According to a study published in the journal Stroke, individuals who consume fish on a few occasions weekly may face a lower risk of suffering a stroke compared to people who eat little fish or do not eat it at all. Continue reading
The New York Times reports, “Many women take fish oil supplements during pregnancy, encouraged by obstetricians, marketing campaigns, or the popular view that a key fish oil ingredient — docosahexaenoic acid, or DHA — is beneficial to a baby’s cognitive development.” However, a study published “in the Journal of the American Medical Association suggests that the DHA supplements taken by pregnant women show no clear cognitive benefit to their babies.” What’s more, researchers “found no evidence that DHA can reduce postpartum depression, except perhaps for women already at high risk for it.”
“In the new study, 2,399 women at the midpoint of their pregnancies were divided into two groups,” the Los Angeles Times reports. “One took a daily capsule of 800 mg of DHA derived from fish oil until giving birth; the other took an identical capsule filled with vegetable oil.”
Then, “six weeks and six months after each woman delivered her baby, researchers had her complete a psychological inventory to check for symptoms of depression.” Next, when the babies were about 18 months old, investigators subjected them to comprehensive batteries of tests to measure their cognitive ability.
The Wall Street Journal reports that the study authors found no evidence that the fish oil supplements prevented new mothers from postpartum depression or enhanced cognitive development in their babies. However, the study indicated that 800 mg of fish oil daily appeared to decrease the chances of developing postpartum depression by about four percent in women who already had a history of clinical depression. This was not considered a statistically significant difference, however.
According to a report in Bloomberg News, an editorial accompanying the study “said pregnant women shouldn’t give up eating low-mercury fish or taking recommended doses of fish oil, as the mineral does help prevent preterm labor and may have benefits not shown in the study.”
“The study did find that significantly fewer infants from the DHA group spent time in the neonatal intensive care unit, compared to infants in the control group — something that researchers attributed to fewer preterm births in the DHA group,” HealthDay reported. “DHA supplementation was associated with a ‘small to modest increase in the duration of gestation,’ they reported.”
WebMD reported that, despite the study’s conclusions, the authors “concede that further work is needed to determine the benefits of DHA for women with a history of depression or those at risk of delivering prematurely,” a concession echoed by the authors of the accompanying editorial.
Fish, krill, and algal oil supplements now account for approximately $1 billion in sales in the U.S. To help consumers choose among products, ConsumerLab.com selected 24 of the best-selling oil supplements and tested them for EPA and DHA, contamination, freshness, and, if applicable, proper release by enteric coatings. Amazingly, nearly 30% of the fish oil supplements that they selected for testing failed to meet minimum quality standards.
As discussed in the news release below, ConsumerLab found PCBs in all fish oil supplements (including krill and algal oil supplements) but typically at extremely low levels (addressing questions raised by the California lawsuit in March that I discussed here).
ConsumerLab also we found that price is not an indicator of quality with fish oil and that a person need not pay more than about 6 cents a day to get a good product (as I discuss in another blog, here); they also point out that the term “pharmaceutical grade” on products is meaningless; and they note out that actual amount of omega-3’s will range from less than 20% to over 80% of the “fish oil” shown on the front label, so you need to read the Supplement Facts carefully.
Here are more details from the ConsumerLab press release:
Softgels and Liquids for Adults, Children and Pets Tested, Including Krill Oil and Algal Oil Supplements
White Plains, New York – Tests of fish, algal and krill oil supplements revealed quality problems with 7 out of 24 products selected by independent testing organization ConsumerLab.com.
Three products contained less of the omega-3 fatty acids EPA and/or DHA than claimed, spoilage was detected in one of these products as well as in two others (including a children’s supplement), an enteric-coated product released its ingredients too early, and a supplement for pets exceeded the contamination limit for PCBs.
Seventeen other products passed testing as did 15 products similarly tested through ConsumerLab.com’s voluntary certification program. ConsumerLab.com’s report is now available online to its members.
ConsumerLab.com reported these additional, notable findings:
- Labels on some products included terms such as “pharmaceutical grade” and “tested in FDA approved laboratories,” which are meaningless as there is no basis for either claim.
- A krill oil supplement that failed for both spoilage and low omega-3 levels claimed to be quality assured under GMPs (good manufacturing practices).
- Another “krill oil” supplement contained more fish oil than krill oil.
- Most products met ConsumerLab.com’s strict contamination limit for dioxin-like PCBs of 3 picograms per gram (3 parts per trillion). However, one product (a pet supplement) slightly exceeded this limit with 3.14 picograms per gram. However, this exposure is still very small compared to that from fish meat — a small serving (3 ounces) of fatty fish such as salmon may easily provide 170 picograms of dl-PCBs as well as a significant amount of mercury. Trace amounts of dl-PCBs were found in all supplements, despite claims on some of being free of contaminants. There was no detectable mercury in any of the supplements.
- The cost to obtain 100 mg of EPA and/or DHA from fish oil ranged from about 1 cent to 15 cents among fish oil supplements, and was about 30 cents from krill or algae oils. A fairly standard daily dose of 500 mg of EPA + DHA from a quality-approved product could be had for as little as 6 cents. Higher prices were not associated with higher quality.
- Concentrations of EPA and DHA ranged from less than 20% to over 80% of the marine oil content listed on front labels — which is why consumers should specifically look for the amounts of EPA and DHA which typically appear on side labels.
“Supplements providing EPA and/or DHA are a great alternative to fish as a source of beneficial omega-3 fatty acids, as they typically have far fewer contaminants, cost less, and are more convenient to obtain. But products vary in quality, strength, odor-reduction, and price, so you need to choose carefully,” said Tod Cooperman, M.D., ConsumerLab.com’s president.
Consumption of EPA and DHA appears to reduce the risk of coronary heart disease and may be helpful in the treatment of rheumatoid arthritis, other inflammatory diseases, and psychiatric illness. EPA and DHA may also reduce the risk of certain cancers and macular degeneration. Fish oil supplements are given to pets to help maintain their coats and skin.
U.S. sales of fish oil supplements in 2009 were $976 million, up 20% from the prior year, according to Nutrition Business Journal. A recent survey by ConsumerLab.com showed that fish oil had become the most commonly used supplement among people who regularly use supplements, exceeding, for the first time, the use of multivitamins. Seventy four percent of respondents reported using a fish oil supplement.
The new report includes test results, quality ratings, comparisons and reviews of products from the following brands: Advocare, CardioStat (Amerifit), Carlson, CVS, Dr. Sears, Finest Natural (Walgreen), Garden of Life, Kirkland (Costco), Life Extension, Liquid Solutions, Master Omega, Natrol, Natural Factors, Nature Made, New Chapter, Nordic Naturals, NOW, NSI (Vitacost), Olympian Labs, OmegaBrite, Origin (Target), PregnancyPlus, Puritan’s Pride, Quest Longevity (Canadian), Res-Q, Solgar, Source Naturals, Spring Valley (Walmart), Swanson, Trader Joe’s, The Simpsons, Vital Nutrients, VitalOils (VitalRemedyMD), Vitamin Shoppe, Vitamin World, Weil, Wellements, and 1-800-PetMeds. The report also includes information about dosing, side-effects, cautions, reduced-odor products, and proper storage of fish oil.
In addition to the products reviewed, two krill oil ingredients by Enzymotec USA have been tested and approved for quality through ConsumerLab.com’s Raw Materials Testing Program.
ConsumerLab.com is a leading provider of consumer information and independent evaluations of products that affect health and nutrition. The company is privately held and based in Westchester, New York. It has no ownership from, or interest in, companies that manufacture, distribute, or sell consumer products.
They taste like butter and offer a boost of heart healthy omega-3 fatty acids, but these omega-enhanced margarines may NOT actually help your heart, according to new research from the Netherlands. Now, before you read the details, this study examined only older patients (age 60 – 80) living in the Netherlands and thus may not be applicable to the general United States population or to younger people as our diets, lifestyles, and risk factors differ. That said, this new study of almost 5,000 patients who had previously had a heart attack, eating a daily serving of omega-3 charged margarine had NO effect on the likelihood of a second heart attack. In other words, it didn’t help or hurt. So, what should you do? Here are the details from ABC News:
Margarines containing different types of omega-3 fatty acids were tested, one with EPA-DHA, one with ALA and another with both, were tested against a placebo, omega-free margarine.
Patients ranged from age 60 to 80 and were already on medicine to control their blood pressure and cholesterol. After more than three years on this margarine meal-plan, researchers saw no association between eating omega-supplemented margarine and a reduced risk of second cardiovascular event such as heart attack or stroke.
Previous research shows that giving an EPA-DHA supplement to patients with cardiovascular disease reduces their chance of dying from the disease by as much as 20 percent, authors note in the study, but supplementing with margarine didn’t seem to cut it.
This doesn’t mean that those at cardiovascular risk should give up on getting extra Omega-3 fatty acids or pass on margarine, experts say. It’s just about getting the right amount of good fats from the right places.
Omega Enhancement – Myths Busted
Peanut butter, margarine, cheese, baby food, even eggs – you name it and manufacturers are pumping omega-3 supplements into it. But is eating these omega enhanced items actually healthy for your heart?
This study would suggest no, but experts say that it’s not where you get your EPA-DHA omega 3’s, it’s how much you get and how it fits into your diet.
One of the reasons that the Netherlands study may not have seen a benefit was that the dose of omega-3 fatty acid was too low. Researchers were shooting for a daily intake of 400 mg of EPA-DHA and 2 g of ALA, but past research suggests that a therapeutic dose is closer to 850 mg of combined EPA-DHA per day.
Don’t Pass on Omega-3s
“I recommend that all of my cardiac patients [with] significant coronary artery disease&take EPA/DHA at a dose of 800-1000 per day. To get this dose, most require a supplement, either one, two or three capsules of an over the counter supplement depending on the concentration,” says Dr. Carl Lavie, medical director of Cardiac Rehabilitation and Prevention at John Ochsner Heart and Vascular Institute.
Similarly, Dr. Dean Ornish, founder and president of the Preventive Medicine Research Institute at University of California, San Francisco, recommends a fish oil supplement that contains one gram of combined EPA-DHA per day.
On the other hand, the dose given by the study’s EPA-DHA margarine was roughly similar to that provided by two servings of fish a week, the current recommended amount for heart health, so the dose received by subjects was not insignificant, says Alice Lichtenstein, director of the Cardiovascular Nutrition Laboratory at Tufts University.
Another potential reason that the margarine seemed to have no effect is that the patients had been heart attack-free for a couple to several years, which means they were already at relatively low risk of another heart attack, says Lavie. Given the lower risk, it might be hard to gauge the effects.
What’s more, these results can only speak to the effects of a modest supplementation of omega-3s for patients who, like the subjects, have had a previous heart attack and are now being rigorously treated for heart disease, experts point out.
“These results don’t say anything about what omega-3 fatty acids could do for prevention [of a heart attack] or for someone whose heart disease is not as well managed,” says Lichtenstein.
Fish Still Best Bet and Margarine Over Butter
Research on the heart-protective benefits of omega-3 supplements remains inconsistent, though some studies show benefit and these supplements are often suggested to patients with heart disease.
Research on the consumption of fish on the other hand, has shown a strong connection between a diet rich in fish and a decreased risk of heart disease and cardiovascular complications such as heart attack or stroke, experts say.
“Every time we try to isolate a nutrient and supplement it we get disappointed,” says Lichtenstein, “but we consistently see results with those who eat fish on a regular basis.”
One shouldn’t “make a conclusion that fish aren’t important. In general, those who consume fish versus [those who don’t] seem to have less coronary heart disease,” agrees Dr. Robert Eckel, professor of medicine at the University of Colorado School of Medicine.
That said, if eating fish a few times a week is hard for you to do, supplements are still advised, Lavie adds, because “very few people eat enough fish.”
Similarly, when choosing something to spread on your bread, margarine is still a better choice than butter, doctors say, as long as it is low in saturated fat and trans fatty acids. Though Ornish says if you can trade the margarine for olive or canola oil, even better.
Soybean and canola oil contain ALA and have lower saturated fats than other oils, even olive oil, notes Lichtenstein, so these are a good fat to have in moderation.
Krill oil is now being promoted as a better alternative to fish oil supplements. Krill are tiny shrimp-like crustaceans.
Promoters say that krill oil provides similar cardiac benefits as fish oil, but with fewer capsules and no fishy taste.
However, krill oil supplements contain less of the omega-3s EPA and DHA than fish oil supplements. Nevertheless, manufacturers claim krill oil is better absorbed because the omega-3s are in a phospholipid form.
According to the experts at the Natural Medicines Comprehensive Database, “Preliminary evidence shows that a specific krill oil product (Neptune Krill Oil NKO, Neptune Technologies & Bioresources, Inc) can lower cholesterol and triglycerides.”
“But,” they add, “overall there’s much better evidence that fish oil can lower triglycerides and cardiovascular risk.”
Furthermore, krill oil usually costs more than fish oil.
So, the NMCD recommends to prescribers, “For now, advise patients to stick with fish oil. Recommend taking it with food or trying an enteric-coated product if fishy taste is a problem. Suggest krill oil only for healthy people who want to add these omega-3s to their diet but can’t tolerate fish oil.”
All the talk about the benefits of omega-3s has parents asking whether CHILDREN should take fish oil supplements. Omega-3s are important for neurodevelopment … and they’re now showing up in many prenatal vitamins, infant formulas, and foods. Fish oil supplements for kids are often promoted as improving visual acuity, brain function, or intelligence.
But, according to the experts at the Natural Medicines Comprehensive Database, “there’s no proof that omega-3 supplements make kids ‘smarter’…or have any cognitive benefit in most kids.”
In fact, according to the NMCD, “… many of these claims will be removed … due to pressure from the feds.”
The NCMD recommends this to physicians and healthcare professionals who care for kids:
- Tell parents that most kids don’t need fish oil supplements.
- Instead, suggest that kids eat about 4 oz/week of fatty fish … such as canned light tuna, salmon burgers, etc. This provides about 250 mg/day of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA).
- Supplements may be worth a try for kids who don’t get enough omega-3s from diet … especially those with behavioral or psychiatric disorders as preliminary evidence suggests fish oil MIGHT benefit kids with ADHD symptoms … autism … depression … or those at high risk for psychosis.
- Reassure parents that most fish oil supplements don’t contain mercury or harmful levels of PCBs. To be safe, suggest a “USP Verified” or “ConsumerLab” product.
- Tell parents NOT to use cod liver oil, as it has too much vitamin A.
- Tell parents NOT to use flaxseed, as it doesn’t contain the same omega-3s as fish oil.
The amount of fish oil one has to take each day depends upon why one is taking it. Here are some diseases and the amount of the effective daily doses of total fish oil or EPA and DHA (the most active components of fish oil) needed for each disorder (according to the experts at the Natural Medicines Comprehensive Database): Continue reading
Fish oil (omega-3 fatty acids) have been shown effective in treating high levels of triglycerides and in preventing primary and secondary cardiovascular disease. Now comes a new study showing that the fatty acid found in fish oil (EPA) has shown promise in the prevention of colorectal cancer in patients with familial adenomatous polyposis. The study was a randomized study. Although the study was performed in patients with a genetic predisposition to colorectal cancer, the benefits might also extend to non-inherited, or sporadic, colon cancer. Here are the details from MedPage:
An omega-3 polyunsaturated fatty acid significantly reduced both the number and size of rectal polyps in patients with familial adenomatous polyposis, a randomized trial found.
Six months of treatment with the free fatty acid formulation of eicosapentaenoic acid (EPA) led to a decrease in mean number of polyps from 4.13 at baseline to 3.61, a 12.4% decrease, according to Nicholas J. West, MBBS, of St. Mark’s Hospital in London, and colleagues.
In contrast, six months of placebo treatment resulted in an increase from 4.50 polyps at baseline to 5.05, which represented a 9.7% increase, the researchers reported online in Gut.
Familial adenomatous polyposis is an autosomal dominant disorder in which affected individuals are predisposed to colorectal cancer, and prophylactic removal of the colon is recommended.
In younger patients, the procedure generally undertaken is colectomy with ileorectal anastomosis, but the remnant of rectal tissue remains susceptible, so patients must undergo routine endoscopic surveillance.
In the past, patients also were given chemoprevention with cyclo-oxygenase (COX)-2 inhibitors, but the recognition that these drugs have cardiovascular toxicity limits their long-term use today.
Strong preclinical evidence suggests that certain polyunsaturated fatty acids are active against colorectal cancer, but typical fish oil supplements are associated with adverse effects such as dyspepsia.
So a new, enteric-coated, free fatty acid formulation which is released and absorbed primarily in the small intestine was used to evaluate the potential efficacy of EPA for prevention of colorectal cancer in post-colectomy patients.
A total of 55 adult patients with familial polyposis were randomized to receive 2 g EPA per day or placebo.
After six months the difference between the change in polyp number between the EPA and placebo groups was −1.06 (95% CI −1.78 to −0.35, P=0.005), with an overall decrease of 22.4% (95% CI 5.1 to 39.6%, P=0.012).
In addition, the sum of polyp diameters decreased by 12.6% in the EPA group and increased by 17.2% in the placebo group — an overall difference of 29.8% in polyp size (95% CI 3.6 to 56.1, P=0.027).
Video endoscopy determined that EPA treatment was associated with a modest improvement in the global rectal polyp burden (+0.09), compared to overall worsening with placebo (−0.34). The difference was statistically significant (P=0.011).
There also was a mean 2.6-fold increase in rectal mucosal EPA levels associated with the active treatment.
Two patients in the placebo group withdrew because of abdominal pain, nausea, and rash, while one patient in the EPA group withdrew because of nausea and epigastric discomfort.
The most common adverse event in both groups was diarrhea, which may reflect a post-colectomy lack of physiologic control of fecal water, the investigators suggested.
Nausea was reported by nine patients receiving EPA and by three receiving placebo.
Patients reported no bleeding episodes, and there were no serious adverse events attributable to the treatment.
The antineoplastic activity demonstrated in the study “is almost certainly a combination of regression of existing adenomas and prevention of de novo tumor growth,” the researchers concluded.
Comparison of these findings with those from previous studies of chemoprevention in familial polyposis with the COX-2 inhibitor celecoxib found that the magnitude of effect was “remarkably similar.”
The authors said the data also suggest a role for EPA in chemoprevention of sporadic colorectal neoplasia.
The mechanisms by which EPA inhibits neoplastic activity remain uncertain, although both COX-dependent and COX-independent mechanisms of action have been described, including antioxidant effects and alteration of T cell and colonocyte membrane ‘lipid raft’ functions.
Aside from antineoplastic activity, omega-3 polyunsaturated fatty acids have beneficial cardiovascular and antiplatelet properties.
“Therefore, it is possible that EPA [free fatty acid] treatment may combine [colorectal cancer] chemopreventative efficacy with cardiovascular benefits, which is a particularly attractive therapeutic strategy for middle-to-old age populations relevant to secondary prevention of sporadic colorectal neoplasia,” the investigators asserted.
As we head into the Easter weekend, I wanted to offer you some blogs on healthier nutrition choices. Here are ten choices that you can make that will be heart healthy and are adapted from an article at Health.com.
Start your day with a steaming bowl of oats, which are full of omega-3 fatty acids, folate, and potassium. This fiber-rich superfood can lower levels of LDL (or bad) cholesterol and help keep arteries clear. Opt for coarse or steel-cut oats over instant varieties—which contain more fiber—and top your bowl off with a banana for another 4 grams of fiber.
Super-rich in omega-3 fatty acids, salmon can effectively reduce blood pressure and keep clotting at bay. Aim for two servings per week, which may reduce your risk of dying of a heart attack by up to one-third. “Salmon contains the carotenoid astaxanthin, which is a very powerful antioxidant,” says cardiologist Stephen T. Sinatra, MD, the author of Lower Your Blood Pressure In Eight Weeks. But be sure to choose wild salmon over farm-raised fish, which can be packed with insecticides, pesticides, and heavy metals. Not a fan of salmon? Other oily fish like mackerel, tuna, herring, and sardines will give your heart the same boost.
Add a bit of avocado to a sandwich or spinach salad to up the amount of heart-healthy fats in your diet. Packed with monounsaturated fat, avocados can help lower LDL levels while raising the amount of HDL cholesterol in your body. “Avocados are awesome,” says Dr. Sinatra. “They allow for the absorption of other carotenoids—especially beta-carotene and lycopene—which are essential for heart health.”
4) Olive oil
Full of monounsaturated fats, olive oil lowers bad LDL cholesterol and reduces your risk of developing heart disease. Results from the Seven Countries Study, which looked at cardiovascular disease incidences across the globe, showed that while men in Crete had a predisposition for high cholesterol levels, relatively few died of heart disease because their diet focused on heart-healthy fats found in olive oil. Look for extra-virgin or virgin varieties—they’re the least processed—and use them instead of butter when cooking.
Walnuts are full of omega-3 fatty acids and, along with almonds and macadamia nuts, are loaded with mono- and polyunsaturated fat. Plus, nuts increase fiber in the diet, says Dr. Sinatra. “And like olive oil, they are a great source of healthy fat.”
Blueberries, raspberries, strawberries—whatever berry you like best—are full of anti-inflammatories, which reduce your risk of heart disease and cancer. “Blackberries and blueberries are especially great,” says Sinatra. “But all berries are great for your vascular health.”
Fill up on fiber with lentils, chickpeas, and black and kidney beans. They’re packed with omega-3 fatty acids, calcium, and soluble fiber.
Spinach can help keep your ticker in top shape thanks to its stores of lutein, folate, potassium, and fiber. But upping your servings of any veggies is sure to give your heart a boost. The Physicians’ Health Study examined more than 15,000 men without heart disease for a period of 12 years. Those who ate at least two-and-a-half servings of vegetables each day cut their risk of heart disease by about 25%, compared with those who didn’t eat the veggies. Each additional serving reduced risk by another 17%.
Full of fiber and omega-3 and omega-6 fatty acids, a little sprinkling of flaxseed can go a long way for your heart. Top a bowl of oatmeal or whole-grain cereal with a smidgen of ground flaxseed for the ultimate heart-healthy breakfast.
Soy may lower cholesterol, and since it is low in saturated fat, it’s still a great source of lean protein in a heart-healthy diet. Look for natural sources of soy, like edamame, tempeh, or organic silken tofu. And soy milk is a great addition to a bowl of oatmeal or whole-grain cereal. But watch the amount of salt in your soy: some processed varieties like soy dogs can contain added sodium, which boosts blood pressure.
So, use these tips to have a happy and highly healthy Easter … and make it a heart healthy one at that.
Long-time readers to this blog and my best selling book, Alternative Medicine: The Christian Handbook, know of my enthusiasm for fish oil (omega-3 fatty acid foods and supplements). And, you’ve read where I’ve written that no fish oil supplements have been found “to contain detectable levels of mercury, PCBs, or dioxins.” Now comes news about a law suit over PCBs in fish oil supplements. Who are you to believe? Here are the facts:
According to a report in ConsumerLab.com, “A lawsuit was filed on March 2, 2010 by a group that tested ten fish oil supplements and found that all violated California’s Prop 65 labeling requirement because they contained PCBs. While it raises legitimate concerns, the suit may have created some confusion.”
Here are some points to keep in mind:
- Virtually all fish meat and fish oil supplement will contain some PCBs.
- The samples chosen were oils made primarily made from larger fish (including shark) and fish “liver,” which tend to have higher amounts of contaminants.
- The majority of the products had extremely low levels of PCBs. Somewhat higher levels were found in a few products.
- But, NONE of these pose a health risk in themselves, but those with higher levels might unnecessarily contribute to PCB exposure.
- The products are identified by name in a news release about the suit which includes two tables.
- The first table shows total PCBs.
- The second table shows the amount of dioxin-like PCBs, which may be more meaningful as it focuses on the subset of PCBs known to be harmful in animal studies.
- Be aware that results in both tables are skewed against products that suggest higher daily serving sizes.
According to ConsumerLab, “To put the findings in perspective, total daily PCBs reported was under 100 nanograms for most supplements and did not exceed 900 nanograms for any.
“The importance of this is that the FDA permits an 8 ounce serving of fish to contain about 450,000 nanograms of total PCBs, 500 times more than in any of these products. The EPA, using a more conservative approach, estimates that the average adult can consume 1,400 nanograms of total PCBs per day without harmful effects.”
So, I, and the experts with whom I’ve spoken, stand by our previously published statements on the safety of omega-3 fish oil supplements.
You can read a couple of my other blogs on the topic here:
CNN has a nice report about a question that I’m often asked, “Which is healthier — farmed or wild fish?”
These days, it’s hard to know what underwater life you should be eating. There’s talk of great benefits from fish-originating omega-3 fatty acids but worries about contamination and concerns about the environmental impact of farmed fish.
PETA, People for the Ethical Treatment of Animals, even launched a campaign last year to discourage people from killing and eating fish, suggesting that they be called “sea kittens” instead.
In answering a recent reader question about the relative benefits of farmed and wild salmon, CNNHealth’s nutrition expert, Dr. Melina Jampolis, urged the reader to “limit farmed salmon consumption to once a week at most if you are unable to find fresh, wild salmon.”
The answer, which also quoted a spokeswoman for the nonprofit Environmental Working Group, generated a flurry of questions and comments. In response, CNNHealth took a deeper look at the issue.
“It’s really high time that people have a new perspective on farmed salmon from a nutrition standpoint,” said Gavin Gibbons, spokesman for the National Fisheries Institute Inc., the largest seafood trade organization in the United States.
Salmon is rich in omega-3 polyunsaturated fat and is a good source of protein while being low in calories and saturated fat. Omega-3 fatty acids have been shown to reduce the risk of sudden cardiac death and are associated with better cholesterol levels.
Six ounces of East Coast Atlantic salmon has more DHA and EPA omega-3 fatty acids than the same weight of wild salmon, shrimp, chicken or beef (which has none).
Because of these benefits, the American Heart Association says, people should eat fish twice a week, especially fatty fish such as salmon.
But studies have found that some species of fish are contaminated with methylmercury, dioxins and polychlorinated biphenyls (PCBs).
A 2003 report from the Environmental Working Group showed that farmed salmon in the U.S. has the highest levels of PCBs, toxic man-made chemicals. And a widely publicized study in the journal Science in January 2004 suggested that farmed Atlantic salmon had higher levels of PCBs and other toxics than wild Pacific salmon.
Amid public concern, the importation of farmed Atlantic salmon to the United States went down by 20 percent in early 2004.
But subsequent research has found that the health benefits of both farmed and wild salmon exceed potential risks, said Eric Rimm, associate professor of epidemiology and nutrition at the Harvard School of Public Health.
Rimm was a co-author of a study in the Journal of the American Medical Association in 2006 that said the PCB levels in farmed salmon were not a cause of concern compared with the benefits.
“It’s clear that if there is any risk, the benefit is still in the range of 300 to 1,000 times greater from the fact that you’re getting the omega-3s,” he said.
Jampolis, citing the more recent research, agreed that the benefits of eating any salmon outweigh the risks, especially with heart disease being the leading cause of death in the United States and the fact that salmon is one of the best sources of heart healthy omega-3 fatty acids.
She continues to recommend trimming the skin and fat as much as possible and using cooking methods such as grilling and boiling to reduce fat, as this is where the toxic chemicals are stored.
Farmed fish receive a diet that often consists of smaller fish, such as sardines, and if they eat contaminated food, the fish themselves retain that toxicity.
In recent years, fish-feed makers have done a better job of regulating themselves, and the levels of some contaminants have gone down, Rimm said. Farmed salmon is not the main source of PCBs for the average person; in fact, the majority of these chemicals that we ingest daily probably comes from other animal products such as beef and chicken, he said.
Because farmed salmon are fed more, they contain more omega-3 fatty acids than wild fish, which tend to burn off these fats, he said.
Anyone concerned about contamination issues should try to find out where their fish came from and read about any potential problems in that area, said David Love, project director at the Center for a Livable Future at Johns Hopkins School of Public Health. He called for more widespread testing of contaminants in fish in the United States and better labeling practices so consumers know how and where their fish were caught.
Fish eaters should also consider eating smaller fish on the food chain, such as anchovies, mackerel and sardines, because they live shorter lives and don’t have as much opportunity as larger fish to pick up toxics, Love said. Since they are lower on the food chain, they are a more sustainable choice, he said.
The environmental impact of eating particular kinds of fish is an important matter but not so straightforward, experts say. To produce one farmed salmon, you have to feed it more than its weight in smaller fish, which leads to a net loss of fish from the sea and potential ecosystem disruption, Love said.
“It may not hurt my health, and it may not hurt your health, but on a population level, you can see some issues,” Love said.
Some farmed fish may also receive antibiotics that, if spread in the human population in large quantities, could lead to antibiotic resistance, meaning bacteria would no longer respond to these drugs, he said.
But there are also farmed fish produced in environmentally friendly situations, Rimm said. In some cases, it may take more energy to capture wild fish than to keep them in a pen, leading to a negative environmental impact.
Eating different kinds of fish is good for both your individual health and for the environment, experts say. From the health angle, it minimizes your risk of contamination from any one fish group, Jampolis said. From the environmental perspective, it would be detrimental to the ecosystem if everyone ate just one kind of fish en masse, Love said.
The AP reports that “fish oil pills may be able to save some young people with signs of mental illness from descending into schizophrenia,” according to a study published in the February issue of Archives of General Psychiatry. For the study, investigators “identified 81 people, ages 13 to 25, with warning signs of psychosis,” then randomized 41 of them “to take four fish oil pills a day for three months” at a “daily dose of 1,200 milligrams.”
The Los Angeles Times “Booster Shots” blog reported that “for a year after” the study “was completed,12 weeks of dietary supplementation with omega-3 fish oil reduced progression to full-blown psychosis in a large group of adolescents and young adults,” while simultaneously improving “many of the symptoms that identified these young patients as likely schizophrenics and bipolar disorder sufferers.” In fact, “roughly 5% of those on fish oil went on to develop full-blown psychosis during the study period, versus 28% of those who got psychotherapy alone.”
WebMD reported, “No other intervention, including psychiatric” medications, “has achieved as much for so long after treatment stopped.” Unlike antipsychotic medications, “fish oil pills have no serious side effects.”
Reuters noted that fish oils may be used someday to stave off or even prevent psychotic or bipolar illness as well as substance abuse disorder and depression.
You can read my other blogs about fish oil here:
- Americans spend about $34 billion annually on alternative medicine. How can you make wise decisions in this area?
- Twelve Home Remedies for Migraine Headaches
- The Top 10 Natural Products of the Year
- What a woman’s heart needs, at every age
- Red yeast rice, fish oil fight high cholesterol
- Omega-3 Fatty Acids Linked to Lower Macular Degeneration Risk
Some of you are wondering about my response to this news. First of all, you should know that I’m on Vytorin. My doctor had recommended a statin, along with omega-3 fatty acids for my increasing triglycerides and decreasing LDL (lethal) cholesterol. When my cholesterol particle counts (we don’t just follow my lipid profile) didn’t meet goal, my doctor added Zetia (using the statin and Zetia combination drug of Vytorin). Voilà, my particle counts are way normal.
Does this new information change my view about the reasonableness of adding either nyacin or Zetia to a statin as add-on drugs? Absolutely not. You can read my previous blogs on Zetia here:
- Cholesterol Drug Controversy Continues
- A trusted expert speaks out on the Vytorin fiasco (for doctors)
In the meantime, for the many doctors who read this blog, I’ve solicited the opinion of a friend and internationally-recognized lipidologist, Tom Dayspring, MD. Here’s his response to the newest study data. It’s a long, and complex read, but well worth it for medical professionals:
By now you have likely heard something about the ARBITER-6 HALTS trial which was just presented at the AHA and published in the New England Journal of Medicine. Basically this is a trial designed to show what happens to carotid intima–media thickness (IMT) when either Zetia or Niaspan is added to a long term statin use.
For those who do not know, I am a consultant and National Speaker for both Abbott Labs and Merck (Schering Plough). I educate professionals all the time about aggressive use of lipid drugs to achieve goals.
I believe Niaspan, Zetia, fenofibrate, Trilipix, and Lovaza are grossly under prescribed. They are all potential “statin-helper” drugs.
Without outcome data (data on heart attacks, strokes, deaths), no one can ever state one combination is superior to another.
Readers of my newsletters know by now that statins have serious residual risk in all their trials and only get a minority of patients to apoB or LDL Particle Count (LDL-P) goal. Per all guidelines combination therapy is indicated to achieve goal.
There is zero Level One outcome data with any of the potentially available combination therapies that are out there right now.
So the only sane way to know what drugs to add to a statin is will the combo help me get to lipid goals (non-HDL-C) or lipoprotein goals like apoB or LDL-P and perhaps an emerging goal – HDL-P (not always the same thing as HDL-C)).
I happen to very much like both Niaspan and Zetia as wonderful statin-helping therapies.
I personally take 2000 mg of Niaspan as well as Zetia 10 mg every day (along with TriCor) along with once weekly statin (because of myalgia). And, I prescribe Zetia and Niaspan a lot in my practice to help achieve goal.
Based on multiple existing angiographic trials and now the ARBITER-6 HALTS trial it is my belief that if you have coronary heart disease (CHD), I want to know why Niaspan, unless it is not tolerated, is not part of your regimen to help achieve goal (except for unusual circumstances I never use niacin or Zetia monotherapy).
The ARBITER-6 HALTS trial was small, open-label (impossible to do a blinded trial with niacin) randomized trial enrolled CHD patients (with high or very high risk) who were on a statin for several years (mostly atorvastatin with some simvastatin) at or near LDL-C goal (all < 100 mg/dL).
They then received either Niaspan (extended release niacin) titrated to 2000 mg (a dose rarely used in the real world) or Zetia (ezetimibe) 10 mg daily. As expected there were more Niaspan dropouts due to drug side effects in the trial compared to Zetia.
The endpoint was change in carotid IMT over a year.
Unfortunately the trial was stopped prematurely, for no good reasons (both of the editorialists [see the editorials here and here] in the NEJM and the discussants at the AHA meeting agreed on that). Premature stoppage likely means whatever findings occurred are over-exaggerated.
Furthermore, the morons in the press are running around telling people they can take an over the counter vitamin for CHD. Niacin at 2000 mg or more mg per day is way beyond the vitamin dosage: it is a major pharmacological dose of a vitamin B3 and cannot be considered a vitamin at that dose and certainly has issues that must be followed.
Patients in the study had at goal or near goal LDL-C and borderline low HDL-C at the lower end of normal (remember baseline HDL-C was assayed while on a statin – not in a drug naive state).
Tragically the author did not see fit to measure the far more important parameters apoB or LDL-P or apoA-I or HDL-P. That is a mind boggling oversight in 2009 and it also makes it much more difficult to truly interpret what are the benefits of statin/Zetia (Vytorin) or statin/Niaspan (Simcor).
Most of these patients were on statins for over 5 years and thus their carotids have many years of statin therapy. Over the very short 14 month period of this trial the carotid IMT (CMIT) changes regressed on Niaspan/statin while statin/Zetia caused non-progression or miniscule regression (just like Crestor, a proven outcome therapy, did in METEOR).
Thus neither combination therapy failed, but Niaspan/statin induced what certainly seem to be more favorable changes than the statin/Zetia.
However there is no data that event reduction would be any different in patients with no progression versus regression. So until we have outcome trials, no one can conclude which combo therapy is in reality the best therapy.
Both editorialists and all discussants at AHA made that clear. However, let’s be also be very clear that based on CIMT changes statin/Niaspan was the winner.
However, because of the lack of data correlating therapy-produced, precise imaging changes to outcomes, there are no guidelines advising us to judge the efficacy of our drugs by performing repeat imaging procedures (including IMT).
Does everyone remember that estrogen, raloxifene, Fosamax and torcetrapib all have positive CIMT data and NONE have been shown to reduce cerebrovascular disease (CVD) events? Indeed both estrogen and torcetrapib also raise HDL-C.
Statin data on IMT changes are all over the map (positive and negative) yet all statins reduce outcomes. There does not seem to be much linkage. Pravachol reduces outcomes in its trials but was associated with plaque progression in an IVUS study (REVERSAL).
The lipids concentrations and presumably lipoprotein were beneficially altered with the addition of either Zetia or Niaspan. Zetia helped LDL-C more than niacin and niacin helped TG and HDL-C more than Zetia (no surprise there). Both drugs helped non-HDL-C.
My guess is the LDL-P (apoB) was fairly well controlled by the several years of statin use in this trial and both Zetia and Niacin further improved that crucial parameter (LDL-P or apoB). My guess is also that niacin improved apoA-I and total HDL-P and the Zetia did not. That would likely be a benefit in the Niaspan column.
- We grossly under treat our patients.
- Statin monotherapy, usually nontitrated is the routine therapy in the US.
- Stents, strokes, bypass and deaths are way too high despite statin monotherapy.
- We desperately need to get more aggressive to achieve all goals, especially lipoprotein goals.
Want to help lower apoB (LDL-P):
- Use statins — if not at goal add Zetia, Welchol, or Niacin in no particular order although if there are not TG or HDL issues, I prefer Zetia first because of ease of use.
- However if HDL-P (HDL-C) is low in the face of an elevated apoB or LDL-P then Niacin becomes my first add on (which is the exact recommendation made by ACC and ADD position statement published last year).
- If the TG are an issue (> 200 mg/dL) or TG/HDL axis is abnormal then a fibrate, niacin (or high dose or omega-3) is the likely best choice.
So, if I take a drug like Niaspan and can help a statin achieve better apoB levels and raise HDL-P levels, I think I have a great add on. Simcor would save be a copay, but Crestor/Niaspan would be the more potent therapy.
The ARBITER-6 HALTS trial certainly supports Niaspan/statin use. I prescribe Niaspan as they did in the study: get all patients to 2000 mg ASAP. I suggest you do the same. You cannot expect lower doses of Niaspan to achieve these results.
With proper advice, and perseverance Niaspan use is easier done than commonly believed. Abbott also offers a nice program to help patients properly take Niaspan. Talk to your reps.
This study does not change the fact that apoB (LDL-P) reduction is the primary goal, but it enforces the belief that raising HDL-P should be the secondary goal (by the way, fibrates raise HDL-P more so than niacin, yet fibrates, because of what they do to LDL size, do not raise HDL-C anywhere near what niacin does). This is one reason HDL-P is more informative than HDL-C.
If a patient on statin/Zetia is still not at LDL-P goals of therapy, Niaspan can help even if the HDL-C is not low. Also, if I have a patient on statin/Niaspan and LDL-P is not at goal I add Zetia. There is published data that statin/Zetia/Niaspan is a great lipid modulating triple therapy.
- we all need to use a lot more Niaspan (all CHD patients should be on it along with whatever else is needed to get to goal).
- No one needs to stop Zetia in anyone and no one needs to be afraid of using Zetia to help achieve goal.
- For your Vytorin users: if HDL-P is not normal or LDL-P is still high: please add Niaspan AND PLEASE TITRATE IT TO TWO GRAMS.
I want to conclude some of the what I consider outrageous statements made in the paper by the author.
- Is it plausible that Zetia is harmful to atherosclerosis: that is the conclusion by the author speculating on lipid issues that I do not believe have any support? The paper hints Zetia impairs reverse cholesterol transport. I can supply several studies show it improves RCT (start with Arterioscler Thromb Vasc Biol. 2008;27:1296-1297). I also hate to remind everyone: a serum HDL-C has no relationship what so ever to the dynamic process called reverse cholesterol transport. Macrophage RCT (removing cholesterol from the arterial wall) has no influence on serum HDL-C levels. Niacin raises HDL-C by increasing apoA-I production, inducing hepatic lipidation of HDLs, reducing CETP activity, inhibiting hepatic lipase (thus making HDLs large) and reducing the apoA-I beta synthase hepatic holoparticle receptor.
- ACAT (the enzyme that esterifies free cholesterol into cholesteryl ester) inhibition is bad and Zetia is thus bad because it reduces ACAT. ACAT inhibitors, which have failed in clinical trials prevent esterification of cholesterol and the free cholesterol accumulates in macrophages. Zetia reduces ACAT activity and expression because by reducing cholesterol delivery (absorption) ACAT downregulates. There is no cellular cholesterol accumulation on Zetia. In the study quoted, the dose of Zetia that impacted ACAT, was infinitely larger than we use to treat lipids.
- The author states Zetia affects SRB1 and thus impairs RCT. The study referenced was looking at SRB1 in intestinal cells has nothing to do with reverse cholesterol transport. Niacin inhibits ApoA-I beta chain synthase the hepatic holoparticle (HDL catabolism) receptor which decreases hepatic uptake of HDL trafficked cholesterol and potentially decreases RCT. Yet niacin sure works. Statins downregulate ABCA1 the main HDL lipidation enzyme involved with macrophage RCT yet they work.
- Amazing the NEJM published a nonsensical post hoc analysis showing too much LDL-C lowering with ezetimibe worsens CIMT. This trial is not empowered to examine such an endpoint in a univariate analysis. Shame on the NEJM and their reviewers for allowing such speculation. This has outraged many respected lipidologists. The author was taken to task by the discussants on the podium for this type of analysis.
- Implying that Zetia increased CV endpoints in a trial that has no such power to do so is the worst kind of fear mongering analysis and no one should pay any attention to such a statement. The author again was taken to task big time by the discussants on the podium for stating such a thing. The main discussant John Kastelein firmly stated that mortality data has NO MEANING. Shame on the NEJM for letting such statements appear.
In conclusions: FACTS:
- There is no outcome data for Zetia of any kind.
- There is no level one evidence for Niacin: there is secondary endpoint data from CDP.
- There is no outcome data relating what a drug does to HDL-C benefits CVD outcomes, but there is level 2 evidence that raising HDL-P is beneficial (see VA-HIT).
- There is no data relating specific drug induced imaging benefits (including IMT) to CV outcome benefit. Crestor, a drug proven to significantly reduce CV outcomes failed to induce regression in a big CIMT trial (METEOR) but rather inhibited progression (exactly what statin/ezetimibe did in this trial. Yet in an angiographic trial regression occurred with Crestor.
- Fact: every guideline wants you to get to lipid/lipoprotein goal using lifestyle and FDA approved drugs. Statins first line if TG are < 500 mg/dL. In patients with cardiometabolic risk, niacin is the preferred first add on drug (ADA/ACC consensus statement).
- NIASPAN is a great statin helper drug and needs to be prescribed much more frequently than it is.
- Zetia is a great statin helper drug and needs to be prescribed much more frequently.
- No one should be stopping Zetia, no one should be afraid to use Zetia to get to goal and for sure we need to use a lot more Niaspan at 2000 mg.
- Guess what: I am not stopping my Zetia – I surely and happy to continue my Niaspan and I’d ask you all to review the great John Guyton study: Lipid-Altering Efficacy and ”Safety of Ezetimibe/Simvastatin coadministered With Extended-Release Niacin in Patients With Type IIa or Type IIb Hyperlipidemia: (J Am Coll Cardiol 2008;51:1564–72.
Conclusion: Combination treatment with E/S plus N showed superior lipid-altering efficacy compared with N or E/S in type IIa or IIb hyperlipidemia patients and was generally well tolerated aside from N-associated flushing. This combination offers an effective, broad, lipid-altering therapy with improvements in lipid effects beyond LDL-C in these patients.
Tom Dayspring, MD
I will have patients who, from time to time, ask about the various controversies that are swirling around concerning the differing claims of milk producers. What are the facts, and the myths, about milk? How do you decide between cow’s, goat’s, soy, almond, rice, or hemp milk? What are the pros? What are the cons? Continue reading
Breast-fed babies may have an advantage over bottle-fed infants in development and cognition, but a new study shows it may be possible to close the gap using infant formula fortified with DHA, an omega-3 fatty acid found in breast milk. Continue reading
I found this excellent article on home remedies for migraine headaches — which impact more women than men. Several of these I use in my practice. However, I would recommend you discuss any of the natural medications (herbs, vitamins, and supplements) with your personal physician before trying them.
More Information: Continue reading
Fish, which is high in “good fat,” omega-3 fatty acids, confers multiple health benefits, but it can be challenging to find freshest fish as so often fresh fish has been frozen. A surprising tip can be to try whole fish: it shrinks less than fillets when cooking and gives more value. In this article, you’ll find tons of suggestions on how to buy the best fish for your family.
More Information: Continue reading
Reuters Health is reporting new research showing that a regimen of supplements and lifestyle coaching is just as effective as a statin medication for reducing levels of low-density lipoprotein (LDL) or “lethal” cholesterol. Not only that, the combination was shown to be more effective in helping people lose weight.
My Take? Continue reading