Age-Related Eye Disease Study 2 (AREDS2) – an Analysis

What follows is an analysis of the results of the AREDS2 randomized clinical trial “Lutein Zeaxanthin and Omega-3 Fatty Acids for Age-Related Macular Degeneration” (AREDS2) recently published on the JAMA website.

AREDS 2 has been long-awaited. AREDS1 demonstrated decreased progression of AMD with the administration of high dose antioxidants and minerals. There were problems with AREDS1 though; beta-carotene was used whereas lutein and zeaxanthin were not. High dose zinc appeared to increase hospitalizations for GI and GU disorders. The omega-3s DHA and EPA were omitted. In response to these shortcomings, AREDS 2 was established. Now the results are in. Unfortunately the trial raises more questions than it answers.

Here are the issues.

  • Although it is called a “placebo controlled” trial, there is no placebo arm. Everyone in the placebo group was offered the AREDS1 formula as a base. Nearly everyone took it. This confounds results.
  • The use of prior supplementation with omega-3s and carotenoids was not controlled for. As baseline blood levels for lutein, zeaxanthin, DHA, and EPA were higher than normal, the participants likely had a high use of prior supplementation. This confounds results.
  • The omega-3s chosen were 350 mg DHA and 650 mg EPA, yet DHA is known to be a necessary structural element in the macula whereas EPA is thought to be the precursor for signaling molecules that might be important for the eye. DHA is a known quantity; EPA has hypothetical value.
  • The study was enormously complex: Two tiers of randomization occurred in this 2×2 factorial trial. Patient groups included:  (1). Placebo – actually on AREDS1 formula. (2). AREDS1 + EPA/DHA. (3). AREDS1 + lutein/zeaxanthin. (4). AREDS1 + EPA/DHA/lutein/zeaxanthin. (5). AREDS1 + 25 mg Zn (not 80 mg). (6). AREDS1 – beta carotene. (7). AREDS1 with 25 mg Zn and no beta-carotene. Such a complex study design created a great deal of difficulty in understanding the findings. In the authors’ own words, “complicated design involving a secondary randomization which may have affected our ability to evaluate the role of adding lutein+zeaxanthin and DHA+EPA to the AREDS formula”. This unfortunately is the crux of the trial. Introducing doubt in the primary objective of the study is “study suicide” in my view.
  • 30% of participants opted not to undergo the secondary randomization and among those who did decide to move forward, women and highly educated participants did so at a significantly higher rate. This confounds the results.
  • 13% of participants stopped their supplements during the trial. As this was an Intention to Treat study, they remained in the trial even though they were “off drug”.
  • 14% of participants admitted to taking lutein/zeaxanthin/DHA/EPA during the trial even though they were not supposed to do so. This confounded the results.
  • Only 84% of participants took > 75% of their pills.
  • A small portion of patients had blood tests of studied supplements. There was a 200% increase in lutein/zeaxanthin and a 105% increase in EPA, but because of the low dose of DHA there was only a 35% increase in its level.
  • Beta-carotene lowered the effect of lutein, proving the negative interaction between these two carotenoids. This was unexpected by the authors. They stated, “In this analysis we assumed there would be little interaction between the various nutrients used”. To me, this statement is disturbing; this is a nutrient trial. Interactions between nutrients are inevitable and must be considered in such a trial design. This is one of the fatal flaws of the trial.
  • Beta-carotene increased lung cancer. This was previously understood but reconfirmed. In fact, 91% of lung cancer cases occurred in patients taking the standard AREDS formula. Though the patients were former smokers, they were not current smokers. In my view this negates the use of the standard AREDS formula in anyone with a history of smoking.
  • Low dose zinc and the absence of beta-carotene did not diminish efficacy of the formula. This demonstrates that low dose Zn and no beta carotene are preferred.
  • Lutein/Zeaxanthin did demonstrate less AMD progression compared to the AREDS1 formula.

In sum, AREDS2 was a wonderful concept that was poorly implemented. The take-home message from the trial: Do not use beta-carotene; use lutein and zeaxanthin; low dose zinc is optimal; efficacy of omega-s remains unanswered. Interestingly, the May, 2013 issue of JAMA Ophthalmology included the LUTEGA trial in which DHA and lutein/zeaxanthin were found to be beneficial in AMD. LUTEGA used DHA in a dose 3x that of EPA, the relationship that probably should have been used in AREDS2. One final note, meso-zeaxanthin was not studied in either trial. Based upon our current understanding of pathophysiology and biology meso-zeaxanthin should be included in an AMD formulation.

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Are You Getting Enough Omega-3s? Take a blood test and see…

Omega-3 fatty acids are essential fatty acids in the human diet that are primarily found in oily fish like salmon, sardines, albacore tuna, herring, mackerel, etc. They are also available in fish oil soft gels. The principle omega-3 fatty acids are docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA).  Over the last 25 years, compelling evidence has accumulated from epidemiological studies and large clinical trials demonstrating their beneficial impact on joint, brain, eye, and heart function.  With regard to the cardioprotective effects of omega-3 oils, the strongest evidence to date relates to reducing risk for sudden cardiac death, the primary cause of coronary heart disease (CHD) death in the US today.

The American Heart Association reports that CHD is the number one killer of American men and women, accounting for more than one of every five deaths in the United States, usually as sudden death from cardiac arrest.  Recognizing the cardioprotective effects of omega-3s, the American Heart Association (AHA) recommends that patients with documented CHD should consume about 1,000 mg of omega-3s (specifically, combined DHA+EPA) per day; those without documented CHD should eat a variety of fish, preferably oily, at least twice a week, to provide about 500 mg of EPA+DHA per day.  It is very difficult, however, to reliably estimate omega-3 consumption based upon fatty fish intake because DHA and EPA vary greatly with species, season, maturity, fish’s diet, post-catch processing, and cooking methods.  A high-quality, highly purified fish oil supplement can deliver a more precise amount of omega-3s.  Even then, individual differences in absorption, metabolism, and distribution can lead to variable responses to a given intake.

So how do you know if you are getting enough omega-3s?

Now there is a blood test —the HS-Omega-3 Index™— that can measure your levels of the cardioprotective omega-3 fatty acids, DHA and EPA. Researchers have discovered that one of the best risk indicators for sudden cardiac death is the level of omega-3 fatty acids (EPA and DHA) found in red blood cell membranes. The HS-Omega-3 Index test measures levels of DHA + EPA in the phospholipids of red blood cell membranes and is expressed as a percent of total fatty acids in the membrane.  The result is a simple modifiable marker for the risk of death from coronary heart disease.

The target HS-Omega-3 Index is 8% and above, a level that current research indicates is associated with the lowest risk for death from CHD. On the other hand, an Index of 4% or less (which is common in the US) indicates the highest risk.  Low levels are easily corrected through dietary changes or supplements and can quickly improve test results. Of course, this is just one of a number of risk factors that plays a role in CHD.  Risks associated with other factors such as cholesterol, blood pressure, diabetes, family history of CHD, smoking, or other cardiac conditions are completely independent of and not influenced by omega-3 fatty acids. Any and all modifiable risk factors – including the HS-Omega-3 Index—should be addressed as part of any global risk reduction strategy.

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Age-related Macular Degeneration

Leading Cause of Blindness
Age-related macular degeneration (AMD) is the leading cause of blindness in persons over age 55 – it is an incurable eye disease that causes progressive visual loss as a result of degeneration of the macula. The macula is the portion of the retina responsible for our fine central vision; it receives visual information that is sent to the brain. A damaged macula leaves us unable to distinguish detail and causes localized areas of central vision loss. Although peripheral vision remains intact, things that we take for granted like reading, recognizing faces, and driving are just a few of the tasks that become difficult.

No Known Cure
Even more disheartening is the fact that there is no known cure for AMD and no clear understanding of its cause. Some of the most exciting research related to macular degeneration has been in the area of nutrition and has suggested that certain antioxidants including lutein and zeaxanthin may significantly reduce the risk of AMD.  The carotenoids lutein, zeaxanthin and meso-zeaxanthin are the main components of the macula’s luteal pigment that protects the retina by absorbing damaging ultraviolet light and neutralizing free radicals that can harm the eye. Studies have provided evidence that supplementation with lutein and zeaxanthin is associated with significant improvement in the density of the protective macular pigment.  The studies also demonstrated clinical benefits; those who took a 10 mg supplement of lutein every day over a year’s time began to see about one line better on eye charts.

What You Can Do
Manage known modifiable risk factors for AMD. Exercise and eat a healthful diet to prevent obesity, diabetes, elevated cholesterol and high blood pressure. Avoid sugary snack foods. Choose a diet low in saturated fats and high in fruits and vegetables. Lutein and zeaxanthin are found in green leafy vegetables such as spinach and kale, plus broccoli, peas, squash, and egg yolk, corn, orange peppers, oranges and honeydew. Taking a supplement that contains appropriate amounts of antioxidants and lutein, zeaxanthin and meso-zeaxanthin can help preserve vision.  The omega-3s also support eye health; in particular DHA, which accumulates in the eye, protecting nerve cells from damage. Shield your eyes from harmful ultraviolet light by wearing quality sunglasses.  Finally… that ubiquitous warning: STOP smoking.  Studies show that smokers have lower levels of lutein and are at much greater risk of developing AMD.  Even passive smoking doubles the risk of AMD.

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Antioxidants Lutein and Zeaxanthin May Decrease Risk of Cataracts

The antioxidants lutein and zeaxanthin may play an even greater role in maintaining eye health than previously thought. A growing body of scientific literature supports the role of the antioxidants lutein and zeaxanthin in maintaining eye health, particularly in combating age-related macular degeneration. In addition, a recent Finnish study suggests that these nutrients may also provide benefit for those at risk of cataracts.

The Finnish study indicates that oxidative stress plays an important role in cataractogenesis (the process of cataract formation) and that the dietary intake of antioxidants, specifically the beta-carotenes lutein and zeaxanthin, may reduce oxidation and thus decrease the risk of age-related cataracts. The study consists of 1689 elderly Finnish subjects (559 women and 1130 men) aged 61–80 years. One hundred and thirteen cases of incident age-related cataracts were confirmed, of which 108 cases were nuclear cataracts. After adjusting for several factors, including: age, examination year, sex, smoking, alcohol consumption, serum LDL-cholesterol, serum HDL-cholesterol, use of oral corticosteroids, history of diabetes and history of hypertension and antihypertensive medication, the authors found that subjects with the highest blood plasma concentrations of lutein and zeaxanthin had 42 and 41 percent lower risks of nuclear cataract when compared with those with the lowest concentrations. The study suggests that high plasma concentrations of lutein and zeaxanthin were associated with a decreased risk of age-related nuclear cataract in the elderly population.

Risk factors
It should be noted that additional risk factors associated with age-related cataracts include: diabetes, prolonged exposure to sunlight, tobacco use and alcohol drinking.

Eating a healthful diet, in combination with regular exercise can also contribute to eye health — combating the formation of both age-related cataracts, and the progression of age-related macular degeneration (another leading cause of blindness in persons over 55).  Dietary sources of lutein and zeaxanthin include green leafy vegetables such as spinach and kale, broccoli, peas, squash, egg yolk, corn, orange peppers, oranges and honeydew melons. Taking a daily supplement with appropriate amounts of antioxidants lutein, zeaxanthin and meso-zeaxanthin can also help your overall vision; and as the Finnish study suggests, help reduce the incidence of cataract formation.

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Plasma lutein and zeaxanthin and the risk of age-related nuclear cataract among the elderly Finnish population

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Read the Label: A Cautionary Tale

Read the label. Good advice if you know what to look for. Most of us have learned to examine a nutrition label and pay attention to calories, saturated fat content, sugars, sodium, and the latest hot topic for good reason, trans fats. But, that’s old news. When it comes to nutritional supplements you owe it to yourself to learn more.

It used to be that if you ate a healthful diet, you might say that you didn’t need nutritional supplements, but we now know that’s not accurate. Research shows that 80 to 90 percent of the population does not achieve the recommended daily value (RDV) for each vitamin and mineral each day, nor do they even come close. In fact, marginal nutritional deficiencies are present in as much as 50 % of the non-multivitamin-mineral using population. And, keep in mind that RDV levels for each nutrient are only intended to guard against severe nutrient deficiency diseases like scurvy (vitamin C) or beriberi (vitamin B1), but are not intended to serve as levels of vitamin and mineral intake that are optimal in regard to supporting biological functions, preventing degenerative diseases and maximizing our well-being and longevity. Consider the new bottom line: commit to a high quality multivitamin-mineral supplement that provides 100% of the RDV which is intended to be a good base. Then build on that strong foundation with good dietary choices incorporating a variety of foods aimed to achieve even higher levels of vitamins and minerals that are optimal for supporting biological functions, preventing degenerative diseases and maximizing our well-being and longevity.

The following examples looking at several of the most frequently used supplements will give you some idea of what you need to look for in a product. VitalRemedyMD provides top quality pharmaceutical grade supplements that are independently assayed for content, quality and purity. All formulations are designed by Dr. Seth Baum; based on sound scientific evidence and clinical experience, incorporating ongoing research findings when they deserve merit. VitalRemedyMD provides you the peace of mind of knowing that you are receiving products that reflect state of the art in science with unsurpassed quality and safety.

The daily multivitamin-mineral

A daily multivitamin-mineral supplement is essential in addition to a healthful varied diet, avoiding processed foods and fast foods that are either lacking in nutritional value or are flat out working against you to promote better health. It is not necessary to customize a daily multi; it should simply provide the vitamins and minerals truly proven essential to human health in a balanced formulation that provides 100% of the daily recommended value (RDV).

Some of the more common problematic nutritional deficiencies include vitamin B12, magnesium (Mg), calcium and vitamin D. Symptoms of low levels of vitamin B12 may present as subtle cognitive and neurological changes; more serious shortages can result in dementia or anemia because B12 is essential for the production of red blood cells in the bone marrow. Dietary sources are animal derived: meat, fish, poultry, and to a lesser degree, eggs and milk products. Vegetarians can eat tempeh made of fermented soybeans (the bacteria produce B12). The RDV set by the FDA is 6 mcg.

Magnesium is required for 350 enzymes in the body to function, and for healthy maintenance of bones, arteries, heart, nerves, and teeth. A staggering 80% of the population is deficient in this mineral! Dietary sources include dark green vegetables, nuts seeds, and whole grains. The RDV is 400 mg.

Central to the prevention of osteoporosis is adequate daily intake of calcium, vitamin D, magnesium, copper and zinc which work together to strengthen bones. Calcium is essential for bones as well as teeth, blood and muscle contraction. Dietary sources include tofu, sardines, salmon, broccoli, kale, grains, nuts, and seeds. The RDV is 1,000 mg; taken in divided doses of 500mg or less. Vitamin D is essential for absorption of calcium in the body; the RDV is 600 mg. Requirements for calcium and vitamin D are higher in adolescents and the elderly.

A note on vitamin A: it can come from retinol (often called vitamin A palmitate or acetate) or from beta-carotene, or a combination of both. The label should specify. Optimally, vitamin A would be supplied as beta-carotene since the body can convert it to vitamin A on an as needed basis and high levels of retinol have been linked with weaker bones.

Look for things like USP Pharmaceutical Grade Quality products, chelated minerals which enhance absorption and bioavailability, natural color coating which avoids lead and other toxins, and independent assays to ensure safety, purity and content. Vitamin E should be should be natural (specified as d-alpha/mixed Tocopherols) NOT synthetic (dl-alpha Tocopherols). The natural form of vitamin E is better absorbed and retained by the body, but because it is more expensive it may be substituted by synthetic alternatives. Lycopene, an antioxidant found in tomatoes, is often added to a daily multi because of its association with cardiovascular and prostate health. Studies have shown these benefits with doses of 6 mg daily.

Finally, don’t take “one-a-day” multivitamin-mineral formulas seriously; you simply can’t pack in decent amounts of all the necessary nutrients in one tablet or capsule. A good product cannot be packaged in less that 2-4 tablets per day, taken in divided doses with two meals. Many of these details will of course increase the cost of the product, but as an educated consumer you will know just why it may be worth it.

The Essential Fatty Acids: Omega-3s

Essential fatty acids (EFAs) have become best known for their anti-inflammatory effects associated with decreased risk of inflammation based degenerative diseases (like arthritis, Crohn’s disease, ulcerative colitis, psoriasis, lupus, multiple sclerosis, migraine headaches, heart disease and cancer. EFAs belong to a class of healthful lipids known as polyunsaturated fatty acids and are unfortunately consumed far less than unhealthy fats in the typical American diet. Polyunsaturated EFAs include omega-3s, omega-6s, omega-7s, and omega-9s. These occur naturally in vegetables, fruits, nuts, grains, seeds, and various animal sources. Popular sources of omega-3s include fish oil, flaxseed, and hemp, while omega-6 supplements are frequently sourced from evening primrose oil, black currant, and borage. Meanwhile omega-7s are present in palm kernel oil and coconut oil, and omega-9s occur naturally in avocado oil and olive oil.

The omega-3s are comprised by alpha-linoleic acid (ALA) abundant in nuts, flaxseed, and vegetable oils is converted in the body into two other omega-3s derived from marine sources (fish oils): docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). Omega-3s and omega-6s must be consumed in a certain ratio for optimal health. An excess of omega-6s promotes the pathogenesis of cardiovascular, cancerous, inflammatory and autoimmune diseases. Because the average American diet provides a greater amount of the omega-6s we need to supplement our intake of the omega-3s. Because of the heart protective benefits of omega-3s DHA and EPA the American Heart Association currently recommends that people with coronary heart disease consider 1,000 mg of combined EPA and DHA daily.

When you compare VitalRemedyMD’s VitalOils with others ask the following:

  • Does it contain 1,000 mg combined EPA and DHA; not just 1,000 mg “fish oils”?
  • Do I need to take more than 1 soft gel to achieve that goal?
  • How does the cost compare based on the amount of EPA and DHA?
  • What is the source of oils? (small ocean fish are optimal)
  • Do they talk about enhanced purification using supercritical fluid technology?
  • Are soft gels enteric coated to enhance absorption and eliminate indigestion?
  • Is the product independently assayed for content accuracy and purity?

The JOINT Formulas

Did you know that each knee can bear up to four times your body weight? As strong as it is, injuries occur commonly, both from overuse and from under use. Be proactive and prevent injury by maintaining appropriate body weight and exercising 3-4 times a week. Begin with at least 10 minutes of cardiovascular activity like a stationary bike with the seat positioned so that your leg is almost fully extended on the down pedal, or the elliptical machine which allows for a challenging aerobic workout at a variety of levels while minimizing direct impact to the knee joint. Appropriate stretching should follow along with a few exercises that target the quadriceps and hamstrings and surrounding muscles that stabilize the knee. Seek out a personal trainer for advice on a regimen that suits your needs and capability.

Formulations that include glucosamine and chondroitin flood the market. If you pay careful attention to a few key points when choosing a product, you will find out how beneficial they can be. Studies have shown benefit, including both reduced symptoms and decreased joint space narrowing on x-ray exam with the sulfate forms of these supplements (not HCL). In our experience our formulation has been most effective for arthritis involving knees and hands, usually within 1-3 months; it must be taken at the correct dosage as directed.
Look for:

  • Sulfate form of glucosamine (NOT HCL); daily dose of 1500 mg
  • Chondroitin sulfate 1200mg daily
  • Addition of omega-3s DHA and EPA for their anti-inflammatory effect
  • Additional vitamins and minerals that are essential for maintenance of healthy cartilage and joints, including: B6, E, C, B5, zinc, and copper
  • Enteric coating for increased absorption

The EYE Formulas

Are you looking for a nutritional supplement created to support eye health? Go to any supermarket or health food store, or do an on-line search and you’ll quickly find yourself overwhelmed by choices. Some popular companies even have six or seven of their own products for you to consider. Which one should you chose? As Age-Related Macular Degeneration (AMD) is the leading cause of blindness in the western world, most ocular formulations focus on this disorder. We at VitalRemedyMD have spent two years analyzing the medical literature in order to produce the safest and most scientifically validated formulation for preserving eye health: RetinGuard®.

Many small studies that have evaluated nutrition and supplementation for maintaining eye health, but one that has caught the eyes of many people is AREDS (Age Related Eye Disease Study). This trial was published in 2001, and found that individuals with advanced macular degeneration had a 25% reduction in the progression of disease when taking a high dose antioxidant and mineral formulation. As there were a number of worrisome “issues” with the consumption of such high dose supplementation, AREDS II, an ongoing re-examination of this matter, has altered the doses of key ingredients in an attempt to establish optimal effective dosage ranges. Thus, in formulating RetinGuard™ both AREDS and AREDS II had to be duly thought-out. Another major trial to be considered was LAST (Lutein Antioxidant Supplementation Trial). In this study, lutein (10 mg daily) was found to significantly halt the progression of AMD in study participants.

  • Beta-carotene is not necessary since beta-carotene is found only minimally in the retina and because of the association with lung cancer in smokers at higher doses.
  • Lutein 10 mg and zeaxanthin/ mesozeaxanthin (4 mg/6 mg) in a 1:1 ratio as they are found naturally in the retina; these carotenoids function to protect our eyes from damaging sunlight.
  • NAC a precursor for glutathione, which itself is poorly absorbed, protects against free radicals.
  • Vitamin C 500 mg
  • Natural vitamin E 100 IU
  • Riboflavin (vitamin B2) 3.4 mg for maintaining eye health
  • Zinc/Copper 25 mg/ 2 mg in proper ratio; important for maintaining eye health, but at lower doses than AREDS I because of untoward side-effects at higher doses
  • Pure USP Pharmaceutical Grade Quality Independently assayed by FDA registered laboratories for safety and purity

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Differentiating Fish Oils Part 3 – DHA and EPA: The Dynamic Duo of Omega-3 Fish Oils

Reading a fish oil supplement label can be a daunting task. Understanding the difference between DHA and EPA, the active ingredients in fish oil, is even more complex. The reason for this complexity resides in the fact that our understanding of these two fatty acids is in its infancy. Still, let’s try to make some sense of what we’ve learned over the past decade or so.

Fatty acids are comprised of just three different atoms, carbon (the long backbone or skeleton of the fatty acid), hydrogen, and oxygen.  That’s it. The difference among the various fats lies in the length of the backbone (how many carbon atoms there are) and the number of “double bonds” between carbon atoms. Other than these two distinctions, the fatty acids are really the same. So, then why are there such great differences among the fats if they’re so similar, you might ask? It turns out that longer chains tend to be more biologically active, and more double bonds results in more twisted and misshapen molecules which can then take on characteristics akin to complex locks or keys. As signaling and communication between cells often occurs through a lock and key mechanism, the fatty acids with many double bonds turn out to be great candidates for this task.

EPA is shorter than DHA (perhaps a bit less biologically active) and has fewer double bonds (less effective as a lock or key). EPA tends therefore to serve more as a precursor for other molecules that can diminish inflammation, clotting, oxidation, and cell death. DHA is also a precursor for some wonderful molecules that cause reversal of inflammation and tremendous protection of nerve tissue. Additionally, DHA is actively incorporated in our cell membranes where it can help cells communicate with other cells.

Other attributes shared by these two omega-3s include: Lowering triglycerides; raising HDL: and lowering the risk of lethal heart rhythms during and following heart attacks. Our bodies contain far more DHA than EPA, and DHA lasts longer in our bodies than does EPA, but both of these fatty acids have very important roles to play, and should be emphasized in our diets.

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Differentiating Fish Oils Part 2: What’s in your Fish Oil?

So, now that you understand the different forms that fish oils come in, it would be helpful to know what you’re putting in your mouth when you swallow a fish oil soft gel.  To do this, you have to develop the skill of label-reading.  At first blush this may seem to be a simple task, one not worthy of a blog, but in truth deciphering labels can at times be anything but easy.  I am not suggesting that companies intentionally mislead consumers with marketing and catchy phraseology, but at times they certainly don’t go out of their way to clarify what’s being sold to you.  For instance, what does it mean when a label catches your attention with the bold statement, “1,000 mg of fish oil”? Are you to be comforted knowing that taking just one of these pills meets the American Heart Association’s recommendation for heart patients to take 1,000 mg of the essential omega-3s EPA+DHA daily? More often than not, the answer is NO.  That’s because fish oil does not equal EPA+DHA.  And it’s EPA+DHA that you’re after.  EPA and DHA are the active and beneficial ingredients in fish oil, not the other fats (which include saturated fats as well).  To be sure you are getting what you want and deserve, follow these few steps:

  1. Pay attention to only the “Supplement Facts
  2. Read the “Serving size” – how many soft gels does it take to get one serving? Mark that # down.
  3. Read the “Amount per serving” – how much EPA is there, and how much DHA is there in a single serving? Add the amounts of EPA + DHA per single serving. Write that # down. Ignore “other omega-3s’ or “Total omega-3s”
  4. Let’s say your goal is to get 1,000 mg daily of DHA+EPA. Take “1,000” and divide it by the number you got in step 3. For instance, if the number you arrived at is “500 mg”, then 1,000/500 is 2.  You must take 2 servings to get your 1,000 mg of DHA+EPA daily.
  5. But you must be sure how many soft gels make up a single serving! So, now multiply the answer you got in step 4 by the # you got in step 2. For our current example, this will give you the # of pills needed to get your 1,000 mg of DHA+EPA daily. As the serving size can be 1, 2 or even 3 pills, in the case we’ve constructed you might need to take 2, 4, or even six pills to get what you want! That is why this process is so important.

Remember, the more DHA+EPA there is per gram of fish oil, the more concentrated and pure the oil is.  The more pure the oil, the fewer unnecessary fats you are consuming.  Try to get the purest oils. Extra fat gives you extra and unnecessary calories, something most of us do not need these days.

I hope this has been clear and helpful for you. The next blog, Differentiating Fish Oils Part 3, will discuss the different ways our bodies utilize DHA and EPA.

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Differentiating Fish Oils: Part 1, The Form of the Oil

This series will succinctly describe various aspects of the omega-3 fish oils that cause doctors and their patients a great deal of confusion and consternation. We will begin with the form of the oil.

Fish oils come in four forms: Ethyl Ester (EE), Triglyceride (TG), Phospholipid (PL), and Free Fatty Acid (FFA). Most fish oils (including the prescription, Lovaza) come in the EE form.  In fact, the largest and most profound scientific studies to date have used EE omega-3s.  In nature, omega-3s are found in the TG and PL forms.  The problem is that in order for manufacturers to develop pills with highly concentrated important omega-3s, EPA and DHA (also known as the active ingredients in fish), they must first convert the omega-3s to the EE form.  Then these health-promoting omega-3s can be highly concentrated, and depending upon one’s preference, either EPA or DHA can be emphasized (to be discussed in a future blog). Some manufacturers chose to convert the oils back to the TG form (a process that requires the oils to be subjected to high temperatures for long periods of time – not good for the oils in some experts’ opinions).  Others convert the oils into the FFA form to try to enhance absorption.  The Krill oil producers leave the oil in its original PL form with the drawback being that only very small amounts of the key ingredients EPA and DHA can be delivered in each pill.  The Krill and TG contention is that these forms of omega-3s are more “natural” and thus better.  The reality is, however, that all the oils must be changed in our gut to FFA in order to be absorbed.  Thus, they are no longer PL, TG, or EE when they’re absorbed by our bodies.  They are all FFAs. Studies to date have shown this conversion to be an efficient process and up to 95% absorption can be expected when any of the forms are taken with food. In fact, the lion’s share of the current literature indicates that the form of the oil is probably not nearly as important as companies would like you to believe. The most important issue is how much EPA and DHA you are receiving when you swallow a pill or eat a fish.  That is what you need to look for (also the subject of another blog).

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