Post on 30-Mar-2015
CLINICAL AND METABOLIC EFFECTS OF ALTERING
OMEGA-3 AND OMEGA-6 FATTY ACIDS IN MIGRAINE
February 21, 2014
Doug Mann, MD, Professor of Neurology
University of North Carolina, Chapel Hill
Outline
• Specific Aims
• Rationale for testing dietary modification for chronic pain
• Preliminary studies: Basic hypotheses, Chronic Daily Headache study, results from animal studies
• Molecular mechanisms linking endogenously-produced lipid mediators to physical pain
• Current R01 : study design, questions.
Studies of Diet and Chronic Pain at UNC, Program on Integrative Medicine
1.) Closed to enrollment – Chronic Daily Headache (CDH) funded by
Mayday Fund 2011- 2013. Ongoing data analysis outcomes. 2.) Starting - RO1 funded Sept 2013.
Episodic Migraine (EM) and diet --- 3 arms. 153 subjects.3.) Pending Review - Post traumatic headache in soldiers --- 3 arms.
SPECIFIC AIMS: R01 MIGRAINE STUDY
Clinical and metabolic effects of altering
omega-3 and omega-6 fatty acids in migraine
Study Purpose
To assess whether:
targeted PUFA modifications designed to increase dietary n-3 EPA and DHA, with or without concurrent reduction in n-6 LA, can increase analgesic derivatives of n-3 EPA and DHA, and improve headache-related clinical outcomes.
Specific Aim 1
• To assess the efficacy of the dietary interventions in inducing the predicted changes in circulating PUFA endovanilloid derivatives. • (1a) Compared to Diet C, Diet A will produce significant
increases in analgesic derivatives of n-3 EPA and DHA and reductions in pro-nociceptive n-6 AA-derived and LA-derived endovanilloids.
• (1b) Diet B (High n-3, High n-6 LA) will result in values for analgesic derivatives of n-3 EPA and DHA intermediate between Diet A and Diet C.
Specific Aim 2
• To compare the clinical efficacy of the dietary interventions in adults with migraine.
• Compared to Diet C, Diet A will produce significant improvement in: • (2a) the Headache Impact Test—a headache-specific
quality of life measure, and• (2b) a significantly steeper rate of decrease in
headache hours per day as compared with Diet C. • (2c) Diet B will result in changes in clinical outcomes
intermediate between Diet A and Diet C.
Specific Aim 3• To test our model of the proposed causal chain linking
changes in n-3 and n-6 PUFAs, endovanilloid derivatives, and HA endpoints.
RATIONALEClinical and metabolic
effects of altering omega-3 and omega-6 fatty acids
in migraine
Rationale
• Migraine common (16% women, 7% men)• Debilitating, painful, costly, life-impacting• Good abortive therapies (cost & side effects)• Preventive therapies overall somewhat disappointing
• Timing ideal for a new strategy
Rationale: food and headache
• Traditional consensus with limited evidence beyond patient reports. • Neurotransmitter precursors in red wine, aged cheese,
pickled foods, processed meats, other.• Allergies – gluten, dairy.• Allergy testing for specific foods. • Patient reports of specific food triggers: citrus,
aspartame, caffeine, eggs, breads, other. • Elimination diet (chicken and rice) with add-backs
Rationale: other potential dietary influences
• Magnesium intake as a daily supplement is effective in some with EM. No predictive elements except menses. No dietary studies.
• Riboflavin as a daily supplement is effective – replicated outcomes in EM. No dietary studies.
• Alpha-lipoic acid – weak clinical evidence of effectiveness in EM. No dietary studies.
Migraine Co-Morbidities• Obesity --- headache (inflammation) • Crohn’s disease --- migraine • Ulcerative colitis --- migraine• Irritable bowel syndrome (Aydinlar, 2013)• Omega-6 FA consumption• Gastrointestinal symptoms
• Nausea, diarrhea, cramping, bloating, pain
Headache and Fatty Acids
• One prior study of Omega-3 FA supplements in migraine (Pradlier, 2001)• Negative clinical, migraine-related outcomes. • Minimally affected group (average < 3 migraines/month)• No confirmation of compliance, no biomarkers• No biochemical outcomes• No consideration of diet and ratios of omega-3 to
omega-6 FA intake.• Active intervention for 16 weeks• 196 subjects (96 intervention, 87 placebo) • Strong placebo effect
Omega-6 Consumption 1950 to 2000
Polyunsaturated Fats in U.S. Diets 2008
Linoleic AcidAlpha Linolenic AcidArachidonic AcidEPA+DHA
n-3 ALA
Estimated from Day 1 of 24-hour dietary recall interviews conducted in What We Eat In America, NHANES 2007-8
n-6 LA
n-6 AAn-3 EPA+DHA
7 % of energy
US per capita consumption of vegetable oils in the 20th century
Blasbalg et al AJCN 2011
kg/
p/y
0
2
4
6
8
10
12
14
Canola0.9
Year
Palm
Peanut
Safflower
SesameSunflower
0.10.20.30.40.50.60.70.8
1909
1919
1929
1939
1949
1959
1969
1979
1989
1999
Coconut
CornCottonseed
Olive
SoybeanLinoleic Acid
US per capita apparent consumption of n-6 LA and n-3 ALA in the 20th century
Blasbalg et al AJCN 2011
LA 2.2
ALA 0.35
n-6 LA
n-3 ALA
Overview: biochemistry of n-3 and n-6 fatty acids
Linoleic Acid
9-HODE
Arachidonic Acid
Prostaglandin E2
Arachidonoyl Ethanolamide
15-HETE
α-Linolenic Acid
9-HOTrE
Eicosapentaenoic Acid
Docosahexaenoic Acid
Resolvin E1
18-HEPE
Docosahexaenoyl Ethanolamide
Protectin D1
EndoVanilloids
Eicosanoids
EndoCannabinoids
EndoVanilloids
Docosanoids/ Protectins
Synaptamide
Essential Dietary Fats and their Bioactive Metabolites
Eicosanoids
13-HODE
EndoCannabinoids
EndoVanilloids
Omega-6 Omega-3
Diet and Physical Pain: Hypotheses
Targeted changes in dietary fatty acids alter tissue fatty acids.
Alters the endogenous production of bioactive lipid mediators
(e.g. eicosanoids, endovanilloids, endocannabinoids, resolvins).
Alters the neurochemical milieu in a manner that mayattenuate physical pain.
General model
Mechanisms linking n-3 & n-6 fatty acids to physical pain
Rationale for targeted
dietary intervention
PRELIMINARY STUDIESClinical and metabolic
effects of altering omega-3 and omega-6 fatty acids
in migraine
Targeted alteration
of dietary n-3 and n-6 fatty acids
for treatment of chronic headaches:
a randomized trial
Ramsden CE, Faurot K, Mann JD et al., Trials 2011, BJN 2012, PAIN 2013
Chronic Daily Headache
• Up to 5% of adults. Migraine - 16 and 6 % • 15 or more headache days per month. • HA for 4 hours or more per headache day.• Six months or more duration. • With or without migraine features. • Excluded “organic causes”. • Medication responses considered in the dx.
Dietary Interventions
• H3-L6 intervention• Increase n-3 EPA and DHA • Reduce n-6 LA
• L6 intervention • Maintain low n-3 EPA and DHA intakes (typical of US)• Reduce n-6 LA and n-6 AA
MacIntosh BA, Ramsden CE et al. BJN 2012
‘Chronic Daily Headache’
Headache characteristics
Chronic migraine
Chronic tension-type headache
15 headache days per month
4 headache hours per day
Ramsden CE, Faurot K, Mann JD et al., Trials 2011
bumpybrains.com
Patient population
Methods
• Adults meeting Inclusions/Exclusions• Provided 2 meals and two snacks per day• We provided all oils and fats• All provided food - biochemical analyses at NIH• Intensive dietary counseling by study dietitian • Guidelines for cooking, shopping, dining out• Baseline phase - 4 weeks; intervention 12 weeks• Visits every 2 weeks during the intervention for dietary
counseling and food pick up, diary review.
Methods• No supplements: requested they not start on them during
the study. • Not given other dietary suggestions relating to
traditional consensus advice re: diet. • If they were on fish oil or PUFAs for headache,
they were excluded. • Web based headache diary
• Continue care with neurologist or other MD.
Methods
• Arm 1. Low omega-6 (L6)• Arm 2. Low omega-6, high omega-3 (L6 H3)
• Both possibly anti-nociceptive• Clinical and biochemical primary endpoints• Multiple secondary outcome measures
Overview of Trial Design
• Randomized, parallel-group clinical trial
L6 intervention
H3-L6 intervention
• Dietitian counseling and food provision every 2 weeks
• Patients continued usual headache care throughout trial
• Headache-related quality-of-life (HIT-6)• Headache days per month • Headache hours per day• Headache medication use • Psychological distress (BSI-18)• Physical and mental function (SF-12)
Clinical Outcomes
• **Erythrocytes (n-6 LA, AA; n-3 EPA, DHA)
Ramsden CE, Mann JD et al., Trials 2011, PAIN 2013
Biochemical Outcomes
• Eicosapentaenoic acid (e.g. 18-HEPE)• Docosahexaenoic acid (e.g. 17-HDHA)• Linoleic acid (e.g. 9- and 13-HODE and -oxoODEs)• Arachidonic acid (e.g. 5-, 8-, 9-, 11-, 12-, 15-HETE)
Circulating fatty acid biosynthetic precursor pools
Anti- and pro-nociceptive n-3 and n-6 metabolites
Trial ProfileAssessed for eligibilityTotal Screened: n=211
EnrollmentIneligible(n=144)
Randomized(n=67)
Allocated to L6 intervention(n=34)
Allocated to H3-L6 intervention(n=33)
Discontinued intervention(n=6)
Intention-to-treat AnalysisHIT-6 and Headache Days
(n=34)
Allocation
Follow-Up
Analysis
Discontinued intervention(n=5)
Intention-to-treat AnalysisHIT-6 and Headache Days
(n=33)
Chronic Daily Headache Patient Characteristics
(g)
MacIntosh BA, Ramsden CE, Mann JD et al. BJN 2012
LA, EPA and DHA Consumption in Chronic Daily Headache Trial
*LA intake is expressed as a percentage of daily food energy (%E). Median intakes assessed via six 24-hour dietary recalls administered on non-consecutive days.
Diets altered erythrocyte fatty acid content in a manner predicted to reduce physical pain
Ramsden CE, Mann JD et al., Trials 2011, PAIN 2013
% c
han
ge
(12
wee
ks)
L6 H3-L6
H3-L6 intervention produced greater pain reduction
HIT-6Headache days/
month
-50
-40
-30
-20
-10
0
Headache hours/day
Severe Headache
days
Between-group comparisons p<.001 p<.02 p<.01 p<.02
P-diff = 0.01
Headache hours per day by diet group
Ramsden CE, Mann JD et al., Trials 2011, PAIN 2013
Was clinical improvement due to increased medication use?
Change in medication use by diet group
Clinical effects of the H3-L6 and L6 interventions on SF 12
H3-L6 Phys-ical
H3-L6 Men-tal
L6 Physical L6 Mental
Base-line
43 47.5 44.8 43.8
12 weeks
49.7 51.7 45.9 47.2
27.532.537.542.547.552.557.562.5
Ramsden, Faurot, Mann et al, unpublished
self-
repo
rted
hea
lth*
0 20 40 60 80
2.4
2.6
2.8
3.0
days since randomization
Daily ratings of general health
Group difference p-value = 0.03**
H3L6
L6
* 1= poor; 4= excellent ** Proportional odds longitudinal model, group x time interaction
Clinical effects of the H3-L6 and L6 interventionson psychological distress (BSI-18)
Ramsden, Faurot, Mann et al, unpublished
Ge
ne
ral
So
ma
tiza
tio
n
An
xie
ty
De
pre
ss
ion
Ge
ne
ral
So
ma
tiza
tio
n
An
xie
ty
De
pre
ss
ion
H3-L6 L6
59
60
61
62
63
64
65
66
67
68
69
Baseline12 weeks
Diet-induced changes in anti- and pro-nociceptive lipid mediators
Results Summary
The H3-L6 intervention:
Produced marked alterations in circulating n-3 and n-6 derived: Endovanilloids
EicosanoidsResolvin pathway precursors – to be analyzedEndocannabinoids** to be analyzed
Produced statistically significant, clinically relevant improvements in:
Headache hours per daySevere headache days
Quality of lifePhysical functionEmotional distress
Limitations
• Small trial• Changes in fatty acids not independent• No true control group• Mediators still unclear• Used only blood tissues—unable to determine if other
pertinent tissues changed
Potential mechanisms responsible for pain reduction
Attenuation of
TRPV1 hyper-activation
Anti-nociception
TRPV1-mediated neurogenic inflammatory cascade
Substance P
CGRP
TRPV1
Physical Pain Anxiety
Alcohol Craving
NK1 Recepto
r
Physical Pain
VasodilationTolerance
Dependence Withdrawal
CGRP Recept
or
pH
Heat
+
-
Endogenous vanilloid agonists
Endogenous vanilloid inhibitors
Linoleic Acid
9-HODE
Oxidized Linoleic Acid Metabolites are TRPV1 Agonists
13-HODE
9-oxo-ODE 13-oxo-ODE
D-series resolvins and NPD1 inhibit TRPV1 activation
Docosahexaenoic Acid
Resolvin D2
Protectin D1
17-hydroxy-DHA
7 (S) Maresin 1
14-hydroxy-DHA
Endovanilloids and the neurochemistry of pain
Can diet alter endovanilloids in key ‘pain tissues’?
Diet-induced changes in anti- and pro-nociceptive lipid mediators in circulation
Summary & Conclusions
Targeted dietary manipulation of n-3 and n-6 fatty acids: • Reduced pain and improved quality of life in
chronic headache
• Could represent a novel strategy for treating chronic pain in general
• Future trials evaluating clinical efficacy and elucidating biochemical mechanisms in chronic pain are warranted
Future Directions
9-HODE 13-HODE
CO
X/L
OX
15-L
OX
-1
MaR1
14-HDoHE
12
-LO
X
15-LOX
NPD1
17-HDoHE
RvD1
RvD2RvD3
RvD4
LA
PGE2
COX1/2
5-LO
X
5-HETE
LTB4
12-LOX
15-LOX-2
15-HETE
LXA4 & LXB4
5-L
OX
TXB2
AA
DHA
EPA
RvE1
18-HEPECOX2/CYP
5-
LO
X
RvE2
12-HETE
5-L
OX
EH
5-LOX
12-LOX
15
-LO
X-1
9-OxoODE 13-OxoODE
PGD2
PGF2α
20-OH-LTB4
20-COOH-LTB4
5,15-DiHETE
12-L
OX
5-HEPE12-HEPE
5-L
OX
15-HEPE
15-
LOX
RvD5RvD6
5-LOX4-HDoHE
7-HDoHE
PGE3
COX1/2
TXB3
PGD3
PGF3α
CYP
LXA5 & LXB5
5,15-DiHEPE
RvE3
12/1
5-
LOX
8-HETE9-HETE11-HETE
Ramsden, Rapoport, Yuan, RemaleyIndicates mediators assayed for Chronic Daily Headache trial
NIH Clinical Center LC/MS/MS assay for lipid mediators of nociception
DESIGN OF R01 TRIAL: DIET AND MIGRAINE
Clinical and metabolic effects of altering
omega-3 and omega-6 fatty acids in migraine
Three arm trial• ARM 1: Diet A—High n-3 EPA+DHA, Low n-6 LA
• ARM 2: Diet B—High n-3 EPA+DHA, High n-6 LA
• ARM 3: Diet C—Low n-3 EPA+DHA, High n-6 LA (average U.S. intake; control group)
Overview of Trial Design
• Randomized, parallel-group clinical trial
• Dietitian counseling and food provision every 2-3 weeks
• Patients continue usual headache care throughout trial
Randomization,Blood Collection
Study End,Blood Collection
6 wk f/u,
Blood Collection
H3 – L6 intervention
Baseline Phase
H3 – H6 intervention
L3 – H6 control
4 weeks 16 weeks 6 weeks
Fatty Acid Targets
Main diet changes to achieve nutrient targets:• Replace all oils, spreads and salad dressings with those provided by the study• Avoid processed foods that contain oils. Replace with foods provided by the
study• Consume study provided fish daily (or consume low fat meat, fish and poultry on
Control)
Fat Low n-6, high n-3
Ave n-6, high n-3
Ave n-6, Ave n-3 (Control)
Total Fat (%en) 30% 30% 30%
Monounsaturated (%en) 15% 12% 12%
Polyunsaturated (%en) 4% 7.5% 7.5%
Saturated Fat (%en) 11% 11% 11%
Linoleic acid (n-6) (%en) 2% 7.2% 7.2%
EPA + DHA (mg) 1500 1500 150
16-Wk Diet Intervention, 6-Wk f/u• Personalized nutrition counseling–9 sessions• Food provision -prepared and
unprepared foods• Diet education materials• Diet website• Seven day meal plan• Self-monitoring• 24-hr dietary recalls
• baseline, intervention, post-intervention
Diet Methods Paper: MacIntosh BA, Ramsden CE, Raurot KR, Zamora D, Mangan M, Hibbeln JR, Mann JD. Low n-6 and low n-6 plus high n-3 diets for use in clinical research. Br J Nutr. 2013 Jan 18:1-10
Meal Plan Comparisons
Measures-Clinical (in addition to daily diary)
Baseline
Wk 0
Wk 4
Wk 10
Wk 16
Wk 22
Demographics X
Headache History/Physical Exam X x
HIT-6 X X X X X X
PROMIS-29 Profile X X X X X X
Comorbid pain assessment X x x x x x
MIDAS X X
Satisfaction with care/diet X X X X X
Periodic Assessment of Care for Headaches and Pregnancy Status
X X X X X
Expectation of Benefit X
Food Preference / Dispensing X X X
Blood draw X X X X X
Measures-BiochemicalAnalyte Formula Method
n-6 fatty acidsLA 18:2 n-6 GCAA 20:4 n-6 GCDTA 22:4 n-6 GCDPA n-6 22:5 n-6 GC n-3 fatty acidsALA 18:3 n-3 GCEPA 20:5 n-3 GCDPA (n-3) 22:5 n-3 GCDHA 22:6 n-3 GCOmega-3 Index EPA + DHA GC Other fatty acidsPalmitic acid 16:0 GCOleic acid 18:1 n-9 GC Precursor
Endovanilloids (LA and AA-derived TRPV1 agonists)9-HODE LA LC/MS/MS13-HODE LA LC/MS/MS9-oxoODE LA LC/MS/MS13-oxoODE LA LC/MS/MS12-HETE AA LC/MS/MS15-HETE AA LC/MS/MS
Measures-Biochemical Endovanilloids (EPA and DHA-derived TRPV1 antagonists)17-hydroxy-DHA (Primary Outcome) -precursor to D-series resolvins
DHA LC/MS/MS
18-HEPE -precursor to E-series resolvins
EPA LC/MS/MS
Endocannabinoids2-AG AA LC/MS/MSAEA AA LC/MS/MS2-DHG DHA LC/MS/MSDHEA DHA LC/MS/MSOEA Oleic acid LC/MS/MSPEA Palmitic acid LC/MS/MS Eicosanoids PGE2 AA LC/MS/MSLTB4 AA LC/MS/MSTXB2 AA LC/MS/MSLipoxin A4 AA LC/MS/MS Other analytesSubstance P N/A ELISACalcitonin gene-related peptide N/A ELISACytokines (IL-1, Il-6, IL-10, TNF, MCP-1) N/A Multiplex-ELISA
References• Ramsden CE, Mann JD, Faurot KR, Lynch C, Imam ST, MacIntosh
BA, Hibbeln JR, Loewke J, Smith S, Coble R, Suchindran C and Gaylord SA. Low omega-6 vs. low omega-6 plus high omega-3 dietary intervention for Chronic Daily Headache: Protocol for a randomized clinical trial. Trials Journal 12: 97-105, 2011.
• MacIntosh BA, Ramsden CE, Faurot KR, Zamora D, Mangan M, Hibbeln JR, Mann JD. Low n-6 and low n-6 plus high n-3 diets for use in clinical research. Br J Nutr. 18: 1-10, 2013.
• Ramsden CE, Ringel A, Feldstein AE, Taha AY, Macintosh BA, Hibbeln JR, Majchrzak- Hong SF, Faurot KR, Rapoport SI, Cheon Y, Chung Y, Berk M, Mann, JD. Lowering dietary linoleic acid reduces bioactive oxidized linoleic acid metabolites in humans. Prostaglandins Leukot Essential Fatty Acids 87: 135-141. 2012.
References continued
• Finkel AG, Yerry, JA, Mann JD. Dietary considerations in migraine management: Does a consistent diet improve migraine? Curr Pain Headache Rep 1: 373-376, 2013.
• Ramsden CE, Faurot KR, Zamora D, Suchindran CM, Macintosh BA, Gaylord S, Ringel A, Hibbeln JR, Feldstein AE, Mori TA, Barden A, Lynch C, Coble R, Mas E, Palsson O, Barrow DA, Mann JD. Targeted alteration of dietary n-3 and n-6 fatty acids for the treatment of chronic headaches: a randomized trial. Pain, 154: 2441-51, 2013.
Acknowledgements
• UNC Program on Integrative Medicine• UNC Dept of Physical Medicine and Rehabilitation• UNC Department of Neurology. • UNC NCCAM T-32 Integrative Medicine Fellowship• Mayday Fund• UNC TraCS• Intramural Program of NIAAA• UNC-Chapel Hill CTSA • UNC NORC• UNC CHAI Core• John M. Davis
AcknowledgementsChris RamsdenDouglas MannKim FaurotBeth MacIntoshC. SuchindranSusan GaylordDaisy ZamoraChanee LynchAngela JohnstonBecky CobleAmit RingelDavid Barrow
Marjorie BusbyOlafur PalssonBeth FowlerCarol CarrTim McCaskillMerit McMannisRegina McCoyGus SwensonMeg Mangan
Joseph R Hibbeln
Sharon Majchrzak-Hong
Jim Loewke
Ariel Feldstein
Alexandros Makriyannis
Jodi Wood
Trevor Mori
Anne Barden
Departments of Physical Medicine & Rehabilitationand Neurology.