Omega-3 Fish Oil Supplements Archives - Page 2 of 2

Do Omega-3s Oil Your Joints?

March 30, 2021 by Dr. Steve Chaney

Fish Oil And Osteoarthritis

Author: Dr. Stephen Chaney

Osteoarthritis is not just painful. It is one of the leading causes of disability in this country. And because the joint pain associated with osteoarthritis limits activity levels, it is linked to:

Obesity

The diseases associated with obesity (diabetes and heart disease).

- Osteoarthritis increases the risk of heart disease by 50%.

Premature death associated with the increased prevalence of obesity, diabetes, and heart disease.

- Osteoarthritis increases the risk of all-cause mortality by 55%.

If osteoarthritis were rare, these statistics would just be an interesting side note. But osteoarthritis is the most common form of arthritis. It affects more than 32 million Americans. And it is costly. It costs the American economy:

$65 billion in health care costs.

$17 billion in lost wages.

$136 billion in total costs.

Conventional therapy for osteoarthritis is treatment with anti-inflammatory drugs, but they have side effects. They may even increase the risk of premature death in some individuals.

What about natural anti-inflammatory nutrients and phytonutrients? Two that have received a lot of press in recent years are omega-3s (fish oil) and curcumin.

A recent meta-analysis (NK Senftleber et al, Nutrients, 9: 42, 2017) of 42 clinical studies on the effects of omega-3s on various types of arthritis found that:

There is moderate quality evidence that omega-3s reduce the pain associated with rheumatoid arthritis. Basically, this means that there is strong, but not definitive, evidence that omega-3s reduce the pain of rheumatoid arthritis. Other general conclusions with respect to rheumatoid arthritis were:

- The best results were obtained from fish oil preparations with an EPA/DHA ratio of >1.5, suggesting that EPA is more beneficial than DHA.

- Early studies suggested that the optimal dose of omega-3s was ≥2.6 g/day for ≥12 weeks.

There was low quality evidence for an effect of omega-3s on osteoarthritis. Only 5 clinical trials have been published on the topic and the results of those studies are conflicting.

The data for an effect of curcumin on osteoarthritis pain are even more limited. There is some evidence it might be beneficial, but the studies are small and are conflicting.

In this week’s issue of “Health Tips From the Professor” I discuss an exploratory study (JC Kuszewski et al, Rheumatology Advances In Practice 4: 1-9, 2020) on the effect of omega-3s and curcumin on osteoarthritis pain.

How Was The Study Done?

You are probably wondering, “What is an “exploratory study?” Let me start by providing you with a little perspective from my years of heading a cancer research laboratory at the University of North Carolina:

Clinical studies are expensive. And if you are trying to study an approach that has not already proven to be successful, the money needed to fund the study can be hard to come by. It is a “Catch 22” situation. You need to conduct an “exploratory study” to show your project is likely to succeed before the funding agency will give you money to fund your project.

But where do you get the money to fund your exploratory project? One way that investigators overcome that barrier is to use data from a previous study that was originally designed for a different purpose. The study I will describe today is an example of that approach.

The study utilized data collected from a clinical trial designed to measure the effect of omega-3s and curcumin on brain function in older adults. The study recruited 152 older adults (average age = 65) who were overweight to obese (average BMI = 31) and sedentary (˂55 min/week of physical activity) from New South Wales, New Australia.

The participants were randomly divided into 4 groups:

Placebo group. [Note: The fish oil placebo contained 20 mg of fish oil so it would match the odor of the fish oil supplement, and the curcumin placebo contained yellow food dye so it would match the color of the curcumin supplement.]

Fish oil group (2,000 mg DHA & 400 mg EPA per day).

Curcumin group (160 mg/day curcumin).

Fish oil + curcumin group.

Participants were followed for 16 weeks. At the beginning and end of the study participants filled out questionnaires assessing (among other things):

The severity of their chronic osteoarthritis pain.

Disabilities caused by osteoarthritis in the participant’s daily life (physical distress, sleep disturbances, psychological distress, loss of productivity, physical limitations, physical deconditioning due to reduction in physical activity, and financial hardship).

Their physical and mental wellbeing during the past 4 weeks.

Their mood during the past 7 days.

Do Omega-3s Oil Your Joints?

The results were as follows:

Omega-3 supplementation reduced chronic osteoarthritis pain by 42%.

Omega-3 supplementation reduced disability associated with osteoarthritis by 40%.

- The reduction in pain and disability in participants supplemented with fish oil was greatest in those who reported the highest pain/disability at the beginning of the study.

- The reduction in pain was associated with an improved perception of physical and mental wellbeing.

- The reduction in pain was also associated with a decrease in depression and other mood disturbances.

Curcumin did not affect pain or osteoarthritis burden either alone or paired with omega-3s.

What Are The Pros And Cons Of This Study?

Pros:

The results for the effects of omega-3s on osteoarthritis were highly significant. In addition, the questionnaires used were well designed to capture the intensity and location of pain, mood, and feelings of wellbeing.

Cons:

This was an exploratory study using data collected from a study designed to measure the effect of omega-3s and curcumin on brain health in older adults. It was not ideally designed to measure the effect of omega-3s and curcumin on osteoarthritis.

If the original study had been intended for investigating the effect of these supplements on osteoarthritis, it would have been designed differently:

Participants would have been recruited into the study based on the presence and intensity of osteoarthritis pain.

The diagnosis of osteoarthritis would have been confirmed by X-rays.

Participants would have been admitted into the study only if they had moderate to severe osteoarthritis pain. Most of the participants in this study had only mild osteoarthritis pain. That may have limited the ability of this study to find an effect of curcumin on osteoarthritis pain.

The design of the omega-3 supplement would have been different.

- Because the original study was designed to determine the effect of omega-3s on brain health, the omega-3 supplement chosen had more DHA than EPA.

- Had the study been designed to determine the effect on omega-3s on an inflammatory disease like osteoarthritis, the omega-3 supplement would have had more EPA than DHA.

The curcumin supplement was also not ideally designed for this study. The curcumin supplement used in this study contained only 160 mg of curcumin and contained no other ingredients. Well-designed curcumin supplements usually contain around 500 mg curcumin standardized to 95% curcuminoids plus piperine to enhance the absorption of the curcumin.

In the words of the authors, “Further studies are warranted to evaluate the benefits of fish oil, alone or as an adjunct to pharmacotherapy, in patients diagnosed with osteoarthritis who suffer moderate-to-severe pain…” In other words, they now intend to use the data from this exploratory study to apply for funds to conduct a larger study specifically designed to measure the effects of omega-3s on osteoarthritis pain.

The study limitations described above, severely restricted the ability of the study to detect any beneficial effect of curcumin on osteoarthritis pain. The effect of curcumin on osteoarthritis pain is probably less than the effect of omega-3s, but it would be premature to conclude that it has no benefit. However, they obtained no data from their “exploratory study” to justify a follow-up study on the effect of curcumin on osteoarthritis pain.

Fish Oil And Osteoarthritis

This study suggests that 2.4 grams/day of omega-3s may be equally effective at reducing osteoarthritis pain and the effects that osteoarthritis pain has on both physical health and psychological health. However, because this study has several limitations, the evidence cannot be considered definite.

If you have either rheumatoid or osteoarthritis, I recommend trying omega-3 supplementation. Based on the studies described above, you might want to aim for 2-3 g/day of omega-3s with an EPA/DHA ration of 1.5 or greater.

As with any natural approach, this will work better for some people that for others. However, don’t forget that omega-3s are also important for heart health, healthy blood pressure, brain health, and a healthy pregnancy (https://www.chaneyhealth.com/healthtips/omega-3s-during-pregnancy-are-healthy/). If they also happen to reduce your arthritis pain, that is an extra benefit.

As usual, I recommend a holistic approach. You should also:

Follow an anti-inflammatory diet.

Keep active.

Aim for a healthy weight.

Add antioxidant and polyphenol supplements.

These lifestyle changes should allow you to reduce or eliminate any pain medication you may be taking.

Finally, if you are on blood thinners, consult with your physician before adding omega-3 supplements to your diet. My preference is to incorporate omega-3s and reduce other medications, but that is a discussion you need to have with your doctor.

The Bottom Line

A recent meta-analysis has concluded there is moderate quality evidence that omega-3s reduce the pain associated with rheumatoid arthritis. Basically, this means that there is strong, but not definitive, evidence that omega-3s reduce the pain of rheumatoid arthritis. Other general conclusions with respect to rheumatoid arthritis were:

The best results were obtained from fish oil preparations with an EPA/DHA ratio of >1.5, suggesting that EPA is more beneficial than DHA.

Earlier studies suggested that the optimal dose of omega-3s was ≥2.6 g/day for ≥12 weeks.

However, there have been few studies on the effect of omega-3s on osteoarthritis. A new exploratory study looked at the effect of 2.4 g/day of omega-3s for 16 weeks on the pain and disability associated with osteoarthritis. It found:

Omega-3 supplementation reduced chronic osteoarthritis pain by 42%.

Omega-3 supplementation reduced disability associated with osteoarthritis by 40%.

- The reduction in pain and disability in participants supplemented with fish oil was greatest in those who reported the highest pain/disability at the beginning of the study.

- The reduction in pain was associated with an improved perception of physical and mental wellbeing.

- The reduction in pain was also associated with a decrease in depression and other mood disturbances.

The authors concluded, “Our findings indicate potential for fish oil supplementation to reduce mild osteoarthritis pain and burden in sedentary overweight/obese older adults. Further studies are warranted to evaluate the benefits of fish oil, alone or as an adjunct to pharmacotherapy, in patients diagnosed with osteoarthritis who suffer moderate-to-severe pain…”

As with any natural approach, this will work better for some people that for others. However, don’t forget that omega-3s are also important for heart health, healthy blood pressure, brain health, and a healthy pregnancy. If they also happen to reduce your arthritis pain, that is an extra benefit.

As usual, I recommend a holistic approach. You should also:

Follow an anti-inflammatory diet.

Keep active.

Aim for a healthy weight.

Add antioxidant and polyphenol supplements.

These lifestyle changes should allow you to reduce or eliminate any pain medication you may be taking.

For more details read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

How Much Omega-3s Do You Need?

March 5, 2019 by Dr. Steve Chaney

Can You Get The Omega-3s You Need From Diet Alone?

Author: Dr. Stephen Chaney

Two recent studies have provided strong evidence that omega-3s reduce the risk of heart attacks. However, both studies used high doses of omega-3s and did not do a dose-response analysis. That leaves you with several unanswered questions:

How much omega-3s do you need to significantly reduce your risk of heart attack?
Will that amount of omega-3s provide other health benefits?
Can you get that amount of omega-3s from diet alone?
Can you get that amount of omega-3s from supplementation alone?

Fortunately, a recent study (KH Jackson et al, Prostaglandins, Leukotrienes and Essential Amino Acids, 142: 4-10, 2019) has answered those questions. But, before we consider that article, we should look at a biomarker called “Omega-3 Index.”

What Is Omega-3 Index And Why Is It Important?

The Omega-3 Index is a measure of the ratio between the heart-healthy omega-3 fats (EPA + DHA) and all the other fats in red blood cell membranes. It is considered an excellent measure of our omega-3 status.

Dr. William S Harris, one of the top experts in the omega-3 field, first proposed the Omega-3 Index as a biomarker for cardiac health back in 2007. Based on multiple clinical and population studies, he proposed that an Omega 3 Index of 4% was associated with high heart attack risk, and an Omega-3 Index of 8% was associated with low heart attack risk. This has been supported by a recent meta-analysis of 10 clinical studies showing that an Omega-3 Index of 8% was associated with a 35% reduction in cardiovascular death compared to an Omega-3 Index of 4%.

Other studies suggest that an Omega-3 Index of 8% is associated with:

A slower rate of telomere shortening.
A lower risk of death from any cause.
Reduction in symptoms of depression.
Improved recovery from a heart attack.
Reduction in arthritis symptoms.
Reduced age-related brain shrinkage in B-vitamin treated subjects. (I have written about the synergistic relationship between omega-3s and B vitamins with respect to brain health in a previous issue of “Health Tips From the Professor.”

(Note: You will find references to these studies in the paper I have cited.)

For reference, most Americans have an Omega-3 Index between 4 and 6%. In contrast, in Japan, where the incidence of heart disease is much lower, the Omega-3 Index ranges from 6.8% to 9%.

How Was The Study Designed?

The data for this study were derived from 3458 individuals who 1) sent in a dried blood spot to a commercial laboratory for determination of Omega-3 Index between March 30, 2017 and January 15, 2018, 2) filled out a short questionnaire about fish intake and omega-3 supplement use, and 3) were older than 18.

With respect to fish intake, the possible responses were “none per week,” “every other week,” “every week,” “2 times per week,” and “3 or more times per week.”

With respect to omega-3 supplement use, those who reported taking an omega-3 supplement were asked what kind of omega-3 supplement they were taking. Those who said they were taking a flaxseed oil supplement were excluded from the analysis because flaxseed oil contains no EPA or DHA.

The characteristics of the population studied were as follows:

84% came from the United States. The remaining 16% came from 27 other countries.
The average age was 51 years and 40% of the respondents were male.
62% ate little or no fish. The exact breakdown of fish consumption was:
- 5% ate no fish.
- 9% ate fish every other week.
- 6% ate fish weekly.
- 2% ate fish twice a week.
- 8% ate fish three or more times a week.

52% took omega-3 supplements. Of those taking omega-3 supplements, 84% were taking fish oil supplements.

How Much Omega-3s Do You Need?

The correlation between omega-3 intake and Omega-3 Index in these individuals was:

No fish = 4.5%.
- No fish + supplementation = 6.6%.

Bi-weekly = 4.8%
- Bi-weekly + supplementation = 6.9%

Weekly = 5.1%
- Weekly + supplementation = 7.3%

Twice weekly = 5.7%
- Twice weekly + supplementation = 7.8%

3+ times per week = 6.5%
- 3+ times per week + supplementation = 8.6%

The authors said: “We found that those with the best chance of achieving a desirable Omega-3 Index were reporting the consumption of at least 3 fish meals per week and were taking an EPA + DHA-containing omega-3 supplement.”

The authors further concluded that an EPA + DHA intake of around 835 mg per day or higher would be required to achieve an average Omega-3 Index of 8%. This was based on two assumptions:

A 4 once serving of oily fish provides around 1,200 mg of EPA + DHA.
The average omega-3 supplement provides around 300 mg of EPA + DHA.

What Are The Limitations Of The Study?

The two biggest limitations of the study are the assumptions that a serving of fish provides 1,200 mg of EPA + DHA and a fish oil supplement provides 300 mg of EPA + DHA.

Their dietary survey did not ask what kind of fish the respondents were consuming. Some fish provide much less than 1,200 mg of EPA + DHA per serving. This could have caused the authors to overestimate the contribution that fish intake made to the Omega-3 Index in their study.
Some omega-3 supplements provide more than 300 mg EPA + DHA, and some people take more than the recommended number of omega-3 capsules. This could have caused the authors to underestimate the contribution of omega-3 supplements to the Omega-3 Index in their study.

The major implication of these limitations comes when we look at the standard deviation of the correlations between omega-3 intake and Omega-3 Index.

Some people consuming 3 or more servings of fish per week had an Omega-3 Index of well above 8%. This suggests that diet alone can allow you to reach an optimal Omega-3 Index. This conclusion is also supported by dietary studies in Japan (see below).
Some people taking omega-3 supplements had an omega-3 index of above 8% even in the group consuming no fish. This suggests that supplementation alone can allow you to reach an optimal Omega-3 Index as long as your total EPA + DHA intake is 835 mg/day or greater.

These limitations may also affect the calculation of how much EPA + DHA we need to reach an optimal Omega-3 Index. For example, the most widely used omega-3 calculator estimates that you would need 950 mg of EPA + DHA to increase your Omega-3 Index from 4% to 8%.

What Does This Study Mean For You?

At the beginning of this article I said that this study answered 4 questions:

How much omega-3s do you need to significantly reduce your risk of heart attack?
- This study estimated that around 835 mg/day of EPA + DHA is needed to reach an Omega-3 Index of 8%, which previous studies have shown to be associated with low heart disease risk.
- This is similar to the 950 mg/day estimate from a widely used omega-3 calculator.
- There is considerable individual variability, but 835 – 950 mg/day is a good target for most people. If in doubt, I recommend that you get your Omega-3 Index tested.

Will that amount of omega-3s provide other health benefits?
- The evidence is strongest for heart health, but this paper lists other studies suggesting that a high Omega-3 Index is associated with reduced risk of depression, arthritis, age-related brain shrinkage & cognitive decline, and death from all causes.

Can you get that amount of omega-3s from diet alone?
- In this study an optimal Omega-3 Index was achieved only in the group that consumed 3 or more servings of fish per week and took an omega-3 supplement. However, not all those fish were rich in EPA + DHA.
- Previous studies have shown that Japanese who consume 3 or more servings per week of oily fish, rich in EPA + DHA, have an Omega-3 Index of 6.8% to 9%. This shows us it is possible to reach an optimal Omega-3 Index from diet alone.

Can you get that amount of omega-3s from supplementation alone?
- Here the answer is clearly yes. Based on this and other studies, it would require in the range of 835-950 mg/day from supplementation to reach an optimal Omega-3 Index for most people.

Here are some other conclusions from the authors of the study:

“The average Omega3 Index in Japan ranges from 6.8 to 9.0%…So, yes, an Omega-3 Index of >8% is achievable by diet alone. But Japan is fairly unique…The average Omega-3 Index for Americans ranges from 4 to 6%. So, short of adopting the Japanese diet for a lifetime, it appears that taking an EPA + DHA supplement could be an important strategy for achieving a cardioprotective Omega-3 Index.”
They consider current recommendations for omega-3 intake to be inadequate. Their recommended intake of 835 mg of EPA + DHA per day is:
- “>3 times the EPA + DHA recommended by the Dietary Guidelines for Americans (250 mg/day).”
- “1.7 times the amount recommended by the Academy of Nutrition and Dietetics (500 mg/day).”
- “8 times higher than the typical EPA + DHA intake in the US (~100 mg/day).”
The American Heart Association currently recommends the consumption of 1-2 seafood meals per week.
The authors commented: “We do recognize that public health recommendations must balance what is ideal vs. what is practical for the public and must also take into consideration…potentially hazardous components of fish (mercury, PCBs) and the sustainability of the world’s fish supply.”
However, they considered the recommendation of the American Heart Association to be woefully inadequate. Based on their data, they concluded: “To achieve an Omega-3 Index of >8%, either adding an EPA + DHA supplement or increasing to 4-5 servings of fish/week would be necessary.”

Because of the high level of contamination of the world’s fish supply, my personal preference would be to add a high purity omega-3 supplement to my diet rather than consuming fish multiple times a week. I love salmon, but I try to limit myself to a salmon dinner no more than once a month.

The Bottom Line

A recent study looked at how much EPA + DHA you would need to achieve an optimal omega-3 status. The investigators used a measurement called Omega-3 Index, which has been shown to be an excellent measurement of omega-3 status. They asked how much EPA + DHA from diet plus supplementation was required to achieve an Omega-3 Index of 8%, which is associated with a low risk for heart disease. The key findings from this study were:

Around 835 mg/day of EPA + DHA is needed to reach an Omega-3 Index of 8%.
This is similar to the 950 mg/day estimate from a widely used omega-3 calculator.
There is considerable individual variability, but 835 – 950 mg/day is a good target for most people. If in doubt, I recommend that you get your Omega-3 Index tested.
The Japanese eat EPA + DHA-rich fish 3 or more times per week and have an Omega-3 Index of 6.9 to 9.0%, so it is clearly possible to achieve an optimal Omega-3 Index from diet alone. However, the American diet is so different from the Japanese diet that the authors concluded: “Short of adopting the Japanese diet for a lifetime, it appears that taking an EPA + DHA supplement could be an important strategy for achieving a cardioprotective Omega-3 Index.”
The American Heart Association currently recommends the consumption of 1-2 seafood meals/week. The authors consider this recommendation to be woefully inadequate. They said: “To achieve an Omega-3 Index of >8%, either adding an EPA + DHA supplement or increasing to 4-5 servings of fish/week would be necessary.”

Because of the high level of contamination of the world’s fish supply, my personal preference is to add a high purity omega-3 supplement to my diet rather than consuming fish multiple times a week. I love salmon, but I try to limit myself to a salmon dinner no more than once a month.

For more details read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

DHA During Pregnancy; Yes or No?

April 4, 2017 by Dr. Steve Chaney

Are Pregnant Women Deficient In Omega-3s?

Author: Dr. Stephen Chaney

Do women need DHA during pregnancy? Most experts agree that omega-3 fatty acids, especially DHA, are essential for fetal development during pregnancy and for brain development through at least the first two years of a child’s life. That’s because DHA is an important component of the myelin sheath that coats and protects our brain neurons.

During the last two trimesters of pregnancy and the first two years of a child’s life, their brains are growing and maturing at a remarkable rate. The need for DHA during this critical period is huge, and most of that DHA comes from the mom. That’s why the mom’s intake of DHA during pregnancy and breastfeeding is so important.

For example, higher intakes of omega-3s during pregnancy and breastfeeding have been associated with:

Decreased maternal depression.
Increased birth weight.
Reduced risk of preterm birth.
Reduction in ADHD symptoms.
Reduction in allergies and asthma.
Improved developmental and cognitive outcomes such as:
- Increased visual acuity.
- Better problem-solving skills.

I do wish to acknowledge that there is still debate in the scientific literature about the strength of some of these associations. However, there is enough cumulative evidence for the beneficial effects of omega-3s especially DHA during pregnancy and breastfeeding that virtually all experts agree adequate maternal omega-3 intake is important during this crucial period in a child’s life.

How Much DHA During Pregnancy & Breastfeeding Is Needed?

The National Academies of Science have not yet set a Daily Value for omega-3s. However, a group of experts met in 1999 to recommend adequate dietary intake of omega-3s (Simopoulos et al, Prostaglandins, Leukotrienes & Essential Fatty Acids, 63: 119-121, 2000 ). They concluded that an adequate intake of omega-3 fatty acids in adults was at least 650 mg/day with at least 440 mg/day of that coming from EPA + DHA (220 mg/day each of EPA and DHA). They further recommended that DHA intake in pregnant and lactating women should be at least 300 mg/day.

However, because of concerns about seafood contamination with heavy metals and PCBs (both of which are neurotoxins), the FDA recommended in 2004 that pregnant and lactating women limit seafood consumption to two servings a week, which amounts to about 200 mg/day of DHA. This has been subsequently adopted by the American College of Obstetricians and Gynecologists and the European Union as the recommended amount of DHA during pregnancy and lactation (Coletta et al, Reviews in Obstetrics & Gynecology, 3, 163-171, 2010 ).

How Was The Study Done?

The authors of this study (Nordgren et al, Nutrients, 2017, 9, 197; doi:10.3390/nu9030197 ) utilized a nationwide database called NHANES (National Health and Nutrition Examination Survey). NHANES data are based on an annual survey conducted by the National Center for Health Statistics (NCHS) to assess the health and nutritional status of adults and children in the United States, and to track changes over time.

Dietary intake of nutrients is based on two interviewer-administered, 24-hour dietary recalls conducted 3-10 days apart. Omega-3 intake was calculated based on the USDA database of nutrient composition of foods.

The investigators combined NHANES data from the years 2003 to 2012. This included 6478 women of childbearing years (14-45 years old), of which 788 were pregnant at the time of the survey.

Are Pregnant Women Deficient In Omega-3s?

The results of this study were alarming:

Mean EPA + DHA intake was only 89 mg/day with no difference between pregnant and non-pregnant women of childbearing age.

This contrasts to the expert committee’s recommendation of at least 440 mg/day for EPA + DHA (220 mg/day each from EPA and DHA).

Mean DHA intake was only 66 mg/day in pregnant and 58 mg/day in non-pregnant women of childbearing status.

This contrasts to the recommendations of 200 – 300 mg/day for pregnant women.

These intakes did not include dietary supplements, but only 1.8% of non-pregnant and 9% of pregnant women in this survey took supplements containing EPA and/or DHA.

The authors concluded “Our results demonstrate that omega-3 fatty acid intake is a concern in pregnant women and women of childbearing age…” They went on to say: ‘Strategies to increase omega-3 fatty acid intake in these populations could have the potential to improve maternal and infant health outcomes.”

What Do Other Studies Show?

This study is not an outlier. In a previous issue Do Women Get Enough Omega-3 During Pregnancy of “Health Tips From the Professor” I reported on a study showing that 90% of Canadian women were not getting enough DHA in their diet. A similar study in Germany concluded that 97% of middle-aged women had suboptimal omega-3 status (Gellert et al, Prostaglandins, Leukotrienes and Essential Fatty Acids, doi: 10.1016/j.plefa.2017.01.009 ).

More importantly, these omega-3 deficiencies matter. In another issue DHA Supplements During Pregnancy of “Health Tips From the Professor” I reported on a study showing that DHA supplementation significantly reduced preterm births. Based on that effect alone, the authors concluded that DHA supplementation during pregnancy could save the US healthcare system close to $6 billion/year.

Women do need DHA during pregnancy.

The Bottom Line

Optimal intake of omega-3s during pregnancy and breastfeeding is associated with:
- Decreased maternal depression.
- Increased birth weight.
- Reduced risk of preterm birth.
- Reduction in ADHD symptoms.
- Reduction in allergies and asthma.
- Improved developmental and cognitive outcomes such as:
  - Increased visual acuity.
  - Better problem-solving skills.
In 1999, a panel of experts met to set standards for omega-3 intake. They recommended:
- At least 650 mg/day for adults with at least 440 mg/day coming from EPA + DHA (220 mg/day each of EPA and DHA).
- At least 300 mg/day of DHA for pregnant and breastfeeding women.
Because of concerns about seafood contamination with heavy metals and PCBs (both of which are neurotoxins), the FDA reduced the recommendation for pregnant and breastfeeding women to 200 mg/day of DHA. That recommendation has been subsequently adopted by the American College of Obstetricians and Gynecologists and the European Union.
A recent study has found:
- Mean EPA + DHA intake was only 89 mg/day with no difference between pregnant and non-pregnant women of childbearing age.
  - This contrasts to the expert committee’s recommendation of at least 440 mg/day (with 220 mg/day each from EPA and DHA).
- Mean DHA intake was only 66 mg/day in pregnant and 58 mg/day in non-pregnant women of childbearing status.
  - This contrasts to the recommendations of 200 – 300 mg/day for pregnant and breastfeeding women.
- These intakes did not include dietary supplements, but only 1.8% of non-pregnant and 9% of pregnant women in this survey took supplements containing EPA and/or DHA.
- This study is in line with recent studies in Canada and Germany. Clearly pregnant and Breastfeeding women in developed countries like the US are getting suboptimal amounts of omega-3s in their diet.
- This is alarming because these findings come amidst mounting evidence that optimal omega-3 intake during pregnancy and breastfeeding is important for the health of both mother and child.
These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

Are Some Omega-3 Fish Oil Supplements Better Than Others?

September 13, 2016 by Dr. Steve Chaney

Author: Dr. Stephen Chaney

The ethyl ester form of omega-3 fatty acids from fish oil has been the industry standard for high purity omega-3 fish oil supplements for many years. It is very stable, easily purified, and well absorbed by the body. What’s not to like?

If you believe some recent advertisements, there is a lot not to like about the ethyl ester form of omega-3s. These ads each claim that their particular form of omega-3s is more natural, better absorbed, and more efficiently incorporated into cell membranes, or some combination of those features. They each cite clinical studies “proving” that their products are superior. These advertisements seem so plausible and so compelling.

However, most of these advertisements come from relatively new companies that are trying to make a name for themselves in a very profitable and competitive product niche. Are the advertisements true, or is it all just smoke and mirrors? Most of these advertisements rate at least one Pinocchio.

However, it is almost impossible to tell you why I consider these advertisements omega-3 fish oil supplements to be misleading without getting a little “techie”, so let’s start with some basic definitions. I call this section “Omega-3s 101.”

Omega-3s 101

Let’s start with some basic definitions:

Free fatty acids (FFA) are long chain hydrocarbons with a single acid group at the end. They are only slightly water soluble. They are important intermediates in metabolism, but they are almost always combined with something else in the body.
Saturated fatty acids contain no double bonds, monounsaturated fatty acids contain one double bond, and polyunsaturated fatty acids contain multiple double bonds. The number of double bonds primarily affects whether they are liquids (polyunsaturated) or solids (saturated) at room temperature.
There are two classes of polyunsaturated fatty acids that are essential because the body cannot make them. Those with a double bond 3 carbons from the end are called omega-3s(If you think about the Greek alphabet, omega is at the end). Those with a double bond 6 carbons from the end are called omega-6s.
When 3 fatty acids are combined with a single molecule of glycerol they form very water insoluble compounds commonly referred to as fats or triglycerides. The proper chemical name is triacylglycerol, which is abbreviated TAG.
If one of the fatty acids on the glycerol chain is replaced by a compound containing phosphate and other charged residues, the resulting complex is called a phospholipid (PL). Because these compounds have a hydrocarbon surface that is attracted to fats and a highly charged surface that is attracted to water, they are good at emulsifying fats and are an important part of membrane structure. One phospholipid that is a major component of membranes is called phosphatidylcholine (PC), also known as lecithin.

Next, let’s look at how omega-3 fatty acids are metabolized:

The omega-3s in fish oil are primarily in the form of triglycerides, with small amounts of phospholipids. The omega-3s in most omega-3 supplements are in the form of ethyl esters for the reasons stated above.
Before the omega-3s leave the intestine they are hydrolyzed to free fatty acids.
In the cells that line the intestine the omega-3s are reconverted back into triglycerides and phospholipids and incorporated into special lipid-protein complexes for transport through the blood.
Once these lipid-protein complexes reach our cells, their contents are delivered to the cell where they can be stored as fat (TAG), used for energy (FFA), or incorporated into membranes (PL). It is primarily the omega-3s incorporated in cellular membranes that are thought to be responsible for the beneficial effects of omega-3s.

Finally, we should ask how one measures the bioavailability of the various forms of omega-3s:

While there are some nuances that I did not cover, the basic mechanisms of absorption and metabolism of omega-3s are remarkably similar regardless of whether they start out in the ethyl ester, triglyceride, phospholipid, or free fatty acid form. The questions then become, how does one test how efficiently the various forms are utilized by the body and how much do these individual test actually tell us?

When we look at what happens in the bloodstream, we need to be aware that we are looking at a combination of two effects – how rapidly the substance enters the bloodstream and how rapidly it leaves from the bloodstream. There are three important parameters we can measure when looking at delivery of omega-3s to the bloodstream:
- The maximum concentration achieved (Cmax)
- How rapidly that maximum concentration was achieved (Tmax)
- The total amount in the bloodstream over time (AUC)
When you look at some of the ads touting specialized forms of omega-3s, they are usually based on studies looking at either the maximum levels of omega-3s in the bloodstream (Cmax) or how rapidly those maximum levels were achieved (Tmax). (One suspects the ads may have selectively featured whichever parameter made their product look best). However, the parameter that really matters is the total concentration of omega-3s achieved over time (AUC).
Finally, the most important question is how much of the omega-3 is actually incorporated into cellular membranes. Once again, there is more than one parameter that can be measured.
One can measure the level of omega-3s found in cellular membranes in a short term study (a few hours) or in a long term study following many weeks of supplementation.
The short term studies only measure the rate of incorporation. The long term studies measure the steady state levels attained over time, which is a much more relevant measure.
Once again, the ads touting specialized products are usually based on short term studies which are really measuring an initial rate of incorporation of omega-3s into cellular membranes, not on long term studies that measure the steady state level of omega-3s achieved over time.

Are Some Omega-3 Fish Oil Supplements Better Than Others?

There has been a lot of confusion in the literature about whether the form of omega-3 supplements matters. Various studies have been published supporting the superiority of one form or another of omega-3s. Most of these studies have been supported by manufacturers who have a particular form of omega-3s they want to sell, and, as I mentioned above, the parameters tested seem to have been selected to make their supplement look good. So, are some omega-3 fish oil supplements better than others?

Finally, someone has designed a comprehensive study to clear up all the confusion and provide answers that can be trusted (West et al, British Journal of Nutrition, 116: 788-797, 2016). Interestingly, this research was supported by a pharmaceutical company (Vifor Pharma) that does not appear to sell an omega-3 product currently. Perhaps they simply wanted to find out what worked best before designing their own product. What a novel concept!

The authors tested 4 different forms of omega-3 fish oil supplements:

Unmodified fish oil containing the omega-3s primarily in triglyceride form (uTAG).
An omega-3 supplement in which the omega-3s in the fish oil had been hydrolyzed to free fatty acids (FFA).
An omega-3 supplement in which the omega-3s in the fish oil had been hydrolyzed to free fatty acids and converted back to triglycerides (TAG)
An omega-3 supplement in which the omega-3s in the fish oil had been hydrolyzed to free fatty acids and converted to ethyl esters (EE)

All 4 supplements contained 1.1 grams of EPA and 0.37 grams of DHA.

The authors conducted two studies:

One was a cross-over study where healthy men consumed each of the supplements in random order on different days with 14 days between tests. Blood samples were collected over the next 6 hours and levels of EPA and DHA in the blood and cellular membranes was determined.
The other was a long term study in which a randomized group of healthy men and women consumed one of the supplements for 12-weeks and incorporation of the EPA and DHA into cellular membranes was measured.

The results were pretty clear cut:

In the short term study there were no significant differences between the various supplements in the rate of uptake, maximum concentration achieved, or the total concentration over time when uptake of omega-3s into plasma triglycerides and phospholipids was measured.
The ethyl ester form was less efficiently incorporated into plasma free fatty acids than the other forms as reported in some previous studies, but this is perhaps the least important parameter measured, and there was large variability from subject to subject.
In the long term study, no significant differences were seen between the various supplements in omega-3 incorporation into cellular membranes.

The authors concluded: “Together, these findings show that in healthy individuals neither the lipid structure nor the overall fatty acid composition of supplements influence their bioavailability during dietary supplementation, despite the apparent lower postprandial availability [in short term studies] of EPA + DHA ethyl esters compared with triglycerides or free fatty acids.”

What Do These Studies Mean For You?

You can forget all those ads hyping the newest, greatest form of omega-3 fish oil supplements. Objective research has shown there is not a dimes worth of difference between the various forms of omega-3 supplements.

A far more important question is the purity of the omega-3 supplement you are using. Purity of omega-3 supplements is a huge issue. You need to remember that the EPA + DHA supplements you purchase come from polluted fish. Unfortunately, many manufacturers have inadequate purification and quality control standards. In other words, neither you nor they know whether their omega-3 products are pure. You need to make sure that the omega-3 supplement you purchase is made by a manufacturer with stringent quality control standards.

Sustainability is also an issue, so you should choose manufacturers who source their omega-3s in a sustainable manner. There are two comments I will make about sustainability so you won’t be misled.

Krill oil is marketed as a more sustainable source of omega-3s. Krill reserves are quite large, but they are not infinite. Krill is also the very foundation of the food chain that supports a large percentage of our ocean’s fish. We need to be very cautious about depleting our krill reserves.
Omega-3s derived from algae are also marketed as a more sustainable source of omega-3s. Algae-derived omega-3s have purity issues of their own, but may become an important source of omega-3s once those issues have been resolved.

The Bottom Line

The ethyl ester form of omega-3 fatty acids from fish oil has been the industry standard for high purity fish oil supplements for many years. It is very stable, easily purified, and well absorbed by the body.
However, in recent years, some manufacturers have been claiming that their omega-3 fish oil supplements were better utilized by the body because their supplements contained the omega-3s in triglyceride or free fatty acid forms.
Unfortunately, the clinical studies supporting those claims have been supported by the manufacturers making the products. There is reason to suspect that the data has been “cherry picked” to support the conclusions that support the manufacturer’s claims.
Finally, an independent and comprehensive study has compared the various forms of omega-3 fatty acids. It found that neither the lipid structure nor the overall fatty acid composition of omega-3 supplements influenced their bioavailability during long term dietary supplementation.
A far more important question is the purity of the omega-3 supplement you are using. Purity of omega-3 supplements is a huge issue. You need to remember that the EPA + DHA supplements you purchase come from polluted fish. Unfortunately, many manufacturers have inadequate purification and quality control standards. In other words, neither you nor they know whether their omega-3 products are pure. You need to make sure that the omega-3 supplement you purchase is made by a manufacturer with stringent quality control standards.