Omega-3 fatty acids: Frequency vs. quantity

20. October 2007 William Davis (8)
I believe I have been observing an unexpected phenomenon: When it comes to fish oil and omega-3 fatty acids, the frequency of dosing may be as important, perhaps more important, than the actual dose.

First of all, why advocate omega-3 fatty acids from fish oil? There’s a list of lipid/lipoprotein reasons, including reduction of triglycerides and triglyceride-containing particles (VLDL, intermediate-density lipoproteins), reduction of small LDL, and increase in HDL. There’s also solid benefit in reduction of heart attack risk, reduction in death from heart attack, and reduction in stroke. There are also anti-inflammatory benefits and improvements in mood, reduction in depression.

Fish oil is a crucial ingredient in the Track Your Plaque program. I am honestly uncertain of just how much success we would give up if fish oil were NOT a part of the program, but I am unwilling to find out. The data are simply too compelling to not include omega-3 fatty acids from fish oil. Of course, supplementation of omega-3 fatty acids assumes greater importance in a modern world in which your food has become terribly depleted of the omega-3 fraction of oils. (Cultures that rely heavily on fish or wild game probably would not benefit to the same extent, since these foods contain omega-3 fatty acids.)

But I believe I have observed a curious effect over the past year or two. With the proliferation of many different preparations of fish oil that provide seemingly endless choices—low-potency fish oil, high-potency fish oil, paste forms of fish oil like Coromega, liquids such as Carlson’s, etc.¾I’ve observed that frequency of dosing may exert as much of an effect as the dose.

For example, someone might take the basic, low-potency preparation like Sam’s Club that contains 180 mg EPA and 120 mg DHA per capsule, four capsules per day. That yields a total of 1200 mg EPA and DHA per day. This is our minimum dose that provides the basic heart attack-reducing effect, though with modest effect on triglycerides and associated patterns.

Say someone switches to a high-potency preparation of 360 mg EPA and 240 mg DHA, providing a total of 600 mg omega-3 fatty acids per capsule, or twice the dose of the low-potency preparation. Would you expect double the effect?

Curiously, no. What I have observed, however, is that more frequent dosing may provide a larger effect. The least effective dosing is once per day; twice per day is far more effective. Three times per day¾though cumbersome¾provides even greater effect.

So, which is more important: dose or frequency?

I can’t say for certain, since my observations are informal and have not been obtained by a formal statistical analysis of our data. That will come with time.

For the present, suffice it to say that, if you are struggling with suppression of patterns like increased triglycerides, IDL, or low HDL, then at least twice- or three-times-per-day dosing might be worth considering, even before you increase the dose further.

Best: Greater dose, or higher-potency preparation, combined with higher frequency.
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Comments (8) -

  • Anonymous

    10/20/2007 5:44:00 PM |

    Dr. Davis, what do you think of Krill Oil as opposed to fish oil as a source of EPA and DHA?

  • Dr. Davis

    10/21/2007 1:01:00 AM |

    Well, the one published study that I've seen was very promising. I have no personal experience, however.

    I'd like to see more data generated before we jump in deeper.

  • BarbaraW

    11/30/2007 3:32:00 AM |

    Dr. Davis,
    What about fish oil supplementation for people who are taking Warfarin? I see on our bottle of fish oil a notice to consult a health care professional if you are on an anticoagulant.  What can you tell us about this?  Thank you.

  • Dr. Davis

    11/30/2007 4:01:00 AM |

    Hi, Barbara-

    Because of the mild platelet-blocking, blood thinning effect of fish oil, you'll find that warning on all preparations. In our patients, we have never seen any meaningful interactions--no bleeding, no strokes, no other adverse consequences of the combination. In fact, in my view, the combination is beneficial.

    However, legal concerns force me to say that you should always consult with your doctor first.

  • Dr. Davis

    11/30/2007 4:02:00 AM |

    Let me add that taking fish oil with warfarin is no more risky than eating salmon or other oily fish every day while on the drug.

  • BarbaraW

    11/30/2007 4:25:00 PM |

    Thank you, Dr. Davis!
    I understand that you are not giving specific advice here, but it is helpful to have your professional perspective on these matters.  From your posts, it certainly sounded like you must have some patients who are on warfarin and taking fish oil, too.

    My husband had a PE (cause undetermined) last January and has been on warfarin since then.  As he was lucky enough to survive the PE, he decided to get serious about improving his health.  I had been nagging him for some time before his near-death experience, to no avail, to try the Protein Power plan. As I've mentioned in other posts, he's lost quite a bit of weight (now 50 lbs) with the low-carb way of eating and is feeling better than he has in years - younger, actually, and he looks it, too!  I've benefited, too, much to my delight.  We can still each lose a few more pounds to be at optimal weights, and we're getting there, slowly but surely. We're never going back to wheat and sugar, that's for sure.

    BTW, I just finished Dr. Malcolm Kendrick's book, The Great Cholesterol Con, and I think it's a great read (I was highly entertained - I enjoy his writing style!) and helpful in understanding heart disease.  Your comments on this book would be a great blog post, although I'm sure you have a long reading list!  

    Thanks again.

  • Dr. Davis

    11/30/2007 5:25:00 PM |

    Hi, Barbara-

    I've not read Dr. Kendrick's book but, based on your comments and those of others, I'm adding it to my list.

    A reader also brought some of his webcasts to my attention:

    Part 1: Cholesterol: http://uk.youtube.com/watch?v=XPPYaVcXo1I
    Part 2: Familial Hypercholesterolaemia: http://uk.youtube.com/watch?v=-Xrr8MjDJ78
    Part 3: About Statins: http://uk.youtube.com/watch?v=jE_RIQY53ys
    Part 4: Stress and the HPA axis (Bjorntorp): http://uk.youtube.com/watch?v=fHIA8usGxEM
    Part 5: CVD Populations and Stress: http://uk.youtube.com/watch?v=Na_Ear8OdJM
    =

  • buy jeans

    11/3/2010 9:53:31 PM |

    Say someone switches to a high-potency preparation of 360 mg EPA and 240 mg DHA, providing a total of 600 mg omega-3 fatty acids per capsule, or twice the dose of the low-potency preparation. Would you expect double the effect?

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A dirty little secret

A dirty little secret

21. April 2007 William Davis (0)
Here's a dirty little secret many people don't know about.

If I implant a stent, I might get paid somewhere around $2000 for the heart catheterization, stent implantation, femoral artery closure device, hospitalization charges. That's not too bad.

But what if I'd like more? What if I'd like to squeeze this unsuspecting patient for more, or actually his/her insurance company?

Easy: Add on complex procedures to the basic procedure that yield more professional charges. For instance, I could perform laser angioplasty, a procedure that adds another couple thousand dollars. I might pull out the old rotational atherectomy device, a high-speed diamond tipped drill that also adds substantial professional charges. I might also use the intracoronary ultrasound device, an otherwise helpful device, but I might pull it out to use on everybody.

With the exception of ultrasound, all the "add-on" procedures were more popular in the early and mid-1990s--before they were shown in clinical studies to provide no advantage, perhaps even add to procedural risks.

Thus, a patient might undergo a heart catheterization, balloon angioplasty with stent implantation into the proximal left anterior descending coronary artery (LAD), followed by laser angioplasty of the mid-LAD, followed by intracoronary ultrasound of the vessel. Next, rotational atherectomy of the circumflex, followed by stent and ultrasound. Total charges for this 2-3 hour procedure? Somewhere around $8000 to the cardiologist. Of course, hospital charges are far more.

Ironically, patients are invariably impressed. Hearing that they went through all sort of high-tech procedures makes them grateful for receiving the benefits of the skills of their cardiologist. Of course, they would like have done as well with a far simpler procedure. Perhaps they didn't need the procedure at all.

If the excessive use of procedures and devices fails to benefit patients, why don't hospitals discourage it? Two reasons: 1) It's difficult to legislate or regulate decisions made on judgement, which can be a tough issue with many fuzzy edges, and 2) hospitals made oodles more money from the practice.

If you have a salesman in your new car lot and he outsells all his colleagues by 30-50% and makes you a couple hundred thousand a month more in sales. You've watched him at work and he's clearly good at it. But you suspect that he pushes the envelope of propriety frequently--badgering customers, add rustproofing to a little grandmother's car that will be driven 3000 miles a year, selling cars for prices far above what they would have sold for had the customer bargained more vigorously.
do you put a stop to it at the risk of pushing your star salesman away? Few would.

Only a minority of my colleagues are guilty of this despicable practice. I only know of a few who openly do it. Hopefully, you're not among their patients.
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Eggs: Good, bad, or indifferent?

Eggs: Good, bad, or indifferent?

5. August 2006 William Davis (3)
Eggs have been in the center of the cholesterol controversy almost from the very start.

The traditional argument against eggs went that eggs, high in cholesterol (210-275 mg per egg)and with some saturated fat (1.5-2.5 grams per egg), raised blood cholesterol (and LDL). Out went the daily fried, scrambled, poached eggs that many Americans indulged in most mornings. (We replaced it with more breakfast cereals and other carbohydrate conveniences, then got enormously overweight.)





A large Harvard epidemiologic study in 1999 called this observation into question. They tracked the fate of 117,000 thousand people and then compared the rate of heart attack, death, and other cardiovascular events among various people correlated to the "dose" of eggs they ate. Egg intake varied from none to 7 or more per week. Lo and behold, people who ate more eggs appeared to not suffer more events.

This study, large and well-conducted by an internationally respected group of investigators, seem to reopen the gates for more egg consumption, though most Americans still consume eggs cautiously.

Deeper down in this study, however, was another observation: People with diabetes who ate 1 egg per day had double the risk of heart attack. Because this study was observational, no specific conclusion as to why could be drawn.

A new study conducted by a Brazilian group may shed some light. Healthy (non-diabetic) men were fed an emulsion of several eggs. Inclusion of plentiful yolks caused a dramatic slowing of fat clearance from the blood. Specifically, "chylomicron remnants" were abnormally persistent in the blood. Chylomicron remnants are potent causes of coronary plaque. (Chylomicron remnants can be measured fairly well by intermediate-density lipoprotein and VLDL by NMR, or IDL by VAP.)

Diabetics are know to have substantial disorders of after-meal fat clearance, including an excess of chylomicron remnants. Could the Brazilian observation be the explanation for the increased event rate in diabetics in the Harvard study? Interesting to speculate.

We continue to tell our patients that eating eggs in moderation is probably safe. After all, there are good things in eggs: the high protein in the egg white, lecithin in the yolk. It is the yolk's contents that are in question, not the white. Thus, you and I can eat all the egg whites (e.g., Egg Beaters) we want. It's the safety of yolks that are uncertain.

The abnormal after-eating effect suggested by the Brazilians opens up some very interesting questions and confirms that we should still be cautious in our intake of egg yolks. One yolk per day is clearly too much. What is safe? The exisitng information would suggest that, if you have diabetes, pre-diabetes, or a postprandial disorder (IDL, VLDL), you should minimize your egg yolk use, perhaps no more than 3 or so per week, preferably not all at one but spaced out to avoid the after-eating effect.

Others without postprandial disorders may safely eat more, perhaps 5 per week, but also not all at one but spaced out.

Track Your Plaque Members: Be sure to read our upcoming Special Report on Postprandial Disorders. It contains lots of info on what this important pattern is all about. Postprandial disorders are largely unexplored territory that hold great promise for tools to inhibit coronary plaque growth and drop your heart scan score. The Brazilian study is just one of many future studies that are likely to be released in future about this very fascinating area.




Hu FB, Stampfer MJ, Rimm EB, Manson JE, Ascherio A, Colditz GA, Rosner BA, Spiegelman D, Speizer FE, Sacks FM, Hennekens CH, Willett WC.A prospective study of egg consumption and risk of cardiovascular disease in men and women. JAMA 1999 Apr 21;281(15):1387-94.

Cesar TB, Oliveira MR, Mesquita CH, Maranhao RC. High cholesterol intake modifies chylomicron metabolism in normolipidemic young men. J Nutr. 2006 Apr;136(4):971-6.
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Comments (3) -

  • Dani Aldred

    5/22/2009 7:56:58 PM |

    G'Day

    I stumbled upon your article when I google searched "Egg yolk Robb Wolf" ... First off, I eat two omega 3 eggs every morning and take 6g of fish oil per day (0.5g per 10lbs body weight). I like that you are open to both sides of the great egg debate. Personally, I think Egg Beaters are crap:

    http://lifespotlight.com/health/2009/03/16/selling-ill-health-real-foods-fake-foods/

    How do you feel about omega 3 eggs? Are they safer? Can we eat more of them if we are cutting out those damn dirty grains and supplementing with fish oil?

  • Anonymous

    10/24/2010 9:07:47 PM |

    Seems to have changed his mind - http://heartscanblog.blogspot.com/2010/08/whats-for-breakfast.html

  • buy jeans

    11/3/2010 6:45:59 PM |

    Diabetics are know to have substantial disorders of after-meal fat clearance, including an excess of chylomicron remnants. Could the Brazilian observation be the explanation for the increased event rate in diabetics in the Harvard study? Interesting to speculate.

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