Pescatarian Diet:

The Effect of Fish Consumption

on Cardiovascular Disease
By: Madeline Waters

Outline
Define: What is a Pescatarian diet?
Explore Scientific Studies Focused on:
Vegetarian Diet, Omega-3 Fatty Acids, and
Fish Consumption
Conclude
Practical Application
Future Direction
Questions

What is a Pescatarian Diet?

A type of vegetarian diet
Plant-based diet that includes freshwater and
saltwater fish in addition to the whole grains,
fruits, vegetables, legumes, eggs, and dairy
that vegetarians typically consume
Heart healthy diet because it provides both
plant-based benefits along with marinederived benefits
Fish is a source of marine-derived fatty acids EPA
and DHA that are not sufficient in vegetarian
diets

To get a better understanding

A vegetarian diet (without fish) has has

proven to be heart healthy
Many studies have proven the health benefits
Lower BMI, lower serum LDLC, lower blood
pressure, lower risk of diabetes vs.
nonvegetarians
Note that the benefits target risk factors of CVD
Logical to assume that vegetarians risk for CVD
would be lower than nonvegetarians due to
decreased risk factors
Studies support this logic.

Vegetarian Diet
Crowe, FL, Appleby PN, Travis RC, Key TJ. Risk of
hospitalization or death from ischemic heart disease among
British vegetarians and nonvegetarians: results from the
EPIC-Oxford cohort study. The American Journal of Clinical
Nutrition. 2013. 97(3): 597-603.
Objective: to analyze the relationship between a vegetarian
diet with the risk of incident fatal and nonfatal ischemic heart
disease
Subjects: total of 44,561 men and women living in England &
Scotland
FFQ estimated intake of food over the past 12 months
Height, weight, smoking, exercise, & education data gathered
Cholesterol and blood pressure measurements taken

Vegetarian Diet
Outcome: after 12 years, 1235 cases of IHD
Adjusted for age and sex, total cholesterol
and blood pressure were significantly
lower in vegetarians vs nonvegetarians
Non-HDL cholesterol concentrations were
0.45 mmol/L lower (95%CI: 0:30, 0.60)
Systolic blood pressure was 3.3 mm Hg lower
(95% CI: 0.7, 5.9)

Vegetarians have 1/3 lower risk of heart disease

Vegetarians had a 32% lower risk of IHD

than nonvegetarians due to lower
cholesterol and blood pressure (HR:0.68;
95%CI: 0.58, 0.81)
Better lipid profile of vegetarians
attributed to higher ratio of PUFA:SFA in
the diet and an overall lower BMI.

Vegetarians have 1/3 lower risk of heart disease

Conclusion:
Vegetarianism can reduce the risk of heart
disease by up to 1/3.
The difference in heart disease risk between
vegetarians and nonvegetarians was attributed
to dietary effects on cholesterol and blood
pressure, which are well-established risk
factors for CVD.

 This study was of great importance to my

paper because it exemplifies the power of a
vegetarian diet on heart health without the
benefits of marine-derived EPA and DHA

Take the health benefits a step further.

Fish consumption has proven heart

health benefits
Add fish to a vegetarian diet =
Pescatarian diet
Pescatarian diet = health benefits of
vegetarian diet AND added heart health
benefits of marine derived EPA & DHA

The Importance of EPA and DHA

Marine derived EPA and DHA have great
significance in controlling cardiovascular
related events due to their anti-arrhythmic
effects.

What role do omega-3 fatty acids

play in heart disease prevention?
Mozaffarian D, Lemaitre RN, King IB, et al. Circulating long-chain n-3 fatty acids and
incidence of congestive heart failure in older adults: the cardiovascular health study: a
cohort study. Ann Intern Med. 2011; 155(3): 160-170.

Study: Prospective cohort study 1992-2006

Objective: to examine the relationship between seafood-derived
long-chain omega-3 polyunsaturated fatty acids and congestive
heart failure
Subjects: 2753 adults free of heart disease in the United States
Methods: Plasma phospholipid levels and other CVD risk factors
were measured via blood samples and the relationship with
congestive heart failure was analyzed

 Analysis and Results:

After multivariable adjustment, EPA was
associated with 50% lower risk in the highest
quartile (1.18 g EPA) versus lowest quartile
(0.25 g EPA).
[HR (95% CI) = 0.52 (0.38-0.72) P-trend=0.001]

Further analysis censored 7 years follow

up
EPA was associated with 52% risk reduction,
DHA with 36% risk reduction , and total n-3
fatty acids were associated with 49% risk
reduction for CHF

 Conclusion: Circulating individual and

total n-3 fatty acids were indeed associated
with lower incidence of congestive heart
failure in older adults.
This study exemplifies the importance of
n-3 fatty acids in decreasing the risk of
heart disease.

Higher EPA levels

associated with lower
risk of Congestive
Heart Failure

Serving size? Type of fish?

Now that the heart health benefits of EPA
and DHA are well-established.need to
translate this into dietary
recommendations
Increasing omega-3 fatty acids in the diet
through food rather than supplement is
preferred
Studies focused on the serving size and
type of fish:

Serving Size
Goede J, Geleinjnse J, Boer J, Kromhout D, Verschuren W.M.
Marine (n-3) fatty acids, fish consumption, and the 10-year risk of
fatal and nonfatal coronary heart disease in a large population of
Dutch adults with low fish intake. The Journal of Nutrition. 2010.
140(5): 1023-1028.
A large population of 21,342 participants aged 20-65 years old with
no history of myocardial infarction or stroke were studied to assess
the dose-relationship between EPA, DHA, and fish intake on
coronary heart disease and nonfatal myocardial infarction.
Using dietary assessment questionnaire, mortality data, covariates,
and hazard ratios:
The median intakes in quartiles of EPA and DHA were 40 mg/d, 84 mg/
d, 151 mg/d, 234 mg/d.
Medians of fish consumption in quartiles were 1.1 g/d, 4.2 g/d, 10.7 g/d,
and 17.3 g/d.

Serving Size
Results seen in a 9-14 year follow up
analysis revealed that the lowest quartile
compared to the highest quartile, top
quartile participants had a 49% lower risk
of fatal CHD and 62% lower risk of fatal
MI due to EPA and DHA.
Conclusion: Fish intake may lower the risk
for fatal CHD and MI due to EPA and
DHA.

Serving Size: 250 mg

EPA/DHA per day
Agrees with the current DG:
2 servings per week = 8 oz. = average
consumption of 250 mg EPA/DHA per
day
Note the 62% lower risk of fatal MI was
attributed to 234 mg/d EPA/DHA

Type of fish?
Mozaffarian D, Pstay BM, Rimm EB, Lemaitre
RN, Burke, GL, et al. Fish Intake and Risk of
Incident Atrial Fibrillation. Circulation. 2004.
110(4): 368-373.

Prospective study: Focused on the

relationship between fish intake, atrial
fibrillation, and the type of fish.

Fatty Fish vs. Lean Fish

24% lower risk of AF with tuna/other fish intake 1-3 times
per month (HR=0.76, 95% CI=0.61 to 0.95, P=0.02)
30% lower risk of AF with intake 1-4 times per week
(HR=0.70, 95% CI=0.57 to 0.87, P=0.001)
Further 35% lower risk with intake >5 times per week
compared to less than one time per month (HR=0.65, 95%
CI=0.51 to 0.84, P=0.001).
Fried fish/fish sandwich consumption of greater than
once per week was associated with a 24% higher risk of atrial
fibrillation (HR=1.24, 95% CI= 1.03 to 1.49 P=0.03).

Fatty Fish vs. Lean Fish

There was not a lower risk of AF observed with fried
fish or fish sandwiches because these are made with
lean fish that do not supply n-3 fatty acids.
Fried fish and fish sandwiches were linked to an
increase risk of AF.
Could be a result of other lifestyle or dietary factors such as
increase in saturated fat, increase in meat consumption,
etc.
Additionally, the frying preparation method of the fish also
alters the nutrient composition increasing the n-6 fatty
acids, trans-fatty acids, and oxidation products when the
same oils are continuously used for frying foods.

Choose Fatty Fish for Heart

Health Benefits
Despite these alternative explanations, the study
concluded that the findings suggest that intake of
fried fish or fish sandwiches are unlikely to reduce
the risk of AF
Bottom line: For optimal heart healthy benefits
provided by fish, consumers must choose fatty fish
sources of n-3 fatty acids rather than lean fish
Sources of fatty fish high in omega-3s:
Salmon
Albacore Tuna
Lake Trout

Conclusion
Differences in all studies set aside, studies agree
that the more EPA+DHA consumed the better the
outcome on heart health
Due to these findings
2010 Dietary Guidelines were the first to recommend
increasing seafood in the diet to 8 oz. per week
2015 Dietary Guidelines recommend 8 oz.per week of
a variety of seafood, which provides an average
consumption of 250 mg per day of EPA and DHA
AHA recommends at least 2 servings of baked or
grilled fish each week, especially oily fish

Conclusion
Americans currently are consuming 100 mg of
EPA and DHA, which translates to 1 serving
per week rather than the recommended 2
servings
Most Americans eat fish less than once per
week or do not consume fish at all
There is a need to educate the public on the
importance of fish and EPA and DHA
consumption for heart health

Practical Application
Educate on diets such as pescatarian style diet for optimal disease
protection: whole grains, fruits, vegetables, legumes, fatty fish
Howeveralso be realistic: It is not likely that the average American is
going to want to follow a pescatarian style diet
Rather, focusing on increasing fish in diet will improve heart health

Shift the protein food groups to increase seafood intake to at least 8 oz.
per week
Choose seafood in place of meat, poultry for meals

Address concerns on fish contaminants: Explain that contaminants can

be avoided by choosing seafood that is low in mercury. Explain that by
choosing fatty fish low in mercury they are choosing safe sources of
heart healthy n-3 fatty acids

Future Direction
Progress is being made towards providing education
on vegetarian-style diets
2010 DG developed a vegetarian adaptation of the Food
Patterns to provide guidance for consumers wishing to
follow a vegetarian diet
2015 DG developed a new Healthy Vegetarian Food
Pattern based on food intakes of vegetarians

More research exemplifying the overall health benefits

of specifically a pescatarian diet
The pescatarian diet could serve as a promising diet in
terms of disease prevention with the added benefits of
heart health due to EPA+DHA, therefore it should be of
focus for future studies.

Questions?