DR. ROLLINS: Don’t cast away the fish oil
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Are fish oil supplements not helpful? Reporting in the New England Journal of Medicine last week, Italian researchers came to the conclusion that in a group of patients with existing artery disease, taking fish oil did not lower the risk of a subsequent heart attack. Dr. Eric Topol, M.D., cardiologist at Scripps Institute and editor-in-chief of Medscape, opines, “Fish oil is a no-go.” Have the omega-3 fatty acids found in fish oil lost their luster?
The Risk and Prevention Study Collaborative Group, a collective of Italian researchers led by Maria Carla Roncaglioni, looked at the effect of 1 gram of fish oil versus placebo in more than 12,000 patients with multiple cardiovascular risk factors or atherosclerotic disease. They found no difference in death or hospitalizations from cardiac events. There was an 18% reduction in adverse events in the female subgroup.
Two other recent studies fail to show much support for low doses of fish oil in patients that have already had a heart attack and are on multiple medications. The ALPHA-OMEGA TRIAL used 400mg of fish oil, and the OMEGA study used 1 gram of fish oil, with both studies looking for benefit in well-treated patients after heart attack. The bottom line is that with excellent medical therapy after a heart attack, the risk of a recurrent heart attack is already low and adding fish oil did not lower that risk any further.
TOO LITTLE TOO LATE?
The above studies are good examples of “secondary prevention” trials in which a disease is already present and the study is designed to see if a therapy will lower the chance of the disease progressing. This is in contrast to “primary prevention” studies that look to see if a therapy will prevent a disease from starting in patients that do not yet have the disease.
Adding a low dose of fish oil to patients with existing artery disease is a bit like trying to put out a raging house fire with a garden hose. Obviously, with the garden hose analogy, a small fire would easily be extinguished while it would be of little help with the full-blown house fire. Thus, one could conclude that a garden hose of water does not put out fire. Clearly, it would depend on whether it was a primary or secondary prevention effort.
The dose of fish oil used in the above-mentioned studies is quite low and numerous studies show that higher doses of fish oil are associated with less cardiovascular disease (Singh, 1997; Yokoyama, 2007; Svensson, 2006; von Schacky, 1999).
Still, other secondary prevention studies simply conflict by showing that fish oil does lower the risk of heart disease (Bucher, 2002; Leon, 2008; Zhao, 2009; Marik, 2009). Consider the GISSI-Prevenzione study (a large, randomized, controlled trial) which found that 1,000 mg/day of fish oil in patients with a history of recent myocardial infarction reduced the risk of total mortality by 20% and sudden death by 45%.
We need a primary prevention trial in an average population that examines whether fish oil supplementation will lower the risk of ever-developing artery disease. The VITAL trial is one such study that is looking at the effects of vitamin D or fish oil (1 gram) on multiple outcomes, including risk for diabetes, high blood pressure, cognitive decline and depression, osteoporosis and autoimmune disorders.
ABOUT FISH OIL
Fatty acids called eicosapentanoic acid and docosahexanoic acid, abbreviated EPA and DHA, are the primary health-promoting portion of fish oil, and are found in darker oily fish such as salmon, halibut, anchovies or sardines. They are also found in krill oil. EPA/DHA are made from another fatty acid called alpha-linolenic acid, which is found in flax and hemp seeds. These are the familiar “omega-3” oils.
In the body, DHA plays a key role in development of the brain and retina and may help with nerve transmission. EPA is well documented to lower inflammation, reduce the tendency of blood to clot, and lower the risk of abnormal heart rhythms. It is the “drug of choice” to lower heart disease promoting triglycerides. There is ongoing research teasing out the differences between DHA and EPA.
The American Heart Association recommends eating 2-3 servings per week of fish. Based on the bulk of research showing benefits of fish oil supplements, it has been recommended that we consume 1 gram per day of EPA/DHA for general prevention, 2 gram per day or more for treating existing diseases such as heart disease or inflammatory conditions. Doses as high as 10 grams per day are sometimes used. At higher doses the blood-thinning effects need to be watched, especially if patients are taking other blood thinners.
A key point on dosing of fish oil… Most capsules are listed as 1 gram; however, the portion of EPA and DHA is only part of that 1 gram. Look on the label and you will see something like EPA 240mg and DHA 120mg, totaling 360mg EPA/DHA. That is the number to look for and the amount actually taken. In this example, the fish oil has about a 36% concentration of the EPA/DHA. One would need to take 3 capsules to get a total of 1080mg EPA/DHA.
Note that cheaper brands of fish oil will only have about 10-20% EPA/DHA concentration, and the remaining oils tend to smell fishy and go rancid quickly. Better quality oils will be 50-60% concentrated. One of the best I’ve come across is Quell Fish Oil from Douglas Labs, which has about 80% concentration of EPA/DHA. Nordic Naturals and Life Extension are two other excellent brands. The better quality translates to taking less capsules and little to no fishy aftertaste.
TO FISH OR NOT?
I recommend increased consumption of foods that contain more of the healthy omega-3 fatty acids, such as venison and fish. Grass-finished beef and free-range poultry also have higher omega-3 levels. Based on decades of research in dozens of health areas, I think it is clear that supplementing fish oil is a good idea.
In the late stages of disease, such as the first study noted above, simply adding a low dose of fish oil does not appear to add much benefit. A much more complex process is well underway and a much more aggressive combination of supplements would be more helpful. Just as one medication is seldom enough for advanced disease, similarly it is myopic to expect one supplement alone would turn the course of disease.
Don’t cast away the fish oil just yet.
Scott Rollins, M.D., is board certified with the American Board of Family Practice and the American Board of Anti-Aging and Regenerative Medicine. He specializes in bioidentical hormone replacement, thyroid and adrenal disorders, fibromyalgia and other complex medical conditions. He is founder and medical director of the Integrative Medicine Center of Western Colorado (www.imcwc.com) and Bellezza Laser Aesthetics (www.bellezzalaser.com). Call 970-245-6911 for appointments or more information.
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