REBUTTAL TO THE ATTACK ON FISH OIL!
By LIFE EXTENSION.COM
If you had to rely on the media’s sensationalist reporting of the study published in the Journal of the American Medical Association (JAMA), you might think there is no value to omega-3 supplementation.
Yet the JAMA study itself reported on published benefits of fish oil as follows:
• Substantial reduction in triglycerides (even the FDA recognizes this)
• Reduction in serious arrhythmias (irregular heartbeat)
• Decreased platelet aggregation (protects against clots forming in arteries)
• Modest reduction in blood pressure
There are other mechanisms by which fish oil helps prevent heart attack, such as protecting against inflammation, but just the four benefits outlined in the JAMA study itself provided a scientific rationale for anyone concerned aboutvascular health to ensure adequate omega-3 intake.
What many people have yet to grasp is the magnitude of damage that is already present in the inner arterial lining (endothelium) in cardiac patients. These are people who either have suffered a heart attack or developed problems that required intervention with stents, bypass surgery, and/or aggressive drug therapy.
In my previous career, I was involved in thousands of autopsy cases where I could see and feel the effects of aging in the form of blocked and hardened arteries throughout a deceased person’s body. There was often such extensive arterial occlusion that my colleagues would question how the person lived as long as they did.
Arterial disease begins at birth and progresses as we mature. Over a certain age, many people become victims of “accelerated atherosclerosis” whereby a coronary artery that was only 30% occluded three years earlier becomes90%–100% blocked.
What is remarkable is how much damage can be inflicted to our vital circulatory system before death ensues. The point I’m getting at is that by the time people manifest outward signs of vascular disease (such as needing a stent), there is araging inferno going on inside their arterial walls that is not going to be extinguished with fish oil alone.
Most of the subjects in these studies analyzed by JAMA had already suffered a heart attack or coronary artery blockage and the fish oil was being used for “secondary prevention” purposes. At this advanced stage, the window had long ago closed for a modest dose of any treatment to be effective.
To clarify, let’s say you are barbecuing outdoors and you accidentally ignite a bush next to your house. You turn your garden hose on full blast and rapidly extinguish the fire.
Based on your experience, you can categorically state that garden hoses are effective in preventing houses from burning down.
Now let’s say you come home and find your house engulfed in flames. You take your garden hose and turn it only half-way on, but your house burns to the ground anyway. At that point you state that garden hoses are useless in preventing houses from being destroyed by fire.
While there is solid evidence to document that fish oil is more effective than a garden hose in this analogy, what JAMA has in essence published are efforts of mainstream doctors using an inadequate dose of fish oil, over too short a timeperiod, to put out a raging inferno going on inside the arterial systems of cardiac patients.
Comparison with statin drugs
By reducing LDL cholesterol, statin drugs have been shown to lower heart attack risk.
A healthy person without arterial disease can sometimes get by with using a modest dose (at least 10 mg/day) of a drug like simvastatin. Along with healthier dietary patterns, this can slash LDL levels from a dangerous 140 mg/dL to the safe range for healthy people now recognized to be under 100 mg/dL.
This dose of statin drug, however, will not reduce LDL-C levels aggressively enough for those with pre-existing arterial disease. These individuals need to get their LDL under 70 mg/dL, which, in the example cited, may require a daily dose of simvastatin of 80 mg per day or higher. It is at these high doses that statin drugs inflict most of their nasty side effects.
Since the medical establishment recommends that those with pre-existing arterial disease take higher doses of statin drugs, it is ludicrous to think that a modest dose of fish oil would show a significant effect on the relatively unhealthypatient population used in the JAMA report.
How much EPA/DHA should be consumed each day?
About 60% of your brain mass consists of fats that comprise vital cell membranes. DHA is the dominant omega-3 fat in healthy brain cells. Since people cannot make DHA internally, it has to come from diet or supplemental sources.
For the JAMA authors to state that there is no place in clinical practice to encourage omega-3 intake borders on medical negligence. The fact that they hand-selected studies where inadequate doses of omega-3s were used hints at a sizeable bias against non-drug approaches to treating disease.
Based on the totality of evidence showing multiple health benefits associated with greater omega-3 intake, Life Extension long ago recommended that members should supplement at minimum with 2,400 mg of EPA/DHA each day. This recommendation was based on the following assumptions:
• Foundation members are health-conscious individuals who consume food sources of omega-3s like cold-water fish, thus providing greater average intake of omega-3 than 2,400 mg daily.
• Foundation members take annual blood tests that measure triglyceride levels. If triglycerides are over 100 mg/dL of blood, there would be a greater consumption of omega-3s (along with lifestyle, drug, and other supplement alterations). Some people, for instance, require daily doses of 4,800 mg of EPA/DHA to suppress artery-clogging triglycerides.
• Findings from Omega Score blood test results showing that at least 2,400 mg a day of EPA/DHA is needed to achieve optimal omega-3 blood levels. Some people require more than 2,400 mg of omega-3s to boost blood levels.
The media used the JAMA study to create headlines like “Fish oil supplements don’t prevent heart attacks, study says.”1 The JAMA study, however, was based on an average daily intake of only 1,370 mg of EPA/DHA in individuals who mostly suffered significant pre-existing arterial disease, i.e., atherosclerosis. In fact, half of the studies included in the meta-analysis used an omega-3 dose of less than 1,000 mg daily. This amount of EPA/DHA is too low to reverse the underlying progression of atherosclerosis that most of the study group suffered from.
These unhealthy study subjects consisted of average population groups in countries throughout the world that, according to the JAMA authors, presumably consumed less than 58% of the minimum amount of EPA/DHA that Life Extensionmembers take. Some of these population groups took no other supplement to protect against heart attack since these nutrients are not openly sold in those countries.
I use the term “presumably consumed” in the previous paragraph because it is not clear that study subjects even got58% of the EPA/DHA they needed. The JAMA study results were based either on patients instructed to take fish oil capsules or patients provided with “dietary guidance counseling.” This kind of diet counseling is notoriously unreliable, especially over the longer term when people tend to gravitate back to unhealthy dietary habits. The same is often true of people who are told to swallow large fish oil capsules by their doctors but fail to comply for all kinds of reasons including the fact they don’t like swallowing large capsules!
As you will read, the findings from the JAMA study, where lower-dose EPA/DHA was inconsistently used on unhealthy patient groups for a relative short term, have nothing to do with what health-conscious people are doing today to guard against heart attack, which includes taking the proper dose of EPA/DHA each day.
Other studies indicate substantive benefits with fish oil
A number of studies have indicated that higher doses of fish oil leads to beneficial effects in preventing cardiovascular disease events or reducing risk factors. For example:
• A randomized, placebo-controlled trial found 1,800 mg of combined EPA plus DHA was associated with a 10.2% lower rate of cardiac events, 12.4% lower rate of non-fatal infarctions, and a 10.6% lower rate of cardiac deaths.2
• In a large intervention study, 18,000 patients were randomized to receive either a statin medication alone or a statin plus 1,800 mg of EPA daily. After 5 years, those with a history of coronary artery disease had a 19% lower rate of major coronary events in the statin-plus EPA group compared to the statin-only group.3
• A randomized, double-blind, placebo-controlled trial with chronic hemodialysis patients found that 1,700 mg of omega-3 fatty acids daily was associated with a 70% reduction in the relative risk of myocardial infarction.4
• A randomized, controlled trial using 3,300 mg of EPA and DHA (and then a decreased dosage) found a trend toward lower cardiovascular event occurrence with fish oil supplementation. Seven cardiovascular events occurred in the placebo group while only two cardiovascular events occurred in the fish oil-supplemented group during the study.5
• A meta-analysis with an average fish oil dose of 3,700 mg found lowered systolic blood pressure by an average 2.1 mmHg and diastolic by 1.6 mmHg.6
• In a randomized trial with peripheral arterial disease patients, 2,000 mg of omega-3 fatty acids daily resulted in a 49% improvement in flow-mediated dilation, a marker of endothelial cell health.7
In contrast to the findings of the JAMA meta-analysis, two important studies demonstrated significant benefits with even moderate fish oil doses:
• The GISSI-Prevenzione study (a large, randomized, controlled trial) found that 1,000 mg/ day of EPA and DHA in 11,324 patients with a history of recent myocardial infarction reduced the risk of total mortality by 20% and sudden death by 45%.8
• The DART study — a randomized, controlled trial that examined the effects of advising 2,033 subjects to increase dietary fatty fish — revealed a 29% reduction in all-cause mortality compared with those not advised.9
The JAMA meta-analysis also conflicts with other reviews of fish-oil research. Other meta-analyses have demonstrated a reduced risk of cardiovascular disease outcomes in those supplemented with omega-3 fatty acids from fish oil. For example:
• A 2009 meta-analysis of randomized, controlled trials found that dietary supplementation with omega-3 fatty acids reduced the incidence of sudden cardiac death in subjects with prior myocardial infarction.10
• Another 2009 meta-analysis of randomized, controlled trials found that dietary supplementation with omega-3 fatty acids reduced the risk of cardiovascular death, sudden cardiac death, all-cause mortality, and non-fatal cardiovascular events in patients with a history of certain cardiovascular events or risk factors.11
• A 2008 meta-analysis found a significant reduction in death from cardiac causes with fish oil supplementation.12
• A 2002 meta-analysis of randomized, controlled trials concluded that omega-3 fatty acids reduced overall mortality, mortality due to myocardial infarction, and sudden death in patients with coronary heart disease.13
Methodological Problems with the JAMA Meta-Analysis
Flaws in the design of the JAMA meta-analysis of 20 self-selected studies call its findings into question for the following reasons:
1. Inclusion of trials of poor methodological quality. Nearly half of the sample size of the meta-analysis came from two open-label trials. Open-label trials allow both the subjects and researcher to know what treatment is being provided in the study. This type of study is considered to be of inferior quality compared to double-blind, placebo-controlled trials, where researchers and subjects do not know which intervention the subjects are receiving.
2. High level of variability in the trials’ cardiovascular event rates & baseline risk. There was a high degree of variability in the baseline cardiovascular risk and cardiovascular event rates in the trials included in this meta-analysis. This means it was difficult to assess what subjects were at greater risk of heart attack at baseline. If those given fish oil, for instance, also had higher vascular risk at beginning of the study, then the validity of the data is severely compromised.
3. Limited number of studies included. Only 20 of 3,635 studies the authors examined were used in this meta-analysis. This provides a very limited view of the research that has been conducted on fish oil for cardiovascular disease.
There has been a significant amount of research conducted on the cardiovascular benefits of fish oil beyond what was selected for the JAMA analysis. For example, in a PubMed.gov (U.S. National Library of Medicine) search for clinical trials relating to fish oil and triglycerides, there were 499 results.
Why most consumers don’t benefit from fish oil
The environment that we at Life Extension exist in is far from the mainstream. We are privileged to interact with exceptional physician/scientists and the world’s most knowledgeable health consumers (i.e., our members).
Recently, we found ourselves so out of touch with the mainstream that we went to considerable expense to empanel outside Focus Groups to educate us on how the lay public thinks about nutrition and their health. To participate in these focus groups, people had to be health-conscious, dietary supplement consumers. The level of ignorance uncovered by these focus group sessions was appalling.
Virtually all the focus group participants had “heard” good things about omega-3s, but they had no idea how much they were taking or how much EPA/DHA they should be taking.
Most of them claimed to purchase omega-3 supplements on a somewhat irregular basis, usually when they see them displayed on a pharmacy or supermarket shelf. Some claimed to take one fish oil capsule daily while others claimed to take them when they would remember.
If a survey were conducted to identify people who took omega-3 supplements, virtually every participant in these focus groups would have been categorized as an omega-3 supplement user. Yet virtually none of them was taking the potency needed to stave off heart disease.
When conventional doctors and the media claim that people don’t benefit from supplements, they are mostly correct in that most consumers have no idea how much of what supplement they should take to stave off disease. This should notdissuade knowledgeable individuals, who know what to take and have the discipline to do so on a consistent basis, from following an evidence-based program that includes at least 2,400 mg of supplemental EPA/DHA daily along with healthy dietary patterns.
Good ratings for the media
Just imagine being in the “news” business where every day you have to generate attention-grabbing headlines to sell newspapers or attract viewers.
The Journal of the American Medical Association publishes a study meant for doctors, but since it relates to one of the most popular dietary supplements, you have a strong sound-bite headline for the day. No need to look at details — such as the ones in the JAMA study explaining that even subjects who consumed inadequate doses of fish oil appeared to derive an 11% reduction in heart attack risk — because the study’s authors cite them as statistically insignificant.
Just hype-up the JAMA study’s conclusion and you have yourself a headline that most of your audience will want to know more about.
This is how the general public makes their life-and-death decisions, which is rather pathetic considering we live in a world where most everyone has Internet access to assess the facts for themselves.
Bottom Line: The subjects in the JAMA report were people with existing heart problems, the dosages they were taking were too small, and they probably were not taking the additional supplements that have long been recommended to generate a multi-pronged attack against heart disease.
What do humans need to do to prevent atherosclerosis?
The aging process damages blood vessels even when conventional risk factors such as cholesterol and blood pressure are within normal ranges.
Despite aggressive intervention with diet, exercise, supplements, and drugs, pathological changes still occur in the arterial wall that predispose aging adults to vascular diseases. The encouraging news is that validated methods have been developed to address the underlying reason why arteries become occluded as people reach the later stages of their lives.
For the past 40 years, the standard way to treat coronary atherosclerosis has been to bypass the blocked arteries. Recuperation from coronary bypass surgery can take months, and some patients are afflicted with lifetime impairments such as memory loss, chronic inflammation, and depression.
The scientific literature reveals that atherosclerosis is associated with high blood levels of C-reactive protein, insulin, iron, LDL, homocysteine, fibrinogen, and triglycerides, along with low levels of HDL and testosterone (in men). Optimizing blood levels of these substances can dramatically reduce heart attack and stroke risk.
A coronary artery with atherosclerosis.
Prescribing a statin drug is what doctors typically do to prevent and treat coronary atherosclerosis. Cholesterol and LDL, however, are only players in the atherosclerosis process.
There are now two fish oil “drugs” approved by the FDA to lower triglycerides. Fish oil also protects against atherosclerosis by reducing inflammation and inhibiting abnormal platelet aggregation. But even fish oil and statin drugs are not going to adequately counteract allfactors involved in coronary artery disease.
Mainstream cardiologists fail to appreciate that coronary atherosclerosis is a sign ofsystemic arterial dysfunction requiring aggressive therapy to correct.
2. Singh RB, Niaz MA, Sharma JP, et al. Randomized, double-blind, placebo-controlled trial of fish oil and mustard oil in patients with suspected acute myocardial infarction: the Indian experiment of infarct survival. Cardiovasc Drugs Ther. 1997;11(3):485-91.
3. Yokoyama M, Origasa H, Matsuzawa M, et al. Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis. Lancet. 2007;369(9567):1090-8.
4. Svensson M, Schmidt EB, Jørgensen KA, et al. N-3 fatty acids as secondary prevention against cardiovascular events in patients who undergo chronic hemodialysis: a randomized, placebo-controlled intervention trial. Clin J Am Soc Nephrol. 2006 Jul;1(4):780-6. Epub 2006 Jun 14.
5. von Schacky C, Angerer P, Kothny W, et al. The effect of dietary omega-3 fatty acids on coronary atherosclerosis. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 1999;130(7):554-62.
6. Geleijnse JM, Giltay EJ, Grobbee DE, et al. Blood pressure response to fish oil supplementation: metaregression analysis of randomized trials. J Hypertens. 2002;20(8):1493-9.
7. Schiano V, Laurenzano E, Brevetti G, et al. Omega-3 polyunsaturated fatty acid in peripheral arterial disease: effect on lipid pattern, disease severity, inflammation profile, and endothelial function. Clin Nutr. 2008 Apr;27(2):241-7. Epub 2008 Jan 31.
8. Marchioli R, Barzi F, Bomba E, et al. Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI)-Prevenzione. Circulation. 2002 Apr 23;105(16):1897-903.
9. Burr ML, Fehily AM, Gilbert JF, et al. Effects of changes in fat, fish, and fibre intakes on death and myocardial reinfarction: diet and reinfarction trial (DART). Lancet. 1989 Sep 30;2(8666):757-61.
10. Zhao YT, Chen Q, Sun YX, et al. Prevention of sudden cardiac death with omega-3 fatty acids in patients with coronary artery disease: a meta-analysis of randomized controlled trials. Ann Med. 2009;41(4):301-10.
11. Marik PE and Varon J. Omega-3 dietary supplements and the risk of cardiovascular events: a systemic review. Clin Cardiol. 2009;32(7):365-72.
12. León H, Shibata MC, Sivakumaran S, et al. Effect of fish oil on arrhythmias and mortality: systemic review. BMJ. 2008;337:a2931.
13. Bucher HC, Hengstler P, Schindler C, et al. N-3 polyunsaturated fatty acids in coronary heart disease: a meta-analysis of randomized controlled trials. Am J Med. 2002;112(4):298-304.
Dr. Pinna says:
This a “Must Read” article. But it is lengthy. May take several reads. But, it tells the truth. And it gives references.
Like Obama and Romney “I endorse this article!” And, I’m not even running for President.
BTW–MOST IMPORTANTLY! FISH OIL DOES NO HARM!