Rebuttal to JAMA article on fish oil

Another Bogus “Scientific Study” Saying Supplements Not Effective

Well, here we go. A large study gets published in a major journal, in this case, the Journal of the American Medical Association Cardiology with a conclusion that fish oil for cardiovascular problems is not effective. Title of the article “Associations of Omega-3 Fatty Acid Supplements Use with Cardiovascular Disease Risk”. January 31, 2018. A better title would be “an example of an unscientific attempt at sabotage of fish oil use for aiding cardiovascular health”.

This study illustrates a common method of nutritional study sabotage, that is insufficient dosing for an insufficient duration. More on this later.

JAMA Makes Anti-Nutrition Articles Free To Maximize Views

If JAMA publishes an article that is against nutrition, they publish the article online for free. This will ensure the greatest number views. Within two weeks, this article has already racked up over 100,000 views.

JAMA Makes Big Money Being Pro Drug

JAMA is considered to be authoritative and is used extensively by the media. We should keep in mind that JAMA is notorious for publishing pro-drug and anti-nutrition articles. We are seeing a massive conflict of interest as journals such as JAMA make multi-million dollar profits for their pro-drug stance.

JAMA and similar journals make money by making space for pro-drug ads, by selling reprints of the pro-drug articles to drug companies. Richard Smith, former editor of the British Medical Journal, stated that these journals and their practices makes them effectively extension of the marketing departments of drug companies. (PLoS Med May 2005).

The journals endorse pro-drug treatment protocols, the drug companies take this validation (along with the reprints) to help pass pro-drug legislation and we end up with mandatory drug and vaccine protocols.

Example of Study Designed to Fail

An example is an article titled Effect of Soy Protein Containing Isoflavones on Cognitive Function, Bone Mineral Density and Plasma Lipids in Postmenopausal Women. July 7, 2004. This is a study designed to fail as each of these conditions should be analyzed separately and require completely different metrics. Also this study was immediately made available free online as is their practice for nutrition negative articles. Dr. Alex Vasquez et al replied to the journal to point out serious failings of the study and conclusions but their response was heavily edited to make sure the study would appear to stand on its own.

Analysis of Fish Oil Study Designed to Fail

Going back to the article at hand. We are looking at a meta-analysis of 10 trials involving about 78,000 patients. Their findings: randomization to omega-3 fatty acid supplementation (eicosapentaenoic acid dose range, 226-1800 mg/d) had no significant associations with coronary heart disease death rate, non-fatal myocardial infarction or any coronary heart disease events. Therefore, there is no basis for continued use of fish oil (omega-3 fatty acids) for anyone with risk or history of cardiovascular disease.

All major media outlets quickly ran with the news with headlines like “Omega-3 Supplements Don’t Protect Against Heart Disease” or “Fish Oil Supplements May Not Help Your Heart: Study”.

Sounds convincing, so far, doesn’t it. Well let’s pull back the curtain and see who is really behind there by looking at study errors.

ERROR 1-Why Was Data Excluded?

The authors excluded studies with fewer than 500 participants and duration of less than a year with no justification. There has to be a reason to exclude data. It isn’t proper to make a note that some data was excluded without justification. Why were smaller studies, that are generally easier to manage and sometimes with higher quality supplements, excluded? Why was only American literature reviewed? Often studies from other countries show a greater knowledge of nutritional topics and are often less influenced by drug companies. Excluding European studies perpetuates medical and cultural blindness and ignorance of superior treatment options.

ERROR 2-Use of Non Therapeutic Dosing

Inclusion of studies that employed nontherapeutic dosing.The authors stated that no minimum dose of EPA or DHA was specified. Reading this should give you serious pause. Here is a study that is supposed to draw important conclusions with no control of the active ingredient being tested. You don’t have to be an experienced scientist to see how ridiculous this study is just from this point alone. It follows that subtherapeutic dosing should lead to subtherapeutic results. Too many studies that try to demonstrate a negative outcome use less than therapeutic dosing and this study is one of those. To put a fine point on this concept, to get therapeutic results, we should study therapeutic doses. It is easy to short change a nutrition supplement by using either low doses and/or low-quality supplements and/or short durations.

Therefore ERROR 2 demonstrates a serious study design error and not an effectiveness problem of omega-3 supplementation. Any researcher knows that a thorough pharmaceutical study will have strict definitions of dosages with body weight and sex and age taken into account. Likewise a credible nutritional supplement study will begin with target dosages and not leave this as an undefined variable.

Therefore this study has deviated from the basic norms of science and isn’t worth the paper it is written on so to speak. A study like this highlights the inherent bias of a journal like JAMA Cardiology and the bias of the editors to allow a flawed study like this move through the screening system. It makes you wonder how a serious scientist would put their name on something as flawed as this without some career and/or financial incentive.

Higher Doses Would Be Reasonable for the Sick People in this Study

Let’s continue with ERROR 2. The majority of people involved in the study were elderly people with conditions such as metabolic syndrome, obesity and a history of cardiovascular disease like post myocardial infarction. It is not appropriate to use a preventative therapy like fish oil as a disease treatment. These high-risk people would naturally need higher doses than might be appropriate for younger, healthier people. Many authors would recommend a minimum of 1800 mg of EPA + DHA, not one or the other. DHA is not specified in one study and this is critical for lower inflammation and balancing blood lipids. (Am J Clin Nut 10.3945/ajcn.116.131896).

Only three of the ten of the studies analyzed used even a minimum therapeutic, prevention dose. A pharmaceutical study would NEVER say that 10 mg was a therapeutic dose and then gather several studies that used only 3 mg and then decide based on the collection of those studies that the drug was ineffective.

The article “Supplementation with high-dose docoahexaenoic acid increases the omega-3 index more than high-dose eicosapentaenoic acid” Prostaglandins, Leukotrienes and Essential Fatty Acids, Vol 120, May 2017, indicates that DHA supplementation is more important than EPA for raising the O3 Index that relates most positively to CV risk.

To say this more simply, DHA has been shown to be more cardio protective than EPA. In this JAMA study, 6 of the 10 studies has little or no DHA supplementation so we can expect little or no cardio protective activity from this dosing. See Dosing of DHA.

Nutritional interventions such as fatty acid supplementation function via changes in structure and function in cell membranes and gene expression, not the drug blocking effects of enzymes and receptors. Therefore it takes time to see physiological changes to reach a new steady state and that can easily take 5 months of constant treatment.

Note the article: “Determinants of Erythrocyte Omega-3 Acid Content in Response to Fish oil Supplementation: A Dose-Response Randomized Controlled Trial.” J Am Heart Assoc 2013. O3I (omega -3 index) which is the sum of EPA-DHA content in red blood cell membranes is a biomarker of omega-3 fatty acid status, that is highly correlated with myocardial EPA-DHA content. A O3I of >8% (10% is better) has been recommended as a cardioprotective level on the basis of associations with reduced risk of primary cardiac arrest, sudden cardiac death, coronary atherosclerosis and acute coronary syndrome. Studies of people not taking omega-3 fatty acid supplements mean O3I values range from 4-5%.

Study participants who took 900 mg/day raised their O3I to 6.6% to 8.3%. Those taking 1800 mg/day achieved O3I to 8.9% to 10.5%.Again 3 studies of 10 of the original article provided something like 1800 mg/day of omega-3 fatty acids. So how does a study of omega-3 fatty acids in a cardiology-based journal get published without even mentioning the omega -3 index (O3I)?This is the intentional perpetuation of nutritional ignorance in a clinical population that receives little or no nutritional education.

ERROR 3-Use of Synthetic fatty acids

9 if the 10 studies analyzed used a synthetic ester form of fatty acids in contrast to the natural triglyceride. This is similar to a study a few years ago that supposedly found a negative response in the prostate health of men using vitamin E. Instead of natural E, a synthetic form was used that was not vitamin E at all but was called vitamin E for the purposes of this study.

ERROR 4-Data Actually Shows Fatty Acid Supplementation Improved Health

Conclusion stated that no significant associations with coronary heart disease death, nonfatal myocardial infarction or any coronary heart disease events. Looking at the actual data, however, even with the subtherapeutic dose and poor-quality omega-3 fatty acids, we see actual improvements in those three cardiac categories listed. Most of the graphs actual show more data points favoring fish oil supplementation.

ERROR 5-Financial Conflicts of Interest

Authors were associated with medical schools with a history of being hostile toward nutrition or were paid directly by pharma that provide drug therapies for CV disease.

Good EPA DHA Options

A good option for you might be Nordic Naturals ProDHA. It comes in two strengths with 2 softgels containing 205 EPA/480 DHA or 410 EPA/960 DHA. For a minimum therapeutic dose, you would need 3 of the larger dose soft gels or 6 of the lower dose version. You can always start with the lower dose and work up to give your body a chance to adapt. We don’t see many problems with taking fish oil but if you are highly sensitive to supplements there is no harm in working up to that higher dose.

You might imagine that we are going full steam ahead with recommending things like DHA and EPA and L-arginine and L-citrulline for those with heart issues or those with any kind of family history of heart problems and want to stack the deck in your favor.