How much fish oil should you take? What kind of fish oil? Are certain brands better than others? In watching a documentary several years ago on Alaskan Eskimos (I was watching because of my long-time interest in Alaskan Malumute dogs) I couldn’t help but notice their meals. In particular, not only were they mostly fish, but they also used a fish oil mixture made from whale blubber almost like salt. It was literally sprinkled on almost everything they ate. I started to wonder at that point, are we taking too little fish oil? Much of this research on fish oil began in the 1970-80’s with Dyerberg’s group studying Eskimos in Greenland and comparing them to Danes. Basically, despite the Eskimos being quite fat, their blood work was better than Danish men and women, and they had far fewer episodes of fatal heart attacks. Other research since has also shown that fish oil consumption among Eskimo tribes has been linked to reduced heart disease and metabolic syndrome. One recent study found that high levels of EPA and DHA in Eskimos was associated with good blood markers like lower triglycerides and lower c-reactive protein (a test for bad inflammation).
Eskimos also seem to have less arthritis. The story on arthritis and fish oil began in the late 1970’s when a study was published that showed that Eskimo women (despite being quite heavy) had less knee arthritis. So if Eskimos have less arthritis, how would fish oil help?
Fish oils suppress the formation of inflammatory cytokines and eicosanoids and this is believed to be associated with less pain and inflammation. However, rather than shutting down the COX inflammatory pathway (like NSAID drugs-so called “COX inhibitors”) they are metabolized by that pathway into powerful anti-inflammatory molecules known as the resolvins and the protectins. These have been shown to have many effects, not the least of which is activating the the recovery process of inflammation. So unlike NSAID’s (Motrin, Alleve, Ibuprofen, Voltaren, Celebrex) which block an important inflammation pathway and cause sudden death via heart attacks and fatal stomach ulcers, fish oil increases good molecules that can control inflammation. They also do more than just turn down the inflammation knob, they switch inflammation from a bad chronic state to a good recovery state. That last inflammation recovery function likely needs a little explanation. Inflammation is good as it’s the body’s process to allow repair. Treatments like prolotherapy increase acute inflammation to allow tissue repair. However, acute inflammation from an ankle sprain is to be distinguished from it’s evil twin brother-chronic inflammation. This is the kind of inflammation that leads to heart attacks and other chronic diseases and is increased in patients with metabolic syndrome (overweight, high blood pressure, high triglycerides, pre-diabetes). So the fish oil effect that leads to molecules that move inflammation toward recovery phase means that chronic inflammation (which never gets to that recovery phase) gets moved toward something that looks more like helpful acute inflammation (which has a recovery phase). To use another analogy, chronic inflammation is like trying to bake a cake in a 200 degree oven. The oven isn’t hot enough to trigger the chemical processes that “bake” the cake-so all you get is mush. This is like chronic inflammation. However, turn the heat up to 400 degrees, and you get a “baked” cake (this is like acute inflammation). So increasing the recovery phase of inflammation is like turning the heat up in the oven.
Which components of fish oil help arthritis? There are a number of different component fatty acids that have been studied, the best known of which are DHA, EPA, and AA. EPA has been shown in a recent study to block the bad chemicals that lead to cartilage degeneration. DHA also has the same, but lesser effect. Another lab study also found that EPA was better than DHA or AA in reducing bad cartilage breakdown chemicals. Finally, a third recent study concluded the same thing (EPA>DHA). DHA was also strongly associated with modulating pain. It up regulates “feel good” endorphins much more strongly than other types of unsaturated fat (in this case olive oil).
Are there any clinical studies testing these lab findings in real patients? Yes. For example, one study showed that adding Glucosamine and EPA/DHA together was better at reducing osteoarthritis pain that just Glucosamine alone. Our triathlete neurosurgeon patient (Joe Maroon, M.D.) also studied neck and low back pain patients and found that he was able to get about 60% off NSAID’s by using fish oil. In addition, a recent MRI study found fewer bone marrow lesions (which happen because of bad cartilage) in the knees of patients with higher omega 3’s in their diets. On the other side of that coin-does eating less omega 3’s and more saturated fat rich in omega 6’s (the black sheep of the omega family), make a difference? Yes, one recent study found an association between synovitis (a chronically swollen joint) and high Omega-6 fatty acids. Does drinking a milkshake high is saturated fats really increase inflammation? Not so much say these scientists, who actually measured inflammatory blood markers right after the actual consumption of a milk shake rich in saturated fats. In this study, inflammation wasn’t immediately increased by this type of meal, nor did a fish oil milkshake reduce inflammation. Why? The fish oil effect takes awhile to build up, so don’t expect the same kind of sledgehammer anti-inflammatory results seen in popping a Motrin.
If it’s good for arthritis, how much should you take? The FDA says it’s safe to take up to 3000 mg of omega-3 per day. However, this isn’t the same as mg of fish oil, as 1,000 mg of fish oil has about 300mg of omega 3’s. However, one study found that Greenland Eskimos consumed on average 5,700 mg of Omega-3 EPA per day. So using this math, these Eskimos consume about the equivalent of 28 usual fish oil caps (8,400 mg of omega 3’s) per day (assuming a usual 2:1 ratio of EPA to DHA). I’d recommend something closer to this higher “Eskimo” dose. Having said that, you should find out what levels of fish oil consumption reduce your aches and pains. This may be different for everybody. One way to cut down on all of those capsules is to find a brand of EPA/DHA purified fish oil. These can have as much as 600 mg or more of omega 3’s. So for a concentrate that has 600 mg of omega 3’s, this would means about 9-10 caps a day, or 3 with each meal per pill. A concrete example is a brand called Nordic Naturals that makes an EPA Xtra formulation with about 1,000 mg of EPA and 1,500 mg of omega 3’s per 2 capsules. Here, you would start at 2 pills twice a day (4 pills per day or 3,000 mg total omega 3’s). If that doesn’t work over 1-2 weeks to reduce joint aching, then go to 2 pills three times a day (4,500 mg) or 4 pills in the morning, 2 with lunch, and 2 with dinner (6,000 mg/day).
How about fish oil quality? Fish oils like to oxidize (turn rancid). You can easily test if you’re buying the cheap stuff that’s less likely to help and is oxidized by a smell test. If the bottle smells very fishy, the stuff is bad. As an example, on a recent trip I ran out of my usual high quality fish oil brand and went to GNC. All they had was their GNC brand which I bought. It smelled very fishy, so I went back until I found a brand that didn’t have that odor.
How about contaminants? A March 2010 lawsuit claimed that 8 brands of fish oil supplements (CVS, Nature Made, Rite Aid, GNC, Solgar, Twinlab, Now Health, Omega Protein, and Pharmavite all contained excessive levels of PCBs. Most of these supplements were either cod liver or shark liver oils. Since the liver is the main detoxifying agent in these animals, it may concentrate these PCBs. Another concern has been raised about Mercury, but a Harvard study found negligible amounts of mercury in 5 major brands.
How about stem cells and fish oil? We have serious concerns that patients with a classic American style metabolic syndrome (high blood pressure, high triglycerides, overweight) have trouble growing stem cells in culture. This seems very much linked to triglyceride levels. Since fish oils reduce triglycerides, if you numbers are high, you may want to add fish oil and see if the toxic triglyceride levels come down before a stem cell procedure.
The upshot? If you’re the average American who buys cheap fish oil at the store and takes two capsules a day, you’re likely not getting the full effects of fish oil and you’re certainly not replicating the health benefits experienced by our Eskimo cousins. Up the quality of the stuff you take and up the dosage (after consulting with your physician). In addition, all that fish oil may just end up helping both your arthritis and your stem cells!