Fish Oil: It Conveys Much More Than Cardiovascular Health

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Numerous studies have evaluated the effects of the omega-3 fatty acids, DHA and EPA, on cardiovascular health. Overwhelmingly, scientists and clinicians involved in such research believe that omega-3 fatty acids play various beneficial roles in preserving optimal vascular and cardiac health: Anti-Inflammatory, Anti-Thrombotic, Anti-Arrhythmic, and TG-Lowering effects are considered to be the most relevant. Recently, Smith et al. published a fascinating and novel clinical trial looking at a non-cardiovascular yet widespread adverse aspect of aging: muscle mass decline. They published their findings in the American Journal of Clinical Nutrition: Fish oil–derived n–3 PUFA therapy increases muscle mass and function in healthy older adults. All parameters evaluated improved with the administration of 3,200 mg of daily DHA+EPA. Thigh muscle volume, handgrip strength, one-repetition maximum (1-RM) lower- and upper-body strength, and average power during isokinetic leg exercises all demonstrated statistically significant improvement. Improving muscle strength as we age can have far-reaching beneficial consequences that could reduce both morbidity and mortality. Thus, these findings need to be further studied in larger and even more consequential trials. But what additional meaning can we garner from their trial?

I believe that beyond their fascinating and clinically pertinent findings there actually lies a far more evocative message. It is simply that we should be extraordinarily cautious about abandoning the evaluation of therapies (even dietary) when they make biological and physiological sense. Fish oil consumption is woefully low in the US when compared to the far more healthy Japanese population. Our life expectancies are far shorter and various cancers occur more frequently in the US. It is scientifically quite plausible that our deficiency in omega-3 fatty acids plays a significant role in our relatively diminished health. But, after the publication of a few clinical trials failed to demonstrate the cardiovascular benefit of fish and fish oil in select patient populations, some physicians truly abandoned their prior admonitions for patients to augment fish consumption. They were derailed by the controversial results of just a few trials (that many exceptional researchers consider to be flawed in the first place). This type of knee jerk reaction has no place in medicine. It is dangerous and counterproductive. To protect our patients and maintain our scientific integrity, we must always practice with open and attentive minds. Once again I implore my scientific colleagues as well as the oftentimes superficially inquisitive media to follow the science, not the hype.

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Hot Off the Press

In medical school we learned about a life threatening form of polydipsia. A subset of patients with schizophrenia consume so much water their sodium can fall to levels unable to sustain life. Twenty liters per day often leads to not just severe illness, but death. How could this be? Water is life’s elixir, and therefore more must be better; correct? Well, simply put, the answer is no. Our kidneys can only handle a water intake of less than one liter per hour. When people exceed this limit, blood becomes diluted; sodium levels fall; and cells swell. As our brain is encased in bone, it has nowhere to go when it swells. Consequently swollen brain cells can lead to permanent damage and even death. It’s not just the unfortunate schizophrenic patients who succumb to such a fate; others do as well. One woman died after drinking six liters in just three hours during a “water drinking competition.” Others have died similarly during college hazing. The point is that a rapid, excessive and unnatural intake of our most vital ingredient for life can kill us in a matter of hours. More is definitely not always better. Aristotle was correct in his dictum of moderation. So where am I going with this you might ask. Let’s consider the most recent “negative” fish oil study by Dr. Voest that was published in a most reputable journal. (For my take on other similar articles please see prior blog posts).

Based upon the fact that some cancer cells can produce long chain fatty acids, Dr. Voest hypothesized that the omega-3 fatty acids in fish could blunt the effect of chemotherapy (such a thought process itself lacks strong scientific validity). Testing his hypothesis he administered 100 microliters of fish oil to 20 gm mice. He was right; fish oil did blunt the effects of chemotherapy. And so his findings were published in the prestigious JAMA Oncology. But let’s look at his study in proper perspective. Ignore the fact that mice are not the optimal animals to study here. Also, ignore the fact that tumor cells produce many substances that have nothing to do with their “desire” to counteract chemotherapy.  Simply examine the administered dose. One hundred microliters of fish oil for a 20 gm mouse is equivalent to 400 ml of fish oil for an 80 kg (175 pound) man. Can you imagine guzzling nearly a half-liter of fish oil? The very thought is life threatening! That’s also tantamount to swallowing around 400 fish oil capsules. Who in his right mind would do that? I’d guess no one. The study therefore has no clinical relevance. The author’s conclusion that patients should avoid fish the day prior to receiving chemotherapy has no basis in science. Yet, the study is on the news; patients are concerned that fish causes cancer; doctors who don’t fully understand this area of medicine will become as alarmed as the patients; doctors’ offices will once again be flooded with unnecessary and distracting queries born of inappropriate trial conclusions; and some people who desperately need to consume fish will place themselves in harm’s way by eschewing vital nutrients. The fallout is, and will continue to be, monumental.

Why such studies are done, and why they are published in top-notch journals eludes me. I understand why the media exploits them; they are fodder for ratings. Still, I will continue to proclaim that such studies must be quelled, and the media must become more cautious. It is fine to conjecture, study, and test hypotheses no matter how outlandish they may seem. What is not acceptable however is perpetuating false conclusions as though they are hardened facts. Such a practice – which is prevalent today – leads both doctors and patients astray and pulls us from important issues, those that can truly save lives and help humanity. Let’s get back on track and re-emphasize honesty in medicine as our prime agenda. Honesty should always trump a good story.

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The 2015 Dietary Guidelines: Defining a Healthful Diet

The 2015 Dietary Guidelines have been released, and some supposedly significant changes, advised. Cholesterol intake is no longer limited. Saturated fat is to represent < 10% of daily caloric intake. Sustainability considerations are now to be considered. Simple sugars are anathema and caffeine is okay. Vegetables and fruits remain highly emphasized. Has much changed? Not really. Most of us in Cardiology and Lipidology dropped the cholesterol ban a decade ago. We typically emphasize fresh fruits and vegetables, low fat meat that is organic and devoid of antibiotics, and a limitation of simple sugar. Most of us don’t consider sustainability issues when advising our individual patients. Many of us believe that world issues – including economics – should stay out of the exam room and remain in the courtroom. (I am a member of that camp). But what is the layperson to do with these Guidelines? Does he or she have to make dramatic changes in his or her diet? The answer of course depends upon the individual patient’s status. Is weight loss necessary; does the patient have cardiovascular disease or very high LDL cholesterol, for instance? Let’s first look at the history of man, briefly examine the state of dietary literature, and then make some generalizations.

Anthropology unequivocally demonstrates that human beings are omnivores. In fact, all of our primate relatives also rely upon meat in the wild. They even need it in captivity. When the Washington DC Zoo attempted to breed the Amazon Golden Marmoset monkey, they failed miserably. It was not until meat was added to their diet that the monkeys begin to thrive and reproduce. Since the beginning of our tour on earth we have also eaten meat. In fact, for the first 4 million years of our existence, meat was our main source of nourishment. About 10,000 years ago we introduced farming and animal husbandry. Most farming was done to feed our animals as they represented our most desirable food source. Recently we have fallen prey to our own impact on nourishment – we have started processing, and ruining, our food. Sugar has been added; nutrients have been stripped from grains; grains are squeezed (instead of eaten whole) to produce oils; and animals have been raised in pens, limiting their ability to develop lean muscle mass, and also often requiring the introduction of antibiotics. We have created a food supply that is most likely killing us.

In response to our understanding of the role cholesterol plays in heart disease – and it does play a significant one – we have introduced guidelines to try to reduce cholesterol. Saturated fat eaten to excess does raise LDL (not a good thing), but cholesterol consumption has little impact on our LDL levels. Therefore the current Guidelines did what was appropriate and removed restrictions on cholesterol consumption while maintaining limitations on saturated fat. They also appropriately implore us to eschew sugar. No one will argue against the latter recommendation (except perhaps the sugar industry). But are there studies to support such advice? Unfortunately, beyond PrediMed (which demonstrated the cardiovascular advantage of a Mediterranean diet) no high level studies have been performed. Many observational studies exist, but doing a solid dietary trial is actually immensely difficult. Thus we are left to rely upon our understanding of basic science, animal experiments, pathophysiology, and anthropology. The conclusion for most of us I believe follows Aristotle’s ancient tenet of moderation. We should consume natural foods whenever possible, avoid processed foods, eat copious quantities of vegetables, consume ample fruit, and don’t worry so much about consuming lean meat, fatty fish, and some chicken as well. We should do this in the context of seeing our physicians, discussing our own personal issues, and modifying our diets to adjust to individual needs when indicated. Eating has become a complex endeavor, yet it ought to be much more straightforward. What we need though is access to the aforementioned natural food, the type of food that has been unscathed by human hands. And therein, unfortunately, lies the rub.

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Diet Tip: Please Read the Label

A good deal of my time with patients is spent teaching. I teach about theories regarding plaque formation, consequences of a ruptured plaque – heart attack being the most feared – and the spectrum of cardiac risk factors. In discussing risk factors I then delve deeper. I discuss LDL particles and why counting them is so important. I discuss the role of inflammation in heart disease. We talk about eating a balanced and healthful diet, and of course we always discuss achieving and maintaining an optimal weight.

For the last few years I have been working with a gentleman in his forties who suffers from premature coronary artery disease. He’s already had one stent and our mission is to prevent a second event. And so we have systematically and effectively mitigated each of his risk factors. Except for his weight. As hard as we’ve tried, we have failed. His stubborn 15 to 20 pounds of excess overweight has been a thorn in both of our sides.  He really has tried quite hard. He’s trimmed portions, eliminated all simple carbohydrates, stopped drinking excess alcohol, and religiously exercised an hour a day. Yet, no weight loss… Until his last visit.

The other week my young patient entered the room with draping pants and a flouncy shirt. His clothes were not those of an older, larger brother. They were his. Somehow he had done it. He had lost 19 pounds. And his smile betrayed his brimming desire to let me know his secret.  So here it is. He started reading labels. Though we had previously discussed the importance of label reading, I apparently had failed to adequately emphasize the point. Now here he stood, proving the power of the label. What he had discovered is quite fascinating. My patient, a lover of coffee, had been consuming over 3,600 calories each week in the form of coffee creamers. Although the creamer labels revealed a mere 20 calories per serving, he had failed to recognize just how many servings he used per cup of coffee. It wasn’t until he had counted the bottles of creamer he used on a weekly basis, along with the total number of calories per bottle, did he recognize just how caloric and fattening was his coffee creamer habit. He responded to his newfound knowledge with discipline and resolve, and in three short months without doing anything other than eliminating excess coffee creamer he achieved his desired weight.

The lesson here is simple: Know exactly what you’re consuming. Be careful about portions. And don’t be misled. Do the math if you’re having trouble losing weight. Count the calories you consume and eliminate those you don’t need. This basic approach worked magic for my patient; I’m confident it can do the same for you.

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Time for a Food Police Force?

Incessantly the media, scientists, doctors, self-proclaimed experts of this or that pronounce they have found the answer to some burning issue. Mostly the matters involve health. What fat is best, or are carbohydrates better than saturated fats, or is fish oil really any good, or is the rampant use of statins the product of evil pharmaceutical propaganda. The list is interminable. And everyone has a voice. Actors and actresses somehow as a consequence of their on-screen fame have absorbed knowledge beyond that which is possessed by even our greatest scientists. Newscasters weigh in and authors sell their latest tomes with promises of truth. The whole dance of the experts would be quite amusing were it not so dangerous.

What seems to be missing from all those who have managed to communicate so easily with the almighty is a sense of responsibility. When people voice their opinions with such certitude, and their audience believes in their veracity with such solidarity, what is truly opinion then masquerades as fact. As a consequence, fiery battles flare among opposing sides. The vegans pound their fists shouting, “Not even a drop of oil! No fat at all!” The Wheat Belly folk eschew the grains, while the dairy exorcists discard the milk, and the Atkins aficionados chow down on meat and more meat. Get them together on TV and you have a firestorm.

Now bring in the politicians and celebrities. They take whatever “science” they find most convincing and try to turn it into law. No large sodas for the sugar busters; no trans fats for practically everyone (that one I have to admit is compelling), nothing with a face for the vegans. In short order there won’t be much left to eat at all.

I have my own take on the diet issue. In short I’m fairly certain we are all quite different, and consequently do better with different diets. As a generalization though I’d recommend moderation in all things, avoiding processed foods, eating a balanced diet, maintaining an optimal weight, and exercising daily. Perhaps that prescription would make a good law.

Fundamentally it comes down to this. We should all be permitted to eat whatever we wish as long as it doesn’t harm anyone but us. Government should not have the right to tell an individual what he or she can or cannot consume. There is a key caveat though. This holds true, “as long as it doesn’t hurt anyone else.” So what do we do about the ailments that occur as a consequence of food-induced obesity – diabetes for one? Do we penalize the consumers of sugar who as a consequence of their dietary predilections become obese and diabetic? Do they pay higher health insurance premiums? Probably not a popular notion. How about the smokers, should everyone foot the bill for his or her heart disease, COPD, and lung cancer treatments? Clearly these issues are slippery slopes, ones upon which I have no desire to tread.

I will emphasize one point however, and of this I am sure. No one knows what diet is best for all mankind. And until such a discovery is made, creating a food police force is probably not a good idea at all.

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Two Recent Supplement Studies Merit Mentioning – Vitamin D and Glucosamine Sulfate

Two recent trials addressing commonly used supplements are worth noting as they exemplify pertinent and prevalent issues facing physicians and patients every day. One deals with vitamin D, the other with Glucosamine Sulfate.

The vitamin D study, published out of the University of California San Diego in Anticancer Research, is entitled “Meta-analysis of Vitamin D Sufficiency for Improving Survival of Patients with Breast Cancer.” In the trial, patients with the highest vitamin D levels had the best outcomes. This group had an average 25, OH-Vitamin D level of 30 ng/ml. The initiated should instantly recognize that this number lies on the lowest edge of a normal range for vitamin D. Yet, the press reported the following, “High vitamin D levels may increase breast cancer survival.” So what might an uninformed reader assume? Take large quantities of vitamin D to shield you from breast cancer, of course. This clearly is not at all what the study concluded. A more appropriate title for the press might have been, “Very low vitamin D levels associated with worse breast cancer outcomes.” Our takeaway message is probably to avoid very low levels of D. But, we should in no way infer that very high D levels protect us from cancer (or anything else for that matter). Some trials even suggest that very high D levels might be dangerous. Once again the ideal reaction to this single piece of evidence is simply to speak with your doctor. Have your vitamin D tested. If your level is very low, supplementation is likely in order. If your level is normal, probably no further action need be taken. The key though is not to act alone. This type of discussion is another opportunity to engage your physician and help develop your own brand of personalized medicine.

The second trial evaluated what was described by the press as a “new form of Glucosamine” – Glucosamine Sulfate. First, please understand that Glucosamine Sulfate has been available for decades. Being more costly than its counterpart, Glucosamine HCL, it is typically found in only superior products. For me the interesting aspect of this trial (published in The Annals of Rheumatologic Disease) is that in a double blind placebo controlled fashion (the purported king of clinical trials) Glucosamine Sulfate was shown to statistically significantly decrease joint space narrowing over a two-year follow-up period. Older studies had similar findings, and consequently for the past ten years I’ve recommended a Glucosamine Sulfate-containing joint product that I formulated for VitalRemedyMD called JointFormula (catchy name I know). I’ve received nearly universal patient reports of improvement in joint discomfort. Anecdotally, results have been most dramatic in the hands and knees. Many of those who take JointFormula have written notes of gratitude, thanking us for helping them avoid knee replacement surgery. Yet, some trials other than the above-mentioned have “proved” the worthlessness of Glucosamine. How do we explain this to our grateful patients? Placebo effect is surely a possibility. It is also possible that what works in one person might fail in another. And, we must always acknowledge that clinical trials are not the final word. We see enough discordance of conclusions among the trials; so by this observation alone we should know that trials are hardly ever truly “conclusive.” The lesson from this study is that there will always be conflicting results among clinical trials. The ultimate decisions regarding patient care always reside between patient and doctor. Trial results help guide doctors; they should not shackle them. And, patients should not be made to feel foolish for their beliefs, nor should doctors be made to feel unscientific for theirs. Instead, doctors need to continue “practicing” medicine as best as they can, and patients must remain their own most potent advocates for health and wellness.

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Sugar: Our Unrequited Love

It has become common knowledge that sugar is bad for us. Interestingly, human beings require both fat and protein for optimal health and even survival, but we needn’t consume even a grain of sugar to live full and robust lives. Our love of sugar is unrequited; sugar in many ways is our enemy. It is quite probable that you’ve been to your doctor who, in reviewing blood tests, has informed you of your Hemoglobin A1c (HgA1c) level. He or she might have told you that HgA1c is a measure of your blood sugar level over the past three months. I’ve said that on many occasions to my own patients. Recently I recognized a lost opportunity in conveying the aforementioned message. Therefore, I am writing this brief note to clear the air.

Although it’s true that HgA1c tells us whether or not one’s blood sugar has been too high over the previous three months, it actually tells a far more important story. Hemoglobin (the Hg part of HgA1c) is an iron-containing protein. Proteins, and fats, are susceptible to permanent damage by high blood levels of sugar. HgA1c is actually the amount of damaged hemoglobin in our blood. It is not alone however. All proteins and fats can be victims of sugar-induced damage and the process whereby sugars permanently injure proteins and fats is termed glycation. Thus, when one has a high HgA1c he or she should understand that hemoglobin is not the only molecule in the body bearing the brunt of high sugar levels; it’s simply an easy one for us to test. Other fats and proteins such as those in our arteries, brains, nerves, kidneys, and eyes are also being marred by sugar. And when these proteins are hurt, the organs within which they reside are also damaged. Thus we experience heart disease, brain injury, peripheral neuropathies, kidney failure, and even blindness from high sugar levels.

So the message when it comes to elevated HgA1c is not simply, “you have high sugar”, it’s really, “your high sugar levels are taking a terrible toll on the many proteins and fats that support your body’s normal functioning.” So please be mindful when it comes to sugar. Sugar may be sweet, but sugar is not your friend.

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When Passions Collide – Omega-3s Are Essential So Why Would We Remove Them From Our Diets?

Last week the Cleveland HeartLab held its fourth annual Clinical Symposium. Excellent speakers addressed the group of some four hundred physicians and nurse practitioners from across the country. One in particular spoke with passion and unswerving conviction about his brand of a “no heart disease” diet. Dr. Caldwell Esselstyn vociferously and vehemently admonished the audience not to include any oils in their diets. “No oils” he repeatedly shouted pounding his fists in the air. No one can deny he walks his talk; he is extraordinarily svelte, clearly carrying no superfluous fat on his own body. My talk was about the essential role omega-3 and omega-6 fatty acids play in health and disease. And I too have my convictions and passions. And so we collided.

I steadfastly adhere to a worldview incorporating moderation, scientifically rigorous reflection on every aspect of human beings (from our evolutionary roots to the most reductionist biologic understanding), and acknowledgement that we do not and likely will never know everything. My position does not make room for Dr. Esselstyn’s view. His is simply too extreme. It also fails to consider the fact that human beings cannot adequately produce some vital fats such as EPA and DHA; those afforded us by our friends, the fish. EPA and DHA are indisputably essential contributors to the entire gamut of health considerations. From skin to eyes to brains and hearts, our organs need these fats to thrive. In fact, every cell in the human body requires DHA for optimal function. And even more compelling is the fact that we cannot adequately manufacture this fat. We need to eat it. So why eschew it? That is the problem with his thesis. Even if his handful of subjects adhering to this diet fails to develop cardiovascular events, it does not prove that the lack of fat plays any role. There are just too many other variables left unconsidered. Additionally, what diseases might be borne of such an unnaturally restricted diet? Too many questions remain for us to make a global experiment of Dr. Esselystyn’s hypothesis. We’ve done this before with dietary advice and hormone replacement recommendations and sadly we’ve been wrong every time.

In sum, I genuinely applaud Dr. Esselstyn for his dedication to extinguishing heart disease. His passion is real and his motivation pure. Still, that does not mean I must agree with him.

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Prostate Cancer and Omega-3 Fish Oils: Beware Conclusions Born of Misinformation

The recent conclusions of Brasky et al must be examined closely as they are not only misleading but potentially dangerous. This statement may appear extreme, but omega-3 fatty acids have been repeatedly shown to protect us against cardiovascular disease (CVD), the leading cause of death in the Western World. Therefore, if men stop eating fish and taking fish oil pills for fear of prostate cancer, they may be putting themselves at risk for CVD, a disorder that kills seven times as many men as does prostate cancer. Such a decision would be not only unwise, but potentially damaging. To better understand this, let’s examine Brasky’s findings in the context of prior data as well as our understanding of the biology of DHA and EPA.

First, many earlier trials have demonstrated a correlation between high fish consumption and low rates of prostate cancer. Some examples are: Lancet, 2001 Terry et al showed a significant correlation between high fish consumption and a low incidence of prostate cancer. The Physician’s Health Study in 2008 revealed a correlation between high fish consumption and improved survival in men with prostate cancer. A 2003 Harvard study of 48,000 men showed a higher intake of fish to be associated with a lower risk of prostate cancer. There are many other examples, but this should suffice.

Second, let’s look at plasma levels of EPA and DHA in Brasky’s trial. The reported EPA+DHA level in the plasma phospholipids was 3.62% in the non-cancer control group and 3.74% in the high-grade cancer group. This difference between controls and the worst cases is extremely small, frankly with no clinical significance.  It is simply within the normal laboratory variation.

Third, is association tantamount to cause? No. Even if there were a clear association between prostate cancer and high EPA and DHA levels, that would not prove causality. Other plausible explanations exist. In fact, this would more likely be a case of reverse causation. We know that two cancer-related phenomena will increase DHA and EPA levels. First, cancerous tissues can upregulate the genes for enzymes that cause long chain fatty acids to “grow” into EPA and DHA – the desaturases and elongases. Second, we know that genetic polymorphisms in the fatty acid desaturases are associated with an increased risk of cancer. So what may be occurring here (if anything is occurring at all) is that cancer-induced changes in desaturases, or cancer-producing genetic polymorphisms in these same enzymes are causing an increase in EPA and DHA. DHA and EPA are not causing the cancers.

Fourth, we are not told the source of omega-3s in this study group. Is it mostly from fish? Some fish have very high levels of PCBs, substances known to be carcinogenic. To conclude that people should stop their fish oil supplements when some supplements are actually far “cleaner” than fish, might therefore be very misguided.

Fifth, let’s examine another population with vastly different omega-3 levels to see whether Brasky’s assertions are relatable to real life. The Japanese consume eight times as much EPA and DHA as do Americans, yet their risk of prostate cancer is about one eighth of ours. If anything, one should conclude that omega-3s are protective here.

Sixth, we can’t ignore the biology of the fatty acids. A plethora of data has demonstrated the anti-inflammatory impact of the omega-3 fatty acids EPA and DHA. Data have also uniformly shown the pro-inflammatory effects of trans-fatty acids. When trial conclusions fly in the face of our understanding of human biology (in this case, trans fats not being harmful while omega-3s causing harm) we must consider them to be highly suspect.

Finally, let’s not forget that EPA and DHA are considered by experts to be “essential” fats. In other words, we must consume them in order to live. Before we discard these indispensable fatty acids, let’s await better clinical trials, and ones that are plausible in the context of prior literature and well-documented pathophysiology.

Additional resource : Dr. Gerald Chodak’s article entitled “Fish Oil’s Link to Prostate Cancer Unproven”  featured on Medscape.

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