Complete Product Reference Guide - Dr. Marina Johnson Store

Complete Product Reference Guide

Ortho Molecular Products 3017 Business Park Drive Stevens Point, WI 54481

www.orthomolecularproducts.com

Table of Contents:

Supplement Facts Box Introduction to Fish Oils Health benefits of Omega-3 fatty acids Quality of OrthoMega and other fish oils Content of OrthoMega Allergen information What is Pharmaceutical Grade Fish Oil Ethyl Esters versus Triglycerides Commonly asked Questions

Supplemental Facts Box

Label

Introduction Omega-3 fatty acids have received a great deal of attention lately. The health benefits of Omega-3 fatty acids are just coming to light after years of research. The American Heart Association recognizes that consuming Omega-3 fatty acids derived from fatty fish benefit the hearts of healthy people and those at risk for cardiovascular disease. The AHA recommends that individuals eat fatty fish at least two times per week. While, for a number of different reasons, this is not always achieved, many people supplement their diets with fish oil products. FDA allows the following health claim to be placed on fish oil products: “Supportive but not conclusive research shows that consumption of EPA and DHA omega-3 fatty acids may reduce the risk of coronary heart disease. One serving of [name of product] provides [x] grams of EPA and DHA omega-3 fatty acids”.

Health Benefits of Omega-3 fatty acids:

Omega-3 fatty acids have been shown to prevent primary and secondary cardiovascular events, reduce triglycerides, and help improve conditions associated with Metabolic Syndrome. They also exhibit anti-inflammatory effects and help those with depression and other mood disorders. Omega-3 fatty acids are also beneficial to developing children and can increase ocular and cognitive health. For more detailed information on the health benefits of Fish Oils, please see the attached JANA article.

Quality

There are a number of different fish oil products on the market today. Quality is a major concern for numerous consumers, labels and advertising that accompany many of these fish oil products are often times confusing and at times misleading Ortho Molecular Products has set very high standards for our OrthoMega fish oil capsules (Specification Sheet Attached). OrthoMega has one of the highest EPA:DHA ratios available in capsule form, which makes patient compliance easier. OrthoMega exceeds the specifications set by the CRN (Council for Responsible Nutrition) monograph (Attached) in all areas of purity testing, including mercury. Ortho Molecular Products also has the only fish oil in the industry that is USP verified (Attached you will find a Frequently Asked Questions sheet about USP and The USP ingredient verification program process). A quality fish oil product will have low p-Anisidine and peroxide values. Peroxide values are used to measure primary oxidation of fish oil and p-Anisidine values are used to measure secondary oxidation levels. High results indicate that the oil may be rancid. Ortho Molecular Products has set standards for p-Anisidine and peroxide levels that coincide with the CRN monograph and continuously exceed these specifications with each lot.

What kind of fish are in OrthoMega? The fish used in OrthMega include: Anchovy (Engravlis ringerns, 95-99%), Sardine (Sardinops sagax, 1-5%), and occasionally Mackerel (Scomber japonicus). The fish are from the cold deep waters off the coast of Peru. Fish taken from cold deep waters are more fatty and contain more Omega-3 fatty acids. The water where they are harvested has significantly less environmental impurities than in North America.

Allergen Information Fish are recognized as allergens; however, the allergens in fish are proteins. A quality fish oil product will have very little protein matter left in the oil. The food Allergy Research And Resource Program Laboratory has tested the oil in OrthoMega for residual protein content. In their expert opinion fish oil containing less than 10 ppm of residual fish protein, presents no allergenic hazard to fish allergic consumers. OrthoMega contains less than 10 ppm of residual protein content.

What is Pharmaceutical Grade Fish Oil?

The term “pharmaceutical grade” fish oil was coined by Barry Sears in his book “The Omega Rx Zone”, and is not recognized by any standardization authorities, like USP. Many companies tout that their product is pharmaceutical grade, but this is merely a marketing scheme.

Ethyl Ester and Triglyceride forms of Fish Oil Fish oil supplements are available in ethyl ester or triglyceride forms. Ethyl esters are formed by breaking the bonds of the original triglyceride molecule, concentrating the fatty acids, and then bonding the fatty acids to ethanol. Generally, ethyl ester fish oils allow for higher concentrations of Omega-3 fatty acids than triglycerides do. Triglyceride forms have the concentrated fatty acids esterified to a glycerol backbone to create a re-esterified triglyceride. Ortho Molecular uses the triglyceride form of Omega-3 fatty acids. There have been a small handful of studies done on the differences between ethyl esters and triglycerides. A few studies show that our bodies more readily absorb the triglyceride form, although this data is preliminary. For a complete review of ethyl esters versus triglyceride forms, please see the attached JANA article.

EPA- Ethyl EsterEPA- Ethyl Ester

Triglyceride Form Ethyl Ester Form

Commonly Asked Questions

Does OrthoMega contain any Vitamin E? OrthoMega contains approximately 2.3 mg of mixed natural tocopherols per capsule. We do not label this in the supplemental facts box, but instead put it in the other ingredients section. The tocopherols are added to help preserve the fish oil and keep it from oxidizing. What is the source of the gelatin used in OrthoMega? The gelatin in OrthoMega is bovine. Does OrthoMega contain any cholesterol? OrthoMega contains approximately 0.28 mg of cholesterol per capsule. What size bottle is OrthoMega available in? OrthoMega comes in a 60, 120, and 180 count bottle. It is also available in a convenient 6 count blister package.

Product Name: 300/210 TG 1365 mg Fish Oil CapsuleProduct Code: 300210B1365Vendor: Ocean Nutrition CanadaExpiration Date: 1 year from date of receiptSpecifications:Identity analysis: Spectral IdentificationFree Fatty Acids: Max. 1.5%Acid Value: Max. 3.0 mg of KOH/gp-Anisidine Value: Max. 20Peroxide Value: Max. 5 meq/KgColor: YellowMoisture: Max. 0.1%Totox Number: Max. 26Average Fill Weight: 1129-1501 mg/capsuleDisintergration: Max. 45 minutesFatty Acid Profile:EPA mg/g (expressed as TG): Min. 420 mg/capsuleDHA mg/g (expressed as TG): Min. 300 mg/capsuleEPA mg/g (expressed as FFA): Min. 400 mg/capsuleDHA mg/g (expressed as FFA): Min. 290 mg/capsuleTocopherols:Mixed Natural Tocopherols: Min. 2.0 mg/gMicrobiological Specifications:Total Count: Max. 3000 CFU/gYeast/Mold: Max. 300 CFU/gPseudomonas: NegativeSalmonella: NegativeS.aureus: NegativeE.coli: NegativeColiforms: Max. 10 MPN/gPCB and Heavy Metals:PCB's: Max. 0.09 ppmDioxins: Max. 2 pg WHC-PCDD/FTEQ/gArsenic: <0.1 ppmCadmium: <0.1 ppmLead: <0.1 ppmStontium: Max. 0.5 ppmMercury: Max. 0.01 ppm

Because efficacy matters. ™

3017 Business Park Drive, Stevens Point, WI 54481Phone: 715-342-9881 Fax: 715-342-9866

ORTHOMEGA SPECIFICATION SHEET

PRODUCT NAME: Ortho Mega MANUFACTURED DATE: 12/18/2005RAW MATERIAL#: M400 RELEASE DATE: 2/8/2006LOT#: 20857 EXPIRATION DATE: 12/08

IDENTITY ANALYSIS METHOD SPECIFICATION RESULT PASS/FAILUSP 25 <197> SOP# 4101 Spectral Identification CONFORMS PASS

SPECIFICATIONS METHOD MAXIMUM VALUE RESULT PASS/FAILAnisidine Value ISO/CD 6885.2 20 14.3 PASSPeroxide Value USP <401> 5 meq 0.10 meq PASS

EACH CAPSULE CONTAINSCLAIM %RDA RESULT PASS/FAIL

EPA Triglyceride 420mg * 420mg PASSDHA Triglyceride 300mg * 300mg PASS

* % Daily Value Not Established

MICROBIAL LIMITS TESTUSP 25 <2021> SPECIFICATION RESULT PASS/FAIL

Total Plate Count max 3000 CFU/g <10 CFU/g PASSMold and Yeast max 300 CFU/g <10 CFU/g PASSColiforms max 10 MPN/g <3 MPN/g PASSE. Coli NEGATIVE NEGATIVE PASSPseudomonas NEGATIVE NEGATIVE PASSSalmonella NEGATIVE NEGATIVE PASSStaphylococcus NEGATIVE NEGATIVE PASS

TRACE HEAVY METALS MAXIMUM VALUE RESULT PASS/FAILArsenic <0.1 ppm COMPLIANT PASSCadmium <0.1 ppm COMPLIANT PASSLead <0.1 ppm COMPLIANT PASSMercury <0.01 ppm COMPLIANT PASS

PESTICIDE RESIDUES MAXIMUM VALUE RESULT PASS/FAILPCB's 0.09 ppm COMPLIANT PASSDioxins 2 ppt COMPLIANT PASS

APPROVED BY/DATE:Deborah ZurawskiQuality Manager

Because efficacy matters.TM

3017 Business Park Drive, Stevens Point, WI 54481Phone: 715-342-9881 Fax: 715-342-9866

min 300mg

ACTIVE INGREDIENTSmin 420mg

CERTIFICATE OF ANALYSIS

SPECIFICATION

Q & A about the CRN Voluntary Monograph on Long Chain Omega-3 EPA and DHA

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1. Is there a standard that identifies high quality long chain Omega-3 EPA and DHAproducts?

Yes. The Council for Responsible Nutrition (CRN) has sponsored a group ofindustry leaders to determine a consistent standard for measuring various qualityindicators including oxidation, purity, and the amount of EPA and DHA inproducts, and to set standards for purity and stability of long chain Omega-3 EPAand DHA products. This standard is set forth in a voluntary monograph on longchain Omega-3 EPA and DHA.

2. What industry leaders participated in the working group?

The CRN Omega-3 Working Group is comprised of 24 suppliers andmanufacturers of omega-3 oils. These include a steering committee from OceanNutrition Canada, CRN, Croda Oleochemicals, Roche Vitamins Inc., PronovaBiocare a.s., and Denofa. Additional corporate members include Access BusinessGroup, Arista Industries Inc., BASF Corporation, Berg Lipidtech a.s., BioriginalFood & Science Corporation, Clover Corporation Ltd., ERBL/Coromega, LeinerHealth Products, Loders-Croklaan LIPID Nutrition, Marine NutriceuticalCorporation, Maritex a.s., MARTEK Biosciences a.s., Napro Pharma a.s., NordicNaturals, Omega Protein, Inc., Pharmaline Inc., Seven Seas Ltd., Soft GelTechnologies, Inc. and Spectrum Organic Products Inc.

3. Describe the monograph.

The voluntary monograph applies to long chain Omega-3 EPA and DHA obtainedfrom fish, plant and microbial sources of marine algae. It sets forth rigorous andvalidated methodology for the assay methods measuring the amount of long chainOmega-3 EPA and DHA, as well as quality standards and limits on environmentalcontaminants.

4. Do all participants comply with the standards set forth in the monograph? Howwill compliance be recognized?

Compliance with the monograph is voluntary. Within the trade, products thatcomply with the monograph will be identified by comparing the certificate ofanalysis with the standards specified by the monograph. If companies choose todo so, they could highlight compliance with the monograph on the product labelor product data sheets.


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5. European monographs have already been developed for omega-3 products. Howdoes this monograph differ?

This monograph specifically focuses on EPA and DHA and uses the EuropeanPharmacopoeia assay methods to quantify these two fatty acids. The differencebetween the two monographs is that the European monograph includes otheromega-3 fatty acids, in addition to EPA and DHA.

6. Why is cod liver oil excluded from the monograph?

An official monograph specifically for cod liver oil has previously been presentedin the United States Pharmacopeia.

7. How are consistent measurements established? What is the process?

Six monographs were considered in establishing the quality standards set forth inthis monograph for long chain Omega-3 EPA and DHA products 1. Based on areview of these available assay methods, the European Pharmacopoeia method toquantify EPA and DHA content in omega-3 products was used to provide asimple and uniform measurement of long chain Omega-3 EPA and DHA forproduct labeling. This method should guarantee at least 100% of stated contentclaim over the lifetime of the product.

8. What are the proposed standards for quality?

The quality of products is measured by the amount of free fatty acid (acid value),primary oxidation products (peroxide value), and secondary oxidation products(anisidine value) and total oxidation (TOTOX value).

Quality standards for long chain Omega-3 EPA and DHA products will measure:Acid Value, Peroxide Value (PV), Anisidine Value (AN) and TOTOX (acalculation based on (2 x PV) + AN).

The proposed limits for PV (5 meq/kg maximum) and anisidine value (20maximum) represent the most stringent quality standards established for DHA andEPA products (see referenced monographs on next page) 1.

The creation of a TOTOX value of 26 maximum further tightens quality standardswhile allowing manufacturers flexibility in individual PV and AN values.

9. What is TOTOX?

TOTOX is a measure of total oxidation calculated as a combined limit of peroxideand anisidine values.


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10. Which environmental contaminants and heavy metals are measured by thismonograph?

Environmental contaminants measured are dioxins (PCDDs and PCDFs) andPCBs. Heavy metals measured include Lead, Cadmium, Mercury and Arsenic.The limits set forth in the monograph are consistent with current or emergingEuropean standards and with limits established under California’s Proposition 65.

11. What does this mean to me?

It means that when buying long chain Omega-3 products EPA and DHA, you cantrust products that meet the standards set forth in this monograph to consistentlyreport accurate amounts of long chain Omega-3 EPA and DHA, to be free ofcontaminants to a specified level, and to be stable for their labeled period of time.

1 The following monographs (draft or accepted) were considered in establishingquality standards for omega-3 EPA and DHA products: Omega-3-AcidTriglycerides Monograph 1352, Pharmeuropa Vol. 12, No. 3, July 2000; FishOil, Rich in Omega-3-Acids, Pharmeuropa Vol. 12, No. 3, July 2000;Omega-3 Acid Ethyl Esters Monograph 1250, European Pharmacopoeia –Supplement 2000; Omega-3-Acid Ethyl Esters 60, Pharmeuropa Vol. 12, No.3, July 2000; Docosahexaenoic Acid Oil, Preview Monograph inPharmacopeial Forum Vol. 26(6) [Nov. – Dec.]; Docosahexaenoic Acid,Preview Monograph in Pharmacopeial Forum Vol. 26(6) [Nov. – Dec.]

112602/tr

CRN Omega-3 Working Group

VOLUNTARY MONOGRAPH

Council for Responsible Nutrition October 2002

Omega-3 DHAOmega-3 EPAOmega-3 DHA & EPA

DEFINITION

Omega-3 fatty acids, EPA and DHA, consist of the all cis forms of 5, 8, 11, 14, 17-eicosapentaenoicacid and 4, 7, 10, 13, 16, 19-docosahexaenoic acid, respectively. Omega-3 fatty acid products may befound with DHA as the predominant fatty acid, EPA as the predominant fatty acid or mixtures of DHAand EPA in varying combinations.

The content of omega-3 EPA and DHA is expressed as free fatty acid equivalents on a weight/weightbasis, as mg EPA per gram or mg DHA per gram when available as single sources of omega-3. If amixture of EPA and DHA exist in the product, the total omega-3 EPA and DHA content may be ex-pressed individually and as total mg EPA and DHA per gram.

For other Omega-3 Fatty Acids see Assay method.

Food approved antioxidant may be added to enhance omega-3 EPA, omega-3 DHA, and omega-3 EPAand DHA product stability.

SCOPE

Applicable to omega-3 EPA and DHA fatty acids obtained from fish, plant, or microbial sources. Notapplicable to cod liver oil. Omega-3 EPA and DHA may be found esterified as triglycerides, re-esterified as glycerides, or esterified as ethyl esters. Not applicable to free fatty acid product forms.Applicable to bulk oil product and encapsulated oil intended for use as dietary supplements. Not appli-cable to formulations, specialty delivery systems, and EPA and DHA concentrates >80% wt/wt. Thespecifications described herein apply throughout the stated lifetime (shelf-life) of the product.

CHARACTERISTICS

Long chain omega-3 EPA and DHA products are generally liquids at ambient temperature. The colorvaries from pale, light-yellow to orange. The products have a characteristic odor ranging from bland tomild fish-like.

IDENTIFICATION

Examine the chromatograms obtained in the assay for long chain omega-3 EPA and DHA. The pres-ence of EPA and/or DHA based on retention time comparison to authentic reference standards estab-lishes the identity of the product.


TESTS

Acid value. Maximum 3 mg KOH/g; AOCS Official Method Cd 3d-63

Peroxide value. Maximum 5 meq/kg; AOCS Official Method Cd 8-53

Anisidine value. Maximum 20; AOCS Official Method Cd 18-90

TOTOX. Maximum 26 (result of calculation, (2 x PV) + AV)

PCDDs and PCDFs. Maximum 2 pg WHO-PCDD/F-TEQ/g

Dioxin limits include the sum of polychlorinated dibenzo-para-dioxins (PCDDs) andpolychlorinated dibenzofurans (PCDFs) and are expressed in World Health Organi-zation (WHO) toxic equivalents using WHO-toxic equivalent factors (TEFs). Thismeans that analytical results relating to 17 individual dioxin congeners of toxicologi-cal concern are expressed in a single quantifiable unit: TCDD toxic equivalent con-centration or TEQ.

PCBs. Total polychlorinated biphenyls ( PCBs): Less then 0.09 mg/kg

Total PCBs should be expressed on a weight/weight basis and should include IUPAC congeners 28, 52, 101, 118, 138, 153 and 180, pending EU establishment of limits for four individual non-ortho PCBs and eight mono-ortho PCBs in 2004.

Sample preparation and appropriate methods of analysis for PCDDs, PCDFs, and PCBs are describedin draft European Commission Directive “laying down the sampling methods and the methods ofanalysis for the official control of dioxins and the determination of dioxin-like PCBs in foodstuffs”.Annex II of this document describes appropriate methods of analysis along with a specific list ofPCDD, PCDF and PCB congeners to be included in the calculation. Gas chromatography coupled withhigh-resolution mass spectrometry has proved to provide required sensitivity and specificity. Identifi-cation of congeners should be performed according to EPA Method 1613 revision B: Tetra- throughocta-chlorinated dioxins and furans by isotope dilution HRGC/HRMS or similar.

Heavy Metals.

Lead (Pb): Less than 0.1 mg/kgCadmium (Cd): Less than 0.1 mg/kgMercury (Hg): Less than 0.1 mg/kgArsenic (As ) : Less than 0.1 mg/kg

Note: The maximum intake of PCDDs, PCDFs, PCBs, other pesticides, and heavy metals in variousparts of the world are based on Maximum Allowable Daily Levels (MADL) instead of absoluteamounts in oil; therefore, appropriate consideration should be given to recommended daily serving andintake.


ASSAY

The assay used for quantitative determination of EPA and DHA content in omega-3 products is appli-cable to triglyceride and ethyl ester product forms with results expressed as mg DHA/g and mg EPA/gafter correction to free fatty acid equivalents.

EPA and DHA. Carry out the operations as rapidly as possible, avoiding exposure to actinic light,oxidizing agents, oxidation catalysts (for example, copper and iron) and air.

Gas chromatography.

The assay is carried out on the methyl or ethyl esters of all-cis-eicosa-5,8,11,14,17-pentaenoic acid(EPA; 20:5 n-3) and all-cis-docosa-4,7,10,13,16,19-hexaenoic acid (DHA; 22:6 n-3) in the sample tobe examined.

Internal standard. Methyl tricosanoate R.

Test solution (a). Prepare 3 solutions for each sample.

1. Dissolve the sample to be examined according to the table below and about 70.0 mg of the internalstandard in a 0.05 g/l solution of butylhydroxytoluene R in trimethylpentane R and dilute to 10.0 mlwith the same solution.

Approx. sum EPA + DHA Amount sample to be weighed30 – 50 % 0.4 – 0.5 g50 – 70 % 0.3 g70 – 80 % 0.25 g

Ethyl esters are now ready for analysis. For triglycerides continue as described in 2.

2. Introduce 2.0 ml of the solution obtained from step 1 into a quartz tube and evaporate the solvent at40-50°C with a gentle current of nitrogen R. Add 1.5 ml of a 20 g/l solution of sodium hydroxide R inmethanol R, cover with nitrogen R, cap tightly with a polytetrafluoroethylene-lined cap, mix and heaton a steaming water-bath for 7 min. Allow to cool to 40-50°C.

3. Add 2 ml of boron trichloride-methanol solution R , cover with nitrogen R, cap tightly, mix and heaton a water-bath for 30 min. Cool to 40-50°C, add 1 ml of trimethylpentane R, cap and shake vigorouslyfor at least 30 s. Immediately add 5 ml of a saturated solution of sodium chloride R, cover with nitro-gen R, cap and shake vigorously for at least 15 s. Transfer the upper layer to a separate tube. Shake themethanol layer once more with 1 ml of trimethylpentane R . Wash the combined trimethylpentane ex-tracts with 2 quantities, each of 1 ml, of water R and dry over anhydrous sodium sulphate R.


Test solution (b). (to be prepared at the same time as test solution (a))

Dissolve 0.300 g of the sample to be examined in a 0.05 g/l solution of butylhydroxytoluene R intrimethylpentane R and dilute to 10.0 ml with the same solution. Proceed as described for test solution(a).

Reference solution (a). Prepare 3 individual solutions (to be prepared at the same time as test solution(a))

Dissolve 60.0 mg of docosahexaenoic acid ethyl ester CRS, about 70.0 mg of the internal standard and90.0 mg of eicosapentaenoic acid ethyl ester CRS in a 0.05 g/l solution of butylhydroxytoluene R intrimethylpentane R and dilute to 10.0 ml with the same solution. For analysis of ethyl esters the solu-tions are now ready for analysis. For analysis of triglycerides continue as described in step 2 for prepa-ration of test solution (a).

Reference solution (b).(for system suitability of recovery vs. the theoretical response of the FlameIonisation Detector (FID))

Introduce 0.3 g of methyl palmitate R, 0.3 g of methyl stearate R, 0.3 g of methyl arachidate R and 0.3g of methyl behenate R into a 10 ml volumetric flask, dissolve in a 0.05 g/l solution of butylhydroxy-toluene R in trimethylpentane R and dilute to 10.0 ml with the same solution.

Reference solution (c). (for system suitability of chromatographic resolution)

Introduce a sample containing about 55.0 mg docosahexaenoic acid methyl ester CRS and about 5.0mg of 15-tetracosenoic acid methyl ester CRS diluted to 10.0 ml of a 0.05 g/l solution of butylhy-droxytoluene R in trimethylpentane R.

Column:1

— material: fused silica

— dimensions: l = at least 25 m, Ø = 0.25 mm,

— stationary phase: bonded polyethylene glycol polymer (film thickness 0.2 µm).

Carrier gas: hydrogen for chromatography R or helium for chromatography.

Split: 1:200, alternatively splitless with temperature control (samples need to be diluted 1:200 with a0.05 g/l solution of butylhydroxytoluene R in trimethylpentane R before injection)

1 CP-Wax 52CB, 25 m x 0.25 mm I.D. 0.2. µm film thickness, Chrompack cat. no. 7713 or equivalent will be suitable


Temperature:

Time(min)

Temperature(°C)

Column 0 – 2 170

2 – 25.7 170 - 240

25.7 - 28 240

Injection port 250

Detector 270

Detection: flame ionisation.

Injection: twice 1 µl of each solution.

The assay is not valid unless:

— the chromatogram obtained with reference solution (b) gives area per cent compositions increas-ing in the following order: methyl palmitate, methyl stearate, methyl arachidate, methyl behenate;the difference between the percentage area of methyl palmitate and that of methyl behenate is lessthan 2 area per cent units,

— the chromatogram obtained with reference solution (c) shows 2 resolved peaks corresponding todocosahexaenoic acid methyl ester CRS and 15-tetracosenoic acid methyl ester CRS, giving achromatographic resolution of minimum 1.2,

— the chromatogram obtained with test solution (a) shows a resolution of methyl tricosanoate R andany heneicosenoic acid methyl ester present when compared with the chromatogram obtained withtest solution (b) (if not, a correction term has to be used),

— experiments using the method of standard additions to test solution (a) show more than 95 per centrecovery of the added eicosapentaenoic acid ethyl ester CRS and docosahexaenoic acid ethyl ester CRS, when due consideration has been given to the correction by the internal standard.


Calculate the content of EPA and DHA as mg fatty acid/g oil using the following expression andtaking into account the certified value of the reference substances. The results should be rounded tothe nearest 10 mg/g based on the method’s precision.

1

2 ,

,

1

1

3

3 ↔

↔

↔

↔

↔

↔ C

m A

m

A

m

m

A A

r x

r x x 1000

m1 = mass of the internal standard in test solution (a), in milligrams,

m2 = mass of the sample in test solution (a), in milligrams,

m3 = mass of the internal standard in reference solution (a), in milligrams,

mx,r = mass of eicosapentaenoic acid ethyl ester CRS or docosahexaenoic acid ethyl ester CRS inreference solution (a), in milligrams,

Ax = area of the peak corresponding to eicosapentaenoic acid ester or docosahexaenoic acid esterin the chromatogram obtained with test solution (a),

Ax,r = area of the peak corresponding to eicosapentaenoic acid ester or docosahexaenoic acid ester inthe chromatogram obtained with reference solution (a),

A1 = area of the peak corresponding to the internal standard in the chromatogram obtained with testsolution (a),

A3 = area of the peak corresponding to the internal standard in the chromatogram obtained with ref-erence solution (a),

C = a conversion factor to fatty acids based on the difference in molecular weight of ethyl esters inthe standard and fatty acid

CEPA = 0.915

CDHA = 0.921


Total omega-3-acids. From the assay for EPA and DHA, calculate the content of the total omega-3-acids using the following expression and identifying the peaks from the chromatograms:

DHAEPA

3n

) (

AA

DHAEPAADHAEPA

++++ −

EPA = content of EPA obtained from the assay for EPA and DHA,

DHA = content of DHA obtained from the assay for EPA and DHA,

An-3 = sum of the areas of the peaks corresponding to C18:3 n-3, C18:4 n-3, C20:4 n-3, C21:5 n-3and C22:5 n-3 methyl esters in the chromatogram obtained with test solution (b),

AEPA = area of the peak corresponding to EPA methyl ester in the chromatogram obtained with testsolution (b),

ADHA = area of the peak corresponding to DHA methyl ester in the chromatogram obtained with testsolution (b).

USP Fact Sheet What is the United States Pharmacopeia? The United States Pharmacopeia (USP) is a nonprofit, nongovernmental, standards-setting organization that advances the public health by ensuring the quality and consistency of medicines, promoting the safe and proper use of medications, and verifying ingredients in dietary supplements. Standards are developed by a unique process of public involvement and are accepted worldwide. USP achieves its goals through the contributions of volunteers representing pharmacy, medicine, and other health care professions, as well as science, academia, the U.S. government, the pharmaceutical industry, and consumer organizations. USP’s Internet address is www.usp.org.

What does USP do? USP’s activities and initiatives revolve around several focus areas: Publications and Standards. Establishing standards is a core USP activity. Currently, USP provides standards for more than 4,000 prescription and non-prescription drugs, dietary supplements, veterinary drugs, and health care products. These standards are published in the United States Pharmacopeia and National Formulary (USP–NF), which are officially recognized in the Federal Food, Drug, and Cosmetic Act (21 U.S.C. § 321 et seq.). USP also produces over 1,700 Reference Standards, which are an integral part of USP’s standards program. In addition, USP offers a Pharmacopeial Education program to provide continuing education courses for professionals working in the pharmaceutical industry – helping those who use the USP–NF better understand pharmacopeial processes, standards, tests, and methods. Patient Safety. USP operates two medication error reporting programs: the Medication Errors Reporting (MER) Program and MEDMARXSM . The MER program is operated in collaboration with the Institute for Safe Medication Practices. MEDMARX is an Internet-accessible program for collecting, analyzing and reporting medication errors and adverse drug reactions anonymously. MEDMARX is used by subscribing hospitals and health systems as part of their quality improvement activities. Verification Program. The Verification Program for dietary supplements was developed in response to the increasing concerns expressed about dietary supplements in the marketplace. Through compliance testing and document review, adherence to good manufacturing practices (GMPs), and post-marketing surveillance, the USP Verification Program is designed to help ensure that dietary supplement products contain the ingredients and quantities listed on the label. USP also operates an Ingredient Verification program that verifies ingredients used to manufacture and market dietary supplements in the United States and around the world. Health Care Information. USP is actively working with its volunteer Expert Committees to provide health care information to improve the use of medicines. Recently, USP was called upon in the Medicare Modernization Act to create Model Guidelines (a list of drug categories and classes) for the Medicare prescription drug benefit. Having successfully completed this initial activity, USP is building an ongoing relationship with the Centers for Medicare and Medicaid Services (CMS) to revise the Model Guidelines to reflect new drug approvals, new therapeutic uses of existing drugs, and other new information. In addition to the Model Guidelines activity, USP will also be developing peer-reviewed articles on drug information for publication in the Annals of Internal Medicine. Global Assistance Initiatives (GAI). USP's GAI program consists of numerous global initiatives. USP was awarded several grants by the United States Agency for International Development's (USAID) Bureau for Global Health (BGH). Currently, USAID is supporting the USP Drug Quality and Information (USP DQI) program, which has programs in Ecuador, Peru, Paraguay, Bolivia, Mekong Delta region, Nepal, Romania, Russia, Mozambique, Madagascar, Ghana and Senegal. Who are USP’s members and volunteers? About 650 elected scientists and practitioners comprise USP’s scientific decision-making body by serving as members of the Council of Experts (CoE) or on expert committees. An additional 11 elected officers and trustees have fiduciary responsibilities for the management and policies of the organization. About 400 members represent state associations and colleges of medicine and pharmacy; the federal government; national and international professional, scientific, and trade organizations; the pharmaceutical industry; and consumer organizations. USP members meet once every five years to adopt resolutions and elect the CoE and Board of Trustees. The next member meeting will be held in 2010.

Feb 05

The USP Ingredient Verification Program Overview The United States Pharmacopeia’s Ingredient Verification Program (USP-IVP) verifies ingredients used to manufacture and market dietary supplements in the United States and around the world. It is a natural progression of USP’s long history of establishing officially recognized public standards for medicines and dietary supplements. USP has been a trusted and recognized source of standards for identity, strength, quality and purity of medicines and dietary supplements since 1820. The program verifies ingredients such as vitamins, minerals, amino acids, botanical extracts and nonbotanicals as well as other ingredients used as either an active or inactive ingredient in the manufacture of dietary supplement products. The USP-IVP process includes:

• Evaluation of a manufacturer’s quality systems through an audit for compliance with Good Manufacturing Practices (GMPs);

• Review of manufacturing and quality control documents for ingredients submitted for verification;

• Laboratory evaluation of ingredient samples from USP selected lots for compliance with label claim and program requirements;

• Granting of the USP-IVP verification mark; and • Post-verification surveillance testing of ingredients bearing the USP-IV

mark.

The USP-IVP Verification Mark The use of the USP-IVP verification mark is granted for ingredients that meet the program’s requirements for verification. The mark indicates the verification of an ingredient’s quality by a trusted and established authority, which is USP. The mark provides dietary supplement manufacturers assurance that:

• The manufacturer’s quality system helps to ensure that the ingredient evaluated meets its label or certificate of analysis claim for identity, strength, purity and quality and that it is consistent in quality from batch-to-batch;

• The ingredient is prepared under accepted manufacturing practices; and • The ingredient meets requirements for acceptable limits of contamination.

Participation Participation in the program is voluntary and open to companies manufacturing fine chemicals and/or ingredients marketed for use in the dietary supplement industry in the United States or abroad.

The Journal of the American Nutraceutical Association www.ana-jana.org

Vol. 8, No. 1, 2005 Reprint

A Peer-Reviewed Journal on Nutraceuticals and NutritionMark Houston, MD

Editor-in-ChiefISSN-1521-4524

The Use of Fish Oil Supplements in Clinical Practice: A Review

Thomas G. Guilliams, PhDDirector of Science and Regulatory Affairs- Ortho Molecular Products, Inc.,

Stevens Point, WisconsinClinical Instructor- University of Wisconsin-Madison School of Pharmacy

Reprinted with permission from the Journal of the American Nutraceutical Association.Duplication in whole or part is not permitted without permission.

R E V I E W A R T I C L E

JANAFishOilReprint8 #1 3/8/05 3:15 PM Page 1

21JANA Vol. 8, No. 1, 2005

The Use of Fish Oil Supplements in Clinical Practice: A Review

Thomas G. Guilliams, PhD*Director of Science and Regulatory Affairs- Ortho Molecular Products, Inc.,

Stevens Point, WisconsinClinical Instructor- University of Wisconsin-Madison School of Pharmacy

R E V I E W A R T I C L E

* Correspondence:Thomas G. Guilliams, PhDOrtho Molecular Products Inc.3017 Business Park DriveStevens Point, WI 54921Phone: 715-342-9881 Fax: 715-342-9866E-mail: [email protected]

ABSTRACT

Increasing dietary consumption of fish high in omega-3(n-3) fatty acids is well established as a way to improvenumerous health outcomes. The prevention of both primaryand secondary cardiovascular events, as well as interventionfor such unrelated outcomes as depression and rheumatoidarthritis are now linked with n-3 fatty acid intake. Increasingfish consumption is neither an exact science, nor without riskof consuming toxins of various kinds. The advent of highlypurified fish oil supplements, now widely available, hasallowed very high levels of n-3 fatty acid consumption forboth preventative and therapeutic clinical use. This reviewwill focus on the data concerning fish consumption, fish oilsupplements and their fatty acids as it pertains to clinicaloutcomes, with an emphasis on cardiovascular health.

BACKGROUND

In the early 1970s, it was observed that high levels offat intake in the form of long-chain omega-3 fatty acids inGreenland Eskimo populations resulted in fewer cardiovas-cular events than Western populations who ingested lesstotal dietary fat.1 In fact, these studies and others prompted

the scrutiny of fatty acids based upon whether they wereomega-3 (n-3), omega-6 (n-6) or omega-9 (n-9). Fatty acidsin the n-3 and n-6 families are considered essential tohumans because our metabolism is unable to de-saturate(make a double-bond) between carbons-3 and 4 (n-3) orbetween carbons 6 and 7 (n-6); counting from the omega orlast carbon (See Figure 1 for basic fatty acid information).Typical Western diets provide much in the way of polyun-saturated fatty acids from vegetable sources, which supplyhigh levels of n-6 fatty acids. Data from numerous epi-demiological studies have suggested that lowering one’sratio of n-6/n-3 in the range of 3:1 to 6:1 (typical Americandiet may be as high as 20:1) will have great health benefits.2

The creation of trans-fatty acids through food processingand cooking further complicates the issues both metaboli-cally and epidemiologically.

N-3 FATTY ACIDS

Alpha-linolenic acid (ALA) is an n-3 essential fattyacid found primarily in certain seeds and green leafy veg-etables. Flaxseeds are one of the richest sources of ALA.Converting this 18 carbon fatty acid to the 20 and 22 car-bon fatty acids found primarily in fish oils requires severalsteps of elongation and de-saturation (see Fig. 1), reportedto be a very inefficient process in adults, suggesting thatdirect consumption is more reliable.3,4 And while somedata suggests that ALA may help prevent secondary cardio-vascular events,5 most of the focus on n-3 fatty acidresearch is with consumption of eicosapentanoic acid(EPA) and docosahexanoic acid (DHA) from fish and fishoil supplements. In humans, the retroconversion betweeningested DHA to plasma EPA seems to be higher than theconversion of EPA to DHA.107,110


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Figure 1:


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CARDIOVASCULAR USES

Primary Cardiovascular Event Prevention

Numerous reviews have summarized the cardiovascularbenefits of fish and fish oil consumption.6,7,8,9,10 The dataconcerning primary prevention, however, is less straightfor-ward than the data relating to secondary prevention. In sever-al large cohort studies, the relative risk for CHD and suddendeath is reduced with increased fish consumption in men andwomen,11,12,13,22,27 while others showed no statistical differ-ences based on fish consumption.14,15 Plasma EPA and DHAlevels measured upon initiation of the Physicians’ HealthStudy did not relate inversely with incidence of myocardialinfarction,16 however in this same group both fish consump-tion, based on dietary questionnaire, and blood n-3 levelswere statistically related to reduced risk of sudden cardiacdeath.17,18 In this cohort of 20,551 men, the multivariate rel-ative risk for sudden cardiac death in those consuming 1 fishmeal per week was 0.48, compared with men who consumedfish less than once per month.17 The adjusted relative risk inthe 4th quartile of red cell n-3 levels was 0.19.18

The Honolulu Heart Program, following Japanese-Americans living in Hawaii, found that the relative risk forCHD mortality was cut in half for heavy smokers (>30cig/day) if they consumed greater than 2 fish meals perweek.19 Siscovick20 reported that in a population-based case-control study in King County, WA that both dietary intake ofseafood containing n-3 fatty acids and red blood cell mem-brane n-3 fatty acid concentrations were inversely related toprimary cardiac arrest. Both of these associations were dose-related. Among the Nurses’ Health Study cohort, fatty fishintake was associated with a reduced risk of thromboticstroke, while there was no increased risk for hemorrhagicstrokes in women.183 A similar large cohort in thePhysicians’ Health Follow-up study found the same loweredrisk of stroke with fish consumption in men.184 TheAmerican Heart Association recommends that patients with-out documented coronary heart disease (CHD) eat a varietyof (preferably fatty) fish at least twice a week, including oilsand foods rich in alpha-linolenic acid (flaxseed, canola andsoybean oils; flaxseed and walnuts).9,21

Secondary Cardiovascular Event Prevention

One of the first studies to assess the secondary preven-tion potential of n-3 fatty acids from fish was the diet andreinfarction trial (DART).23 The men randomized to receiveadvice to increase fatty fish consumption (others wereadvised to increase fiber or reduce fat intake) after recoveryfrom MI, had a 29% reduction in 2-year all cause mortality.Unfortunately, like many lifestyle changes, this advice wasdifficult to maintain over many decades and both complianceand benefits seem to have been diminished after a decade.24

The largest secondary prevention trial to date is theGISSI-prevention trial.25 In this study, over 11,000 patients(surviving a recent MI) were randomized to receive 1 g/day

n-3 fatty acids (capsules containing a minimum of 850 mgEPA and DHA as ethyl esters), 300 mg of vitamin E (acetyld,l-alpha tocopherol), both or placebo. Most of thesepatients were concomitantly on cardiovascular pharmaceu-ticals of various kinds, as well as advised about diet andlifestyle changes. Total (RR=0.59) and cardiovascular mor-tality (RR=0.66) were significantly reduced in the fish oilgroup as early as 3 and 4 months into the study, respective-ly. The most dramatic reduction was in sudden deaths, forwhich relative risks of 0.37 (after 9 months) and 0.55 (42months) were reported.26 Among the lipids measured, onlytriglyceride levels showed significant improvements. In all,there are over 20 randomized, placebo-controlled trials ofdietary n-3 fatty acid from fish in CHD patients. A meta-analysis28 of these trials shows a 3-year average reductionof all cause mortality of 16% and death from MI of 24%.The American Heart Association recommends that patientswith documented CHD consume about 1 g of EPA+DHAper day, preferably from fatty fish; EPA+DHA supplementscould be considered in consultation with a physician.9,21

Anti-arrhythmic Effects of Fish Oils

Both primary and secondary prevention studies showedthat n-3 fatty acid intake was profoundly better at preventingsudden deaths than reducing the incidence of non-fatal MI.Over 50% of the deaths attributed to CHD are sudden deaths(within 1 hour) caused by sustained ventricular arrhythmias.These data suggested that n-3 fatty acids may have anti-arrhythmic effects which initially do not lower the incidenceof MI, but prevent many of these events from becomingfatal.10 This anti-arrhythmic effect has been reported in sev-eral animal and cell culture models.29-33 It is fairly wellestablished that the incorporation of EPA and especiallyDHA within the plasma membrane of electrically excitablecardiac tissue changes membrane fluidity and modulates theactions of ion channels to prevent the destabilization thatpermits arrhythmias and ventricular tachycardia.34-37

One small pilot study was conducted with 10 patientswho had implanted cardioverter defibrillators and repeatedepisodes of documented, sustained ventricular tachycardia.38

Compared with baseline, after these patients were infusedwith n-3 fatty acids, sustained ventricular tachycardia wasnon-inducible in 5 of the 7 (3 of the 10 patients who ate sig-nificantly more dietary fish were non-inducible at baseline).More research, including controlled trials, needs to be doneusing oral doses of fish oil preparations and clinical out-comes. Leaf et al.10 recommend that those with a family orpersonal history of CHD should supplement their diets with600 mg of EPA plus DHA, and higher, 1 to 2 grams, if thereis also a family history of sudden cardiac death.

Reducing Triglycerides

Elevated triglycerides (TG), both fasting and postpran-dial, are directly related to the progression of atherosclero-sis and are considered independent risk factors for CHD,


JANA Vol. 8, No. 1, 2005 24

especially in women.39,40 Long-chain n-3 fatty acids fromfish like EPA and DHA have shown consistent TG loweringeffects in both animals and humans.42 A meta-analysis of 65published reports showed TG reduction averaging 25% wastypical with fish oil consumption (mean dose 4 g/day EPA +DHA) in both normolipidemic and hypertriacylglyc-erolemic subjects.41 These data also show a dose-responserelationship between fish oil intake and triglyceride lower-ing as well as a slight rise in LDL cholesterol (5-10%) anda smaller elevation in HDL cholesterol (1-3%).

Post-prandial (after a fatty meal) plasma TG levels mayeven be more correlated to atherosclerotic progression thanfasting TG levels.43 Chronic intake of n-3 fatty acids fromfish has been shown to reduce post-prandial plasma TG lev-els.44 A recent study showed that exercise when combinedwith fish oils was additive in post-prandial TG lowering.45

Ten healthy recreationally-active subjects in a cross-overdesign were tested for changes in fasting and post-prandial(after 1,000 calorie shake- 99% fat after 12-hour fast) TGlevels after 5 weeks of fish oil supplementation (4 g/day in8 capsules of 300 mg EPA and 200 mg DHA each) or exer-cise (60% VO2max on treadmill for 1 hour), both or neither(control). When exercise was added to fish oil supplementa-tion, the peak plasma TG levels went from 38% reduction(fish oil vs. control) to 50% reduction (fish oil + exercise vs.control). Total area under the TG curve was reduced from27% to 42% respectively. While both EPA and DHA seemto have triglyceride lowering benefits, DHA may have amore favorable effect. The American Heart Association rec-ommends that under a physician’s care, patients who need tolower triglycerides should consume 2 to 4 grams ofEPA+DHA per day provided as capsules.9,21

Other Cardiovascular Risk Factors

In general, fish oil supplements have a favorable, butsmall effect on HDL cholesterol levels (1-5%). Combinedwith the more widely observed TG lowering, this (thiswhat?) improves the important TG:HDL ratio. A smallstudy (n=14) was conducted in patients with familial com-bined hyperlipidemia, noted for their increased cardiovascu-lar risk due to elevated atherogenic lipoproteins anddecreased protective lipoproteins.57 In a cross-over design,patients were given either 4 g/day of a concentrated fish oilpreparation in capsules (Omacor- 44%EPA, 36% DHA asethyl esters) or placebo (corn oil) for eight weeks. Asexpected, TG levels were lowered significantly (378 to 210),while HDL cholesterol rose a non-statistical 8%. The rela-tive increase in HDL2, a more cardioprotective lipid sub-fraction, was statistically significant. LDL, but not total cho-lesterol, was significantly increased in the fish oil group. Inone group of hyperlipidemic patients, DHA (4 g/day) had amore significant (29%) increase in HDL2 levels than equiv-

alent levels of EPA.106 Other clinical trials have also report-ed that DHA has a slightly more favorable effect on lipid

profiles (TG lowering, TG:HDL ratio and lipoprotein frac-tioning),107 and post-prandial lipid margination.108

It is not uncommon to see elevations in plasma LDLcholesterol after fish oil intake, especially in individualswith elevated triglyceride levels. Since total cholesterolusually remains unchanged in these subjects and it is knownthat most of the increase is due to an increased shift fromVLDL to LDL, the clinical significance of this elevation inplasma LDL cholesterol is not yet known, but LDL sub-fraction analysis suggests that it is the larger, less-dense(and less atherogenic) LDL fraction which is raised and notthe smaller (more atherogenic) LDL particles.46,186,187 Onereport suggested a potential down-regulation of LDL recep-tors to account for part of this phenomenon.47

In a group of patients (n=64) with chronic renal failure,assigned to either 2.4 g/day fish oil (4 capsules- 3:2EPA:DHA) or olive oil for 8 weeks; those receiving fish oilhad statistically lower TG (21%), higher HDL cholesterol(8%) and no change in total or LDL cholesterol. A small,non-statistical, drop in Lp(a) was seen in these patients butLp(a) is very rarely measured in other studies and similardrops were not reported in those studies where it was mea-sured. Also, little effect is reported in lowering high sensitiv-ity C-reactive protein (hsCRP), a marker of inflammationand an independent risk factor for cardiovascular disease.48,49

Metabolic Syndrome and Diabetes

Metabolic syndrome is a disorder characterized byinsulin resistance, high triglycerides, high LDL and lowHDL cholesterol, hypertension and central adiposity. Anincreasingly prevalent condition considered “pre-diabetic,”individuals with metabolic syndrome are also at anincreased risk of cardiovascular disease even before a dia-betes diagnosis.51,52 In both sucrose and fructose-inducedanimal models of metabolic syndrome, EPA and DHA fromfish oils were able to prevent the onset or diminish severalparameters (hypertension, adiposity, dyslipidemias) associ-ated with the syndrome.53,54 One animal study concludedthat insulin-sensitive GLUT4 activity is enhanced inadipocytes (not myocytes) to account for the fish oil’simprovement of insulin sensitivity in these animals.55 Whilemany of the subjects in the TG lowering trials mentionedpreviously would likely be categorized as having metabolicsyndrome, a trial looking at either the prevention or treat-ment of individuals by this diagnosis as an end-point hasapparently not been performed. In one study of overweighttreated hypertensive patients (n=69), likely to be deemed ashaving metabolic syndrome if lipids were reported, com-bining fatty fish consumption (dietary) with weight-losshad an additive effect on ambulatory blood pressure anddecreased heart rate.56

Like those with metabolic syndrome, type 2 diabeticpatients are characterized with various lipid disorders,insulin resistance and increased risk for CHD. A cohort


JANA Vol. 8, No. 1, 2005

within the Nurses’ Health study (n=5103) who were free ofCHD but with diagnosed type 2 diabetes were evaluated forCHD risk, relative to n-3 intake from fish.58 After adjustingfor age and other cardiovascular risk factors, the RRs forCHD were 0.70 (1 to 3 fish meals per month), 0.65 (2 to 4times per week) and 0.38 (>5 times per week). Fish con-sumption in this cohort was more protective against CHDby quintile than it was when looking at all the women in theNurses’ Health Study,27 implying that n-3 fatty acid supple-mentation in diabetic patients may prove even more benefi-cial than in the general population. Consumption of fish isassociated with a significantly reduced progression of coro-nary artery atherosclerosis in women (a higher correlationin diabetic women) with coronary artery disease. Generally,fish and fish oil supplements reduce triglyceride levels andimprove HDL levels but seem to have no clinically signifi-cant affect on fasting glucose, fasting insulin, HbA1c, orglucose tolerance tests in diabetic subjects.59-61

In one study, fish protein consumption was associatedwith a significantly lower risk of microalbuminuria in anested case-control study of 1150 type 1 diabetic patients,62

although this lowered risk was also reported in a smallgroup (n=16) of type 1 and 2 diabetic patients consumingonly concentrated EPA (1.8 g/day).63 Several animal mod-els have suggested a role for fish oil in general, and DHAspecifically, for increasing nerve conduction velocity indiabetic neuropathy. Collectively, these data suggest thatdiabetic patients should consume 1 to 2 grams per day of n-3 fatty acid from fish, balanced between EPA and DHA.

Hypertension

There is a dose-dependent inverse relationship betweenn-3 fatty acid intake and blood pressure in hypertensivepatients, but little effect is noted in normotensive or border-line hypertensives. A meta-analysis of 31 placebo-con-trolled trials found an average -0.66/-0.35 mm Hg drop insystolic/diastolic blood pressure per gram of n-3 fatty acidconsumed in hypertensive patients.67 Many of these trialsused doses in excess of 5 grams per day and were associat-ed with gastrointestinal complaints. Another meta-analysisreported an average reduction of 5.5/3.5 mm Hg in hyper-tensive patients given at least 3 g/day of n-3 fatty acids.Fish oil consumption (~3.6 g/day from diet) had an additiveeffect when combined with weight loss in overweighthypertensives (-6.0/-3.0 fish alone, -5.5/-2.2 weight lossalone, -13.0/-9.3 mm Hg combined).56 The authors con-clude that given the magnitude of the BP reduction with thefish/weight loss combination, withdrawal of antihyperten-sive therapy may have been possible.

DHA and EPA have been tested separately for theirhypertensive activities. Mori et al. has reported that 4 g/dayof DHA, but not EPA, reduces ambulatory blood pressureand has favorable effects on arterial compliance.104,105

Additional Cardiovascular Mechanisms77

Discussing the various potential biological mecha-nisms in detail is beyond the scope of this review. For thesake of those interested in pursuing this avenue, however, alist of reported potential mechanisms attributed to n-3 fattyacids and several references are included below.

• Anti-inflammatory68-73

• Arterial compliance74,75,76

• NO- induced endothelial relaxation78,79

• Reduced asymmetric dimethyl arginine (ADMA)80,81

• Reducing atherogenic adhesion molecules82,83,84

• Anti-thrombogenic85,86,87

• Stabilizing atherosclerotic plaques88

• Peroxisome proliferator-activated receptors (PPAR)regulation89,90

NON-CARDIOVASCULAR USES

Anti-inflammatory- Rheumatic Diseases115,116

The well-known pathways which covert the 20 carbon n-6 fatty acid arachidonic acid into pro-inflammatory cytokinesis often termed the arachidonic acid cascade. Key enzymes inthe formation of pro-inflammatory prostaglandins andleukotrienes are the cyclooxygenase (COX) and lipoxyge-nase (LOX) enzymes. Inhibition of these enzymes is one ofthe most popular anti-inflammatory mechanisms in the phar-maceutical trade. Since the substrate for each of theseenzymes is a 20 carbon fatty acid, eicosapentanoic acid(EPA) is capable of both competing for the use of the enzymeas well as forming eicosanoids which function to counteractthe activity of eicosanoids derived from arachidonic acid.127

These mechanisms have led to the proposal that increasing n-3 (especially EPA from fish) and lowering n-6 fatty acidintake would have a favorable benefit on the overall inflam-matory burden, particularly in individuals with chronic con-ditions such as rheumatoid arthritis.117,118

Omega-3 fatty acids from fish oil have been studiedextensively in patients with rheumatoid arthritis.119 Meta-analysis data suggest a modest improvement in tender jointsand morning stiffness with the addition of fish oil supple-mentation.120 Dosing and fish oil content vary widely in dif-ferent clinical trials. The most significant benefits seem torequire at least 3 grams/day, although benefits were seen insome trials with 2.6 grams/day,121 30 mg/kg/day122 and 40mg/kg/day.123 Significantly more benefit is seen whenpatients who use fish oil supplements are also consuming alow arachidonic acid, anti-inflammatory diet.122

The role of fish oils has also been explored in patientswith inflammatory bowel diseases such as ulcerative colitisand Crohn’s disease. Reviews of the various clinical trialshave shown that doses as high as 4.5 and 5.4 grams per dayhave limited benefit on preventing relapses, but often

25


26 JANA Vol. 8, No. 1, 2005

reduce the dependence on steroid therapy and dramaticallyreduce inflammatory markers.124 A specially preparedenteric-coated, free fatty acid preparation (1.8 g/day EPA,0.9 g/day DHA) was able to significantly reduce the level ofrelapse compared to placebo in a group of Crohn’s diseasepatients (n=78).125 Another group recently reported thatstimulated T-cells and monocytes taken from Crohn’s dis-ease patients supplemented with fish oil (1.6 g/day EPA,1.08 g/day DHA- non-enteric coated) and an antioxidantblend (Vit. A, C, E, selenium, manganese ) produced lowerinterferon-gamma and PGE2, compared to placebo.126 Ingeneral, these data suggest that individuals with inflamma-tory bowel conditions may be benefited by increasing fishoil intake equivalent to 2.5-5 grams per day.

Depression and Other Mood Disorders

Long chain n-3 fatty acids are important components ofmembranes within neurological organs and tissues. Theyaffect membrane fluidity and excitability, influence synapticfunction, and perhaps serotonin and dopamine metabo-lism.128,145 In several epidemiological studies, fish con-sumption is related to decreased risk of depression, espe-cially in women.129,130,131 Although not all cohort studiesproved statistically significant,132,133 a recent case-con-trolled study (China) reported that low red blood cell EPAlevels are associated with increased risk for attempting sui-cide.139 Previous reports suggest there is a link between vio-lent suicides and seasonal intake of EPA.140

Several clinical trials have used n-3 fatty acids to treatdepression and related disorders.141 Most of the studies todate have used a preparation of pure EPA (EE form). Peet etal.142 reported that 1 gram (but not 2 grams) of EPA improveddepression scores in patients (n=17 each group) with ongoingmedicated depression. However, Nemets et al.143 reportedthat similar patients (n=20) receiving 2 grams per day of acomparable preparation had highly significant reduction inHamilton depression scale scores (mean 12.4 point reduc-tion vs. 1.6 for placebo). This same group attempted to usethis preparation at the same dose to treat medicated patientswith obsessive compulsive disorder (OCD) without suc-cess.144 Pure DHA (2 g/day) had only a small, non-statisticalbenefit in patients with major depression. Bipolar patientsgiven high doses of fish oil (6.2 g EPA/3.2 g DHA) had a sig-nificantly longer period before relapse than similar patientstaking olive oil.147 Physicians treating patients with depres-sion or related disorders should consider measuring patientserum fatty acid levels and including fish oil supplements(particularly EPA) at 1-2 grams per day.

Maternal and Infant Care

Maternal fatty acid levels, especially DHA levelssteadily drop in late pregnancy,135 increasing risk for post-partum depression.136,137 A meta-analysis of 41 studiesshowed that lower fish consumption and breast milk DHAcontent were associated with increased risk for post-partum

depression.134 Low doses of DHA (200 mg/day -algae-derived) given post-delivery, however, were unable to sig-nificantly lower symptoms of post-partum depression.138

The role of n-3 fatty acids in maternal gestation andparturition, as well as offspring development has beenreviewed elsewhere.148 Generally, women with higher n-6 ton-3 intake have a higher likelihood to deliver prematurely.This phenomenon is thought to be related to changes ineicosanoid production (prostaglandins, leukotrienes) whichtake place prior to parturition. Epidemiological studies sug-gest that gestation is generally longer in women with high-er intake of n-3 fatty acids from fish in some cohorts,149,150

but not in others.151,152,153 High n-6 to n-3 fatty ratios alsocorrelate to an increased risk for preeclampsia.154,155

Intervention trials, during high risk pregnancies have shownsome improvement in prolonging gestation (2.7 g/day n-3),156,157 but not in pregnancy related hypertension.157-160

Rapid growth in the brain occurs during the lasttrimester of pregnancy and the first several postnatal months.The need for maternal DHA is critical during these monthssince fetal and newborn fatty acid metabolism is inadequateto provide proper levels of DHA for brain development.Several reports suggest that maternal supplementation of fishoils or DHA alone during the third trimester and whilebreast-feeding can improve cognitive development in new-borns,161 improve sleep patterns (a measure of brain devel-opment),162 and even increase IQ scores at age 4.163 Maternalfish oil supplementation (3.7 g/day n-3, 56% DHA) in atopicwomen (offspring considered at high risk for allergic dis-eases) significantly increased breast milk levels of the pro-tective Immunoglobulin A (IgA) and CD14.164 Children bornfrom these mothers have reduced levels of allergic relatedcytokines and allergen-specific immune respons-es.165,166,167,168 Children at high risk for atopic diseases hadreduced allergy-related cough at age 3 if they were supple-mented with fish oil (500 mg of tuna oil/d- 185 mg n-3) from6 months to 3 years.169 Eating high levels of n-3 fatty acidsdirectly from fish is contraindicated in young children andpregnant women due to the potential for ingesting mercuryand other toxins. Fish oil supplements, virtually free of thesetoxins,170,171 are safer and allow for specific dosing regimens.Many liquid as well as capsule preparations can be usedwhich provide varying levels of DHA, some of which arespecially prepared and flavored for children.

Ocular and Cognitive Health

As a specialized portion of the nervous system, theretina has one of the highest levels of long-chain fatty acidsin the human body; especially concentrated is the level ofDHA.172,173 Infant visual acuity is diminished in n-3 defi-ciency. Children supplemented with DHA (115 mg/day)from 6 months to 1 year of age had significantly betterimproved visual acuity than similar control children.174 Thelong-term visual benefits for infant supplementation is not


27

yet known. In adults, fish and DHA intake (determined byfood questionnaire) reduces the risk for age-related maculardegeneration.175,176 Preventative or intervention trials inpatients with or at risk for macular degeneration have notbeen published.

The relationship between DHA and retinitis pigmen-tosa (RP) is currently being investigated. RP patients havelower levels of DHA,177 partly due to reduced activity of theenzyme delta-5-desaturase.178 Despite this relationship, tri-als attempting to slow the progression of RP with supple-mentation of DHA have been unsuccessful,179,180 althoughchronic vitamin A users who added 1200 mg/d of DHA hadsome slowing in progression after 2 years.181

Increased dietary intake of fish and DHA (but not EPA)is correlated (cohort of 815) with a decreased risk ofAlzheimer’s disease.182 Whether this correlation will proveto be of preventative or therapeutic benefit is yet to bedetermined. Studies also suggest that DHA is protectiveagainst dendritic cell damage in a mouse model ofAlzheimer’s disease.185

Fish Oil- The Product

Recommendations to increase fish consumption are notalways straightforward. Some fish have high levels of EPAand DHA; others do not (see chart figure 1). How the fish isprepared also has a significant affect on whether these long-chain fatty acids will be beneficial. In a population-basedcohort study, dietary fish consumption was correlated withincreased plasma n-3 levels and reduced risk of cardiovas-cular death in individuals consuming tuna or other similarfish (broiled or baked), but neither was associated with friedfish or fish sandwiches (fish burgers).91 The same groupreported similar differences for reducing the risk of atrialfibrillations in these different populations based on type offish consumed.92 The susceptibility to loss or modificationof EPA and DHA has been reported in various cookingprocesses, especially deep-frying.93 The additional potentialhazard of consuming environmental toxins such as methylmercury and other heavy metals or pesticides like DDT,DDE or PCBs is a concern for many. The EnvironmentalProtection Agency warns those most at risk (pregnantwomen, nursing mothers and their infants and young chil-dren) to limit fish intake to avoid potentially dangerous mer-cury levels.94 Several advantages of fish oil supplementsdirectly address these concerns. Levels of EPA and DHAare consistently dosed in capsule or liquid products. Levelsof heavy metals and pesticides can be dramatically reduced,often below detectible limits, when using fish oil supple-ments in lieu of consuming more fish.170,171 Fish oil isinherently more susceptible to oxidation, requiring thatmost products contain additional fat-soluble antioxidantssuch as natural vitamin E, fat soluble ascorbates or othernatural antioxidants to protect them from becoming rancidunder normal storage conditions.

Commercial fish oil is a by-product of the fish mealindustry. It is typically a blend of many different fishspecies including mackerel, anchovies, sardines, tuna,salmon and others. The raw oil from these fish is then puri-fied and concentrated by removing (hydrolyzing) the indi-vidual fatty acids from the fish triglycerides so the variousfatty acids can be separated and concentrated. This processallows for the separation of contaminant toxins, proteins(which may increase allergenicity and burping), and othernon n-3 fatty acids. These concentrated fatty acids remainas free fatty acids (FFA) before they are stabilized by ester-ification to ethanol (ethyl esters, EE) or further esterifiedback to a glycerol backbone to create a re-esterified triglyc-eride (rTG). Both EE and rTG forms of varying concentra-tion (30-70% EPA+DHA) are used in the dietary supple-ment industry throughout the United States.

Few studies have looked at differences between fish oilsupplements provided as EE or rTG. One study reportedthat plasma EPA and DHA levels were higher when equiv-alent levels of these fatty acids were consumed directlyfrom salmon than from fish oil supplements provided asethyl esters.95 Whether the ethyl ester form diminished orsome fish component enhanced bioavailability is notknown. Several studies have shown that plasma bioavail-ability of the EE form is less than 50% of that from the rTGform.96,97,98 Other studies, however, show no difference inbioavailability between these two forms.99,100 All of thesestudies were uncontrolled and involved very few subjects.Dyerberg et al.114 completed a study involving 72 subjects,comparing the bioavailability of EPA and DHA from natur-al fish triglycerides, EE, rTG, cod liver oil and FFA. Theyfound that compared to natural fish TG (100% standard),the bioavailability of EPA and DHA combined was highestfrom the re-esterified TG (124%) and lowest from EE(73%). The EPA and DHA incorporated into phospholipidswas 62% and 290% greater when consumed as rTG ratherthan EE. At this time there are no trials comparing thepotential differences in the EE and rTG forms as it pertainsto clinical outcomes (triacylglyeride lowering, hyperten-sion, etc.); many reports don’t specify the forms used. Sincedata suggests that individuals are likely to absorb the rTGform better, and lipase and biological incorporation of theEE is diminished,99,101 clinical trials should be done toassess whether the rTG form may have better clinical out-comes, or require lower doses for equivalent results.Consistent results at a lower dose would help increase com-pliance and reduce both side-effects and cost.

As with any dietary supplement, choosing a high-qual-ity fish oil product is important. The Council forResponsible Nutrition (CRN), along with many of the lead-ing fish oil manufacturers in the world, published a mono-graph in 2002 outlining various quality aspects which theindustry should use to regulate fish oil products.102 Thismonograph stipulates upper limits for mercury and other

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28 JANA Vol. 8, No. 1, 2005

heavy metals, pesticide levels and oxidation levels such asperoxide and anisidine values. These guidelines have beenadopted by the United States Pharmacopoeia (USP) fortheir current n-3 fatty acid from fish oil monograph.103

Additionally, some companies monitor the production fromcatch to finished product in order to provide kosher productsto the market.

Side-effects and Contraindications

High-dose fish oil supplementation is extremely welltolerated in nearly all individuals. The most common side-effect is a fishy aftertaste or “burping” associated with highdoses. When products are consumed with meals and car-bonated beverages are avoided, this unpleasant feature isdramatically reduced. The complete purification of the fattyacids from fish proteins virtually eliminates the potential forallergic components in the fish oil supplements. Becausefish oil is prone to oxidation, consuming high doses withoutadditional antioxidant protection (from diet or supplementalsources) may increase vulnerability to lipid peroxidation,especially in warm and sunny climates. While the in vivoconsequences of this vulnerability are still being debated,antioxidant supplementation should be recommended forevery individual consuming high amounts (3 grams ormore) of fish oil daily. These high doses can be consumeddirectly from bottles for those wanting to avoid gelatin cap-sules due to concerns about consuming non-fish animals ingeneral or bovine-derived products specifically.

The most frequent contraindication concern is the com-bination of high dose fish oil with pharmaceutical drugs thataffect blood clotting (coumadin, aspirin, etc.), used by manycardiovascular patients. A group of 250 patients who hadundergone coronary artery bypass surgery were given 4g/day of fish oil concentrate and either aspirin (300 mg/d) orwarfarin therapy.111 Compared to patients not receiving fishoil, these patients had no increase in bleeding time. Anotherreport showed no change in INR when 6 g/day of fish oilwas given to patients on chronic warfarin therapy.112

However, one case report has been published of a woman(67 years old on coumadin, 1.5 years at 1.5 mg/day) whohad an increased INR (2.8 to 4.3) in the month she doubledher fish oil supplement from 1 to 2 g/day.113 These data sug-gest that the concern for bleeding times is generally not anissue, but INR should be checked in patients on both war-farin and fish oil therapies.

CONCLUSION

Epidemiological evidence is quite clear in demonstrat-ing numerous health benefits in consuming long-chainpolyunsaturated n-3 fatty acid from fish, especially as aratio to n-6 fatty acids derived from vegetable oils. Even an“Omega-3 Index” of RBC EPA and DHA levels is beingproposed as a routine laboratory test for measuring cardio-vascular risk.109 In the past decade, the clinical use of fish

oil supplements has greatly increased, as has the data sup-porting their use. While dietary and lifestyle changes areideal ways to modify a number of cardiovascular risk fac-tors, many individuals with personal or family history ofcardiovascular disease cannot safely consume high levels ofn-3 fatty acids from fish alone, or do not maintain thedietary habit.24 Since fish oil supplements have been shownto have beneficial effects on nearly every risk factor for car-diovascular disease, and so many individuals are currentlyat risk, the recommendation to use these supplements inclinical practice is encouraged. There are few patients whowould not realize some benefit by increasing their fatty fishconsumption or adding fish oil supplements to their dailyroutine. Patients with previous CHD, hypertriglyceridemia,hypertension, type II diabetes or metabolic syndromeshould be taking at least 2 g/day of n-3 fatty acids from fishoil daily via supplements. Pregnant women should beencouraged to consume fish oil supplements to increase n-3 fatty acids, particularly DHA throughout the second halfof pregnancy and while breast-feeding.

Disclosure statement: This author is affiliated with acompany, Ortho Molecular Products, that manufactures anddistributes dietary supplements, including fish oil products.

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800-332-2351 OrthoMolecularProducts.comThese statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.

Supplement FactsServing Size 1 Soft Gel CapsuleServings Per Container: 60

Amount Per % Daily1 capsule contains Serving ValueEPADHA

* % Daily Value not established

420 mg300 mg

**

60/120/180

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