Effect of Fish Consumption on Cardiovascular Risk Factors
Condition: Fish Consumers
Study type: Interventional

Summary: 
      IConsumption of fish provides a vital contribution to the survival and health of a
      significant portion of the world's population. Lipids in fish foods consist mainly of
      long-chain polyunsaturated fatty acids (PUFAs) such as eicosapentaenic acid (EPA, C20:5n-3)
      and docosahexaenoic acid (DHA C22:6n-3) which belongs to the physiologically important group
      of n-3 fatty acids. The increase of unsaturated fatty acids, along with the reduction of
      saturated fats, supports the lowering of blood cholesterol in humans and causes a positive
      impact on human nutrition. Polyunsaturated fatty acids (omega-3 fatty acids) plays a role in
      preventing heart disease and has anti-inflammatory and anti-thrombosis effects and these
      fatty acids cannot be synthesized and they must be obtained through diet. These nutritional
      benefits of fish consumption is mainly attributed to the effect of omega-3 polyunsaturated
      fatty acids , which are thought to have several potential cardio protective actions. This
      research is focused mainly identify highly consumed food fishes available in Batticaloa
      district( fresh, lagoon and sea water ) and their consumption pattern (cooking methods) of
      local community and by cardiovascular patients (CV) . Secondly Omega-3- Polyunsaturated fatty
      acid (PUFA) and tocopherol content (Vit E) in the fresh fish and dried or smoked fish of the
      highly consumed food fishes would be assessed and the relationship between fish consumption
      and its PUFA and Vit E content would be known. Also research will focus how lifestyle,
      socio-demographic factors' influences on the Cardiovascular diseases among community.
    

Detailed description: 
      1. Introduction

           Consumption of fish provides a vital contribution to the survival and health of a
           significant portion of the world's population. Lipids in fish foods consist mainly of
           long-chain polyunsaturated fatty acids (PUFAs) such as eicosapentaenic acid (EPA,
           C20:5n-3) and docosahexaenoic acid (DHA C22:6n-3) which belongs to the physiologically
           important group of n-3 fatty acids. The increase of unsaturated fatty acids, along with
           the reduction of saturated fats, supports the lowering of blood cholesterol in humans
           and causes a positive impact on human nutrition. Polyunsaturated fatty acids (omega-3
           fatty acids) plays a role in preventing heart disease and has anti-inflammatory and
           anti-thrombosis effects and these fatty acids cannot be synthesized and they must be
           obtained through diet. These nutritional benefits of fish consumption is mainly
           attributed to the effect of omega-3 polyunsaturated fatty acids , which are thought to
           have several potential cardio protective actions. This research is focused mainly
           identify highly consumed food fishes available in Batticaloa district( fresh, lagoon and
           sea water ) and their consumption pattern (cooking methods) of local community and by
           cardiovascular patients (CV) . Secondly Omega-3- Polyunsaturated fatty acid (PUFA) and
           tocopherol content (Vit E) in the fresh fish and dried or smoked fish of the highly
           consumed food fishes would be assessed and the relationship between fish consumption and
           its PUFA and Vit E content would be known. Also research will focus how lifestyle,
           socio-demographic factors' influences on the Cardiovascular diseases among community.

        2. Justification Since the consumption of marine fish have high omega-3 fatty acid and
           showed the reduction of death by CVD, there is no record about the content of omega-3
           fatty acid in fresh and brackish water fishes and effects on consumption of fresh and
           brackish water fishes by South Asian population. Nearly 50 % of population of Sri Lankan
           consume Inland fishes and it is not known the lipids content, omega-3- fatty acids and
           tocopherol in muscle of these fishes. This would be first study to understand the
           content of type of lipids , omega-3 fatty acids, tocopherol and the relationship with
           fish consumption and CVD. This research will identify the formula of cooking and
           consumption method of fish.

        3. Over all Objectives i) Identification of highly consumed food fish varieties (fresh,
           marine and lagoon) in the district and consumption rate.

           iii) Quantifying the Omega-3 -Polyunsaturated fatty acid and Tocopherol content of flesh
           of selected highly consumed fishes.

           iv) Compare the lipid profile of the randomly selected CVD patients and apparently
           healthy subjects and to relate it to PUFAs content of fish v) Assess all the factors
           related with fish consumption and CVD and to finding a new method of consumption of
           fish.

        4. Literature Review Consumption of fish provides an important nutrient for 135 billions of
           people worldwide and thus makes a very significant contribution to nutrients (FAO,
           2010). Fish consists of polyunsaturated fatty acids in the form of arachidonic acid,
           eicosapentaenoic acid and docosahexaenoic acid (Kinsella et al.1990). Marine species
           have high level of PUFAs and those species are less likely consuming by the poor and low
           income people. And Small pelagic forage fish species have rich PUFAS and they are
           cheaper and preferably consumed by them (Tacon and Metain, 2009). Increasing consumption
           of omega-3 fatty acid can benefit health by reducing Cardiovascular diseases (Udani and
           Ritz, 2013). Kinsella (2005) reported that the increase of unsaturated fatty acids along
           with the reduction of saturated fats , supports the lowering of blood cholesterol in
           humans. Din et al., ( 2004) stated that the fish consumption were mainly attributed to
           the effect of omega-3 polyunsaturated fatty acids which are thought to have several
           potential cardio protective actions. It was observed that Greenland Eskimos exhibited
           significantly lower rates of mortality from coronary heart disease (CHD) compared to
           Danes due to high intake of fish which are rich of omega -3 PUFAs (Menotti et al, 1999
           Heidel et al ., 2007). However, Coronary heart disease is still the leading cause of
           death and disability in the world. Well known risk factors for heart diseases include
           age, sex, smoking, diet, physical inactivity, high blood pressure, diabetes and high
           cholesterol level and some more factors associated such as life style, social class,
           income and occupational factors comprising job stress, combustion products and
           environmental factors (Yasunori Suematsu et al,2013). The consumption of fish and fish
           products is recommended as a means of preventing cardiovascular diseases and greatly
           increased over recent decades in many European countries (Cahu et al .,2004).
           Modification in the fatty acids profiles by different culinary technologies in cooking
           fish for consumption alters the nutritive value of final product is major importance of
           human health. Therefore, the fatty acids profile in fish varied with fresh, processed
           and cooked form(Garcia-Arias et al., 1998).

           In Sri Lanka, as per the 2011 health ranking report 11.69% of total population death
           reported due to Coronary heart disease and 7.41% hypertension.Some Nutritionally
           important fatty acids in seven type of fishes eaten in Sri Lanka has been studied
           (Liyanage et al., 1989). And the fish consumption behaviors is determined by many
           factors (Pethiyagoda and Olsen, 2012). . Some nutritionally important fatty acids in
           seven varieties of fish eaten in Sri Lanka has been studied (Liyanage, et al., 1989) and
           the fish consumption behaviour is determined by many factors ( Pethiyagoda and Olsen,
           2012). The peroximate composition of three species of Scomberoides fish from the Sri
           Lankan waters was done by (Sutharsiniy and Sivashanthy, 2011b) and stated Scomberoid
           commonsonianus is good diatetic species. The total lipid and cholesterol content of the
           five commercial important fish species has been assessed by the ((Sutharsiniy and
           Sivashanthy, 2011a). Wimalasena and Jayasuriya ( 1996) studied the nutritional analysis
           of some freshwater fishes in Sri Lanka

        5. Methodology 5.1. Study Design Annexure I

           . 5.2.Hypothesis of study Omega-3- fatty acid (PUFAs) and Tocopherol content in fish
           flesh are high in inland fishes and it prevents CVD diseases as per the interview from
           the fish eating people.. However, there are many factors such as life style and
           socio-demographic factors and eating methods of fish will be taken into our study since
           those are influencing factors of CVD and the Lipid profile of CVD patients and non- CVD
           people will be compared with fish consumption. This research is justified as a first
           study in Sri Lanka to understand the relationship of fish consumption and its pattern in
           naïve and CVD from Eastern Sri Lankan Community 5.3.Study Area

           Study is carried out in Batticaloa District from Vakarai to Kalar.

           5.4. Study Setting

           Study has been planned to collect the information from fish consuming people in the
           Batticaloa district randomly representing different ethnicity and religion by
           distributing structured questionnairre.

           5.5. Study Population

           The one fifth (1/5- 2500) of total population in Batticaloa district who consume fish
           and shellfish as their major proteinous diet will be the subjects of study. In addition,
           a special focus on the people (250) who have cardiovascular diseases who engaged in
           treatment.

           5.6. Sampling method

           The selection of subjects for survey will be done by stratified random sampling with
           consideration of population of divisional secretariat (14) proportionately whole in
           Batticaloa District. A special focus in the selection of subjects in three DS
           secretariat ( Manmunai West, KoraliPattu South and Porathivu Pattu).

           Semi-Structured Questionnaire will be used to gather the data with their full permission
           of subjects.

           Experimental Method- Observation and Analytical Method

           Total fat content and Lipid profile of mostly consuming fishes( muscle) by the subjects
           ( 10) in fresh , processed and cooked form will be taken for analysis in (triplicates)
           using standard method. (Annexure2) Omega-3 fatty acids and tocopherol content
           (triplicates) will be measured from the same set of fishes. Both analytical methods will
           be carried out in ITI laboratory in Colombo .

           Lipid Profile of Naïve fish consuming people (as control) and People who are suffering
           CVD diseases will be measured and primary data of demographics, history and lifestyle of
           the subjects will be studied (. Annexure 2 )

           5.6. Inclusive Criteria People (subjects) must be regular fish consumer and mostly
           brackish and fresh water consumers.

           5.7. Study Period 3 years study starting from Dec 2013 upto Nov 2016.

           5.8. Materials Used Annexure 2

           5.9. Data Collection

           It will be done by three ways: structured questionnaire, primary data, secondary data,
           direct interview, Observation data- Market Survey Analytical data- Total lipid content
           in fish, Fatty acid content in fish, Omega three fatty acid and tocopherol Lipid profile
           of naïve regular fish consuming people (250) and CVD people who are engaged in treatment
           .

           Lipid profile for selected subjects (naïve) after 6 month of fish consumption lipid
           profile will be tested.

           Blood (2ml) will be collected from the subjects for the lipid profile analysis with
           their consent.

           ( This procedure will be done once the ethical clearance certificate issued)

           5.10 Data Analysis SPSS -19 package , EXCEL and SAS ( if needed) for ranking will be
           used.

           5.11. Study Sensitization This study will reveal the different fatty acids in fish and
           the content and these will not be sensitized issue. Since lipid profile of naïve human
           and CVD people will be treated confidentially and data will be treated same and after
           research . All data will be destroyed.

           5.12. Consent Statement- Annexure 3

           5.13. Confidentiality Statement Annexure 3

           5.14. Work Plan Annexure 4

           Annexure 2 Phase I This survey will be specially focused on the relationship between
           consumption of fish /food and its preference of quality, the impact of consumer
           involvement, role of life styles, experience and habit, quantity intake, time of
           consumption, socio-demographic characteristics, health and diet beliefs and convenience.
           It would be done among one in 500 people of total population(525142). That is nearly
           1500.

           Of the randomly selected people of fish consumers , nearly 250 people (male & female),
           aged between 35 to 50 who are engaging in treatment for Cardiac vascular disease (CVD) ,
           hypertension and stroke in three different national hospitals in Eastern Province. The
           daily fish consumption data, type of fish, amount of fish consumption in three times
           will be assessed during health survey among patients. During the survey fish eating
           frequency, cooking method, special ingredients used to cook fish , how many minutes they
           cooked fish, and processing technique will be interviewed.

           Phase II By doing Market survey (nearly 5 city markets and 5 local markets) the major
           food fishes would be identified taxonomically and fish consumption rate will be
           calculated.

           Phase III The total fat content subjected to the study will be extracted according to
           the Soxhlet protocol (ADAC,1995 ) from the flesh of 10 highly consumed fishes. Total
           lipid extraction was made with chloroform methanol (2:1) and according to Folich et al
           ,.(1957) methodology modified by Bligh and Dyer (1959). Fatty acid methyl esters (FAME)
           will be prepared with methanol using BF3 -MeoH complex, as catalyst, according to the
           method of Metcalfe et al (1966). Omega-3 fatty acid of the highly consumed fresh, cooked
           and dried fish muscle would be analyzed using Gas Liquid Chromatography and the
           tocopherol content will be analyzed using High Performance Liquid Chromatography (HPLC).
           These would be correlated with consumer preference of fish and CVD. The omega-3 -PUFA
           and Tocopherol content of all samples would be analyzed at same time. Sample of ten
           selected highly consumed fish species will be taken for this study. Lipid profile of
           randomly selected (50) CVD patients who will be selected with the help of the Batticaloa
           cardiology unit will be taken in our study and it will be monitored monthly for five
           months.

           Phase IV The correlation between the fish consumption and the cooking methods and life
           style of the community and Cardiovascular diseases in the Eastern Community will be
           analyzed.

           Phase V The nutritional composition of identified of selected highly consumed fish and
           existing cooking method would be studied and new method of cooking style formulated and
           would be tested and will be introduced among consumers.
    

Intervention name(s): Fish consumption and lipid profiles
Intervention type(s): Other
Allocation: Non-Randomized
Intervention model: Single Group Assignment
Intervention model description: Quasi Experimental / non-randomised trial
Masking: None (Open Label)
Primary purpose: Supportive Care
Keywords: Fish Consumption, Fatty acid composition, Lipid Profile, Tocopherol, Sociodemographics