Is Your Prenatal Supplement Adequate?

November 8, 2022 by Dr. Steve Chaney

What Should You Look For In A Prenatal Supplement?

Author: Dr. Stephen Chaney

You want to do the best for your unborn child. So, you try to find the best prenatal supplement. You may ask your doctor to recommend a prenatal supplement. You may ask your best friend what supplement she used when she was pregnant. Or perhaps you scan online reviews of prenatal supplements by random dietitians or nutrition gurus to select the “best” prenatal supplements.

Then you read the supplement label or the company’s website and see claims like:

“Supports optimal nutrition before, during, and after pregnancy”

“Packed with 16 nutrients to support fetal development, immunity, energy metabolism, and more”

“Concise prenatal formula supports both bone and brain development”

It sounds so good. You think you have found the perfect prenatal supplement. “Right?”

Perhaps not. A recent study (JB Adams et al, Maternal Health, Neonatology, and Perinatology, 8:4, 2022) did an in-depth review of prenatal supplement recommendations and how well prenatal supplements on the market met those recommendations.

The results were not encouraging. The authors concluded, “[Our] analysis found that prenatal supplements vary widely in content, often only contain a subset of essential vitamins, and the levels were often below…recommendations.”

In other words, their study found that most prenatal vitamins may not be adequate to support your needs and the needs of your child through pregnancy and breastfeeding.

I know this is likely to be a topic of great concern for many of you. So, I will examine the study in detail and give you some guidelines for selecting the perfect prenatal supplement.

How Was This Study Done?

This study can be divided into two parts.

#1: What Should The Ideal Prenatal Supplement Contain:

The authors started off by reevaluating the optimal recommendations for prenatal supplements. They reviewed over 200 articles, focusing on articles that:

Provided insight into optimal dosage [of essential nutrients] such as treatment studies on the effects of different doses on outcomes and biomarkers.

Were larger, more rigorously designed, such as randomized double-blind placebo-controlled studies.

The studies included in their review fell into three categories:

The association of low levels of vitamins with health problems [during pregnancy and in the child after birth].

2) Studies on the changes in [blood] vitamin levels during pregnancy [when the mother is either] un-supplemented or supplemented (The blood level of many vitamins decreases dramatically during pregnancy without supplementation).

3) Clinical trials on the effect of vitamin supplementation on health problems [during pregnancy].

They used these data to create their recommendations for what an ideal prenatal supplement should contain. In some cases, their recommendations were higher than current RDA recommendations for pregnant women.

#2: How Do Currently Available Prenatal Supplements Compare With Their Recommendations For The Ideal Supplement?

For this part of the study, they created a comprehensive list of the nutrients provided by 188 prenatal supplements currently on the market using databases created by the National Institutes of Health. Where these databases were outdated, the nutrient list for that supplement was updated using information on the manufacturer’s websites or labels on retail websites such as Amazon.

Finally, they compared the nutrient content of all 188 prenatal supplements with their recommendations for the ideal prenatal supplement.

Is Your Prenatal Supplement Adequate?

There are four points I wish to make before I review the results of this study.

I suspect you are most interested in finding out how prenatal supplements on the market compare with their recommendations for an ideal supplement, so that is what I will discuss below.

2) As I mentioned above, some of their recommendations exceed the current Daily Value (DV) recommendations for pregnant and lactating women. I will point that out whenever it significantly affects the comparisons.

3) The authors of this article made the point that most women going on a prenatal supplement will probably discontinue taking their multivitamin supplement. Thus, their recommendations included nutrients commonly included in multivitamin supplements. This is a valid point, and something you should consider when choosing a prenatal supplement. However, in my discussion below I will focus on the nutrients that are universally recognized as important for pregnancy and lactation.

4) The authors focused on prenatal supplements that had less than the recommended amount of essential nutrients. They did not ask how many of those supplements had excessive amounts of certain nutrients. In my non-systematic review of prenatal supplements, I found several that had doses of some nutrients in thousands of percent of the DV recommendations. In my opinion, this is potentially unsafe for pregnancy and nursing. I will cover this topic in more detail in my discussion.

With that in mind, here are the results of their review.

Vitamins:

When you look at vitamins that have long been recognized as essential for pregnant women, the results are encouraging:

Vitamin D, folate, vitamin B12, and vitamin B6 are found in adequate amounts compared to the DV in most prenatal supplements.

However, when you look at nutrients that have more recently been recognized as essential for pregnant women, the story is very different:

For vitamin K only 31% of prenatal supplements contain vitamin K and only 16% meet or exceed their recommendation for vitamin K.

- Their recommendation (90 mcg/day) is identical to the DV for vitamin K. So, there is no doubt that most prenatal supplements do not provide adequate amounts of vitamin K.

For choline only 40 % of prenatal supplements contain choline and only 2% meet or exceed their recommendation for choline.

- Their recommendation (350 mg/day) for choline is less than the 450 mg/day recommended by the NIH and the American College of Obstetricians and Gynecologists.

- The average prenatal supplement only provides 25 mg of choline, which is wildly inadequate by any standard.

For DHA only 42% of prenatal supplements contain DHA and only 1% meet or exceed their recommendation for DHA.

- Their recommendation (600 mg/day) for DHA is higher than the 200 – 300 mg/day recommended by the most health organizations.

- However, the average prenatal supplement only provides 94 mg of DHA, so even at 200 – 300 mg/day a substantial percentage of prenatal supplements do not provide adequate amounts of DHA.

Minerals:

This study did not consider minerals, so I will draw on another source to estimate the adequacy of minerals in prenatal supplements.

Three key minerals for a healthy pregnancy are iron, calcium, and iodine (Yes, I realize that iodine is not a mineral, but it is usually listed with the minerals on supplement labels. And it is also essential for a healthy pregnancy). Fortunately, another recent study (LG Saldanha et al, Journal of the American Academy of Dietetics, 117: 1429-1436, 2017) looked at the adequacy of these nutrients in 214 prenatal supplements. This study found:

The iron DV for pregnant and lactating women is 27 mg/day and 95% of prenatal supplements contained iron at the recommended level.

The calcium DV for pregnant and lactating women is 1,300 mg/day. A high percentage (91%) of prenatal supplements contain calcium, but many prenatal supplements only provide 100-200 mg of calcium. That is far less than the DV.

The situation for iodine is even more alarming. Only 50% of prenatal supplements contain iodine. And for those that do contain iodine, the average iodine content is only 150 mcg (The DV for pregnant and lactating women is 290 mcg/day).

It is no wonder the authors of these two studies concluded that most prenatal supplements on the market do not provide adequate amounts of all the nutrients needed for a healthy pregnancy. The shortfalls are particularly acute for vitamin K, choline, DHA, iodine, and calcium.

What Should You Look For In A Prenatal Supplement?

By now you are probably wondering how you know a good prenatal supplement from a bad one. Here are six simple rules for choosing the ideal prenatal supplement.

Don’t rely on health “gurus” to choose your prenatal supplement for you. I did a little “sleuthing” for you. I searched the internet for websites claiming to have identified the “best” prenatal supplements. I checked out the supplements they recommended, and here is what I found:

The supplements the gurus recommended checked all the boxes in that they had some of all the nutrients required for a healthy pregnancy.

However, the amount of those nutrients ranged from lows of 10-20% of the DV for pregnant and lactating women to thousands of percent of the DV for others.

In other words, they contained grossly inadequate levels of some nutrients and potentially toxic levels of others.

2) Don’t believe label claims or claims made on the manufacturer’s website. Remember the claim, “Concise prenatal formula supports both bone and brain development”, that I mentioned at the beginning of this article? The supplement associated with that claim had only 100 mg of calcium and no DHA. It is hard to imagine a supplement like that supporting either bone or brain health. The claim was bogus.

3) Don’t assume your doctor’s recommendation is the ideal prenatal supplement. A recent study (LG Saldanha et al, Journal of the American Academy of Dietetics, 117: 1429-1436, 2017) compared prescription (the kind your doctor is likely to prescribe) and non-prescription prenatal supplements. It found:

Compared with non-prescription supplements, prescription supplements contained significantly fewer vitamins (9 versus 11) and minerals (4 versus 8).

While prescription supplements contained more folic acid than non-prescription supplements, they contained significantly less vitamin A, vitamin D, iodine, and calcium.

4) Look for a prenatal supplement containing all the essential nutrients, not just those important for a healthy pregnancy. The authors of the first study made the point that most women will stop taking their regular multivitamin when they start their prenatal supplement. If that is you, your prenatal supplement should contain the nutrients you were getting from your multivitamin.

5) Look for a prenatal supplement that provide 100% of DV for all nutrients except the bulky ones. The ideal prenatal supplement should contain 100% of the DV for pregnant and lactating women for all essential nutrients. Avoid supplements with very low amounts of some nutrients and large excesses of others.

Bulky nutrients like calcium, magnesium, and choline are exceptions. It would be hard to get 100% DV for those nutrients in any supplement you could swallow.

6) Look for a prenatal supplement that “fills the gap” for bulky nutrients.

Fortunately, the NIH has estimated how much of these nutrients the average American woman gets in her diet. That allows us to estimate how much the average woman needs to get from her prenatal supplement to bring her total intake up to the DV for pregnant and lactating women. That amounts to 458 mg for calcium, 166 mg for magnesium, and 272 mg for choline.

- That gives you a reasonable benchmark for assessing whether a prenatal supplement is providing enough of those important nutrients. When you read their labels, you will find most prenatal supplements are woefully inadequate for these nutrients.

- You also need to ask whether your diet is “average”. For example, the average American gets 72% of their calcium from dairy foods. If you do not consume dairy, you may need to get more calcium from your supplement.

7) Avoid the excesses. Your unborn baby is precious. You don’t want to expose it to potentially toxic doses of vitamins or minerals. Avoid any prenatal supplement containing thousands of percent of the DV for some nutrients. And I would recommend caution with supplements containing over 200% of the DV for some nutrients if you are taking other supplements that may provide the same nutrient(s).

The Bottom Line

Two recent studies have surveyed hundreds of prenatal vitamins and asked whether they provided adequate amounts of the nutrients that are essential for a healthy pregnancy. The results were shocking.

While most prenatal supplements provided adequate amounts of folic acid, vitamin B12, vitamin B6, vitamin D, and iron…

They were woefully inadequate for vitamin K, calcium, choline, iodine, and DHA – all nutrients that are essential for a healthy pregnancy.

Furthermore, prescription prenatal supplements (the kind your doctor is likely to prescribe) were no better than non-prescription supplements.

The authors of the first study concluded, “[Our] analysis found that prenatal supplements vary widely in content, often only contain a subset of essential vitamins, and the levels were often below…recommendations.”

In other words, their study found that most prenatal vitamins on the market may not be adequate to support your needs and the needs of your child through pregnancy and breastfeeding.

For more details on this study and my discussion of how you can select the ideal prenatal supplement for you and your unborn child, 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

Can Healthy Eating Help You Lose Weight?

September 27, 2022 by Dr. Steve Chaney

Who Benefits Most From A Healthy Diet?

Author: Dr. Stephen Chaney

Fad diets abound. High protein, low carb, low fat, vegan, keto, paleo – the list is endless. They all claim to be backed by scientific studies showing that you lose weight, lower your cholesterol and triglycerides, lower your blood pressure, and smooth out your blood sugar swings.

They all claim to be the best. But any reasonable person knows they can’t all be the best. Someone must be lying.

My take on this is that fad diet proponents are relying on “smoke and mirrors” to make their diet look like the best. I have written about this before, but here is a brief synopsis:

They compare their diet with the typical American diet.

- Anything looks good compared to the typical American diet.

- Instead, they should be comparing their diet with other weight loss diets. That is the only way we can learn which diet is best.

They are all restrictive diets.

- Any restrictive diet will cause you to eat fewer calories and to lose weight.

- As little as 5% weight loss results in lower cholesterol & triglycerides, lower blood pressure, and better control of blood sugar levels.

Simply put, any restrictive diet will give you short-term weight loss and improvement in blood parameters linked to heart disease, stroke, and diabetes. But are these diets healthy long term? For some of them, the answer is a clear no. Others are unlikely to be healthy but have not been studied long term. So, we don’t know whether they are healthy or not.

What if you started from the opposite perspective? Instead of asking, “Is a diet that helps you lose weight healthy long term?”, what if you asked, “Can healthy eating help you lose weight?” The study (S Schutte et al, American Journal of Clinical Nutrition, 115: 1-18, 2022) I will review this week asked that question.

More importantly, it was an excellent study. It compared a healthy diet to an unhealthy diet with exactly the same degree of caloric restriction. And it compared both diets to the habitual diet of people in that area. This study was performed in the Netherlands, so both weight loss diets were compared to the habitual Dutch diet.

How Was The Study Done?

This was a randomized controlled trial, the gold standard of clinical studies. The investigators recruited 100 healthy, abdominally obese men and women aged 40-70. At the time of entry into the study none of the participants:

Had diabetes.
Smoked
Had a diagnosed medical condition.
Were on a medication that interfered with blood sugar control.
Were on a vegetarian diet.

The participants were randomly assigned to:

A high-nutrient quality diet that restricted calories by 25%.
A low-nutrient-quality diet that restricted calories by 25%.
Continue with their habitual diet.

The study lasted 12 weeks. The participants met with a dietitian on a weekly basis. The dietitian gave them the foods for the next week and monitored their adherence to their assigned diet. They were advised not to change their exercise regimen during the study.

At the beginning and end of the study the participants were weighed, and cholesterol, triglycerides, and blood pressure were measured.

Can Healthy Eating Help You Lose Weight?

To put this study into context, these were not healthy and unhealthy diets in the traditional sense.

Both were whole food diets.
Both included fruits, vegetables, low-fat dairy, and lean meats.
Both restricted calories by 25%.

The diets were designed so that the “high-nutrient quality” diet had significantly more plant protein (in the form of soy protein), fiber, healthy fats (monounsaturated and omega-3 fats), and significantly less fructose and other simple sugars than the “low-nutrient-quality” diet.

At the end of 12 weeks:

Participants lost significant weight on both calorie-restricted diets compared to the group that continued to eat their habitual diet.

- That is not surprising. Any diet that successfully restricts calories will result in weight loss.

Participants on the high-nutrient quality diet lost 33% more weight than participants on the low-nutrient-quality diet (18.5 pounds compared to 13.9 pounds).

Participants on the high-nutrient quality diet lost 50% more inches in waist circumference than participants on the low-nutrient-quality diet (1.8 inches compared to 1.2 inches).

- This is a direct measure of abdominal obesity.

When the investigators measured blood pressure, fasting total cholesterol levels, and triglyceride levels:

These cardiovascular risk factors were significantly improved on both diets.

- Again, this would be expected. Any diet that causes weight loss results in an improvement in these parameters.

The reduction in total serum cholesterol was 2.5-fold greater and the reduction in triglycerides was 2-fold greater in the high-nutrient quality diet group than in the low-nutrient-quality diet group.

The reduction in systolic blood pressure was 2-fold greater and the reduction in diastolic blood pressure was 1.67-fold greater in the high-nutrient quality diet group than in the low-nutrient-quality diet group.

The authors concluded, “Our results demonstrate that the nutrient composition of an energy-restricted diet is of great importance for improvements of metabolic health in an overweight, middle-aged population. A high-nutrient quality energy-restricted diet enriched with soy protein, fiber, monounsaturated fats, omega-3 fats, and reduced in fructose provided additional health benefits over a low-nutrient quality energy-restricted diet, resulting in greater weight loss…and promoting an antiatherogenic blood lipid profile.”

In short, participants in this study lost more weight and had a better improvement in risk factors for heart disease on a high-nutrient-quality diet than on a low-nutrient-quality diet. Put another way, healthy eating helped them lose weight and improved their health.

Who Benefits Most From A Healthy Diet?

None of the participants in this study had been diagnosed with diabetes when the study began. However, all of them were middle-aged, overweight, and had abdominal obesity. That means many of them likely had some degree of insulin resistance.

Because of some complex metabolic studies that I did not describe, the investigators suspected that insulin resistance might influence the relative effectiveness of the two energy-restricted diets.

To test this hypothesis, they used an assay called HOMA-IR (homeostatic model assessment of insulin resistance). Simply put, this assay measures how much insulin is required to keep your blood sugar under control.

They used a HOMA-IR score of 2.5 to categorize insulin resistance among the participants.

Participants with a HOMA-IR score >2.5 were categorized as insulin-resistant. This was 55% of the participants.

Participants with a HOMA-IR score ≤2.5 were categorized as insulin-sensitive. This was 45% of the participants.

When they used this method to categorize participants they found:

Insulin-resistant individual lost about the same amount of weight on both diets.

Insulin-sensitive individuals lost 66% more weight on the high-nutrient-quality diet than the low-nutrient-quality diet (21.6 pounds compared to 13.0 pounds).

The investigators concluded, “Overweight, insulin-sensitive subjects may benefit more from a high- than a low-nutrient-quality energy-restricted diet with respect to weight loss…”

What Does This Study Mean For You?

Simply put this study confirms that:

Caloric restriction leads to weight loss, and…

Weight loss leads to improvement in cardiovascular risk factors like total cholesterol, triglycerides, and blood pressure.

- This is not new.

- This is true for any diet that results in caloric restriction.

This study breaks new ground in that a high-nutrient quality diet results in significantly better:

Weight loss and…

Reduction in cardiovascular risk factors…

…than a low-nutrient quality diet. As I said above, the distinction between a “high-nutrient-quality” diet and a “low-nutrient-quality” diet may not be what you might have expected.

Both diets were whole food diets. Neither diet allowed sodas, sweets, and highly processed foods.

Both included fruits, vegetables, grains, and lean meats.
Both reduced caloric intake by 25%.

- If you want to get the most out of your weight loss diet, this is a good place to start.

In this study the investigators designed their “high-nutrient-quality” diet so that it contained:

More plant protein in the form of soy protein.

- In this study they did not reduce the amount of animal protein in the “high-nutrient-quality” diet. They simply added soy protein foods to the diet. I would recommend substituting soy protein for some of the animal protein in the diet.

More fiber.

- The additional fiber came from substituting whole grain breads and brown rice for refined grain breads and white rice, adding soy protein foods, and adding an additional serving of fruit.

More healthy fats (monounsaturated and omega-3 fats).

- The additional omega-3s came from adding a fish oil capsule providing 700mg of EPA and DHA.

Less simple sugars. While this study focused on fructose, their high-nutrient-quality diet was lower in all simple sugars.

All these changes make great sense if you are trying to lose weight. I would distill them into these 7 recommendations.

Follow a whole food diet. Avoid sodas, sweets, and highly processed foods.

Include all 5 food groups in your weight loss diet. Fruits, vegetables, whole grains, dairy, and lean proteins all play an important role in your long-term health.

Eat a primarily plant-based diet. My recommendation is to substitute plant proteins for at least half of your high-fat animal proteins. And this study reminds us that soy protein foods are a convenient and effective way to achieve this goal.

Eat a diet high in natural fibers. Including fruits, vegetables, whole grains, beans, nuts, seeds, and soy foods in your diet is the best way to achieve this goal.

Substitute healthy fats (monounsaturated and omega-3 fats) for unhealthy fats (saturated and trans fats) in your diet. And this study reminds us that it is hard to get enough omega-3s in your diet without an omega-3 supplement.

Reduce the amount of added sugar, especially fructose, from your diet. That is best achieved by eliminating sodas, sweets, and highly processed foods from the diet. I should add that fructose in fruits and some healthy foods is not a problem. For more information on that topic, I refer you to a previous “Health Tips” article .

Finally, I would like to remind you of the obvious. No diet, no matter how healthy, will help you lose weight unless you cut back on calories. Fad diets achieve that by restricting the foods you can eat. In the case of a healthy diet, the best way to do it is to cut back on portion sizes and choose foods with low caloric density.

I should touch briefly on the third major conclusion of this study, namely that the “high-nutrient quality diet” was not more effective than the “low-nutrient-quality” diet for people who were insulin resistant. In one sense, this was not news. Previous studies have suggested that insulin-resistant individuals have more difficulty losing weight. That’s the bad news.

However, there was a silver lining to this finding as well:

Only around half of the overweight, abdominally obese adults in this study were highly insulin resistant.

- That means there is a ~50% chance that you will lose more weight on a healthy diet.

Because both diets restricted calories by 25%, insulin-resistant individuals lost weight on both diets.

- That means you can lose weight on any diet that successfully reduces your caloric intake. That’s the good news.

- However, my recommendation would still be to choose a high-nutrient quality diet that is designed to reduce caloric intake, because that diet is more likely to be healthy long term.

The Bottom Line

A recent study asked, “Can healthy eating help you lose weight?” This study was a randomized controlled study, the gold standard of clinical studies. The participants were randomly assigned to:

A high-nutrient quality diet that restricted calories by 25%.
A low-nutrient-quality diet that restricted calories by 25%.
Continue with their habitual diet.

These were not healthy and unhealthy diets in the traditional sense.

Both were whole food diets.
Both included fruits, vegetables, low-fat dairy, and lean meats.
Both restricted calories by 25%.

At the end of 12 weeks:

Participants on the high-nutrient quality diet lost 33% more weight than participants on the low-nutrient-quality diet (18.5 pounds compared to 13.9 pounds).

When the investigators measured cardiovascular risk factors at the end of 12 weeks:

The reduction in total serum cholesterol was 2.5-fold greater and the reduction in triglycerides was 2-fold greater in the high-nutrient quality diet group than in the low-nutrient-quality diet group.

The reduction in systolic blood pressure was 2-fold greater and the reduction in diastolic blood pressure was 1.67-fold greater in the high-nutrient quality diet group than in the low-nutrient-quality diet group.

For more details on this study, what this study means for you, and my 7 recommendations for a healthy weight loss diet, 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 Children Need?

September 6, 2022 by Dr. Steve Chaney

What Does This Study Mean For Your Children?

Author: Dr. Stephen Chaney

It is back to school time again. If you have children, you are probably rushing around to make sure they are ready.

Backpack…Check.
Books…Check
School supplies…Check
Omega-3s…???

Every parent wants their child to do their best in school. But do they need omega-3s to do their best? I don’t need to tell you that question is controversial.

Some experts claim that omega-3 supplementation in children improves their cognition. [Note: Cognition is defined as the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses. In layman’s terms that means your child’s ability to learn.]

Other experts point out that studies in this area disagree. Some studies support these claims. Others don’t. Because the studies disagree these experts conclude there is no good evidence to support omega-3 supplementation in children.

The authors of this study (ISM van der Wurff et al, Nutrients, 12: 3115, 2020) took a different approach. They asked why these studies disagreed. They hypothesized that previous studies disagreed because there is a minimal dose of omega-3s needed to achieve cognitive benefits in children. In short, they were asking how much omega-3s do children need.

They based their hypothesis on recent studies showing that a minimum dose of omega-3s is required to show heart health benefits in adults.

What Have We Learned From Studies on Omega-3s And Heart Health?

The breakthrough in omega-3/heart health studies came with the development of something called the omega-3 index. Simply put, omega-3s accumulate in our cell membranes. The omega-3 index is the percent omega-3s in red blood cell membranes and is a good measure of our omega-3 status.

Once investigators began measuring the omega-3 index in their studies and correlating it with heart health, it became clear that:

An omega-3 index of ≤4% correlated with a high risk of heart disease.

An omega-3 index of ≥8% correlated with a low risk of heart disease.

Most Americans have an omega-3 index in the 4-6% range.

Clinical studies in which participants’ omega-3 index started in the low range and increased to ~8% through supplementation generally showed a positive effect of omega-3s on reducing heart disease risk. [I say generally because there are other factors in study design that can obscure the effect of omega-3s.]

This is the model that the authors adopted for their study. They asked how much omega-3s do children need to show a positive effect of omega-3s on their cognition (ability to learn).

How Was The Study Done?

The authors included 21 studies in their analysis that met the following criteria:

All studies were placebo controlled randomized clinical trials.

The participants were 4-25 years old and had not been diagnosed with ADHD.

Supplementation was with the long-chain omega-3s DHA and/or EPA.

The trial assessed the effect of omega-3 supplementation on cognition.

I do not want to underestimate the difficulties the authors faced in their quest. The individual studies differed in:

The dose of omega-3s.

- The relative amount of DHA and EPA.

- Whether omega-3 index was measured. Only some of the studies measured fatty acid levels in the blood. The authors were able to calculate the omega-3 index in these studies.

How cognition (ability to learn) was measured.

The age of the children.

- 20 of the studies were done with children (4-12 years old) or late adolescents (20-25 years old).

- Only one study was done on early to middle adolescents (12-20 years old).

All these variables influence the outcome and could obscure the effect of omega-3s on cognition.

In short, determining the omega-3 dose-response for an effect on cognition was a monumental task. It was like searching for a needle in a haystack. These authors did a remarkable job.

How Much Omega-3s Do Children Need?

Here is what the scientists found when they analyzed the data:

60% of the studies in which an omega-3 index of ≥6% was achieved showed a beneficial effect of omega-3 supplementation on cognition (ability to learn) compared to 20% of the studies that did not achieve an omega-3 index of 6%.

- That is a 3-fold difference in effectiveness once a threshold of 6% omega-3 index was reached.

50% of the studies in which a dose of ≥ 450 mg/day of DHA + EPA was used showed a beneficial effect of omega-3 supplementation on cognition (ability to learn) compared to 25% of the studies that used <450 mg/day DHA + EPA.

- That is a 2-fold difference in effectiveness once a threshold of 450 mg/day DHA + EPA was given.

The authors concluded, “Daily supplementation of ≥450 mg/day DHA and/or EPA and an increase in the omega-3 index to >6% makes it more likely to show efficacy [of omega-3s] on cognition (ability to learn) in children and adolescents.”

What Does This Study Tell Us?

It is important to understand what this study does and does not tell us.

This study does not:

Prove that omega-3 supplementation can improve cognition (ability to learn) in children and adolescents.

Define optimal levels of DHA + EPA.

Tell us whether DHA, EPA, or a mixture is better.

It was not designed to do any of these things. It was designed to give us a roadmap for future studies. It tells us how to design studies that can provide definitive answers to these questions.

This study does:

Define a threshold dose of DHA + EPA for future studies (450 mg/day).

Tells us how to best use the omega-3 index in future studies. To obtain meaningful results:

- Participants should start with an omega-3 index of 4% or less.

- Participants should end with an omega-3 index of 6% or greater.

In my opinion, future studies would also be much more effective if scientists in this area of research could agree on a single set of cognitive measures to be used in all subsequent studies.

In short, this study provides critical information that can be used to design future studies that will be able to provide definitive conclusions about omega-3s and cognition in children.

What Does This Study Mean For Your Children?

As a parent or grandparent, you probably aren’t interested in optimizing the design of future clinical studies. You want answers now.

Blood tests for omega-3 index are available, but they are not widely used. And your insurance may not cover them.

So, for you the most important finding from this study is that 450 mg/day DHA + EPA appears to be the threshold for improving a child’s cognition (their ability to learn).

450 mg/day is not an excessive amount. The NIH defines adequate intakes for omega-3s as follows:

4-8 years: 800 mg/day
9-13 years: 1 gm/day for females, 1.2 gm/day for males
14-18 years: 1.1 gm/day for females and 1.6 gm/day for males.
With at least 10% of that coming from DHA + EPA

Other organizations around the world recommend between 100 mg/day and 500 mg/day DHA + EPA depending on the age and weight of the child and the organization.

Most children need supplementation to reach adequate omega-3 intake. The NIH estimates the average child only gets around 40 mg/day omega-3s from their diet. No matter which recommendation you follow, it is clear that most children are not getting the recommended amount of DHA + EPA in their diet.

Genetics.
Diet.
Environment.
The value placed on learning by parents and peers.

Supplementation is just one factor in your child’s ability to learn. But it is one you can easily control. . And if your child is like most, he or she is probably not getting enough omega-3s in their diet.

The Bottom Line

It is back to school time again. Every parent wants their child to do their best in school. But do they need omega-3s to do their best? I don’t need to tell you that question is controversial.

Some studies support these claims, but others don’t. Because the studies disagree some experts conclude there is no good evidence to support omega-3 supplementation in children.

The authors of a recent study took a different approach. They asked why these studies disagreed. They hypothesized that previous studies disagreed because there was a minimal dose of omega-3s needed to achieve cognitive benefits in children. They asked how much omega-3s children need.

They analyzed the data from 21 previous studies looking at the effect of omega-3 supplementation on cognition (ability to learn) in children and adolescents. Their analysis showed:

60% of the studies in which an omega-3 index of ≥6% was achieved showed a beneficial effect of omega-3 supplementation on cognition (ability to learn) compared to 20% of the studies that did not achieve an omega-3 index of 6%.

- That is a 3-fold difference in effectiveness once a threshold of 6% omega-3 index was reached.

50% of the studies in which a dose of ≥ 450 mg/day of DHA + EPA was used showed a beneficial effect of omega-3 supplementation on cognition (ability to learn) compared to 25% of the studies that used <450 mg/day DHA + EPA.

- That is a 2-fold difference in effectiveness once a threshold dose of 450 mg/day DHA + EPA was given.

The authors concluded, “Daily supplementation of ≥450 mg/day DHA + EPA and an increase in the omega-3 index to >6% makes it more likely to show efficacy [of omega-3s] on cognition (ability to learn) in children and adolescents.”

For more details on the study and what it means for your children and grandchildren, 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.

Omega-3s Reduce Preterm Births

August 9, 2022 by Dr. Steve Chaney

Do Omega-3s Make For A Healthy Pregnancy?

Author: Dr. Stephen Chaney

The role of omega-3s on a healthy pregnancy has been in the news for some time. Claims have been made that omega-3s reduce preterm births, postnatal depression, and improve cognition, IQ, vision, mental focus, language, and behavior in the newborn as they grow.

The problem is that almost all these claims have been called into question by other studies. If you are pregnant or thinking of becoming pregnant, you don’t know what to believe.

Should you eat more fish?
Should you take omega-3 supplements?
Or should you just ignore the claims about omega-3s and a healthy pregnancy?

These are not trivial questions. Let’s consider preterm births as an example. The medical profession has made enormous advances in keeping premature babies alive. However, premature babies are still at higher risk of several health conditions including:

Visual impairment.
Developmental Delay.
Learning difficulties.

Plus, it is expensive to keep premature babies alive. One recent study estimated that increasing omega-3 intake during pregnancy could reduce health care costs by around $6 billion in the United Stated alone.

Unfortunately, it’s not just omega-3s and pregnancy. The same is true for almost all nutritional health claims. One day a study comes out claiming that nutrient “X” cures some disease or has some miraculous benefit. The bloggers and news media hype that study. Suddenly you see that health claim everywhere. It becomes so omnipresent that you are tempted to believe it must be true.

But wait. A few months later another study comes to opposite conclusion. Now the media is telling you that health claim is false. The months come and go, and new studies keep coming out. Some support the health claim. Others refute it.

Pretty soon the nutrition headlines just become “noise”. You don’t know what to believe. If you want the truth, “Who ya gonna call?”

Who Ya Gonna Call?

It’s not Ghostbusters. It not Dr. Strangelove’s health blog. It’s a group called the Cochrane Collaboration.

The Cochrane Collaboration consists of 30,000 volunteer scientific experts from across the globe whose sole mission is to analyze the scientific literature and publish reviews of health claims so that health professionals, patients, and policy makers can make evidence-based choices about health interventions.

The Cochrane Collaboration reviews all the relevant studies on a topic, exclude those that are biased or weak, and make their recommendations based on only the strongest studies. Their reviews are considered the gold standard of evidence-based medicine.

If you are of a certain age, you may remember that TV commercial “When EF Hutton talks, people listen.” It is the same with the Cochrane Collaboration. When they talk, health professionals listen.

This week we will examine the Cochrane Collaboration’s review titled “Omega-3 Fatty Acid Addition During Pregnancy”.

How Was The Study Done?

For this analysis the Cochrane Collaboration reviewed 70 randomized controlled trials which compared the effect of added omega-3s on pregnancy outcomes with either a placebo or a diet no added omega-3s. These trials included almost 19,927 pregnant women.

In one sense, Cochrane reviews are what is called a “meta-analysis”, in which data from numerous studies are grouped together so that a statistically significant conclusion can be reached. However, Cochrane Collaboration reviews differ from most meta-analyses found in the scientific literature in a very significant way.

Many published meta-analyses simply report “statistically significant” conclusions. However, statistics can be misleading. As Mark Twain said: “There are lies. There are damn lies. And then there are statistics”.

The problem is that the authors of most meta-analyses group studies together without considering the quality of studies included in their analysis. This creates a “Garbage In – Garbage Out” effect. If the quality of individual studies is low, the quality of the meta-analysis will also be low. Simply put, the conclusions from some published meta-analyses are not worth the paper they are written on.

The Cochrane Collaboration also reports statistically significant conclusions from their meta-analyses. However, they also carefully consider the quality of each individual study in their analysis. They look at possible sources of bias. They look at the design and size of the studies. Finally, they ask whether the conclusions are consistent from one study to the next. They clearly define the quality of evidence that backs up each of their conclusions as follows:

High-quality evidence. Further research is unlikely to change their conclusion. This is generally reserved for conclusions backed by multiple high-quality studies that have all come to the same conclusion. These are the recommendations that are most often adopted into medical practice.

Moderate-quality evidence. This conclusion is likely to be true, but further research could have an impact on it.

Low-quality evidence. Further research is needed and could alter the conclusion. They are not judging whether the conclusion is true or false. They are simply saying more research is needed to reach a definite conclusion.

Omega-3s Reduce Preterm Births

Here are the conclusions that the Cochrane Collaboration said were supported by high-quality evidence:

Omega-3s reduce the risk of preterm births.

Omega-3s reduce the risk of low-birth-weight infants.

The authors concluded: “Omega-3 supplementation during pregnancy is an effective strategy for reducing the risk of preterm birth…More studies comparing omega-3s and placebo are not needed at this point.”

In other words, they are saying this conclusion is definite. Omega-3 supplementation should become part of the standard of medical care for pregnant women.

However, they did say that further studies were needed “…to establish if, and how, outcomes vary by different types of omega-3s, timing [stage of pregnancy], doses [of omega-3s], or by characteristics of women.”

That’s because these variables were not analyzed in the Cochrane study. Their review and meta-analysis included clinical trials:

Of women at low, moderate, and high risk of poor pregnancy outcomes.

With DHA alone, with EPA alone, and with a mixture of both.

Omega-3 doses that were low (˂ 500 mg/day), moderate (500-1,000 mg/day), and high (> 1,000 mg/day).

Do Omega-3s Make For A Healthy Pregnancy?

What about the effect of omega-3s on other pregnancy outcomes?

The conclusions the Cochrane Collaboration said were supported by moderate quality evidence included reductions in:

Perinatal death.

Admissions to the neonatal intensive care unit.

There was not enough high or moderate quality data to determine the effect of omega-3s on other pregnancy outcomes such as postnatal depression. More research is still needed in those areas. However, if you do receive any of these benefits from omega-3 supplementation, you can just consider them as side benefits.

What Does This Report Mean For You?

1) The proven effect of omega-3 supplementation on preterm births is significant because preterm births increase the risk of:

Visual impairment.
Developmental Delay.
Learning difficulties.

2) The likely effect of omega-3s on admission to neonatal intensive care units is significant because those units are very expensive.

3) The Cochrane study did not determine whether omega-3 supplementation was equally important for women at low, moderate, and high likelihood of poor pregnancy outcomes.

Therefore, omega-3 supplementation should be considered for all pregnant women.

4) The Cochrane study did not determine whether omega-3 supplementation was equally important during the first, second, or third trimester.

Therefore, omega-3 supplementation should be considered by all women of childbearing age who might become pregnant and throughout pregnancy.

5) The Cochrane study did not determine whether DHA, EPA, or a mixture of the two was most effective.

Therefore, your omega-3 supplement should probably contain both DHA and EPA. A group of experts recently recommended that adults consume at least 650 mg/day of omega-3s with ≥ 220 mg of that coming from DHA and ≥ 220 mg/day coming from EPA.

Since most pregnant women in this country consume around 89 mg/day of DHA + EPA, omega-3 supplementation is warranted.

The Bottom Line

The effect of omega-3s on pregnancy outcomes have been confusing. Some studies conclude that omega-3s are important for a healthy pregnancy. Other studies suggest they are ineffective. What are you to believe?

Fortunately, a group called the Cochrane Collaboration recently conducted a comprehensive review of this topic. This is significant because Cochrane Reviews are internationally recognized as the highest standard in evidence-based health care. They influence the treatment protocols recommended by the medical community.

This Cochrane Review concluded that omega-3 supplementation during pregnancy:

Reduces preterm births and low birth weight infants.

Likely reduces perinatal death and admissions to the neonatal intensive care unit.

The authors of the review said: “Omega-3 supplementation during pregnancy is an effective strategy for reducing the risk of preterm birth…More studies comparing omega-3s and placebo are not needed at this point.”

In other words, they are saying this conclusion is definite. Omega-3 supplementation should become part of the standard of medical care for pregnant women.

For more details on the study and what it means for you, 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-3 Should You Take During Pregnancy?

June 22, 2021 by Dr. Steve Chaney

Which Omega-3s Are Beneficial?

Author: Dr. Stephen Chaney

Preterm births (births occurring before 37 weeks) are increasing in this country. Just between 2018 and 2019, the percentage of preterm births increased by 2% to over 10% of all pregnancies. That is a concern because preterm births are associated with an increased risk of:

Visual impairment.
Developmental delays.
Learning difficulties.
Problems with normal development of lungs, eyes, and other organs.

Plus, it is expensive to keep premature babies alive. One recent study estimated that reducing the incidence of preterm births by around 50% could reduce health care costs by $6 billion in the United Stated alone.

Of the 10% preterm births, 2.75% of them are early preterm births (births occurring before 34 weeks). Obviously, the risk of health problems and the cost of keeping them alive is greatest for early preterm babies.

We don’t know why preterm births are increasing, but some experts feel it is because in this country:

More older women are having babies.

There is increased use of fertility drugs, resulting in multiple babies

Unfortunately, there is no medical standard for identifying pregnancies at risk for preterm birth. Nor is there any agreement around prevention measures for preterm births.

However, recent research has suggested that some premature births may be caused by inadequate omega-3 status in the mother and can be prevented by omega-3 supplementation.

What Do We Know About Omega-3s And Risk Of Preterm Births?

The problem is that almost all these claims have been called into question by other studies. If you are pregnant or thinking of becoming pregnant, you don’t know what to believe.

Fortunately, a group called the Cochrane Collaboration has recently reviewed these studies. The Cochrane Collaboration consists of 30,000 volunteer scientific experts from across the globe whose sole mission is to analyze the scientific literature and publish reviews of health claims so that health professionals, patients, and policy makers can make evidence-based choices about health interventions. Their reviews are considered the gold standard of evidence-based medicine.

This is because most published meta-analyses simply report “statistically significant” conclusions. However, statistics can be misleading. As Mark Twain said: “There are lies. There are damn lies. And then there are statistics”.

The problem is the authors of most meta-analyses group studies together without considering the quality of studies included in their analysis. This creates a “Garbage In – Garbage Out” effect. If the quality of individual studies is low, the quality of the meta-analysis will also be low.

The Cochrane Collaboration reviews are different. They also report statistically significant conclusions from their meta-analyses. However, they carefully consider the quality of each individual study in their analysis. They look at possible sources of bias. They look at the design and size of the studies. Finally, they ask whether the conclusions are consistent from one study to the next. They clearly define the quality of evidence that backs up each of their conclusions.

For omega-3s and pregnancy, the Cochrane Collaboration performed a meta-analysis and review of 70 randomized controlled trials that compared the effect of added omega-3s on pregnancy outcomes with the effect of either a placebo or no omega-3s. These trials included almost 19,927 pregnant women.

This Cochrane Collaboration Review looked at all the claims for omega-3s and pregnancy outcome, but they concluded that only two of the claims were supported by high-quality evidence:

Omega-3s reduce the risk of preterm births.

Omega-3s reduce the risk of low birth-weight infants.

The authors concluded: “Omega-3 supplementation during pregnancy is an effective strategy for reducing the risk of preterm birth…More studies comparing [the effect of] omega-3s and placebo [on preterm births] are not needed at this point.”

In other words, they are saying this conclusion is definite. The Cochrane Collaboration has declared that omega-3 supplementation should become part of the standard of medical care for pregnant women.

However, the Cochrane Collaboration did say that further studies were needed “…to establish if, and how, outcomes vary by different types of omega-3s, timing [stage of pregnancy], doses [of omega-3s], or by characteristics of women.”

That’s because these variables were not analyzed in this study. The study included clinical trials:

Of women at low, moderate, and high risk of poor pregnancy outcomes.

With DHA alone, with EPA alone, and with a mixture of both.

Omega-3 doses that were low (˂ 500 mg/day), moderate (500-1,000 mg/day), and high (> 1,000 mg/day).

I have discussed these findings in more detail in a previous issue of “Health Tips From The Professor”

How Was This Study Done?

The current study (SE Carlson et al, EClinicalMedicine, 2021) is a first step towards answering those questions.

The authors of this study focused on how much DHA supplementation is optimal during pregnancy. This is an important question because there is currently great uncertainty about how much DHA is optimal:

The American College of Obstetrics and Gynecology recommends supplementation with 200 mg/day of DHA. However, that recommendation assumes that the increase will come from fish and was influenced by concerns that omega-3-rich fish are highly contaminated with heavy metals and PCBs.

Another group of experts was recently asked to develop guidelines for omega-3 supplementation during pregnancy. They recommended pregnant women consume at least 300 mg/day of DHA and 220 mg/day of EPA.

The WHO has recommended of minimum dose of 1,000 mg of DHA during pregnancy.

Many prenatal supplements now contain 200 mg of DHA, but very few provide more than 200 mg.

Accordingly, the authors took the highest and lowest recommendations for DHA supplementation and asked whether 1,000 mg of DHA per day was more effective than 200 mg of DHA at reducing the risk of early preterm births. Their hypothesis was that 1,000 mg of DHA would be more effective than 200 mg/day at preventing early preterm births.

This study was a multicenter, double-blind, randomized trial of 1032 women recruited at one of three large academic medical centers in the United States (University of Kansa, Ohio State University, and University of Cincinnati).

The women were ≥ 18 years old (average age = 30) and between 12 and 20 weeks of gestation when they entered the study.

The breakdown by ethnicity was 50% White, 22% Black or African American, 22% Hispanic, 6% Other.

18% had a prior preterm birth (<37 weeks) and 7% had a prior early preterm birth (<34 weeks).

Prior to enrollment in the study 47% of the participants reported taking a DHA supplement and 19% of the participants took a DHA supplement with > 200 mg/day.

All the participants received 200 mg DHA capsules and were told to take one capsule daily. The participants were also randomly assigned to take 2 additional capsules that contained a mixture of corn and soybean oil (the 200 mg DHA/day group) or 2 capsules that contained 400 mg of DHA (the 1,000 mg DHA/day group). The capsules were orange flavored so the participants could not distinguish between the DHA capsules and the placebo capsules.

Blood samples were drawn upon entry to the study and either just prior to delivery or the day after delivery to determine maternal DHA status.

The study was designed to look at the effect of DHA dose (1,000 mg or 200 mg) on early preterm birth (<34 weeks), preterm birth (<37 weeks), low birth weight (< 3 pounds), and several other parameters related to maternal and neonatal health.

How Much Omega-3 Should You Take During Pregnancy?

The primary findings from this study were:

The rate of early preterm births (<34 weeks) was less (1.7%) for pregnant women taking 1,000 mg of DHA/day compared to 200 mg/day (2.4%).

The rate of late preterm births (between 34 and 37 weeks) was also less for women taking 1,000 mg of DHA/day compared to 200 mg/day.

Finally, low birth weight and the frequency of several maternal and neonatal complications during pregnancy, delivery, and immediately after delivery were also lower with 1,000 mg/day of supplemental DHA than with 200 mg/day.

This confirms the authors’ hypothesis that supplementation with 1,000 mg/day of DHA is more effective than 200 mg/day at reducing the risk of early preterm births. In addition, this study showed that supplementation with 1,000 mg of DHA/day had additional benefits.

This study did not have a control group receiving no DHA. However:

The US average for early preterm births is 2.74%.

For the women in this study who had previous pregnancies, the rate of early preterm birth was 7%.

Of course, the important question for any study of this type is whether all the women benefited equally from supplementation. Fortunately, this study was designed to answer that question.

As noted above, each woman was asked whether they took any DHA supplements at the time they enrolled in the study, and 47% of the women in the study were taking DHA supplements when they enrolled. In addition, the DHA status of each participant was determined from blood samples taken at the time the women were enrolled in the study. When the authors split the women into groups based on their DHA status at the beginning of the study:

For women with low DHA status the rate of early preterm births was 2.0% at 1,000 mg of DHA/day versus 4.1% at 200 mg of DHA/day.

For women with high DHA status the rate of early preterm births was around 1% for both 1,000 mg of DHA/day and 200 mg of DHA/day.

In other words, DHA supplementation only appeared to help women with low DHA status. This is good news because:

DHA status is an easy to measure predictor of women who are at increased risk of early preterm birth.

This study shows that supplementation with 1,000 mg of DHA/day is effective at reducing the risk of early premature birth for women who are DHA deficient.

In the words of the authors, “Clinicians could consider prescribing 1,000 mg DHA daily during pregnancy to reduce early preterm birth in women with low DHA status if they are able to screen for DHA.”

Which Omega-3s Are Beneficial?

DHA is the most frequently recommended omega-3 supplement during pregnancy.

It is not difficult to understand why that is.

DHA is a major component of the myelin sheath that coats every neuron in the brain. [You can think of the myelin sheath as analogous to the plastic coating on a copper wire that allows it to transmit electricity from one end of the wire to the other.]

Unlike other components of the myelin sheath, the body cannot make DHA. It must be provided by the diet.

During the third trimester, DHA accumulates in the human brain faster than any other fatty acid.

Animal studies show that DHA deficiency during pregnancy interferes with normal brain and eye development.

Some, but not all, human clinical trials show that DHA supplementation during pregnancy improves developmental and cognitive outcomes in the newborn.

Recent studies have shown that most women in the United States only get 60-90 mg/day of DHA in their diet.

Clearly, DHA is important for fetal brain development during pregnancy, and most pregnant women are not getting enough DHA in their diet. This is why most experts recommend supplementation with DHA during pregnancy. And this study suggests supplementation with 1,000 mg/day is better than 200 mg/day. However, two important questions remain:

#1: Is 1,000 mg of DHA/day optimal? The answer is, “We don’t know”. This study compared the highest recommended dose (1,000 mg/day) with the lowest recommended dose (200mg/day) and concluded that 1,000 mg/day was better than 200 mg/day.

But would 500 or 800 mg/day be just as good as 1,000 mg/day? We don’t know. More studies are needed.

#2: Can DHA do it all, or are other omega-3s also important for a healthy pregnancy? As noted above, the emphasis on supplementation with DHA was based on the evidence for a role of DHA in fetal brain development during pregnancy.

But is DHA or EPA more effective at preventing early preterm birth and maternal pregnancy complications? Again, we don’t know.

As noted above, the Cochrane Collaboration concluded that omega-3s were effective at reducing early preterm births but was unable to evaluate the relative effectiveness of EPA and DHA because their review included studies with DHA only, EPA only, and EPA + DHA.

This is an important question because the ability of the body to convert EPA to DHA and vice versa is limited (in the 10-20%) range. This means that if both EPA and DHA are important for a healthy pregnancy, it might not be optimal to supplement with a pure DHA or pure EPA supplement.

Based on currently available data if you are pregnant or thinking of becoming pregnant, my recommendations are:

Chose a supplement that provides both EPA and DHA.

Because the evidence is strongest for DHA at this time, chose an algal source of omega-3s that has more DHA than EPA.

Aim for a dose of DHA in the 500 mg/day to 1,000 mg/day range. Remember, this study showed 1,000 mg/day was better than 200 mg/day but did not test whether 500 or 800 mg/day might have been just as good.

As more data become available, I will update my recommendations.

The Bottom Line

The Cochrane Collaboration recently released a report saying that the evidence was definitive that omega-3 supplementation during pregnancy reduced the risk of early preterm births. However, they were not able to reach a definitive conclusion on the optimal dose of omega-3s or the relative importance of EPA and DHA at preventing early preterm birth.

Most experts recommend that pregnant women supplement with between 200 mg/day and 1,000 mg/day of DHA.

A recent study asked whether 1,000 mg of DHA/day was better than 200 mg/day at reducing the risk of early preterm birth. The study found:

The rate of early preterm births (<34 weeks) was less (1.7%) for pregnant women taking 1,000 mg of DHA/day than pregnant women taking 200 mg/day (2.4%).

For women with low DHA status at the beginning of the study, the rate of early preterm births was 2.0% at 1,000 mg of DHA/day versus 4.1% at 200 mg of DHA/day.

For women with high DHA status at the beginning of the study, the rate of early preterm births was around 1% for both 1,000 mg of DHA/day and 200 mg of DHA/day.

The authors concluded, “Clinicians could consider prescribing 1,000 mg DHA daily during pregnancy to reduce early preterm birth in women with low DHA status…”

There are two important caveats:

This study did not establish the optimal dose of DHA. The study concluded that 1,000 mg/day was better than 200 mg/day. But would 500 or 800 mg/day be just as good as 1,000 mg/day? We don’t know. More studies are needed.

This study did not establish the relative importance of EPA and DHA for reducing the risk of early preterm births. DHA is recommended for pregnant women based on its importance for fetal brain development. But is DHA more important than EPA for reducing the risk of early preterm births? Again, we don’t know. More studies are needed.

For more details about this study and my recommendations, 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.

Do Omega-3s Add Years To Your Life?

June 1, 2021 by Dr. Steve Chaney

Why Are Omega-3s So Controversial?

Author: Dr. Stephen Chaney

I don’t need to tell you that omega-3s are controversial. Some experts confidently tell you that omega-3s significantly reduce your risk of heart disease and may reduce your risk of cancer and other diseases. Other experts confidently tell you that omega-3s have no effect on heart disease or any other disease. They claim that omega-3 supplements are no better than “snake oil”.

The problem is that each camp of experts can cite published clinical studies to support their claims. How can that be? How can clinical studies come to opposite conclusions on such an important topic? The problem is that it is really difficult to do high quality clinical studies on omega-3s. I will discuss that in the next section.

The question of whether omega-3s affect life span has also been controversial. Heart disease and cancer are the top two causes of death in this country. So, if omega-3s actually reduced the risk of heart disease and cancer, you might expect that they would also help us live longer. Once again, there are studies on both sides of this issue, but they are poor quality studies.

We need more high-quality studies to clear up the controversies surrounding the health benefits of omega-3s. I will report on one such study in this issue of “Health Tips From The Professor”. But first let me go into more depth about why it is so difficult to do high-quality studies with omega-3 fatty acids.

Clinical Studies 101: Why Are Omega-3s So Controversial?

I have covered this topic in previous issues of “Health Tips From the Professor”, but here is a quick summary.

Randomized, placebo controlled clinical trials (RCTs) are considered the gold standard for evidence-based medicine, but they ill-suited to measure the effect of omega-3s on health outcomes.

- Heart disease and cancer take decades to develop. Most RCTs are too small and too short to show a meaningful effect of omega-3s on these diseases.

- To make up for this shortcoming, some recent RCTs have started with older, sicker patients. This way enough patients die during the study that it can measure statistically significant outcomes. However, these patients are already on multiple medications that mimic many of the beneficial effects of omega-3s on heart disease.

These studies are no longer asking whether omega-3s reduce the risk of heart disease. They are really asking if omega-3s have any additional benefits for patients who are already taking multiple medications – with all their side effects. I don’t know about you, but that is not the question I am interested in.

- Until recently, most RCTs did not measure circulating omega-3 levels before and after supplementation, so the investigators had no idea whether omega-3 supplementation increased circulating omega-3 levels by a significant amount.

And for the few studies where omega-3 levels were measured before and after supplementation, it turns out that for many of the participants, their baseline omega-3 levels were too high for omega-3 supplementation to have a meaningful effect. Only participants with low omega-3 levels at the beginning of the study benefited from omega-3 supplementation.

These studies are often quoted as showing omega-3 supplementation doesn’t work. However, they are actually showing the true value of supplementation. Omega-3 supplementation isn’t for everyone. It is for people with poor diet, increased need, genetic predisposition, and/or pre-existing disease not already treated with multiple medications.

2) Prospective cohort studies eliminate many of the shortcomings of RCTs. They can start with a large group of individuals (a cohort) and follow them for many years to see how many of them die or develop a disease during that time (this is the prospective part of a prospective cohort trial). This means they can start with a healthy population that is not on medications.

This also means that these studies can answer the question on most people’s minds, “Are omega-3s associated with reduced risk of dying or developing heart disease?” However, these studies have two limitations.

- They are association studies. They cannot measure cause and effect.

- Ideally, omega-3 levels would be measured at the beginning of the study and at several intervals during the study to see if the participant’s diet had changed during the study. Unfortunately, most prospective cohort studies only measure omega-3 levels at the beginning of the study.

3) Finally, a meta-analysis combines data from multiple clinical studies.

- The strength of a meta-analysis is that the number of participants is quite large. This increases the statistical power and allows it to accurately assess small effects.

- The greatest weakness of meta-analyses is that the design of the individual studies included in the meta-analysis is often quite different. This introduces variations that decrease the reliability of the meta-analysis. It becomes a situation of “Garbage in. Garbage out”

The study (WS Harris et al, Nature Communications, Volume 12, Article number: 2329, 2021) I am discussing today is a meta-analysis of prospective cohort studies. It was designed to determine the association between blood omega-3 fatty acids and the risk of:

Death from all causes.
Death from heart disease.
Death from cancer.
Death from causes other than heart disease or cancer.

More importantly, it eliminated the major weakness of previous meta-analyses by only including studies with a similar design.

How Was This Study Done?

This study was a meta-analysis of 17 prospective cohort studies with a total of 42,466 individuals looking at the association between omega-3 fatty acid levels in the blood and premature death due to all causes, heart disease, cancer, and causes other than heart disease and cancer.

Participants in the 17 studies were followed for an average of 16 years, during which time 15,720 deaths occurred. This was a large enough number of deaths so that a very precise statistical analysis of the data could be performed.

The average age of participants at entry into the studies was 65, and 55% of the participants were women. Whites constituted 87% of the participants, so the results may not be applicable to other ethnic groups. None of the participants had heart disease or cancer when they entered the study.

Finally, the associations were corrected for a long list of variables that could have influenced the outcome (Read the publication for more details).

A strength of this meta-analysis is that all 17 studies were conducted as part of the FORCE (Fatty Acids & Outcomes Research Consortium) collaboration. The FORCE collaboration was established with the goal of understanding the relationships between fatty acids (as measured by blood levels of the omega-3 fatty acids) on premature death and chronic disease outcomes (cardiovascular disease, cancer, and other conditions).

Each study was designed using a standardized protocol, so that the data could be easily pooled for a meta-analysis. In the words of the FORCE collaboration founders:

The larger sample sizes of [meta-analyses] will substantially increase statistical power to investigate associations…enabling the [meta-analyses] to discover important relationships not discernible in any individual study.

2) Standardization of variable definitions and modeling of associations will reduce variation and potential bias in estimates across cohorts.

3) Results will be far less susceptible to publication bias.

Do Omega-3s Add Years To Your Life?

The meta-analysis divided participants into quintiles based on blood omega-3 levels. When comparing participants with the highest omega-3 levels with participants with the lowest omega-3 levels:

Premature death from all causes was decreased by 16%.

- When looking at the effect of individual omega-3s, EPA > EPA+DHA > DHA.

Premature death from heart disease was decreased by 19%.

- When looking at the effect of individual omega-3s, DHA > EPA+DHA > EPA.

Premature death from cancer was decreased by 15%.

- When looking at the effect of individual omega-3s, EPA > DHA > EPA+DHA.

Premature death from causes other than heart disease and cancer was decreased by 18%.

- When looking at the effect of individual omega-3s, EPA > EPA+DHA > DHA.

The differences between the effects of EPA, DHA, and EPA+DHA were small.

ALA, a short chain omega-3 found in plant foods, had no effect on any of these parameters.

In the words of the authors: “These findings suggest that higher circulating levels of long chain omega-3 fatty acids are associated with a lower risk of premature death. Similar relationships were seen for death from heart disease, cancer, and causes other than heart disease and cancer. No associations were seen with the short chain omega-3, ALA [which is found in plant foods]”.

What Does This Study Mean For You?

If you are thinking that 15-19% decreases in premature death from various causes don’t sound like much, let me do some simple calculations for you. The average lifespan in this country is 78 years.

A 16% decrease in death from all causes amounts to an extra 12.5 years. What would you do with an extra 12.5 years?

A 19% decrease in death from heart disease might not only allow you to live longer, but it has the potential to improve your quality of life by living an extra 15 years free of heart disease.

Similarly, a 15% decrease in death from cancer might help you live an extra 12 years cancer-free.

In other words, you may live longer, and you may also live healthier longer, sometimes referred to as “healthspan”.

Don’t misunderstand me. Omega-3s are not a magic wand. They aren’t the fictional “Fountain of Youth”.

There are many other factors that go into a healthy lifestyle. If you sit on your couch all day eating Big Macs and drinking beer, you may be adding the +12.5 years to a baseline of -30 years.

Clinical studies report average values and none of us are average. Omega-3s will help some people more than others.

I will understand if you are skeptical. It seems like every time one study comes along and tells you that omega-3s are beneficial, another study comes along and tells you they are worthless.

This was an extraordinarily well-designed study, but it is unlikely to be the final word in the omega-3 controversy. There are too many poor-quality studies published each year. Until everyone in the field agrees to some common standards like those in the FORCE collaboration, the omega-3 controversy will continue.

The Bottom Line

A recent meta-analysis looked at the association between omega-3 fatty acid levels in the blood and premature death due to all causes, heart disease, cancer, and causes other than heart disease and cancer.

The meta-analysis divided participants into quintiles based on blood omega-3 levels. When comparing participants with the highest omega-3 levels with participants with the lowest omega-3 levels:

Premature death from all causes was decreased by 16%.

Premature death from heart disease was decreased by 19%.

Premature death from cancer was decreased by 15%.

Premature death from causes other than heart disease and cancer was decreased by 18%.

For more details about study and what this study means for you 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.

Update On Omega-3 Supplementation And Heart Disease

November 10, 2020 by Dr. Steve Chaney

How Much Omega-3s Do You Need?

In previous issues of “Health Tips From The Professor” I have described the medical consensus about omega-3 supplementation and heart disease as resembling a pendulum.

A few positive studies are published, and the pendulum swings in the positive direction. The medical consensus becomes, “Omega-3s may reduce heart disease risk.”

Then a few negative studies are published, and the pendulum swings in the other direction. The consensus becomes that omega-3 supplements are worthless. One review a few years ago went so far as to say that fish oil supplements were the modern-day version of snake oil.

Meta-analyses combine the data from multiple clinical studies to increase statistic power and minimize the effect of clinical studies that are outliers. They are supposed to provide clear answers to medical questions like the effect of omega-3 supplements on heart disease.

However, the meta-analyses published to date have also reached conflicting conclusions about the effectiveness of omega-3 supplementation. No wonder you [and the medical community] are confused!

In 2018 three large, well-designed, clinical studies looking at the effect of omega-3 supplementation on heart disease risk were published. They reached different conclusions. However, they covered a much wider range of omega-3 doses than previous studies. And the studies with the highest doses of omega-3s showed the most positive effect of omega-3 supplementation on the reduction of heart disease risk.

That lead a group of doctors and scientists from the United States and Finland to postulate that many previous studies had failed to find an effect of omega-3 supplements on heart disease risk because the dose of omega-3s they used was too low.

These scientists designed a very large meta-analysis (AA Bernasconi et al, Mayo Clinic Proceedings, doi.org/10.1016/j.mayocp.2020.08.034) to test their hypothesis. In short, their study was designed to:

Determine whether supplementation with the omega-3 fatty acids EPA and DHA resulted in reduced heart disease risk.

Quantify the relationship between the dose of EPA + DHA and the risk of heart disease outcomes.

How Was The Study Done?

This study was a meta-analysis of 40 randomized control clinical studies on the effect omega-3 supplementation on heart disease outcomes. Specifically:

It included all high-quality clinical studies of omega-3 supplementation published before August 2019.

It included a total of 135,267 participants.

It included participants at both low and high risk of developing heart disease.

It included studies of supplementation with EPA alone and with EPA + DHA.

It included omega-3 doses ranging from 400 mg/day to 5,500 mg/day.

It excluded dietary studies because:

- It is difficult to measure the dosage of omega-3s that participants are consuming in dietary studies.

- It is difficult to assure their compliance with dietary advice.

- There is variation in the omega-3 content of various foods.

- Participants in these studies are often advised to make other changes in diet. It then becomes difficult to know whether any benefits observed were from changes in omega-3s or from changes in other components of the diet.

Update On Omega-3 Supplementation And Heart Disease

Here are the results of the meta-analysis. Supplementation with EPA or EPA + DHA reduced:

Coronary Heart disease (defined as diseases caused by atherosclerosis, such as angina, heart attack, and heart failure) by 10%.

Heart Attacks by 13%.

Coronary Heart disease deaths by 9%.

Heart attack deaths by 35%.

Because of the large number of participants in this meta-analysis, they were able to reach some other important conclusions:

Despite the claims you may have heard about a new drug consisting of highly purified EPA, this study found no evidence that EPA supplementation was superior to EPA + DHA supplementation.

Even though heart medications provide some of the same benefits as omega-3s, this study concluded that omega-3 supplementation reduced the risk of heart disease even for patients on multiple heart medications.

This study also concluded that omega-3 supplementation was likely to be effective for people at both low and high risk of heart disease. This means that omega-3 supplementation is likely to be beneficial for preventing heart disease.

The authors concluded: “The current study provides strong evidence that EPA + DHA supplementation is an effective strategy for the prevention of certain coronary heart disease outcomes…Considering the relatively low costs and side effect profiles of omega-3 supplementation and the low drug-drug interactions with other standard therapies…clinicians and patients should consider the potential benefits of omega-3 (EPA/DHA) supplementation…”

What Does This Study Mean For You?

The most significant conclusions from this study are the reduction in heart attacks and heart attack deaths. That is because:

Approximately 1.5 million Americans suffer a heart attack each year. For those who survive their quality of life may be permanently altered.

- A 13% reduction in heart attacks means that something as simple as EPA + DHA supplementation might prevent as many as 195,000 heart attacks a year.

Approximately 100,000 Americans will die from a heart attack each you.

- A 35% reduction in heart attack deaths means that EPA + DHA supplementation might prevent as many as 35,000 deaths from heart attacks each year.

For many Americans sudden death from a heart attack is the first indication that they have heart disease.

- As Benjamin Franklin said, “An ounce of prevention is worth a pound of cure”. That is why EPA + DHA supplementation makes sense for most people.

I can’t say that this study will be the final word on omega-3 supplementation and heart disease risk. However, several recent studies have supported the benefit of omega-3 supplementation at reducing heart disease risk. The pendulum has clearly swung in the direction of omega-3s being beneficial for heart health.

Of course, omega-3 supplementation is not a magic “Get Out of Jail Free” card. You can’t expect it to overcome the effects of a bad diet and lack of exercise with omega-3 supplementation alone. You need a holistic approach.

The American Heart Association recommends:

If you smoke, stop.

Choose good nutrition.

- Choose a diet that emphasizes vegetables, fruits, whole grains, low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils, and nuts.

- Choose a diet that limits sweets, sugar-sweetened beverages, and red meats.

Reduce high blood cholesterol and triglycerides.

Reduce your intake of saturated fat, trans fat and cholesterol and get moving.

Lower High Blood Pressure.

Be physically active every day.

- Aim for at least 150 minutes per week of moderate-intensity physical activity per week.

Aim for a healthy weight.

Manage diabetes.

Reduce stress.

Limit alcohol.

Have a regular physical checkup.

Add in omega-3 supplementation to these recommendations and you have a winning combination.

How Much Omega-3s Do You Need?

As I mentioned at the beginning of this article the omega-3 dosages used in the studies included in this meta-analysis ranged from 400 mg/day to 5,500 mg/day. More importantly, there were enough participants in these studies to obtain a fairly accurate estimate of dose response. This allow the authors to answer the question, “How much omega-3s do I need?”The study found that:

The protective effect of omega-3s for heart attack deaths and coronary heart disease deaths plateaued with dosages of EPA + DHA that exceeded 800 – 1200 mg/day.

The dose response of the protective effect of omega-3s for non-fatal heart attacks was linear over a wider range of dosages, with every increase 1,000 mg/day of EPA + DHA decreasing the risk of heart attack by 9%.

Based on the totality of their data, the authors concluded, “…clinicians and patients should consider the potential benefits of omega-3 supplementation, especially using 1,000 to 2,000 mg/day dosages, which are rarely obtained in most Westernized diets, even those including routine fish consumption.”

The Bottom Line

A recent meta-analysis combined the data from 40 clinical studies with over 135,000 participants looking at the effect of omega-3 supplementation on various types of heart disease. The study found that supplementation with EPA or EPA + DHA reduced:

Coronary Heart disease (defined as diseases caused by atherosclerosis, such as angina, heart attack, and heart failure) by 10%.

Heart Attacks by 13%.

Coronary Heart disease deaths by 9%.

Heart attack deaths by 35%.

Because of the large number of participants in this meta-analysis, they were able to reach some other important conclusions:

This study found no evidence that EPA supplementation was superior to EPA + DHA supplementation.

This study concluded that omega-3 supplementation reduced the risk of heart disease even for patients on multiple heart medications.

This study also concluded that omega-3 supplementation was likely to be effective for people at both low and high risk of heart disease. This means that omega-3 supplementation is likely to be beneficial for preventing heart disease.

The optimal dose of EPA + DHA appeared to be 1,000 – 2,000 mg/day.

The authors of the study concluded: “The current study provides strong evidence that EPA + DHA supplementation is an effective strategy for the prevention of certain coronary heart disease outcomes…Considering the relatively low costs and side effect profiles of omega-3 supplementation and the low drug-drug interactions with other standard therapies…clinicians and patients should consider the potential benefits of omega-3 (EPA/DHA) supplementation, especially using 1,000 to 2,000 mg/day dosages, which are rarely obtained in most Westernized diets, even those including routine fish consumption.”

For more details, including a more detailed discussion of what this study means for you, 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 DHA Is Needed To Prevent Alzheimer’s

September 8, 2020 by Dr. Steve Chaney

What Are We Missing?

We are an aging population. As such, issues like cognitive decline, dementia, and Alzheimer’s Disease are of increasing concern. After all, what is the good of reaching your “Golden Years” with a healthy body if you lose your mind?

The ability of the omega-3 fatty acids DHA and EPA to reduce the risk of cognitive decline, dementia, and Alzheimer’s Disease is controversial. Some studies say yes. Others say no.

When studies are conflicting most experts simply conclude the treatment is unproven. I am sympathetic to that viewpoint, but I first like to ask the questions: “Why are the studies conflicting? What are we missing?”

I start by evaluating the strengths and weaknesses of the individual studies.

If the studies claiming the treatment works are weak, I am content to “join the chorus” and consider the treatment unproven.

If the studies claiming the treatment doesn’t work are weak, I am a strong advocate for more well-designed studies before we conclude that the treatment doesn’t work.

If both the “pro” and “con” studies are strong, I want to ask, “What are we missing?”

This is the situation with studies asking whether DHA reduces the risk of Alzheimer’s Disease and other forms of cognitive decline as we age.

Association studies show that greater intake and higher blood levels of the omega-3 fatty acids EPA and DHA are associated with lower risk of Alzheimer’s Disease.

However, most placebo-controlled clinical trials with either DHA alone or DHA + EPA have come up negative. Of course, one can always argue that most of the placebo-controlled clinical trials were too short or too small to show a statistically significant effect. But, my question remains, “What else are we missing?”

One recent study has provided an interesting clue. The authors of the study postulated that B vitamins were required to deliver omega-3 fatty acids to the brain, and their study showed that omega-3 fatty acids were only effective at decreasing the risk of cognitive decline in subjects who also had optimal B vitamin status.

In other words, this study suggested that studies on the effect of omega-3 supplementation and risk of developing Alzheimer’s are doomed to failure if a significant percentage of the subjects have sub-optimal B vitamin status.

The authors of the current study ( IC Arellanes et al, EBioMedicine, doi.org/10.1016/j.ebiom.2020.102883) proposed two additional hypotheses for the negative results of previous clinical trials and designed an experiment to test their hypotheses. Their hypotheses were:

Uptake of DHA and EPA by the brain is very inefficient, and previous studies have not used sufficient doses of DHA or DHA plus EPA to see a significant effect on cognitive impairment.

The APOE4 gene further decreases the uptake of DHA and EPA by the brain.

Before I describe how the study was done, I should probably provide some context by describing how DHA and EPA reach the brain and the role of the apoE protein in the process. It’s time for my favorite topic: “Biochemistry 101”.

Biochemistry 101: What Does The ApoE Protein Do?

If you have ever tried to mix oil and water, it should come as no surprise to you that fats, including DHA and EPA, and cholesterol are not water soluble. That leaves our bodies with a dilemma. How do they get the fat and cholesterol we eat to pass through our bloodstream and get to our cells, where they are needed?

Our body’s solution is to incorporate the fat and cholesterol into particles called lipoproteins. Lipoprotein particles sequester the fat and cholesterol in their interior and surround them with water soluble phospholipids and proteins. Lipoproteins allow our bodies to transport fat and cholesterol through our bloodstream to the tissues that need them.

The next question, of course, is how the lipoproteins know which cells need the fat and cholesterol. This is where apoproteins like apoE come into play. We can think of the apoE protein as a zip code that directs lipoproteins to cells with an apoE receptor.

Our nervous system contains lots of apoE receptors, and binding of the apoE protein to its receptor is instrumental in the delivery of DHA, EPA, and cholesterol to our nervous system.

DHA and cholesterol are both important for brain health. That is because they are major components of the myelin sheath that wraps around our neurons and protects them. EPA may also be important for brain health because its anti-inflammatory effects are thought to prevent the accumulation of the amyloid plaques that are the hallmark of late-onset Alzheimer’s Disease.

There are three major versions of the APOE gene, APOE2, APOE3, and APOE4. Each of them plays slightly different roles in our body. However, it is the APOE4 version that is of interest to us. About 25% of us have the APOE4 version of the APOE gene and it increases our risk of developing Alzheimer’s Disease by a factor of two.

We do not know why this is, but one hypothesis is that lipoproteins with the apoE4 protein have more difficultly delivering much needed DHA, EPA, and cholesterol to the brain. This is one of the hypotheses that the authors set out to study.

How Was The Study Done?

There are two things you should know about this study.

This was a pilot study designed to test the author’s hypotheses and allow them to choose the correct dose of DHA to use for a subsequent study designed to test whether high-dose DHA can reduce the risk of developing Alzheimer’s Disease.

This was a very small study. That’s because the only way to determine how much DHA and EPA reaches the nervous tissue is to perform a lumbar puncture and obtain cerebrospinal fluid at baseline and again at the end of the study. Lumbar punctures are both painful and a bit risky. They were lucky to find 26 individuals who consented to the lumbar punctures.

This was a double-blind, placebo controlled clinical study.

Half the subjects were given 2,152 mg/day of DHA for 6 months, and half were given a daily placebo consisting of corn and soybean oil for 6 months.

Because previous studies have suggested that B vitamins were important for DHA and EPA uptake by nervous tissue, all subjects received a B vitamin supplement.

Levels of DHA and EPA were measured in both plasma and cerebrospinal fluid at baseline and again at the end of 6 months. Note: The subjects were only supplemented with DHA. The investigators were relying on the body’s ability to convert DHA into EPA.

All subjects were screened for APOE4

Other important characteristics of the study subjects were:

Average age was 69. They were 80% female.

All of them had a close family member who had previously been diagnosed with dementia, but none of them had been diagnosed with cognitive impairment at the time of entry into the study.

Around 45% of them had the APOE4 version of the APOE.

In other words, none of them currently had dementia, but most were at high risk of developing dementia.

How Much DHA Is Needed To Prevent Alzheimer’s?

After 6 months of supplementing with over 2,000 mg/day of DHA:

DHA levels in the blood had increased by 200%.

However, DHA levels in cerebrospinal fluid had increased by only 28%.

Moreover, DHA levels in cerebrospinal fluid were 40% lower in subjects who had the APOE4 gene compared to subjects with the APOE2 and APOE3

EPA levels in cerebrospinal fluid averaged about 15-fold lower than DHA levels. When they looked at the effect of DHA supplementation on EPA levels.

EPA levels in plasma had increased by 50%.

EPA levels in cerebrospinal fluid had increased by 43%.

EPA levels in cerebrospinal fluid were 3-fold lower in subjects who had the APOE4 gene compared to subjects with the APOE2 and APOE3

The authors concluded:

“We observed only a modest (28%) increase in cerebrospinal fluid DHA levels with 2152 mg per day of DHA supplementation. This finding has implications for past clinical trials that have used lower doses (e.g. 1 g daily of DHA supplements or less) and were overwhelmingly negative. Using lower doses of omega-3 supplements may have resulted in limited omega-3 brain delivery.”

“Another aspect affecting the response to DHA supplementation is APOE4 status. Subjects with the APOE4 gene showed lower DHA levels and significantly lower EPA levels than subjects with other APOE genes”.

“In summary, our study suggests that higher doses of omega-3 fatty acids (2 or more g of DHA) are needed to ensure adequate brain delivery, particularly in APOE4 carriers…Past low dose (1 g per day or less) omega-3 supplementation trials in dementia prevention may not have provided adequate brain levels to fully evaluate the efficacy of omega-3 supplementation on cognitive outcomes.”

Based on the results from this study the authors are currently testing the effect of B vitamins and high dose DHA supplementation on cerebrospinal fluid fatty acid levels, brain imaging, and cognitive outcomes in a larger ongoing clinical trial.

What Does This Study Mean For You?

The ability of the omega-3 fatty acids DHA and EPA to reduce the risk of cognitive decline, dementia, and Alzheimer’s Disease is confusing. Studies disagree.

In situations like this, most experts dismiss the hypothesis as “unproven”. However, I like to ask, “What are we missing?”

One recent study provided a clue. It suggested that omega-3s and B vitamins were interdependent. We need both to reduce cognitive decline. However, that might not be the complete answer.

This study gave both DHA and B vitamins to subjects and discovered another interesting clue. The study suggests we may not have been giving subjects enough omega-3s to see a significant effect on cognitive decline.

Let me start by saying this study did not test whether or not DHA supplementation prevents cognitive decline, dementia, and Alzheimer’s Disease. Nor does it tell us how much DHA is needed to prevent Alzheimer’s Disease, other than to show that anything less than 2 g per day is likely to be inadequate.

However, the study did make two important advances:

#1: It showed just how difficult it is to deliver adequate amounts of DHA and EPA to the brain. This is important because it shows:

Most previous studies have not used high enough doses of DHA or DHA plus EPA to evaluate the effect of omega-3 fatty acids on cognitive decline. Those studies were not simply negative. They were doomed to failure. The studies were worthless.

That means we should stop saying that the ability of omega-3s to prevent cognitive decline and diseases like Alzheimer’s is unproven. Instead, we should say that hypothesis has not adequately been tested.

That also means future studies of the ability of DHA to reduce the risk of cognitive decline, dementia, and/or Alzheimer’s will need to use much higher doses or a better delivery system to get adequate amounts of DHA and EPA into the brain.

#2: It showed that the APOE4 gene significantly decreases the ability of the brain to accumulate DHA and EPA. This has several important implications.

Because both DHA and EPA are vital for brain health, this may explain why the APOE4 gene increases the risk of Alzheimer’s Disease.

It also means those at highest risk for Alzheimer’s Disease are the ones who are most likely to have difficulties accumulating DHA and EPA in their brain.

Once again, it means future studies of the ability of supplemental DHA to reduce the risk of Alzheimer’s Disease will need to use much higher doses of DHA.

The Bottom Line

The ability of the omega-3 fatty acids DHA and EPA to reduce the risk of cognitive decline, dementia, and Alzheimer’s Disease is controversial.

Association studies show that greater intake and higher blood levels of the omega-3 fatty acids EPA and DHA are associated with lower risk of Alzheimer’s Disease.

However, most placebo-controlled clinical trials with either DHA alone or DHA + EPA have come up negative.

In situations like this, most experts dismiss the hypothesis as “unproven”. However, I like to ask, “What are we missing?”

One recent study provided a clue. It suggested that omega-3s and B vitamins were interdependent. We need optimal amounts of both to reduce dementia. However, that might not be the complete answer.

This study gave both DHA and B vitamins to participants and discovered another interesting clue. The study suggests we may not have been giving subjects enough omega-3s to see a significant effect on cognitive decline.

The authors of the study hypothesized:

Uptake of DHA and EPA by the brain is very inefficient, and previous studies have not used sufficient doses of DHA or DHA plus EPA to see a significant effect on cognitive impairment.

The APOE4 gene, which is known to increase the risk of Alzheimer’s Disease, further decreases the uptake of DHA and EPA by the brain.

Their study confirmed their hypotheses and made two important advancements:

#1: It showed just how difficult it is to deliver adequate amounts of DHA and EPA to the brain. This is important because it shows:

Most previous studies have not used high enough doses of DHA or DHA plus EPA to evaluate the effect of omega-3 fatty acids on cognitive decline. Those studies were not simply negative. They were doomed to failure. The studies were worthless.

That means we should stop saying that the ability of omega-3s to prevent cognitive decline and diseases like Alzheimer’s is unproven. Instead, we should say that hypothesis has not adequately been tested.

That also means future studies of the ability of DHA to reduce the risk of cognitive decline, dementia, and/or Alzheimer’s will need to use much higher doses or a better delivery system to get adequate amounts of DHA and EPA into the brain.

#2: It showed that the APOE4 gene significantly decreases the ability of the brain to accumulate DHA and EPA. This has several important implications.

Because both DHA and EPA are vital for brain health, this may explain why the APOE4 gene increases the risk of Alzheimer’s Disease.

It also means those at highest risk for Alzheimer’s Disease are the ones who are most likely to have difficulties accumulating DHA and EPA in their brain.

Once again, it means future studies of the ability of supplemental DHA to reduce the risk of Alzheimer’s Disease will need to use much higher doses of DHA.

Based on the results from this study the authors are currently testing the effect of B vitamins and high dose DHA supplementation on DHA and EPA levels in the brain, brain imaging, and cognitive outcomes in a larger ongoing clinical trial.

For more details, read the article above. For a better understanding of the roles of DHA, EPA, and the APOE gene in brain health, you may want to read my “Biochemistry 101” section 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.

Are Saturated Fats Good For You?

April 1, 2014 by Dr. Steve Chaney

Is Everything We Thought We Knew About Fats Wrong?

Author: Dr. Stephen Chaney

Bring out the fatted calf! Headlines are proclaiming that saturated fats don’t increase your risk of heart disease – and that they may actually be good for you.

The study (Annals of Internal Medicine, 160: 398-406, 2014) that attracted all the attention in the press was what we scientists call a meta-analysis. Basically, that is a study that combines the data from many clinical trials to improve the statistical power of the effect being studied.

And it was a very large study. It included 81 clinical trials that looked at the effects of various types of fat on heart disease risk.

Are Saturated Fats Good For You?

The answer to this question is a simple No. The headlines suggesting that saturated fats might be good for you were clearly misleading. The study concluded that saturated fats might not increase the risk of heart disease, but it never said that saturated fats were good for you.

In short, the study concluded that:

Saturated fats, monounsaturated fats and long-chain omega-6 polyunsaturated fats did not affect heart disease risk.

Long chain omega-3 polyunsaturated fats decreased heart disease risk [Note: The original version of the paper said that the decrease was non-significant, which is what the headlines have reported. However, after several experts pointed out an error in their analysis of the omega-3 data, the authors corrected their analysis, and the corrected data show that the decrease in risk is significant.]

Trans fats increased heart disease risk

If those conclusions are correct, they would represent a major paradigm shift. We have been told for years that we should limit saturated fats and replace them with unsaturated fats. Has that advice been wrong?

Is Everything We Thought We Knew About Fats Wrong?

Before we bring out the fatted calf and start heaping butter on our12 ounce steaks, perhaps we should look at some of the limitations of this study.

We Eat Foods, Not Fats

When the authors broke the data down into the effects of individual saturated and unsaturated fatty acids on heart disease risk some interesting insights emerge.

For example, with respect to saturated fats:

Both palmitic acid and stearic acid – which are abundant in palm oil and animal fats – increased the risk of heart disease.

On the other hand, margic acid – which is more abundant in dairy products – decreased the risk of heart disease.

So while the net effect of saturated fats on heart disease risk may be zero, these data suggest:

It is still a good idea to avoid fatty meats, especially red meats, if you want to reduce your risk of heart disease. When you focus on foods, rather than fats this fundamental advice has not changed in over 40 years! In next week’s “Health Tips From the Professor” I will share some of the latest research on the dangers of red meat.

With fatty dairy foods the situation is a little more uncertain. I’m not ready to tell you to break out the butter and whipped cream just yet, but recent research does suggest that dairy foods have some beneficial effects that may outweigh their saturated fat content.

With respect to omega-3 fatty acids:

alpha-linolenic acid – which is found in vegetable oils and nuts and is the most abundant omega-3 fatty acids in our diets – had no effect on heart disease risk.

On the other hand, EPA and DHA – which are found primarily in oily fish and omega-3 supplements – decreased heart disease risk by 20-25%.

Once again, while the net effect of omega-3 fatty acids on heart disease risk was very small, that’s primarily because most Americans consume mostly alpha-linolenic acid and very little EPA and DHA. This study shows that fish oil significantly reduces heart disease risk, which is fully consistent with the heart healthy advice of the American Heart Association and National Institutes of Health over the past decade or more.

What We Replace the Fats With Is Important

A major weakness of the current study is that it did not ask what the individual clinical trials were replacing the fatty acids with. Many of them were simply replacing the saturated fats with carbohydrates. To understand why that is important, you have to go back to the research of Dr. Ancel Keys.

The whole concept of saturated fats increasing the risk of heart disease is based on the groundbreaking research of Dr. Ancel Keys in the 50’s and 60’s. But, it is important to understand what his research showed and didn’t show.

His research showed that when you replaced saturated fats with monounsaturated fats and/or polyunsaturated fats the risk of heart disease was significantly reduced. He was the very first advocate of what we now call the Mediterranean diet. (He lived to 101 and his wife lived to 97, so he must have been on to something.)

Unfortunately, his diet advice got corrupted. The mantra became low fat diets, where the saturated fat was replaced with carbohydrates – mostly simple sugars and refined flours. Since diets containing a lot of simple sugars and refined flours also increase the risk of heart disease you completely offset the benefits of getting rid of the saturated fats.

Just in case you think that is outdated dietary advice, Dr. Key’s recommendations were confirmed by a major meta-analysis published in 2009 (American Journal of Clinical Nutrition, 89: 1425-1432, 2009). That study showed once again that replacing saturated fats with carbohydrates had no effect on heart disease risk, while replacing them with polyunsaturated fats significantly reduced risk.

The Bottom Line:

You can put the fatted calf back out to pasture. The headlines telling you that saturated fats don’t increase the risk of heart disease were overstated and misleading. This study does not represent a paradigm shift. In fact, when you analyze the study in depth it simply reaffirms much of the current dietary advice about fats.

1) When you simply replace saturated fats with carbohydrates, as did many of the studies in the meta-analysis that generated all of the headlines, there is little or no effect on heart disease risk. However, other studies have shown that when you replace the saturated fats with monounsaturated and polyunsaturated fats you significantly reduce heart disease risk.

In short, if you are interested in reducing your risk of heart disease, low fat diets may be of relatively little value while Mediterranean diets may be beneficial. No paradigm shift there. That sounds pretty familiar.

2) Fatty meats, especially red meats, appear to increase the risk of heart disease. No surprises there.

3) Alpha-linolenic acid, the short chain omega-3 fatty acid found in nuts, seeds and vegetable oils, does not decrease heart disease risk. However, EPA and DHA, the long chain omega-3 fatty acids found in fatty fish and fish oil supplements significantly decrease heart disease risk. That’s probably because the efficiency of conversion of alpha-linolenic acid to EPA & DHA in our bodies is only around 10%. No surprises there.

4) The study did suggest that dairy foods may decrease heart disease risk. While there are a few other studies supporting that idea, I’m not ready to break out the butter and whipped cream yet. More research is needed.

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.