You probably don't take enough fish oil

The results of the recent Heart Scan Blog survey in response to the question: MY DAILY DOSE OF EPA + DHA FROM FISH OIL IS revealed:


Zero--I don't take any
17 (7%) of respondents

Less than 1000 mg per day
24 (10%) of respondents

1000-2000 mg per day
91 (38%) of respondents

2000-3000 mg per day
44 (18%) of respondents

3000-4000 mg per day
40 (16%) of respondents

More than 4000 mg per day
20 (8%) of respondents



Based on the above results, I would say that only a minority of respondents are taking an ideal dose of omega-3 fatty acids. Nearly all of us should consider taking more.

Benefits of omega-3 fatty acids (EPA + DHA) from fish oil begin around a dose of 840 mg per day, according to the GISSI Prevenzione Trial of 1999, an 11,000-participant trial. This dose also corresponds to a quantity of omega-3s that have been shown to raise EPA + DHA blood levels and thereby reduce the notoriously high AA:EPA ratio of Americans.

But what dose is sufficient? What dose is ideal?

Well, the answer to a great degree depends on what you are taking the fish oil for. If being taken to reduce triglycerides and triglyceride-containing lipoproteins, like VLDL and the after-eating (postprandial) IDL, then a higher dose will be necessary. (Triglyceride reduction for the genetically-determined very high triglyceride level of familial hypertriglyceridemia is the FDA-approved indication for prescription Lovaza.)

If you are taking fish oil for treatment of ADHD, depression, or bipolar illness, very high doses are often necessary.

But how about maximal reduction of cardiovascular risk and for control or reversal of atherosclerotic plaque?

This conversation is still evolving. But we can learn some important lessons from three populations of the world that are vigorous consumers of fish:

--The Inuits (aka Eskimos) of Greenland and northern Canada
--The Japanese
--The Bantus of Tanzania who live along Nyasa Lake

All three indigenous populations have several-fold greater intakes of fish and omega-3 fatty acids, have higher blood levels of omega-3 fatty acids, and have enjoyed reduced cardiovascular events, reduced atherosclerotic plaque, or improvement in various surrogates of cardiovascular risk (e.g., Lp(a)).

The most recent addition to this conversation is the ERA JUMP Study, discussed in a previous Heart Scan Blog post. In ERA JUMP, despite being heavy smokers and having other markers for greater risk for heart disease, Japanese men living in Japan had markedly less carotid and coronary plaque, as compared to Caucasian men living in PIttsburgh or Hawaiian men of Japanese descent. The difference appeared to be attributable to serum levels of omega-3 fatty acids.

I believe that the trend is here is to increase the amount of omega-3 fatty acids that most of us take. In the Track Your Plaque program, we have been advocating a rock-bottom starting dose of EPA + DHA of 1200 mg per day. However, I believe that this is due for a change.

We will be increasing the minimum dose for plaque regression and control. Please attend our Webinar this evening for a full, in-depth discussion of the rationale behind this important change.

As always, let me remind you that I am not selling, nor ever have sold, fish oil supplements. If I advocate a specific dose, a higher dose, I do so based on my interpretation of the data and experience with patients, not because I am interested in selling brand X of fish oil.

Comments (17) -

  • madcappedmc

    8/20/2008 3:11:00 PM |

    You are probably right that most people should increase their omega-3 intake.  However, all of fish oil pills (and the liquid) that I see have moderate-to-high doses of vitamin E.  So your recommendation appears require supplementing with large doses of vitamin E (in addition to the fish oil); do you think this is a cause for even mild concern?

  • Sven

    8/21/2008 3:26:00 PM |

    What about all those CVD-free populations that don´t eat any fish (e.g. Masai)? Obviously fish (oil) is not necessary to be healthy.

  • anne

    8/21/2008 7:01:00 PM |

    What a range - but must remember that both fish oils omega 3 and omega 6 important herbal supplements.

  • mike V

    8/22/2008 2:42:00 PM |

    I think that it is extremely difficult to separate the benefits of one nutrient from the effects of one's overall diet and supplement regimen.
    Maintaining a low omega 6 to omega 3 ratio has been shown to be very important.
    I have taken 3 standard Sam's/Costco capsules (total EPA+DHA=900 mg) for many years,along with an overall regimen not unlike Dr Davis's recommendation.
    My guess is that an ounce of early prevention is probably worth a pound of later reversal, but perhaps I am simply in the lucky 50%.

    FWIW my HDL at the outset was in the low 30's @ age 40, now runs about 50, @ age 72. CTA scan 1 year ago: "no detectable plaque"
    My Father died of second MI @ age 76.
    Over the years most of us "preventers" have had to read the studies, and take our "shot in the dark" with our supplements.

    Dr Davis, I can't over emphasize the value and encouragement of receiving feedback from you and your patients on the frontline. Please keep up (and promulgate) this excellent work.
    MikeV

  • Peter Silverman

    8/22/2008 2:52:00 PM |

    Is there a reason to eat those omega 3 eggs if you think you're getting enough 3 from fish oil?

  • Kayaman

    8/23/2008 11:31:00 AM |

    Since omega-3 fats are polyunsaturated that renders them prone to peroxidation.  Evidence indicates fishoil improves lipid profile, but at what cost?

  • Anonymous

    8/25/2008 6:32:00 PM |

    I hope that you (Dr Davis) realize that fish oil decreases clotting time. At what point does that come into play as being an undesirable side effect? If it takes longer than 5 or 10 minutes to stop a cut from bleeding, is that too long? What about occult internal bleeding or hemorrhagic stroke? I think this needs to be addressed. In addition many people take aspirin, more than the 81 mgs that is recommended. NSAIDS affect clotting, Vitamin E in larger doses can affect clotting, some herbs affect clotting. While I understand that the cardiovascular effects are desirable, I question the clotting issue.

  • Anna

    8/26/2008 5:15:00 PM |

    I can see why fish oil might seem beneficial to folks who eat the SAD, in a similar way the epi studies indicate eating whole grains trumps refined grains (I think the evidence indicates that no grain is better whole grain).  Fish oils make a crummy standard diet less damaging, so it seems like a great idea.  

    But what about if one avoids industrial foods and the sources of omega 6 PUFA in the first place?  Why supplement with omega 3 if there is no need to offset the omega 6 FAs?  Why purposely raise intake of intake any unstable PUFAs, including omega 3s (fish oil).

    There are considerable concerns about PUFAs consumption in general, particularly cancer.  

    I have greatly reduced or eliminated the most common sources of omega 6 FA (minimal or no grain,  industrial veg oils, or grain-fed meat/dairy/poultry).  Instead, I stick to pastured animal foods and traditional fats that are predominately naturally saturated or monosaturated (unless the PUFAs are in the original intact food, such as nuts, fish, etc.).  

    So if I supplement with fish oil omega 3s (or any concentrated non-food source), I could actually be overloading on omega 3 PUFA intake in relationship to my low omega 6 intake.  

    I've been mulling this over for some time, trying to reconcile the differences in views.  Then Peter's post on Hyperlipid showed up today.  Could this be the interpretation that explains my reluctance on the fish oil supplementation?

    http://high-fat-nutrition.blogspot.com/2008/08/age-rage-and-ale-vldl-degradation-and_25.html

    Dr. Davis, I know you are busy, and I'm not trying to create waves, but since you do advocate fish oil supplementation, I wonder if you can review Peter's post and explain if you have a different interpretation.  

    On the fish oil issue, I just haven't been able to decide my best course of action, other than holding off on supplementation until I am more confidently sure of my understanding of what more omega 3 might or might not do for me and my family (not on the SAD).

  • Sven

    8/27/2008 8:10:00 AM |

    A recent review published in the American Journal of Clinical Nutrition by Dariush Mozaffarian of Brigham and Women's Hospital and Harvard Medical School concluded that omega-3 fish oil fatty acids EPA and DHA help prevent heart disease, but that the benefits only extent to taking 250 mg/day. This conclusion was based on the convergence of data from prospective cohort studies and randomized clinical trials.

    This is from Chris Masterjohn´s newsletter.

  • Anna

    8/28/2008 12:05:00 AM |

    Yes, I've been reading Chris Masterjohn's interpretations of the PUFA and cholesterol literature, too (among others).  Gotta love the access the web gives us, eh?  Though it does give us a lot to ponder...still, I feel better about sifting through some contradictory ideas or ones that don't quite fit the puzzle vs. just accepting the conventional info spooned out to me and burying my head in the sand, like too many do.

  • Dr. B G

    8/30/2008 3:51:00 PM |

    Sven,

    Mozzafarian is misinformed about a lot of things -- he wrote a letter once advising against EBT heartscans (low rad, no dyes, low maintenance) for the general population (he's kinda right -- health insurance may not be able to 'afford' an EBT for 'everyone' however on the flip side, if prevention of expensive procedures and hospitalizations (and optimal health) were goals of health insurance, then eventually they cannot NOT afford to offer EBT to everyone.  

    Darius is young... give him time -- he has done some wonderful research and I believe he's on the right track.

    He was my chief resident on my Internal Med rotation at Stanford, as a pharmacy clerkship student.  My classmates (male and female) all drooled after him... Some thought he was a blond, hazel-eyed Persian god. Very kind, humble, hard worker (despite family wealth) and smart too!  

    -G

  • Dr. B G

    8/30/2008 3:51:00 PM |

    Sven,

    Mozzafarian is misinformed about a lot of things -- he wrote a letter once advising against EBT heartscans (low rad, no dyes, low maintenance) for the general population (he's kinda right -- health insurance may not be able to 'afford' an EBT for 'everyone' however on the flip side, if prevention of expensive procedures and hospitalizations (and optimal health) were goals of health insurance, then eventually they cannot NOT afford to offer EBT to everyone.  

    Darius is young... give him time -- he has done some wonderful research and I believe he's on the right track.

    He was my chief resident on my Internal Med rotation at Stanford, as a pharmacy clerkship student.  My classmates (male and female) all drooled after him... Some thought he was a blond, hazel-eyed Persian god. Very kind, humble, hard worker (despite family wealth) and smart too!  

    -G

  • mike V

    9/2/2008 5:10:00 AM |

    BETTER THAN STATINS

    Keep up the good work folks.
    More vindication from Europe.

    http://www.iht.com/articles/2008/08/31/healthscience/fishoil31.php

    Mike V

  • Anonymous

    11/16/2008 4:31:00 AM |

    "What about all those CVD-free populations that don´t eat any fish (e.g. Masai)? Obviously fish (oil) is not necessary to be healthy"
    thye eat a lot of grass fed animals and their organ and drink their blood all high im omega 3

  • Davide

    11/30/2008 7:51:00 PM |

    Dr. Davis,

    Just came across your blog recently--fascinated by it. Learning a lot. Question: Have you had any experience with Neptune Krill Oil? The DHA and EPA in it is supposedly naturally bound to naturally-occurring phospholipids (the composition of our all our cell membranes), which makes its bioavailability and assimilation so much higher. Consequently, so much less is needed for a therapeutic dose.

    There are also several clinical trials (even though they are small) with really amazing results.

    Check it out and please let me know what you think.

    http://neptunebiotech.com/

  • Anonymous

    3/12/2009 6:44:00 PM |

    I keep reading about getting toxic dose of Vit A with taking high doses of fish oils.  The vegetarian option only seems to have DHA and no EPA.  Sugestions?

  • buy jeans

    11/3/2010 10:44:23 PM |

    Dr. Goldstrich has proven especially adept at understanding how to incorporate new findings from clinical studies in our framework of coronary atherosclerotic plaque management strategies.

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