Source: Kwak SM, Myung SK, Lee YJ et al. (2012)

13 Fish, omega 3 and CVD - summary Population studies suggest that fish has a protective effect on risk of heart disease, and to a lesser extent stroke Where an effect of oily fish but not of white fish was shown could this be due to other reasons than simply the difference in LC n-3 PUFA content? There is uncertainty as to whether omega 3 supplements protect against deaths from CVD (secondary prevention) The beneficial effect of fish may be due to other components or from replacement of other foods in the diet with a less beneficial effect on cardiovascular health (e.g. foods that are high in saturated fatty acids)

14 Fish overweight and obesity Dietary patterns that typically include good amounts of fish, (e.g. Mediterranean diet) are associated with lower risk Few RCTs have shown long chain omega-3 supplements to reduce fat mass One RCT found supplements to lead to a greater weight loss and a fall in waist circumference compared to a control group in men but not in women It has been suggested that a shift in fuel metabolism, away from storage and towards oxidation of fat, may be responsible for these findings However, not all studies have demonstrated an effect of long-chain n-3 PUFAs on body composition, and more studies are needed to draw firm conclusions

15 Main findings: diabetes, cancer and atopic disease Type 2 diabetes: Population studies are inconsistent, some even finding fish intake to be associated with higher risk. Overall, no clear evidence. Cancer: Some cohort studies have suggested a protective effect for colorectal cancer but possibly due to lower meat intake by fish eaters. No conclusive evidence to support any association with other types of cancer. Asthma, eczema and other atopic conditions: Some evidence that eating fish during pregnancy reduces risk of atopic conditions in the offspring, particularly for eczema and that fish intake during early childhood reduces risk of atopic conditions but findings inconsistent and no benefit shown with omega 3 supplements.

16 Main findings cognitive function & bone health Cognitive development: DHA is essential for brain function but contaminants (e.g. mercury) can be harmful. Supplementation with long-chain omega-3s during pregnancy or breastfeeding or via formula feeding has not improved cognitive development. But difficult to study. Dementia: Some, but not all, studies have shown higher fish intake, dietary DHA intake and DHA blood levels to be associated with a lower risk of dementia and Alzheimer's disease but RCTs have not found supplements to be prevent cognitive decline. Bone health: Several nutrients in fish may be of benefit but limited evidence as yet

17 Topical nutrients in fish iodine & selenium Urinary iodine concentration in 737 UK schoolgirls, showing mild (50 99 μg/l), moderate (20 49 μg/l), and severe (<20 μg/l) iodine deficiency Severe Moderate Mild Proportion with selenium intakes below LRNI 4-18 yrs Boys Girls yrs Men 65 years or above Women Men Women 12% 25% 25% 52% 31% 54% SACN statement (2013): whilst there is evidence of temporal decline in selenium intake and status in the UK, there is little evidence that the changes are likely to result in adverse health outcomes Vanderpump et al, 2011

18 Vitamin D Average intake among women (19-64y) from dietary sources is 2.6μg/day Oily fish is richest natural source, also found in fortified spreads & breakfast cereals, red meat, egg yolks Low status common in pregnant women (especially in winter) Current UK advice: pregnant and lactating women, infants, young children (and those 65+ years) to supplement diet Additional roles proposed for vitamin D in protecting against diabetes, CVD and some cancers and in optimising immune function Prevalence of vitamin D deficiency in individuals in the UK (25OHD < 25nmol/L) Lanham-New et al 2011

19 To sum up... Fish plays an important role in a healthy diet and its consumption has long been associated with several health benefits It is not clear to what extent long chain n-3 PUFAs (in oily fish) contribute to the beneficial effects of fish consumption on health It is likely that other components of fish e.g. selenium, potassium, vitamin D or B vitamins contribute also? Replaces less healthy foods in the diet Fish is an important source of several nutrients that need to be increased amongst subgroups of the UK population (and elsewhere in Europe)

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