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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Melatonin for high blood pressure?

Melatonin for high blood pressure?

Melatonin is fascinating stuff.

In addition to its use as a sleep aid, melatonin exerts possible effects on cardiovascular parameters, including anti-oxidative action on LDL, reduction in sympathetic (adrenaline-driven) tone, and reduction in blood pressure.

Several studies document the blood pressure-reducing effect of melatonin:

Daily nighttime melatonin reduces blood pressure in male patients with essential hypertension.

Melatonin reduces night blood pressure in patients with nocturnal hypertension.

Prolonged melatonin administration decreases nocturnal blood pressure in women.

Blood pressure-lowering effect of melatonin in type 1 diabetes.


But blood pressure may be increased when melatonin is added to nifedipine, a calcium channel blocker:

Cardiovascular effects of melatonin in hypertensive patients well controlled by nifedipine: a 24-hour study.


Effects on BP tend to be modest, on the order of 5-8 mmHg reduction in systolic, half that in diastolic.

But don't pooh-pooh such small reductions, however, as small reductions exert mani-fold larger reductions in cardiovascular events like heart attack and stroke. NIH-sponsored NHANES data (see JNC VII), for example, document a doubling of risk for each increment of BP of 20/10. The Camelot Study demonstrated a reduction in cardiovascular events from 23% in placebo subjects to 16.7% in subjects taking amlodipine (Norvasc) with a 5 mm reduction in systolic pressure, 2 mmHg drop in diastolic pressure. Small changes, big benefits.

Many people take melatonin at bedtime and are disappointed with the effects. However, a much better way is to take melatonin several hours before bedtime, e.g., take at 7 pm to fall asleep at 10 pm. Don't think of melatonin as a sleeping pill; think of it as a sleep hormone, something that simply prepares your body for sleep by slowing heart rate, reducing body temperature, and reducing blood pressure. (You may need to modify the interval between taking melatonin and sleep, since individual responsiveness varies quite a bit.)

I also favor the sustained-release preparations, e.g., 5 mg sustained-release. Immediate-release, while it exerts a more rapid onset of sleep, allows you to wake up prematurely, The sustained-release preparations last longer and allow longer sleep.

The dose varies with age, with 1 mg effective in people younger than 40 years, higher doses of 3, 5, even 10 or 12 mg in older people. Sustained-release preparations also should be taken in slightly higher doses.

The only side-effect I've seen with melatonin is vivid, colorful dreams. Perhaps that's a plus!

Comments (15) -

  • Jeanne Shepard

    5/10/2008 2:27:00 PM |

    I've hears that you can take melatonin too long, that is build up a tolerance.
    Any thoughts? I prefer it to other sleep aides, otherwise.

  • Anonymous

    5/10/2008 9:15:00 PM |

    After reading the article, I'm going to give melatonin a try.  Bought a bottle of 1mg tablets.

  • Michael

    5/10/2008 11:09:00 PM |

    I don't know if I have a weird body or something, but melatonin doesn't agree with me at all. It makes me a tiny bit groggy when I take it, but it turns me into a zombie the next day. Even small doses, like 1-2grams, basically makes me feel like I didn't sleep at all that night, and I feel crummy all day.

  • Jenny

    5/11/2008 11:33:00 AM |

    Dr. Davis,

    I have taken melantonin for many years and it helps me not only sleep, but get back to sleep if I wake up in the middle of the night.

    I've found a huge difference in the effectiveness of various company's pills. Trader Joe's for example, don't work for me at all. Schiff work very well.

    I was told years ago to take 1/4 of a pill for best results, and that is what I do. That works better than a larger amount for me.

  • Anne

    5/12/2008 1:10:00 AM |

    I have found melatonin to be very helpful. I go to sleep easily and I stay asleep. After I had bypass 8years ago, I was unable to sleep more than an 4-6 hours without Ambien. 8 months ago I started taking melatonin. It did not work right away, but after a few weeks I started to sleep very well and I have not had to restort to Ambien since. I take 3mg.

    I take 25mg metoprolol, a Beta blockers and found out that BB's decrease melatonin. Found this info through the internet, not my doctor.  

    My BP has been well controlled, even at night so I never checked to see if it went lower with melatonin.

  • Jeanne Shepard

    5/12/2008 3:24:00 AM |

    Jenny,

    Have you ever been told that you can't take it for a long period of time?
    I'd like to keep taking it, but was told not to.

    Jeanne

  • JohnN

    5/15/2008 2:01:00 AM |

    I have been taking melatonin for years and credit it with restorative sleep and general good health.
    Even so, my success rate is only about 70%. I discover that the amount of melatonin (in the blood) for a good night sleep (the desired effect) is a very small fraction of the oral dose that you can take. The difference is how the body (liver) metabolizes the substance. You really have to experiment to find the right dose for yourself; more is not better.
    For someone to try it for the very first time start at .1-.2 mg (a very small chunk of the tablet) and modify the dose accordingly.
    Do not think of it the same way as Ambien. It's best function is to ease you into sleep.
    Good luck.

  • Ann Theresa

    9/27/2008 1:59:00 PM |

    I am so hot at night that when I sleep, I wake up because of it.  I started taking my blood pressure upon waking and found it to be high.  160 or so over  90-95. I could feel the way my body felt. My blood pressure during the day is usually 115-120 over 70.  I knew I was peri menepausal, so the hormone thing was very suspect. After a lot of research, I decided to start taking 3 mg Melatonin. I checked with my doctor and he was catching up with me on his computer as we spoke.It was funny!  But anyway....I have been on these for about 3-4 weeks now and find that although I'm still warm when sleeping,  I am in a deeper sleep. My blood pressure now upon waking is about 123-125 over 82-83.  I have seen a significant improvement in lower blood pressure.  I will add that I have been walking daily and started taking a B complex also before bed.  I take my melatonin just before bedtime.  I have never had any problems with falling asleep. So the timing of use should be adjusted for when you need it.  I would much rather take this hormone than take the blood pressure medicine my doctor was so fast to offer.

  • Anonymous

    11/10/2008 7:54:00 PM |

    I swear by melatonin, and recommend the 5mg time release.  For me, it works best if I take it about 30 minutes before bedtime.  The time release eliminates the problems with waking up too early.

    The only time I have problems with feeling groggy is when I don't get enough sleep.  If you take it at midnight, then get up at 5 am, you're going to feel it.  If I know I'm not going to get at least 7-8 hours of sleep, I will skip the melatonin that night so I don't feel groggy.

    I have seen extreme differences in brands, so I think there is something to the comments about the quality of different manufacturers.

    I've never been told not to take it over long periods, but then I didn't ask a doctor about it.  I've noticed a slight tolerance if you take it all the time, so I sometimes will stop taking it for a while to break that cycle.

  • Improve Health Heart

    4/10/2009 3:43:00 PM |

    Hello.

    Your post looks quite interesting.. I never knew that Melatonin is a substance which has such uses.. I had heard of the term anywhere in any book but never took much interest in it..

    But your post spills out quite knowledgeable information definitely this much that it will hold my attention for a long long time..

    I also have a great interest in Heart related issue's and I have created a blog myself for it..

    I hope my posts will also help you gain some info..

  • Jonathan Byron

    4/22/2009 2:44:00 PM |

    There is some interesting research that suggests that melatonin is one factor that reduces insulin secretion at night.

  • TedHutchinson

    9/6/2009 6:26:07 PM |

    Oxidized-LDL and Fe3+
    /Ascorbic Acid-Induced Oxidative
    Modifications and Phosphatidylserine Exposure in Human
    Platelets are Reduced by Melatonin

    Abstract.
    Low-density lipoprotein (LDL) modifications and platelet activation are major risk factors for cardiovascular diseases. When platelets are exposed to oxidative stress, they become activated. Oxidized LDL (ox-LDL) and metal-catalysed oxidation systems such as Fe3+/ascorbic acid increase free radical production.
    We wanted to verify whether melatonin has a protective effect against oxidative modifications and phosphatidylserine externalization in platelets induced by ox-LDL and Fe3+/ascorbic acid.....snip.... These data suggest that melatonin may protect platelets from iron overload-induced and ox-LDL-induced
    oxidative modifications and also from the triggering signals of apoptosis activation, possibly due to its scavenger effect on toxic free radicals.

    The full text of both abstract and paper are the link above.

  • Serg

    7/21/2010 5:52:26 PM |

    This article regarding Melatonin for high blood pressure? is very interesting and useful, blood pressure may affect your sexual activity, and this not only happen to older people as I used to believed, young people can also be affected so you may need  to buy viagra to help yourself on those situations.

  • buy jeans

    11/3/2010 4:54:14 PM |

    I also favor the sustained-release preparations, e.g., 5 mg sustained-release. Immediate-release, while it exerts a more rapid onset of sleep, allows you to wake up prematurely, The sustained-release preparations last longer and allow longer sleep.

  • mike

    2/22/2011 11:37:17 AM |

    One such remedy that has gained popularity in recent years is melatonin. Melatonin is a growth hormone naturally produced by the pineal gland in your brain. Melatonin hormones are secreted at night or in the dark and helps regulate the sleeping cycle. It is believed that melatonin may help the body know when it is time to go to sleep and when it's time to wake up. These days, melatonin can be taken in pill form to treat everything from jet lag to insomnia. However, like with all medications, there is the potential for serious melatonin side effects if take with other medications.

    Reference:
    melatonin usage consider your age

    melatonin side effects

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