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Many of my patients seem to be taking fish oil supplements these days. When asked why they take them, most really are unsure. They just heard from a friend that it was a good idea. What is the fuss all about? What do these supplements really do? Should you be taking them? For more information, read on...

First of all, fish oil supplements are not the same as fish liver oils which are derived from the livers of fish, such as cod and halibut - i.e. the infamous Cod Liver Oil. Fish oil supplements are dietary supplements that contain oil from the flesh of cold water fish such as mackerel, salmon, albacore tuna, sardines, and herring.

It's all about Omega-3 fatty acids
The fuss is not really about the fish oil itself, but rather a group of essential nutrients in fish oil supplements known as Omega-3 fatty acids. These typically include three important, but unpronounceable compounds: eicosapentaenoic acid, docosahexaenoic acid, and alpha-linolenic acid. We'll just call them EPA, DHA, and ALA for short.

What is an "essential" nutrient?
EPA, DHA and ALA are considered essential nutrients. An essential nutrient is one that your body cannot make on its own and must be obtained directly from your diet. When you think about it, digestion is really a matter of chemically tearing large food molecules into tiny fragments which are small enough to be transported into your bloodstream. Once inside your body, these so-called "building blocks" are rearranged like pieces of a puzzle to create new larger molecules (proteins, carbohydrates, fats) which your body can then use for energy, growth, and repair. Your liver is pretty smart at making just about everything you need from these basic building blocks, but there are over 40 nutrients that your body cannot manufacture on its own. They must come directly from your diet - from food or supplements. Thus, the term "essential nutrient." Three of these essential nutrients are the Omega-3 fatty acids, EPA, DHA and ALA.

Why are Omega-3 fatty acids important?
The main reason is the prevention of heart disease. Numerous scientific studies over the past 25 years have shown that a diet high in Omega-3 fatty acids can significantly reduce the risk of heart disease. An example would be the typical Japanese diet. Fish products are an excellent source of Omega-3 fatty acids. In Japan, fish is a dietary staple and fish products are a part of many everyday foods. Beef and other sources of saturated fat are scarce. The rate of heart disease in Japan is among the lowest in the world. Scientists feel that this is largely due to the high levels of Omega-3 fatty acids in the Japanese diet. Unfortunately, the typical American low-fish high-fat diet has low levels of these important essential nutrients. This is felt to be one cause for the rising incidence of heart disease in this country.

How do Omega-3 fatty acids help prevent heart disease?
Many people have the misconception that consuming more Omega-3 fatty acids will make them healthier by lowering their cholesterol count, but that is really not true. At usual doses, Omega-3 fatty acids have little effect on blood cholesterol levels. Instead, most of the good effects of Omega-3 fatty acids come from two factors - reducing platelet function so blood clots are less likely to form in your arteries and reducing the risk of an abnormal heart rhythm. Omega-3 fatty acids also reduce inflammation, which is a key component in the processes that turns cholesterol into artery-clogging plaques.

While we all hear a lot about the importance of reducing high cholesterol to maintain good health, little is written about triglycerides. Mild elevations of blood triglycerides may not be serious, but when levels are extreme (over 500), the risk of heart disease increases. Very high Triglyceride levels can also cause a serious inflammation of the pancreas, called pancreatitis. Individuals with high blood triglyceride levels can also benefit from Omega-3 fatty acids.

Other benefits of Omega-3 fatty acids
Omega-3 fatty acids are necessary for proper cellular function. All tissues of the body are made of millions of tiny cells. Each cell is surrounded by a thin outer membrane which acts like a gatekeeper. Anything that wants to get into or out of a cell must pass through the cell's outer membrane. These cell membranes are primarily composed of fats - including Omega-3 fats. Omega-3 fats are especially fluid and flexible, make cell transport much easier which maximizes the cell's ability to take in nutrients while eliminating wastes. This is especially true in the brain where EPA and DHA are very important for normal brain cell development. In fact, EPA and DHA make up about 8 percent of the adult human brain making Omega-3 fatty acids a form of "brain food."

Some people with inflammatory bowel disease (Crohn's disease and ulcerative colitis) have low levels of Omega-3 fatty acids in their bodies. Fish oil supplements containing Omega-3 fatty acids have been shown to reduce symptoms of Crohn's disease and ulcerative colitis, particularly if used in addition to medication. Several studies suggest that Omega-3 fatty acid supplements reduce tenderness in joints, decrease morning stiffness, and allow for a reduction in the amount of medication needed for people with rheumatoid arthritis and, probably, osteoarthritis as well.

How much Omega-3 do you need?
There is currently no USDA RDA for Omega-3 fatty acids, but the National Institutes of Health recommends that people consume about 2% of their total daily calories as Omega-3 fats. To meet this recommendation, a person eating 2000 calories per day would have to consume about 2 grams of Omega-3 fats daily. The average American adult gets much less than 1 gram of Omega-3 fatty acids per day.

How much is too much?
The FDA suggests that average individuals not exceed 3 g/day, and encourages manufacturers of dietary supplements not to recommend doses exceeding 2 g/day. A special case is that of high blood triglycerides where doses up to 4 gms/day are needed to significantly reduce serum triglycerides - up to 30% lower.

Fish and Omega-3 fatty acids
The main dietary sources of Omega-3 fatty acids are cold-water fish - particularly oily fish such as wild salmon, mackerel, albacore tuna, sardines, lake trout, and herring. The American Heart Association (AHA) recommends that healthy adults consume at least 2 servings of fish weekly, particularly those that contain higher levels of Omega-3 fatty acids.

Interestingly, fish cannot actually synthesize Omega-3 fatty acids. Instead they obtain them from the plankton they eat in the wild. This is why farm-raised salmon have lower levels of Omega-3 fatty acids than wild salmon.

Do you need fish oil supplements?
It all depends on how much Omega-3 you already obtain from your diet. If you are like the average American, you are getting less than half of what your body needs, and therefore, need to add more to your diet. If you don't like eating fish, over the counter fish oil supplements are a simple and safe way to increase your intake of Omega-3 fatty acids. Fish oil supplements are available under numerous brand names. These come in capsule form and can be purchased inexpensively without a prescription. They are usually enteric coated to maximize absorption in the small intestine and prevent a fishy aftertaste. Most fish oil capsules contain 1000 mg of fish oil which supplies about 300 mg of Omega-3 fatty acids (EPA/DHA combined) per pill. So, three fish oil capsules only add about 1 gram of Omega-3 fatty acids to your diet at a cost of about 20 to 30 cents a day.

Walnuts are also heart healthy
For those who don't like fish and do not wish to take supplements, walnuts are another excellent source of Omega-3 fatty acids. In March 2004, the U.S. Food and Drug Administration cleared the health claim that eating walnuts may reduce your risk of heart disease, the first ever such claim for a whole food. Adding walnuts to your daily diet is a simple way to increase your intake of the important Omega-3 fatty acids. In addition to their heart-protective monounsaturated fats, one-quarter cup of shelled walnuts (about a handful) contains about 2.5 grams of Omega-3 fatty acids, 2 grams of dietary fiber, and no cholesterol. Don't overdo it, though, since each serving also contains about 185 calories.

Due to their high polyunsaturated fat content, walnuts are extremely perishable and care should be taken in their storage. They need to be kept dry and refrigerated to store well; in warm conditions they become rancid in a few weeks, particularly after shelling. Shelled walnuts should be stored in an airtight container and placed in the refrigerator, where they will keep for six months, or the freezer, where they will last for one year. Unshelled walnuts should be stored in the refrigerator, although as long as you keep them in a cool, dry, dark place they will stay fresh for up to six months.

Flaxseed - another excellent source
There's been a lot of talk lately about flaxseed as another excellent source of Omega-3 fatty acids. Flaxseed is just what it sounds like - the seed of the flax plant. Also called linseed, flaxseed has been around for over 5000 years.

Grinding the seeds improves intestinal absorption and is best done just before using them, but pre-ground seeds are more convenient. Keep them refrigerated after opening. I prefer the GNC Natural Brand Cold-Milled Flaxseeds which are pre-ground and supply 3 gms of Omega-3 ALA per tablespoon at a cost of about $10 a month. It has a pleasant, nutty flavor and complement cottage cheese and yogurt. I like to sprinkle it on salads, cooked vegetables, or cereal.

Concentrated flaxseed oil is also available at health food stores and natural foods markets as liquid or capsules and must be kept refrigerated. One teaspoon of liquid flaxseed oil per day, or two (1000 mg) capsules twice daily each supply around 2 gms of Omega-3 ALA. If adding flaxseed to your diet, consider how much you already get from other sources, such as fish and walnuts. If you often eat other Omega-3 rich foods, adjust downward. Too much oil is laxative, but otherwise it's not considered harmful to take too much.

Omacor - a high strength prescription supplement
If you suffer from very high blood triglyceride levels (over 500 mg/dl), you may wish to ask your doctor about Omacor. Approved by the FDA as safe and effective, Omacor capsules provide the highest available concentrations of purified EPA (465 mg) and DHA (375 mg).

While around 2 gms of Omega-3 fatty acids per day are generally recommended, it takes about 4 gms per day to reduce high blood triglycerides. To achieve this level, one would have to take about 12 capsules of regular fish oil supplements each day, compared with only 4 pills of the Omacor formulation. Omacor requires a prescription from your doctor.

What are the risks?
It all depends on how you add Omega-3 fatty acids to your diet. Omega-3 fatty acids themselves appear to be safe, are generally well tolerated, and are highly compatible with statins (Lipitor, Zocor, Crestor, etc) and other therapies.

If you decide to add Omega-3 fatty acids by eating more fish, you should be aware that in 2003 the US Environmental Protection Agency (EPA) issued warnings about pollutants in some fish such as mercury, dioxin, DDT, and other chemicals. Large carnivorous fish such as swordfish, shark, and king mackerel have the highest tissue level of mercury. Canned light tuna, trout, and salmon are much safer. Women who are pregnant, planning to become pregnant or nursing - and young children - should avoid eating potentially contaminated fish.

Although fish oil supplement capsules are made from fish, they appear to be safe due to the rigorous manufacturing process and careful selection of marine sources. Supplements are purified to remove mercury, PCBs and dioxin. You should only buy known brand names and read the label to verify that they are free of contaminants. Walnuts and flaxseed do not contain mercury and are safe.

Since Omega-3 fatty acids can reduce blood clotting, anyone taking aspirin, Plavix (clopidogrel) and Coumadin (warfarin) should report any excessive bruising or other signs of bleeding to their doctor.

Summary
So, the bottom line is that Omega-3 fatty acids are important essential nutrients which may help reduce your risk of heart disease and may also be helpful for those suffering from other chronic conditions. Every adult should consider increasing his or her intake to around two grams per day.

Fish oil supplements are convenient and safe, but each 1000 mg capsule only contains about 300 mg of Omega-3 fatty acids. It takes three capsules of fish oil to obtain one gram of Omega-3 fatty acids. Flaxseed oil capsules are more concentrated. However, you don't need to take more pills if you don't want to. For the average adult, just eating the right kind of fatty fish (wild salmon, herring, sardines, or mackerel) about twice a week, enjoying an occasional handful of walnuts, and adding flaxseed to salads, baked potatoes or granola are simple ways to add these essential nutrients to the diet. Those individuals with established heart disease and other chronic disorders may benefit from more aggressive supplementation. If you need more information, ask your doctor.