**6. Diet, nutrition, and VTE**

Considering the pathogenesis of cancer-associated VTE described in the previous section, it is unlikely that certain diets and nutrition can suppress the development of cancer-associated VTE specifically. Then, are there any diets and nutrition which may prevent the development of VTE in general, not just cancer-associated? The association between diet and nutrition and thrombosis has not necessarily been well analyzed for VTE, but it has been well analyzed for arterial thrombosis such as ischemic heart disease or cerebral infarction. In 2010, the American College of Cardiology announced seven lifestyles to reduce deaths caused by cardiovascular and cerebral infarction by 20% by 2020: (1) nonsmoking, (2) body mass index <25 kg/m2 , (3) physical activity at goal levels, (4) pursuit of a diet consistent with the current guideline recommendations, (5) untreated total cholesterol <200 mg/dL, (6) untreated blood pressure < 120/<80 mm Hg, and (7) fasting blood glucose <100 mg/dL [39]. Do these lifestyles also reduce the incidence of VTE? Hypertension, hypercholesterolemia, diabetes (these are related to diet and nutrition), and smoking are risk factors for atherosclerotic cardiovascular disease, and meta-analysis of nine clinical trials revealed that only smoking is a risk factor for VTE among them [40]. These results suggest that diets and nutrition to prevent arterial thrombosis are not necessarily effective for VTE prevention. On the other hand, obesity, one of the risk factors for arterial thrombosis, is also known to be one of the risk factors for the development of VTE. Analysis of the association between 95 BMI-related gene polymorphisms and VTE development proves that five of the polymorphisms are associated with VTE development [41]. Therefore, taking a diet without too much calories or carbohydrates to maintain proper body weight is considered to be useful for VTE prevention.

Other reports examining the relationship between diet and nutrition and VTE are as follow. The incidence of VTE is 22% lower for those who eat fish three or more times a week than for those who eat twice or less a week [42] and is low for those who eat enough fish, vegetables, and fruits and eat less red meat and processed meat [43]. These reports suggest that diets to prevent arterial

thrombosis might also be useful to prevent VTE. Furthermore, consumption of grape suppresses thrombin generation and enhances fibrinolysis [44]. Diets with 20, 30, and 50% of their calories on protein, lipids, and carbohydrates for 12 months result in reduction of abdominal circumference, increased HDL-C, decreased fibrinogen, and significantly increased interleukin-10 in those with metabolic syndrome [45]. These reports suggest that diet and nutrition might directly affect the blood coagulation and fibrinolysis which play an important role in the development of VTE.

Several reports related to the alcohol consumption and VTE have also been published. Women consuming alcohol daily were at 26% lower risk of VTE than non-consumers [46], and the analysis of three large US cohorts showed no evidence of an association of alcohol consumption amount or frequency with PE risk [47]. These findings suggest that alcohol drinking is not a risk factor for VTE.
