Fish Oil: It Conveys Much More Than Cardiovascular Health

woman jogging at sunrise
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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A Deeper Look at the Omega-3 Fish Oil Question

man jogging on beach
How many times have we borne witness to the medical recommendations and subsequent reversals and re-reversals of prominent medical societies? In the ‘70s the American Heart Association (AHA) advocated the use of margarine’s hydrogenated oils (trans fats) in place of butter. That, we all now know, was a critical error. The AHA also banned eggs – since reversed – and advocates the use of oils high in omega-6 fatty acids (a recommendation that is currently under significant scrutiny by the scientific community). The AHA has also advised people to eat fish and fish oils. That opinion, still widely held by world leaders in this scientific arena, is now in jeopardy. Last week, Rizos et al published a meta-analysis in the famed Journal of the American Medical Association (JAMA). Rizos findings in a nutshell, omega-3s and fish oil do not help stave off heart disease. There are a number of problems with their trial, but I will limit myself to the two that I consider to be most significant.

First, the statistics. There is a convention in medical science that outcomes are considered to be significant when the p value is < 0.05. In English this means that when the probability that a particular outcome is due to chance is less than 5%, we consider it to be true. A p value of 0.01 (which is less than 0.05) means there’s only a 1% likelihood that a finding is due to chance. This, we consider to be true. On the other hand, a p value of 0.5 means that there’s a 50% possibility that a particular finding is due to chance. We would not consider this finding to be true. You see though, it’s all about possibilities. In reality, we never know that something is true or false, just that it’s likely or not to be true or false. It’s important for you to recognize that our p value designation of 0.05 is considered gospel. Any first year medical student can tell you that. Now consider Rizos’ paper. He performed extraordinarily complex statistical maneuvers and ultimately decided to utilize a p value of 0.0063. That’s correct; he changed convention. By so doing he made the possibility of finding fish oil to be beneficial about 10 times as difficult as it would have been had he stuck to the rules. In fact, had he used a p value of 0.05, the trial would have shown that fish oil indeed does lower cardiovascular death. Instead of the media reporting that fish oil has no value, the headlines would have read, “Take your fish oil. It just might save your life!” That’s because the p value found for cardiovascular death reduction was 0.01, meaning that there is only a 1% possibility that this finding is due to chance, and there is a 99% likelihood it is a real finding! So please don’t stop eating fish or taking fish oil because of this trial’s findings.

Another point of contention is that Rizos described the three cardiovascular benefits of fish oil and omega-3s as: triglyceride-lowering, anti-hypertensive, and anti-arrhythmic. He omitted the two most salient cardiovascular benefits, anti-inflammation and anti-thrombosis (blocking blood clots). He ignored fundamental pathophysiology, an error that I feel can have dire and far-reaching consequences.

In sum, we must not abandon fish oil because of this meta-analysis. So many trials have shown the benefits of omega-3s in myriad medical conditions, such as rheumatologic disorders, cardiovascular disease, macular degeneration, and not least of all, the dementias like Alzheimer’s. Our scientific understanding of the advantages of increasing fish consumption is irrefutable. We cannot afford to repeat the 1970’s misguided AHA initiative for margarine to replace butter. Although doctors on the Today Show and many other popular stations took Rizos’ study at face value and unjustly condemned fish and fish oil, we cannot fall prey to this misinformation.

My advice is to continue your fish and fish oil unless your physician offers a solid reason for you to stop.

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