September 2007

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There's nothing fishy about fish oil!

Nothing fishy about fish oil!
The omega-3 way to keep your patients healthy
By Joseph Maroon, MD, and Jeffrey Bost, PAC

Fish oil is hot! Sales of fish oil supplements have nearly tripled in the last three years, as research shows omega-3 fatty acids in fish oils can reduce inflammation and pain associated with arthritis, heart health, lupus, cancer, diabetes, and neurodegenerative diseases such as Alzheimer's disease.

Approximately 35 percent of adults take dietary supplements on a daily basis. The fish oil supplements industry in particular has seen phenomenal growth in recent times, at a rate of about 50 percent per year. In 2003, consumers in the United States spent $190 million on fish oil supplements, and that was predicted to increase to $310 million in 2005.

The increased interest in (and sales of) fish oil can be attributed to several things:

• In September 2004, the Food and Drug Administration (FDA) gave omega-3 fatty acids a qualified health-claim status;

• A large number of randomized research studies have shown the benefits of fish oil to help patients with heart disease; and

• Studies evaluating arthritic pain and fish oil supplements have shown similar joint pain relief as seen with potentially toxic NSAIDs.

Although the lay public has become aware of the benefits of fish oil and omega-3 essential fatty acids (EFAs), they frequently treat fish oil supplements as a commodity to buy at the lowest price. They are rarely aware that the quality of fish oil supplements varies greatly among manufacturers.

WHICH FISH OIL TO RECOMMEND?

Not all fish oil supplements are equal because of the types of fish from which the oil is extracted, processing techniques, and storage conditions.

With fish oil, like most consumer items, you generally get what you pay for. The major manufacturing concerns that separate high-quality supplements from the rest of the pack are purity, potency, and oxidation.

• Purity. Too much of a good thing is bad. Such is the base with fresh fish in a regular diet. Fish can store and concentrate heavy metals, such as mercury and lead, and other toxins, such as polychlorinated biphenyls (PCBs), in their flesh.

This same caution applies to fish oil supplements if special purification techniques are not used in the manufacturing process. The purification technique most commonly used by manufacturers is molecular distillation. This process, which takes place in a vacuum, uses very low heat and enzymes to remove heavy metals, certain vitamins, and saturated fats. What remains are omega-3 EFAs.

• Potency. Generally, the difference between low-end and high-end fish oil supplements is the amount and type of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) they contain.

Most high-end, more expensive fish oil supplements have consider-ably higher potencies of EPA and DHA per capsule, in the range of 2 grams to 4 grams of EPA/DHA. A lower end 1 gram fish oil capsule typically provides only 180 milligrams of EPA and 120 milligrams of DHA. The rest of the capsule content is "marine product," a mix which is an unknown oil product that does not contain omega-3.
If a potent dose of fish oil is 3 grams, consumers who take low-concentrate supplements would have to take 10 capsules to achieve a potent dose of 3 grams. This amount of oil can cause burping, loose stools, and fishy breath.

On the other hand, consumers who take higher-end fish oil capsules (600 to 850 milligrams of EPA/DHA per capsule) would only have to take four or five capsules per day.

Higher-quality fish oil supplements cost more because their manufacturers have put them through more processing to concentrate EPA and DHA.

• Oxidation. Some manufacturers offer flavored fish oil capsules to mask the smell and taste of oxidation, but once a capsule reaches the gut, this rancid oil causes burping up a foul taste due

Oxidized fish oil not only tastes and smells bad, but can also have serious health consequences. High-end manufacturers have found that processing fish oil in an oxygen-free environment (usually a nitrogen environment) significantly reduces the oxidative process. Antioxidants have the ability to minimize oxidation and counteract free radicals that can damage cell membranes. Vitamin E is the most common antioxidant additive.

Fish oil capsules should be stored in a cool dry place away from direct sunlight after the bottle is opened. Refrigeration is recommended for liquid fish oil, but generally is not necessary for capsules. These efforts help prevent oxidation.

The surest sign of rancidity is a strong fishy odor, which indicates that the product probably has some oxidation occurring and the oil may be becoming rancid.

HOW MUCH TO RECOMMEND?

Omega-3 EFAs are important to health, but no guidelines concerning the optimal amount to be consumed exist. For healthy adults, the World Health Organization (WHO) recommends 300 milligrams to 500 milligrams of omega-3 EFAs per day, while the National Institutes of Health recommends 650 milligrams per day and the American Heart Association recommends 650 milligrams to 1,000 milligrams per day.

Recommendations for specific conditions are given in the sidebar, "What's the dose?"

POTENTIAL SIDE EFFECTS AND CONTRAINDICATIONS

Fish oil has very few, if any, ill effects beyond occasional loose stools. But some side effects may occur. The most common include:

• Allergic reaction. People with a history of allergy or hypersensitivity to fish should avoid fish oil and any omega-3 EFA product derived from fish. In rare cases, skin rash, hives, and respiratory symptoms have been reported as side effects of fish oil supplementation.

• Bleeding. Intake of 3 grams or more per day of omega-3 fatty acids may increase the risk of bleeding, but this has generally occurred only in patients with changes in blood-clotting factors and has not been reported clinically in those with normal blood-clotting function.

• Contraindication to blood-thinning drugs. Fish oil is not recommended for those on warfarin (coumadin) or heparin. Fish oil is generally safe for patients who use a platelet inhibitor (such as aspirin or clopidogrel [Plavix]), but such usage should be reviewed on a case-by-case basis with the prescribing medical doctor.

• Gastrointestinal upset. Diarrhea may sometimes occur, but it is rare and generally self-limiting. If diarrhea persists, reducing the volume of oil usually mitigates the condition. Occasional burping, acid reflux, heartburn, and indigestion can also occur.

Abdominal bloating and abdominal pain are rare. If they occur, it may indicate that the fish oil has turned rancid and should be discarded.

POSITIVE REPORTS

Very few other natural supplements have been studied as much as omega-3 fatty acids found in fish oil supplements. The research has almost universally been positive and confirms the body's need to consume and incorporate this essential fatty acid into every cell of our body.

As healthcare professionals, we need to lead the way for our patients and know as much about omega-3's health benefits in order to direct and educate them to the best products on the market.

Editor's note: For a list of resources, go to "Fish oil resources" on www.ChiroEco.com/history. Look under BONUS articles.

Joseph Maroon, MD, a board certified neurosurgeon at the University of Pittsburgh and medical advisor for Nordic Naturals (www.nordicnaturals.com), is a leading advocate of fish oil and has recently authored the book, Fish Oil: The Natural Anti-inflammatory. He can be contacted at info@inflammationsolutions.com.

Jeffrey Bost, PAC, is a clinical instructor in the department of neurosurgery at UPMC Presbyterian University Hospital, Pittsburgh. He can be contacted at 412-647-3604.

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