Are You Afraid of Fish Oil?

Health Professional

Imagine you just learned that olive oil was good for your health (which it is, of course. I'm just using olive oil as an example to make a point.) Would you then take a capsule or two every day?

I hope not. You'd probably pour it liberally on salads, use it in cooking, keep a big jar of it handy. You wouldn't worry whether you poured 1000 mg, 2000 mg or more on your foods.

Fish oil is also an oil with nutritional benefits. The health benefits of fish oil outweigh the health benefits of any other food oil by . .   . miles. The omega-3 fatty acids from fish oil reduce triglycerides, increase HDL, even dramatically slash the likelihood of heart attack and death from heart disease. While other oils, like olive and flaxseed, are also healthy, none achieve the magnitude of benefit that fish oil does.

Then why do most people who take fish oil take only one capsule per day?

Perhaps it's the size of the capsule. Or the smell. Or the fact that a multivitamin comes in a single tablet and more than one capsule of anything is too much.

But every day, I hear people say, "Sure, I take fish oil: one capsule every day." That's simply not enough. No measurable benefits in cholesterol values develop from this small dose. You might eke out a tiny long-term benefit in reduction of death from heart attack, but the full benefits of dramatic risk reduction will not be realized.

"What dose of fish oil should I take?"

To know how much fish oil to take, you need to decide how much of the omega-3 fatty acids, EPA and DHA, you need to achieve your desired goals. As little as a few capsules per month or eating fish two or three times per month yields measurable benefits on reduction of cardiovascular events. The Italian GISSI Prevenzione Trial of over 11,000 participants showed that 850-882 mg of EPA and DHA (1:2 ratio) resulted in a staggering 30% reduction in death from cardiovascular disease and a 45% reduction in sudden cardiac death.

Here are some dose guidelines:

  • Dramatic reduction of cardiovascular risk - Begins with an EPA + DHA dose of 850 mg per day.
  • Reduction of triglycerides and increased HDL - This effect generally begins at 1200 mg EPA + DHA per day.
  • Match the daily EPA + DHA intake of populations with very low heart attack risk─Japanese women experience only 20% of the heart disease risk of American women, while Japanese men experience only 35% of the risk of American men. Much of the reduced risk is likely due to the average Japanese person's intake of omega-3 of 1800-2400 mg per day, often more, from their diet. (The Inuit, often called "Eskimos," the population in which the first connection between fish intake and reduced cardiovascular mortality was first made, typically obtain even more, up to 5000-6000 mg omega-3s per day)

Interestingly, even Japanese people further reduce heart attack an additional 19% when 1800 mg of omega-3s are added to their omega-3-rich diets, according to the 19,000 participant JELIS study.

You might also consider a higher dose of fish oil if you've previously been on (and hopefully are now off) a low-fat diet (<20% of calories from fat) without fish oil supplementation. This is the absolutely wrong diet for omega-3 health. Low-fat diets tend to be seriously deficient in omega-3 fatty acids and long-term deprivation deeply depletes the body's omega-3 levels. All too often, low-fat diets obtain the bulk of fat intake from the omega-6 class of oils that increases thromboxane A2, an inflammation-increasing and vessel-constrictive compound that contributes to heart disease and may promote depression.

In our Track Your Plaque program for stopping or reversing coronary plaque (the material that leads to heart attack), we use several thousand milligrams per day of EPA + DHA for full benefit and to correct specific genetic causes of heart disease. We have never - NEVER - encountered any adverse effect of using this nutritional oil to doses even this high (beyond belching).

The varieties of fish oil supplements

Fish oil supplements come in a variety of shapes and sizes.

Omega-3 fatty acids from fish oil can be obtained as gelcaps, enteric-coated tablets, flavored liquids, emulsions like Coromega ®, even some candy-like preparations for children. All differ widely in the content of active ingredients, the omega-3 fatty acids EPA and DHA. Some people who have difficulty with the large fish oil capsules do well with the flavored oils (e.g., Carlson's). Coromega ® fish oil emulsions come in several flavors and are surprisingly non-fishy, though it may require several packets to achieve higher daily doses of omega-3s. If fishy belching is an issue, refrigerating or freezing the capsules helps, as does switching to an enteric-coated preparation. (Sam's Club and Costco both carry enteric-coated preparations.)

Once you've decided what dose of EPA and DHA you would like to achieve every day, look at whatever preparation you choose and add up the EPA and DHA content per capsule, tablet, teaspoon, or packet. (This should be listed on the label. If not, don't buy it.) You can then do some simple arithmetic to decide how many or how much to take to achieve your daily dose.

Avoid cod liver oil. In addition to omega-3 fatty acids, it also contains vitamin D. While vitamin D is crucial for health, it is too difficult to independently modify your omega-3 and vitamin D intake in the fixed proportions of cod liver oil. In addition, cod liver oil contains vitamin A in a form that has been suggested to pose a risk of toxicity.

A secondary source of omega-3 fatty acids is alpha-linolenic acid (ALA), found in flaxseed, walnuts, and canola oil. However, very little linolenic acid is converted into active EPA or DHA. Alpha-linolenic acid sources like flaxseed oil exert no measurable effects on lipids (e.g., triglyceride reduction) and they cannot replace fish oil. (Nonetheless, flaxseed oil, canola oil, and walnuts are healthy foods.)

So quit being afraid of fish oil. Few nutritional supplements enjoy the large body of clinical data supporting its use that fish oil does. Just be sure to take a dose that provides real benefits, not just drains your wallet for little or no effect.

Coming next: Is fish oil really safe?