Fish oil (which refers to two fatty acids called EPA and DHA) is a general-health supplement of the omega-3 class, which confers a wide variety of benefits when in a proper dietary ratio to omega-6 fatty acids. Fish oil is also a potent triglyceride-reducing agent.
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"Fish oil" is a common term used to refer to two fatty acids: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). They are found in animal products and phytoplankton, but for the most part fish is their only significant dietary source, and the oils derived from fish are a cheap way to deliver them.
Fish oils work through their "eicosanoids," a term used to refer to any fatty acid over 20 carbons in length that can act as a signaling molecule in the body (similar in concept to hormones, adipokines, or cytokines from the immune system). Fish oil is stored in the membrane of a cell and released on an as-needed basis. Having a storage of polyunsaturated fatty acids, as well as having a proper ratio of omega 3:6 fatty acids, both influence which eicosanoids are released; this is because the enzyme that releases EPA and DHA, called phospholipase A2, is the same one that releases the omega-6 counterpart known as arachidonic acid.
Fish oil supplementation is not time-dependent for the most part, but only requires that the body has an overall storage of omega-3 fatty acids. More importantly, the overall intake of omega-3 fatty acids in the diet should be somewhat similar to the intake of omega-6; this can be measured in the blood by an EPA:AA ratio, and a 1:1 ratio is sometimes recommended. However, the standard western diet tends to be much higher in omega-6 than omega-3 fatty acids.
A ratio close to 1:1 has been associated with a better cardiometabolic risk profile (better response of the blood vessels, lower lipids, and less risk for plaque buildup) and a reduced risk for diabetes and some forms of cancer (breast, most notably).
Most benefits associated with fish oil supplementation come secondary to a ratio of omega-3 fatty acids to omega-6 fatty acids present in the cell membrane, the ratio determining what eicosanoids (signaling molecules) are produced in the cell in response to stressors. A 1:1 ratio is currently thought to be near the optimal level, and as the ratio is heavily skewed in favor of omega-6 fatty acids in the diet normally, supplemental omega-3s are recommended.
Beyond the benefits associated with a normalized ratio, fish oil can also be used as a triglyceride-lowering agent, and is commonly taken as 4g of ethyl ester EPA (although all forms of fish oil should work). Using fish oil to reduce triglycerides is highly effective and comparable to many pharmaceutical options (as fish oil itself is a pharmaceutical) and can raise the so-called "good cholesterol" (HDL) as well.
However, fish oil is somewhat limited in its use as a triglyceride-lowering agent for persons with high triglycerides and cholesterol because of an ability of fish oil to increase both LDL cholesterol (so-called "bad cholesterol") and blood glucose; the latter does not appear to be associated with an increased risk of diabetes or HbA1c, but is still notable. Although these negative effects do not occur at all times and low doses of EPA may not cause them, they do appear to exist with moderate doses of DHA or high doses of fish oil in general (EPA is seen as safer since it does not increase LDL cholesterol like DHA does).
Fish oil is a potent triglyceride-lowering drug in people with high triglycerides, and although it can also increase HDL cholesterol, it has the potential to also raise LDL cholesterol (to a level where it might be a concern in high-risk populations) and blood glucose (to a small and probably irrelevant level).
For persons with high blood cholesterol and triglycerides, it may be prudent to pair supplemental fish oil with a statin drug (a nutraceutical option is Red Yeast Rice, which is lovastatin) and possibly Berberine, which is a combination cholesterol-reducing and anti-diabetic drug also synergistic with statin drugs.In regards to the immune system, fish oil supplementation (or more specifically, normalizing the omega ratio towards 1:1) has mechanisms that both support and suppress the immune system. It seems to support the function of B cells (which make antibodies in response to antigens), while it also has the capacity to suppress T cell proliferation, and can suppress the infiltration of immune cells into tissue to exert localized effects (known as chemotaxis).
In practical terms, fish oil seems to be more immunosuppressive than immunopotentiating, but there does not appear to be a significantly higher risk of sickness associated with a normalized ratio. It is uncertain how much of a concern this information is to daily supplementation.
Fish oil supplementation has both immunosuppressive and immunopotentiating mechanisms. The overall idea is that it aids in antibody formation but suppresses the ability of immune cells to destroy invading infections with said antibodies. It is not yet known how much of a concern this presents.
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Eicosapentaenoic Acid, EPA, Docosahexaenoic Acid, DHA, Omega-3 fatty acids, Omega-3, Omega 3, N-3 Fatty Acids
Alpha-Linolenic Acid (the plant-based omega-3)
Not a classical stimulant, but increases brain activity. Stimulatory effects may be felt, but are less potent than and different from classical stimulants like Caffeine
Most benefits of fish oil come from normalizing or preventing changes in a phospholipid omega-3:6 ratio, so the effects will be seen over a matter of days or weeks rather than immediately
"Fish burps" with supplementation can be prevented by either consuming the fish oil with food, or (anecdotally) by freezing the capsules before consumption
All the below numbers are based not on omega-3, but on combined EPA and DHA. Also, total daily EPA+DHA intake should be from both supplements and food intake; a higher intake of EPA+DHA from food would mean less needed from supplements.
For primary prevention (taking some "just because"), a dose of 250mg or above seems to be the minimum.[1] The American Heart Association recommends 1g daily,[2] and it is advised for pregnant women to increase intake of DHA by at least 200mg daily (although mercury should be a concern).[3] These doses are effective, but would not result in any short-term (less than a week) changes.
For more acute and dramatic effects, such as reducing soreness or attempting to increase metabolic flux of muscle cells, a higher dose nearing 6g may be used over the course of a day.
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I find that fish oil helps combat muscle soreness (DOMS).
Sol Orwell!
Right, so I would imagine that supplementing Uridine alongside fish oil would be damn near mandatory (I mean, they are very synergistic) for anything related to neurology.
The most important sections of this article for overall understanding and comprehension would be the eicosanoid section (how fish oil actually does stuff), the nutrient-nutrient interactions (for synergism), and immunology (fish oil is pretty complex, and isn't just immunosuppressive)
Kurtis Frank
The Human Effect Matrix looks at human studies (excluding animal/petri-dish studies) to tell you what effect Fish Oil has in your body, and how strong these effects are.
| Grade | Level of Evidence |
|---|---|
| A | Robust research conducted with repeated double blind clinical trials |
| B | Multiple studies where at least two are double-blind and placebo controlled |
| C | Single double blind study or multiple cohort studies |
| D | Uncontrolled or observational studies only |
| Level of Evidence | Effect | Change | Magnitude of Effect Size | Scientific Consensus | Comments |
|---|---|---|---|---|---|
| A | C-Reactive Protein | Although some decreases have been noted, the vast majority of the evidence suggests that there is no significant influence | |||
| A | Blood Pressure |   Minor | May decrease blood pressure in persons with high blood pressure, but does not appear to have efficacy in persons with normal blood pressure | ||
| A | Inflammation | Minor | Highly mixed and unreliable influences on circulating inflammatory cytokines (although, due to immunosuppression on cellular adhesion factors, the overall effect may still... show | ||
| A | LDL-C | Minor | A decrease has been noted in persons without high cholesterol in the first place, and the decreasing effect of statins appears to be augmented with fish oil. However, in... show | ||
| A | HDL-C | Minor | Mixed evidence, but a possible increase in HDL-C is seen with fish oil supplementation in unhealthy persons | ||
| A | Total Cholesterol | Although some decreases have been noted, overall there does not appear to be a significant clinical reduction in total cholesterol like there is with triglycerides | |||
| A | Triglycerides | Strong | Fish oil, both EPA and DHA, are reference drugs for the purpose of reducing triglycerides with highly reliable reductions in the range of 15-30% (higher reductions seen... show | ||
| A | ADHD in Children | Minor | Supplemental DHA above 300mg appears to be effective in reducing ADHD symptoms in children when supplemented | ||
| A | Depression | Notable | Fish oil supplementation has been noted to be comparable to pharmaceutical drugs (fluoxetine) in majorly depressed persons, but this may be the only cohort that experiences... show | ||
| A | Weight | For the most part, no significant influence on body weight over time | |||
| A | Blood glucose | No significant alterations in fasting glucose are seen over time with fish oil supplementation | |||
| A | HbA1c | Although the majority of evidence suggests absolutely no influence on HbA1c, reductions have been reported and a lone case has noted a clinically irrelevant increase of... show | |||
| A | Insulin Sensitivity | No significant influence on insulin sensitivity seems to be the consensus, although there are isolated reports of both an increase and decrease (in response to a glucose... show | |||
| B | Muscle Soreness | Although one study suggests a decrease, most evidence suggest no significant influence | |||
| B | TNF-Alpha | Minor | May decrease TNF-a | ||
| B | VO2 max | There is no evidence to support an improvement of VO2 max when fish oil is consumed alongside an exercise routine | |||
| B | Cell Adhesion Factors | Minor | Appears to be able to reduce cellular adhesion factors (that draw immune cells into tissue to aid in inflammatory processes, reducing these is immunosuppressive) in elderly... show | ||
| B | Cortisol | Minor | A possible reducing effect of fish oil supplementation on cortisol | ||
| B | Endothelial Function | Minor | There appears to be a slight increase in vascular reactivity and blood vessel responsiveness that may be independent of both blood flow alterations and blood pressure | ||
| B | Platlet Aggregation | Minor | Possible decreases in platelet aggregation | ||
| B | Insulin | No significant influence on fasting insulin levels | |||
| B | vLDL-C | Minor | May decrease vLDL cholesterol | ||
| B | Apolipoprotein B | Although at least one study has noted a decrease, usually there is no significant changes | |||
| B | Blood Flow | Although there is some counter evidence to suggest an improvement of small magnitude, most evidence suggest no significant changes in blood flow | |||
| B | Lipid Peroxidation | Minor | Both increases and decreases in lipid peroxidation have been noted with fish oil supplementation, with the increases in peroxidation usually seen with high doses of fish... show | ||
| B | Natural Killer Cell content | Although one increase in NK cell content has been noted after exercise, the two studies using similar doses at rest have failed to find a significant influence on NK cell content | |||
| B | T cell count | Although there is some evidence to suggest an immunosuppressive effect on T cells, most evidence suggest no significant effect. When the immunosuppresion does occur, it... show | |||
| B | B cell count | The overall quantity of B lymphocytes does not appear to be altered with fish oil supplementation | |||
| B | Natural Killer Cell Activity | Minor | Although there do not appear to be changes in the amounts of NK cells in the body following fish oil, their activity appears to be a tad reduced | ||
| B | Pre-Eclampsia Risk | 100% See 2 studies | There does not appear to be a significant protective effect against pre-eclampsia in women who supplement fish oil during pregnancy | ||
| B | Infant Birth Weight | Minor | 100% See study | There appears to be an increased infant birth weight in mothers that consume fish oil (or fish weekly) relative to no fish oil intake, which may be due to prolonging pregancy... show | |
| B | Postpartum Depression | There does not appear to be any unique effect of supplemental fish oil on postpartum depression. Fish oil in postpartum and perinatal periods follows the same motifs as... show | |||
| B | Photoprotection | Minor | There appears to be reduced risk of DNA damage, immunosuppression, and erythema in response to sunlight associated with fish oil consumption. Studies have only investigated... show | ||
| B | Symptoms of Bipolar Disorder | Minor | There appears to be reduced depressive symptoms in bipolar disorder when the depression is of a large magnitude (similar to the anti-depressant effects of fish oil in general).... show | ||
| B | Insulin Secretion | There does not appear to be an augmented insulin release from dietary carbohydrate nor an inherent insulin release from the pancreas associated with fish oil supplementation | |||
| B | Symptoms of Systemic Lupus Erythematosus | Notable | The decrease in symptoms of lupus as assessed by SLAM-R and BILAG at times reaches up to 50% symptom reduction and tends to exceed 30%, and the first pilot studies noted... show | ||
| C | Muscle Damage | 100% See study | No significant influence on biomarkers of muscle damage seen with fish oil supplementation | ||
| C | Heart Rate | 100% See study | No significant acute effect on heart rate seen with fish oil supplementation | ||
| C | Interleukin 2 | Minor | Mixed effects on IL-2 concentrations, with an increase noted when supplemented around exercise and no change noted at rest. | ||
| C | Interleukin 5 | 100% See study | No significant influence on circulating IL-5 concentrations | ||
| C | Interleukin 1-beta | 100% See study | No significant influence on circulating IL-1β concentrations | ||
| C | Leptin | 100% See 2 studies | No significant influence on Leptin in serum | ||
| C | Adiponectin | No significant influence on Adiponectin concentrations | |||
| C | Testosterone | 100% See study | No detectable influence on testosterone levels in serum | ||
| C | Sex Hormone Binding Globulin | 100% See study | No significant influence on SHBG levels | ||
| C | DHEA | 100% See study | No significant influence on DHEA sulfate in serum | ||
| C | Liver Fat | Minor | 100% See study | A possible decreasing effect of liver fat seen in persons with NAFLD | |
| C | Liver Enzymes | 100% See study | No significant influence on liver enzymes noted | ||
| C | Apolipoprotein A | 100% See 2 studies | No significant influence on Apolipoprotein A concentrations | ||
| C | General Oxidation | Minor | May increase general oxidation in the body, but seems unreliable in doing so | ||
| C | Nitric Oxide | Minor | 100% See study | An increase in exercise-induced nitric oxide production has been noted | |
| C | Exercise-induced Oxidation | Minor | 100% See study | Exercise induced oxidation has been noted to be increased in elite athletes with fish oil supplementation | |
| C | DNA damage | 100% See 2 studies | Does not appear to influence DNA damage | ||
| C | Oxidation of LDL | 100% See 2 studies | No significant influence detected | ||
| C | Homocysteine | Minor | 100% See 2 studies | May decrease homocysteine content | |
| C | Lymphocyte Count | Minor | 100% See study | A decrease in lymphocytic count has been noted in obese persons | |
| C | Anxiety | Minor | 100% See 2 studies | A decrease in anxiety has been noted in medical students | |
| C | Memory | Minor | Possible improvements in memory | ||
| C | Exercise-induced Immune Suppression | 100% See study | Does not appear to augment nor alleviate the immunosuppression that occurs during exercise in otherwise healthy persons | ||
| C | Food Intake | 100% See 2 studies | There does not appear to be a significant influence of fish oil supplementation on food intake | ||
| C | Fat Mass | No significant influence on fat mass with routine supplemental fish oil | |||
| C | Lean Mass | No significant influence on lean mass associated with fish oil supplementation | |||
| C | Ketone bodies | Minor | 100% See study | An increase in ketone bodies has been noted when fish oil is paired with a weight loss diet (relative to placebo) | |
| C | Subjective Well-being | Minor | An improvement in well being has been noted in nondepressed and nonelderly obese persons given fish oil supplementation to a small magnitude. | ||
| C | Interleukin 6 | Minor | 100% See study | A decrease in circulating IL-6 has been noted with fish oil supplementation | |
| C | Infant Death Risk | Minor | 100% See study | A reduced risk of death of infants after pregnancy has been noted with maternal consumption of fish oil, but this information is preliminary and needs replication (noted... show | |
| C | Cognition of Offspring | 100% See study | Despite the importance of DHA in cognition of offspring (and absolute deprivation likely to reduce cognitive development), additional supplemental fish oil does not appear... show | ||
| C | Leukotriene B4 | 100% See 2 studies | No significant influence on LKB4 concentrations | ||
| C | Leukotriene B5 | Minor | 100% See 2 studies | An increase in LKB5 has been noted following fish oil supplementation | |
| C | 5-HETE | 100% See study | 5-HETE is a catabolite of arachidonic acid (omega-6 fatty acids), and its serum levels do not appear to be significantly influenced by ingestion of fish oil supplementation... show | ||
| C | 5-HEPE | Notable | 100% See study | 5-HEPE is a catabolite of EPA, and its blood levels are increased following consumption of EPA in a dose-dependent manner | |
| C | Erythema | Minor | 100% See 2 studies | Ingestion of fish oil appears to prolong the time required for sunlight to induce reddening of the skin, and secondary to this fish oil ingestion above 1,800mg EPA is able... show | |
| C | Cognitive Decline | Minor | 100% See study | High dose (900mg) DHA appears to be somewhat beneficial in reducing the rate of cognitive decline in elderly but otherwise healthy persons | |
| C | Symptoms of Alzheimers | 100% See study | Despite the benefit seen with high dose DHA in cognitive decline, there does not appear to be a proven significant protective effect in persons already with Alzheimer's | ||
| C | Stress | Minor | 100% See study | Self-reported stress in distressed women given fish oil supplementation appears to be reduced | |
| C | Fatigue | No demonstrable benefit to fatigue | |||
| C | Fructosamine | 100% See study | No evidence to support an increase in fructosamine, which alongside HbA1c is thought to indicate pathology from elevated blood glucose (fish oil appears to elevate glucose,... show | ||
| C | Plasminogen Inhibitor 1 | Minor | 100% See study | An increase in PAI-1 is noted with fish oil supplementation | |
| C | Glucagon | 100% See study | No significant influence on plasma glucagon concentrations | ||
| C | Factor VII | Minor | 100% See study | An increase in serum Factor VII has been noted with fish oil supplementation | |
| C | Prostaglandin J2a | Minor | 100% See study | An increase in prostaglandin J2A is noted with fish oil supplementation, which is thought to mediate a variety of fish oil's effects | |
| C | Thromboxane B2 | Minor | 100% See study | An increase in thromboxane B2 is noted with fish oil supplementation | |
| C | Proteinuria | Although a trend to reduce protein losses in the urine was noted (which would be kidney protective), this was a statistically insignificant and secondary to lupus treatment | |||
| C | Attention | 100% See study | Fish oil supplementation in otherwise healthy adults has failed to significantly influence attention processing | ||
| C | Aggression | Minor | 100% See study | A decrease in aggression has been noted, which is thought to be secondary to improvements in mood state and general well being | |
| C | Processing Accuracy | Minor | 100% See study | An improvement in processing accuracy (assessed by amount of errors in a cognitive test) has been noted with fish oil in otherwise healthy adults that do not frequently... show | |
| C | Reaction Time | Minor | 100% See study | A reduction in reaction time has been noted with fish oil supplementation in persons who consume low levels of fish in the diet | |
| C | Cerebral Blood flow | Minor | 100% See study | Appears to improve cerebral blood flow and volume in persons with low dietary fish intake | |
| C | Cerebral Oxygenation | Minor | 100% See study | The increase in cerebral oxygenation appears to exist in otherwise healthy persons with low dietary fish intake, and appears to be secondary to improvements in blood flow... show | |
| D | Metabolic Rate | 100% See study | No significant influence on metabolic rate seen with fish oil supplementation | ||
| D | Fat Oxidation | Minor | 100% See study | An increase in fat oxidation (percentage of energy being taken from fat tissue) has been noted with fish oil supplementation | |
| D | Bone Mineral Density | 100% See study | No significant influence on bone mineral density noted with fish oil supplementation |
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Fish oil is a term used to refer to a certain solution of fatty acids (a component of dietary fat) called eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA); they are referred to as oils from 'fish' (despite a small presence in poultry and presence in neural tissue of all species) as serum EPA and DHA concentrations tend to scale with fish intake, with Americans[5] usally having lower serum levels of these two fatty acids than Japanese[6] and Inuit (Greenland)[7] persons. Fish oil is the bioactive of Cod Liver Oil (alongside Vitamin A and Vitamin D) and Krill Oil (in the form of phopholipids rather than triglycerides).
Any fish oil product may contain more omega-3 fatty acids that are neither EPA nor DHA (for example, the intermediate called DPA[8]) and may contain fatty acids that do not belong to the omega-3 class; exact levels of fatty acids and omega-3 fatty acids depend on the source of fatty acids and processing, and tend to be stated on the label.
'Fish Oil' supplementation tends to refer to two fatty acids called EPA and DHA, which are for the most part unique to animals and found in very high levels in fish (relative to terrestrial meats). Both EPA and DHA belong to the class of fatty acids known as omega-3, and although they do not comprised all the omega-3 fatty acids in fish oil they are commonly seen as the only two fatty acids of concern
With other additives that may or may not be included, depening on processing:
Generally any toxin which is released into the water and is fat-soluble in nature (and thus can be stored in the tissues of fish) has potential to be found in fish oil supplementation. If possible, fish oil supplements from non-predatory and non-bottom feeding fish (such as sardines, herring, or mackeral) should be used, as mercury levels (used as a standard by which to assess 'contaminants' in general) typically are elevated in fish that consume other fish and build up stores of mercury and PCBs[15][16], and bottom-feeders that feed on carcasses of fish and accumulate toxins and minerals.[17] Depth of forage may also be correlated with mercury levels, making surface fish safer.[18]
It is wholly possible that fish oil can be contaminated with the same contaminants found in fish, but this is highly dependent on the processing quality and source of fish oil. It may be prudent to seek out fish oils obtained from low predatory fish such as sardine, cod, or prawns (Krill Oil, if the higher financial cost is not a concern)
The active components of fish oil are generally considered to be the two omega-3 (also written as n3 or ω3) fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Both fatty acids are similar in structure, although DHA a tad longer (eico- refers to a fatty acid with 20 carbons in its chain, while docosa- refers to a carbon chain 22 in length). The term Omega (ω) is used to refer to the 'end' of the fatty acid, and the omega designation of any fatty acid is the distance from the end of the chain where the first double bond occurs.
Any fatty acid that has a double bond is unsaturated (if only once, monounsaturated; if many times like both fish oils, polyunsaturated or PUFA) and thus has an omega designation; saturated fatty acids lack double bonds and thus have no omega designation. The diagram below indicates double bonds via parallel lines
The shortened nomenclature for EPA is 20:5n3 while 22:6n3 is for DHA; the first number refers to the carbons in the sidechain while the second refers to the overall count of double bonds (and the final number referring to the omega designation).
EPA and DHA are omega-3 fatty (refers to double bond placement) polyunsaturated fatty acids (refers to amount of double bonds) that are 20 and 22 carbons in length, respectively
For dietary ingestion of EPA and DHA from fish products, there are a few choices; triglycerides, reesterified triglycerides, ethyl ester (the pharmaceutical Lovaza), and phospholipid (crustacean sources such as Krill Oil). These four all confer dietary EPA and DHA, but krill oil is approximately a third better absorbed than triglyceride form[19][20] and ethyl ester the reverse (if fish oil triglycerides are standardized to 100% absorption, ethyl esters reach 73%[21]) which seem to confer less benefits relative to triglycerides on a gram per gram basis.[22][23] Re-esterification of triglycerides appears to enhance their absorption (124% of triglycerides[21]), but although this is somewhat comparable to phospholipid formation, the two have not been directly compared.
For animal sources of fish oil supplementation, the basic form of triglycerides seems to be outperformed by both Krill Oil based phospholipids and re-esterified triglycerides yet it outperforms ethyl ester formation (Lovaza). Any study using the basic triglyceride form will need about a third lower dose of phospholipid/reesterified or a third higher dose of Lovaza to replicate the effects
Due to fish oil supplements being derived from fish, they are classified as vegetarian but not vegan. Currently, the only significant vegan source of DHA is microalgae (phytoplankton)[24] and its supplement referred to as 'algae oil'.[25][26] The DHA component is equivalent to fish sourced DHA in cardiovacular health[27][28] and seems to have comparable safety[29] suggesting that they are interchangeable.
Other vegetarian sources of omega-3 fatty acids tend to have the parent structure of alpha-linolenic acid (ALA; not to be confused with Alpha-Lipoic Acid which shares the acronym) and significant plant sources of ALA include Hemp Protein and flaxseed while supplements with a smaller ALA quantity include Spirulina and Chlorella.
Vegan sources of EPA and DHA are limited to phytoplankton supplementation, with all other sources of omega-3 fatty acids being derived from ALA
As all fish oil supplementation is derived from fish, these products are animal byproducts. Their usage would thus not be vegan. It should be noted that absolute depletion of EPA and DHA in the blood of vegans does not occur,[30] which is thought to be due to adaptation mechanisms[31] such as increased hepatic production of DHA from the omega-3 precursor ALA[32] [33][34] with no influence on cerebral synthesis[35] and downregulation of enzymes that consume DHA including cyclooxygenase-1 (COX1)[36] and phospholipase A2[37] which prolongs the half-life of DHA.[38] It should be noted that DHA synthesis is decreased with dietary DHA surplus[39] and this adaptive effect is thought to be the reason why there is little to no clinically relevant omega-3 deficiencies in society.[40][41]
Although vegans and vegetarians tend to have reduced circulating EPA and DHA concentrations, there are adaptive mechanisms to attenuate the decline and an absolute depletion of these fatty acids are not seen in one living system and require generational deprivation
Fatty acids (polyunsaturated) are converted from one another in the body via an enzyme class known as desaturases, and the dietary requirement for omega-3 and omega-6 (the essential fatty acids) are due to a lack of the delta (Δ) 15 and Δ12 desaturase, respectively.[42] The enzyme known as Δ6 desaturase is the rate limiting step for producing DHA in the body,[43][44] and supplementation of fish oil tends to circumvent this rate limit; alternatively, the enzyme itself can be targeted to increase DHA concentrations in the body (seen in the Fat-1 mouse line, which naturally has all the benefits of fish oil supplementation without requiring ingestion thereof[45][46][47]) and this is known to be induced by Fucoxanthin.[48][49] Without any modifications and assuming average fish intake, the rate of ALA conversion into DHA tends to be in the 2-10% range.[50][51]
The parent omega-3 fatty acid is converted into EPA and, via EPA, turned into DHA via a chain of enzymes where Δ6 desaturase is the rate limiting step. This enzyme is an active regulator of bodily DHA levels, and increasing the activity of the enzyme will increase DHA stores in the body and is likely synergistic with dietary ALA intake in increasing bodily DHA stores
In animal models (rats[52] and primeapes[53]) a DHA deficiency in critical tissue (retina and brain) only occurs after restricting multiple generations but does result in functional impairment of the eyes and brain.[54][55]
True omega-3 deficiencies (which are related to DHA deficiency) can only be induced with multi-generational depletion of dietary fish oils, and the most drastic impairment is visual processing with some adverse cognitive effects (this correlates well with the structures in the body where DHA is accumulated most, in the retina and brain tissue)
The term 'Eicosanoid' refers to any molecule that is derived from lipids of over 20 carbons in length in the body and serves as a signalling molecule. It is an inclusive term, and all the following sections (resolvins, protectins, and prostaglandins) are subcategories of eicosanoids
These molecules are the metabolites of EPA and DHA that actually mediate effects, and are how fish oil supplements exert their beneficial effects. The final section of this header discusses when EPA and DHA per se also act directly on receptors
An enzyme located on the cellular membrane called Phospholipase A2 is able to hydrolyze (free up) a fatty acid from the middle of a glycerol backbone upon activation, and due to both DHA and arachidonic acid being in the middle of a triglyceride frequently they are frequently mobilized by Phospholipase A2.
Phospholipase A2 is stimulated by seizures,[56][57] ischemia,[58] and NMDA-receptor stimulation[59] as well as various inflammatory cytokines (IL-1β,[60] TNF-α,[61] and PMA[62]) and oxidation products.[63] The molecules that stimulate phospholipase A2 tend to be associated with cellular and metabolic damage, and thus eicosanoids are thought to be hormetically induced.
The enzyme known as Phospholipase A2 exists on the cell membrane and releases stored polyunsaturated fatty acids in response to stress. 'Eicosanoids' from DHA and arachidonic acid (AA) are released upon stressors influencing the cell including both inflammation and oxidation
The cellular membrane ratio of omega 3 to 6 fatty acids is important as phospholipase A2 is not discriminatory as to which polyunsaturated fatty acids it releases, and the eicosanoids that are produced when a cell is stressed correlate directly with the polyunsaturated fats that make up the membrane.
The standard western diet (mostly in reference to the US) tends to have a ratio highly favoring omega-6 fatty acids in the range of 15-20:1 approximately (varies depending on source).[64][65][66] A modern European diet (using data from the UK and Britian) is not significantly better at around 15:1[67] modern day Japan has a more desirable ratio at around 4:1.[68] Interestingly, India has a large disparity between rural areas (5-6.1:1) and urban areas (38–50:1).[69]
It has been hypothesized that paleolithic humans had an omega ratio around 0.79 (slightly more omega-3 than omega-6) due to low dietary omega-6 intake[64][70] and it has been reported that the diet of Grecians prior to 1960 was in the 1-2 range;[71] interestingly wild animals tend to also have something similar to a 1:1 ratio.[72][73] due to these low ratios and the evidence that omega-6 consumption has increased in the past 150 years due to technological development[71][64] there does appear to be a paleolithic argument for a normalized ratio.
The ratio of omega 3 to omega 6 fatty acids in the cellular membrane (either as an EPA:AA ratio, a DHA:AA ratio, or an EPA+DHA:AA ratio) is a quantifiable way to predict which eicosanoids are produced in response to stress and there appears to be correlational and epidemiological data in support of a normalized ratio
Interestingly, there is also an argument for a normalized ratio being similar to a paleolithic diet
Resolvins (resolution-phase interaction products[74]) are potent signalling molecules involved in inflammation[75] derived from omega-3 fatty acids, and those that are derived directly from EPA (without requiring metabolism into DHA) are referred to as the E series while those derived from DHA are called the D series.[76][77] The E series or resolvins involves one of two pathways, either the lipoxygenase pathway (favoring R isomers) or the aspirin-inducable COX2/P450 pathway (favoring S isomers); regardless of the pathway, the first intermediate after EPA is known as 15-HEPE.[76][77][78] DHA and the D series follows a similar motif (having a LOX pathway and an aspirin inducable pathway[79][80][74][81]) although its first intermediate is 15-H(p)DHA[77] which has been confirmed to increase in plasma following supplementation of fish oil.[77]
The aspirin-inducable conversion requires both the presence of aspirin and the COX2 enzyme (as aspirin modifies the actions of the enzyme in this regard[82][83]) which appears to convert resolvins to R isomers rather than S isomers.[81] COX1 is inactive in this regard,[84] acetominophen and indomethacin are unable to exert the same effects,[81] and treatment with aspirin alone does increase these two molecules due to DHA already being present in the body.[81]
Resolvins are molecules named after their ability to 'resolve' inflammation, and are produced by both EPA and DHA (of which they are divided into an E and D series, accordingly) and are the molecules of interest when synergism between fish oil and aspirin is of concern
Resolvins of the E series include:
While resolvins of the D series include:
E series resolvins are derived from EPA, and D series resolvins are derived from DHA.
RvE1 has been identified to be a ligand of the ChemR23 GPRC receptor,[85][86][87] which is analgesic.[75] The resolvin of the D series of similar structure (RvD1) also appears to be a ligand.[75]
Resolvins of the D series have antiinflammatory properties by inhibiting TNF-α induced cytokine expression in microglia in the picomolar range (IC50 of 50pM).[81] They are deactivated by oxidation, where they are converted to oxidized resolvins (at either the 8 or 17 position).[74]
Protectins are molecules that are produced from DHA and are structurally docosatrienes, alongside resolvins they mediate many benefits associated with fish oil ingestion.[74]
Protectins are molecules also derived from DHA, but they do not belong to the D series of resolvins
Marisen 1 is named after macrophage mediators in resolving inflammation and is present in macrophages and platelets and formed via the actions of 12-lipoxygenase,[74] but beyond that is not fairly well researched.
Neuroprotectin D1 (NPD1) is more well understood. Produced by a 15-lipoxygenase like action[89] after cleavage from phospholipase A2[88] where the metabolite 17SH(p)DHA (same as the D series of resolvins) is converted into a 16(17)-epoxide and then reconfigured to NPD1.[90]
NPD1 appears to have potency antiinflammatory properties (by dysregulating IL-1β induced COX2 induction[90]) in the brain in response to stroke and ischemia[91] and anti-Alzheimer's actions by preventing the inflammatory response to the protein agggregates seen in the disease state with an IC50 of 50nM (β-amyloid,[92] may also reduce levels of the pigmentation[93]). This protection is via a PPARγ dependent mechanism[92] and as DHA has been noted to reduce amyloid buildup in animals and in vitro[94][95][96] it is thought that NPD1 mediates these effects.
The first metabolite of DHA can be converted into either D series resolvins or protectins, and NPD1 is a notable protectin with potent anti-Alzheimer's actions and neuroprotective properties
While both resolvins and protectins are fatty acid chains derived from EPA or DHA, prostaglandins are characterized by having a pentacyclic ring in their structure (ie. a pentagon in the fatty acid sidechain similar to furan fatty acids).
Prostaglandins include:
Prostaglandins are eicosanoid metabolites with a pentacyclic structure (pentagon) in their side-chain, and are also bioactive metabolites of polyunsaturated fatty acids
15-deoxy-Δ12,14 prostaglandin J2 (15d-PGJ2 or just Prostaglandin J2) is a derivative of that can activate PPARγ with an EC50 of around 20μM[99][97][98] and inhibit platelet aggregation with an IC50 in the 5-10nM range.[100][101]
Prostaglandin J2 is related to PPARγ activation and platelet aggregation inhibition
Prostaglandin F2α has been confirmed to be increased in young men following supplementation of fish oil, and has been noted to increase concentrations of Thromboxane B2 (inactive metabolite of the omega-6 eicosanoid thromboxane A2).[102]
EPA and DHA tend to be digested and taken up as normal dietary fats, by getting packaged into micelles in the intestines and being subsequently dropped off at fat cells and muscle cells by chylomicrons (a transport molecule) before the chylomicron remnant goes to the liver.
If the fish oils are microencapsulated (which occurs in some functional foods to avoid a fishy taste) they tend to be absorbed in the upper small intestines[103] although a large bit is incorporated into the intestinal wall as well.[104]
Bodily loading of fish oil seems to be maximal after approximately 3 weeks of supplementation with no significant difference between doses tested (210-630mg EPA and 150-450mg DHA).[105]
Fish oil fatty acids interact with the peroxisome proliferator-activated receptor (PPAR) system, which are a class of receptors (PPARα, PPARβ/δ, and PPARγ) that seem to respond to dietary lipids and similarly structured molecules. They are highly involved in the treatment of diabetes and metabolic syndrome (via the drug classes of fibrates and thiazolidinediones), with varying effects on fat mass (PPARα increases beta-oxidation of fatty acids[106] while PPARγ promotes fat storage but improves insulin tolerance;[107] PPARδ appears to be similar to PPARα in this regard[108]).
PPARs are fairly general receptors, as their binding site is 3-4 times larger than other receptors[109] which means they have a very general binding capacity.
The PPAR system is a receptor class that is activated by dietary fatty acids and pharmaceuticals that is highly involved in lipid and glucose metabolism. It is a druggable target for diabetes and obesity (via PPARγ and PPARα/δ respectively)
15-deoxy-Δ12,14 prostaglandin J2 (15d-PGJ2) is an endogenously produced highly effective PPARγ ligand with an EC50 of 20μM[99][97][98] and its induction (Fuligocandin B from Fuligo candida[110]) carries the benefits of targeting PPARγ.
18(S)HETE from aradchidonic acid metabolism activates PPARβ and γ with moderate affinity (20μM and greater than 50μM)[111] and cellular incubation with parent arachidonic acid (without controlling for metabolites) appears to have an EC50 of 1.6μM.[112]
Both omega-3 and omega-6 metabolism have PPARγ activators
Although a few eicosanoids of both omega-3 and omega-6 origin appear to activate PPARα[111][113] it appears that Leukotriene B4 (from arachidonic acid metabolism) is the most biologically potent and relevant with an EC50 of around 100nM.[114] The arachidonic acid (AA) metabolite 18(S)HETE also appears to be 10-fold weaker (1μM; R isomer much weaker[111]) but is better able to recruit the coactivator of SRC-1 (30% the concentration required for 18(S)HETE relative to LKB4[99]). Parent AA is a weak activator per se (50μM or more[99]) but past studies that did not control for metabolites noted more efficacy due to its metabolites (1.2μM[112]).
PPARα is activated potently by metabolites of the arachidonic acid (omega-6) pathway. Although the significance of this information is unknown, normalizing a ratio of omega 3:6 may reduce overall PPARα stimulation
Adenosine monophosphate kinase (AMPK) is a nutrient signalling molecule that is antagonistic of mTOR and activated in periods of nutrient deprivation; it is also the molecular target of various supplements like Berberine or the pharamceutical Metformin. The activation of AMPK (seen with both EPA[115] and DHA[116]) is partly downstream of PPARγ (noted in general[117] and with EPA[118]) and likely mediated by the eicosanoids mentioned in the PPARγ section.
EPA has been found to activate AMPK in adipocytes via insulin-indepedent means (not requiring activation of PI3K)[115] and fish oil in macrophages.[116] The α1 subset of AMPK appears to be mostly affected[116] and both Thr172 phosphorylation (on AMPK) and Ser431 (on LKB1) noted,[118][119] and DHA has also shown efficacy in isolation in promoting AMPK activity.[116][120][121]
Both fish oils appear to activate AMPK, and this is partly due to the eicosanoids activating PPARγ (which increases the activity of AMPK when it itself is activated).
Via AMPKα1 activation, DHA may increase SIRT1 expression[116] and suppress inflammation by hindering (via deacetylation[122]) nF-kB signalling;[123] this is also a plausible antiinflammatory pathway of fish oil. EPA has been noted to dysregulate inflammatory signalling in adipocytes (usually by suppressing the actions of TNF-α),[124][125]
Activation of AMPK by EPA may underlie release of adipokines,[126][115] some inflammation (macrophages can hinder AMPK activation via SIRT1[123] and EPA preserves this[116]), improved endothelial function,[118] hepatoprotection,[119] insulin sensitivity (related to the liver),[127] and autophagy (seen with DHA[120] but a normal consequence of AMPK activation as seen via p53, which induces AMPK[128][129]).
AMPK activation has been confirmed in mice given 500mg/kg EPA (no reference drug, but just over a doubling in vasculature[118]) and other studies using fish oil at 1mL/kg[119] or 15% of the diet.[127]
AMPK activation has been noted to occur in rodents following oral ingestion of EPA, and due to activation of AMPK being confirmed in rodents and knockout mice (without AMPK) failing to show some benefits of omega-3 supplementation it appears that this pathway is highly relevant to the benefits of omega-3s
The free fatty acid receptor (FFA), also known as GRP120, is a G-protein coupled receptor (rhodopsin-like[130]) with a short (361 amino acids; 97.5% homologous between rodents and primeapes[131]) and long (377 amino acids; possibly only in humans[131]) variation expressed mostly in enteroendocrine L cells.[132] This receptor is named the free fatty acid receptor as it responds to a variety of fatty acids[133] and some omega-3 fatty acids (ALA and DHA) have been confirmed to be agonists with DHA stimulating activity to 276+/-25% (short variant) and 177+/-13% (long) at a concentration of 100μM.[134] Elsewhere, mixtures of omega-3 fatty acids have been able to signal via the receptor.[132]
Activation of this receptor by omega-3 fatty acids is known to secrete some gut hormones (Glucagon-like peptide 1[135][136] and cholecystokinin[137]) and is involved in insulin sensitization secondary to antiinflammatory effects[132] and possible anti-obese effects (as loss of GRP120 is a risk factor for obesity and GRP120 knockout mice are obese[138]).
It has not yet been confirmed whether DHA and EPA are direct agonists of the receptor or whether they work via eicosanoids, although the ability of alpha-linolenic acid to activate the GRP120 suggests the former.
Activation of the GRP120 (Free fatty acid receptor) by fish oil supplementation and/or derivative eicosanoids has been confirmed in animals and may underlie some bioactivity of fish oil supplementation
Other fatty acid receptors exist (all with a GPR designation) including FFAR1 (GPR40), FFAR2 (GPR43), FFAR3 (GPR41), and GPR84.[139] FFAR1 responds mostly to medium chain fatty acids (palmitic acid and linoleic acid[140][141]) and both FFAR2 and FFAR3 respond to shorter chain fatty acids (acetate and butyrate[142]) with GPR84 being the sensor for medium chain fatty acids (lauric acid[143]). Although these are free fatty acid receptors, they are not seen as molecular targets of EPA nor DHA due to the long length of fish oil fatty acids.
Other free fatty acid receptors are not likely molecular targets of fish oil supplementation as they respond to shorter chain fatty acids
It has been hypothesized that dietary DHA is required for optimal neural functioning due to some evidence suggesting a diet low in DHA reduces brain phospholipid content by 32% (high dietary ALA) or 53% (low ALA), relative to a diet high in DHA,[31] although losses of DHA from the brain are somewhat difficult over the short term in non-neonates and seem to be regulated[144][145] and neonates seem more sensitive, with DHA deprivation from young mice resulting in DHA losses in the brain within 2 weeks.[146] Losses have been reported in adult primeapes on dietary restriction of DHA (and are likely to apply to huamns), but this requires a time period of 18 months[147] or 5 years (70% reduction)[148] with the inclusion of Alcohol to deplete DHA stores.[147][148]
Short term dietary restrictions, in adults, are unlikely to modify cerebral concentrations of DHA. However, prolonged absence of DHA in the diet seems to be able to progressively reduce brain DHA concentrations
It has been hypothesized that aggression is a symptom of DHA deficiency,[149] in which case supplemental DHA would alleviate this deficiency.
In otherwise healthy persons, DHA appears to prevent excessive aggression in times of stress[150][151] and has been found to prevent a decline in aggression during destressing follow-up periods.[152] These effects are seen (like depression and stress) in the range of 1.5g daily, and don't appear to occur at 150mg DHA daily.[151] An exception may be schoolchildren, who showed benefit at 3.6g per week.[153]
With DHA and aggression, it seems to reduce aggression when deficient (as aggression may be a side-effect of deficiency) and has an effect on normalizing aggression levels; which can be good in the face of stress, but at least once has noted a prevention of decline in stress. These results may be confounded with influences on noradrenaline, in the 'Stress' section to follow.
DHA is investigated for its role in memory formation as higher serum DHA concentrations are correlated with greater verbal fluency skills in older humans[154] and a deficiency of DHA is known to damage rat memory processing.
For animal models, administration of DHA (300mg/kg is the standard dose) appears to promote cognition with improvements noted in reference memory (without affecting working memory) in otherwise healthy rats.[155]
There is animal evidence to support DHA improving memory in otherwise healthy rats
One study conducted in otherwise healthy young (18-25) persons noted that, after 6 months of supplementation with 2g Lovaza (750mg DHA; 930mg EPA) that working memory was enhanced as assessed by a verbal n-back test (with improvements in 3-back but not 1 or 2-back); this was deemed to be independent of dopamine metabolism but instead correlated with the EPA and DHA content or Red Blood Cells (RBCs; up 75% from 2.9+/-1.0% for DHA, and up 350% from 0.4+/-0.1 for EPA) when looking at the RBCs of persons low in DHA.[156] Elsewhere, youth who have low dietary intake of fish have experienced improved memory retention and reaction time with supplemental DHA at 1,160mg over 6 months.[157] Some isolated studies not reporting dietary intake of fish oil also report benefits to memory formation (as well as attention and reaction time).[158] Interventions in older adults tend to note benefit in persons with[159] and without[160] apparent cognitive decline.
Some studies fail to find a significant benefit of fish oil supplementation on cognition in healthy adults (400-1,800mg EPA+DHA,[161] 1,400mg EPA and 800mg DHA,[162] or 1g EPA+DHA over 12 weeks[163]) with one of these studies[162] having an exclusion criteria of 'no more than once weekly' for fish intake but otherwise diet was not reported.
There is human evidence to support an increase in memory (working and episodic) associated with DHA supplementation. Although it cannot be ruled out, it is plausible that this is only for persons with low dietary DHA intake
A meta-analysis on fish oil supplementation and depression (inclusive of disease states such as schizoprhenia or bipolar disorder)[164] able to assess 28 studies with a dosage range of 136-6,200mg EPA and 88-3,400mg DHA (Postpartum or perinatal depression,[165][166][167][168][169] major depression disorder or depression without other cognitive diseases,[170][171][172][173][174][175] depression associated with fatigue,[176][4] bipolar disorder,[177][178][179][180] schizophrenia,[181] Parkinson's disease,[182] self-harm,[183] personality disorders,[184] or no significant disease state or just mild depression[185][186][187][188]) noted that a higher EPA:DHA ratio was predictive of anti-depressive effects and that the three studies using pure DHA[167][171][168] outright failed to exert antidepressive effects. Oddly, 1g of EPA supplementation (as ethyl ester) appears to be more effective than 2-4g in one trial[172] or at least 2g fails to outperform 1g[179] and the meta-analysis came to the same conclusion where supplemental EPA dose was inversely related to efficacy (with higher doses being less effective).[164]
Beyond identifying the efficacy of lower doses, this meta-analysis found evidence for publicity bias (was unsure if this was due to heterogenity in the studies assessed as it was very inclusive or other influences) and suggested that persons with higher baseline depression experienced more benefit, with the group with low depressive symptoms having a reduction of −0.074pts on mean depression (95% CI of −0.317 to 0.169) that was not statistically significance but the higher depressive group having a reduction of −0.605 (95% CI −0.871 to −0.339).[164] The robustness of the studies (assessed by Jadad) was similarly heterogenous with some poor quality studies included.[164]
Supplementation of 1g EPA (higher doses not being more effective) appears to be around the dosage where most benefit to depression exists, with DHA not being associated with any significant anti-depressive effect. The antidepressant effects appear to only be significant in severely depressed persons
It is plausible that fish oil is an augmentor of antidepressants, as the above meta-analysis did note that most trials conducted in major depression or disease states were also mediated with standard antidepressant drugs (such as lithium).[164] At least one study has noted that fish oil (in isolation at 1,000mg ethyl-EPA) is comparable to the SSRI drug fluoxetine (20mg) but also supports the idea that combination therapy is best, as response rates were in the range of 50-56% (monotherpaties) and rose to 81% with both.[189] This synergism has been noted in animal studies with traditional anti-depressants (fluoxetine and mirtazapine)[190] and with nutraceutical anti-depressants such as Uridine.[191]
There is evidence to support fish oil being able to be antidepressant by itself, but there is also enough evidence and suspicion to suspect that most significant effects come from combination therapy (taking fish oil alongside a more proven antidepressant)
In otherwise healthy elderly adults with minor depressive symptoms, fish oil supplementation does not appear to further increase well-being and reduce depression at 1800mg EPA+DHA,[185] and has failed to reduce depressive symptoms (or increase well being) in adults who do not report depression.[192][193]
There is insufficient evidence to support a mild antidepressive effect in persons who report mild but not debilitating depression. Fish oil supplementation appears to be ineffective for mild depression in the studies that investigate it
Fish oil supplementation is hypothesized to aid bipolar symptoms as reference drugs (lithium carbonate and valproate) reduce neuronal signal transductance systems[194][195] which appears to have been noted with omega-3 fatty acids in regards to arachidonic and phospholipid signalling.[180] Bipolar disorder does appear to also be associated with alterations in membrane lipids, but this is more related to GLA and the omega-6 fatty acids than it is to fish oil.[196]
However, despite a preliminary study noting that fish oil supplementation may aid symptoms of bipolar disorder at 9.6g daily (6,200mg EPA and 3,400mg DHA)[180] and (albeit cautious) promise for depressive symptoms mentioned by one meta-analysis on the topic,[197] a followup study using smaller doses (2g twice a day, totalling 1,680mg EPA and 1,120mg DHA) with or without 1g cytidine delivered via CDP-choline (twice daily; forms Uridine in the body[198]) failed to replicate the results over a similar time period of 16 weeks, and actually reported a nonsignificant trend to worsen symptoms.[199]
Currently there is mixed evidence as to whether fish oil supplementation can aid bipolar disorder. The limited studies on the topic are too different to compare against each other (large differences in dosage) and although a beneficial effect cannot be ruled out a worsening effect is also plausible
Fish oil supplementation in rats (at 5% food intake) was found to normalize the stress response after being subject to footshock, a research test used to mimic long-term environmental stress.[200] This has been replicated in other models on animals and in humans with DHA supplementation at high doses (1.5-1.8g DHA) daily in which adrenaline response to stress is attenuated.[149][201] In longer term models to assess cortisol (long term stress hormone), students taking 20 exams had a similar decrease in noradrenaline (-31%) at 1.5g DHA daily, although no changes in cortisol were noted.[202]
In regards to stress, both EPA and DHA seem to have implications. EPA from modulating some immune functions associated with stress[203] and DHA is tied in with aggressive increases during stressful times.[204]
Interestingly, a low dose of 762mg EPA+DHA daily can reduce noradrenaline levels even in healthy non-stressed persons.[205]
A deficiency of omega-3 fatty acids has been noted to reduce glucose metabolism in the brain in rats[206] thought to be related to reduced GLUT1 transporters[207] which is amendable with supplemental omega-3 fatty acids (in vitro).[208][209]
In primeapes, DHA supplementation (150mg/kg) has been noted to improve neuronal glucose uptake[210] although this does not appear to occur in humans per se (independent of age);[211] there does appear to be an inverse correlation between cerebral glucose utilization and serum triglycerides[211] suggesting that treatment of dyslipidemia may be beneficial.
It is unlikely that fish oil increases cerebral glucose metabolism in completely healthy individuals per se, although those with metabolic syndrome or high triglycerides might experience a benefit secondary to reducing triglycerides. This latter claim has not been thoroughly investigated
Isolated EPA has been noted to modulate cerebral blood flow in spontaneously hypertensive rats at 100mg/kg for 8 weeks.[212]
As assessed by haemodynamics in functional near IR spectroscopy (NIRS) where total blood hemoglobin is closely correlated to blood volume and oxygenation rates can be measured[213] it has been noted that in otherwise healthy young adults not consuming more than one fatty fish product per week who then recieved 450mg DHA and 90mg EPA for 12 weeks was able to increase cerebral oxygenation during cognitive testing (without affecting deoxygenated hemoglobin as total hemoglobin increased);[214] this study is duplicated in Medline.[215]
Appears to promote blood flow to the brain of otherwise healthy adults who have low dietary fish intake
Most epidemiological evidence,[216][217][1][218] but not all,[219] suggest a reduced risk of stroke associated with high dietary fish consumption particularly in elderly persons[218] and following standard dose-response;[216] this is thought to be related to the omega-3 fatty acids[220] and particularly DHA.[221][31]
Intravenous administration of fish oil triglycerides to mice given a stroke (hypoxia/reperfusion; 100-375mg/kg fish oil) noted that a 43-47% reduced infarct size resulted with both pre-treatment and up to 2 hours post-stroke,[222] and 100mg/kg of EPA (as ethyl ester) for 8 weeks in spontaneously hypertensive stroke-prone rats has noted a modulation of cerebral blood flow.[212]
It is possible that fish oil supplementation has both therapeutic and preventative roles in strokes
The amount of DHA complexed with Phosphatidylcholine in plasma appears to be negatively correlated with the risk of dementia in humans[223] and high dietary intakes of fish have been noted to be protective against the rate of developing dementia and related cognitive decline disease states in older and middle aged persons.[224][225][226]
When assessing older adults, higher cerebral levels of EPA (surprisingly, not DHA) are related to less atrophy of select brain regions (hippocampus, right amygdala) when followed over 4 years[227] and lower erythrocytic EPA and DHA are associated with reduced brain mass in older adults in cohort studies.[228] These results suggest a protective role of EPA, and 2,000mg of supplemental DHA for 18 months in older adults has failed to reduce the rate of atrophy.[229]
Higher fish intake is associated with lower risk of developing dementia, and reduce DHA levels in serum are associated with a higher risk of dementia. EPA appears to be associated with preserving brain mass over time
A higher intake of omega-6 relative to omega-3 can be associated with increased activity of COX enzymes as they are competing substrates[230] although the subsequent production of PGE(2) (known to increase amyloid secretion[231] via inducing γ-seceratase[232]) which is known to be reduced with fish oil[233] appears unrelated to DHA-induced suppression of amyloid secretion.[234]
As mentioned in the protectin section, it is plausible that the mechanism of protection against amyloid buildup is mediated via Neuroprotectin D1 as it potently (EC50 of 50nM) suppresses amyloid formation[92] and promotes its removal[93] via PPARγ-dependent mechanisms.[92]
The mechanism of neuroprotection in Alzheimer's does not appear to be related to PGE(2)induced amyloid buildup, but is likely tied back into Neuroprotectin D1
In animals, provision of DHA at 300mg/kg (rat dose) for 12 weeks appears to promote cognition, memory, and reduce the rate of cognitive decline in a model of Alzheimer's disease characterized by β-amyloid pigmentation.[235][236][237] Furthermore, the dendritic/synaptic decay seen in Alzheimer's disease[238][239] appears to be reduced with provision of DHA[240] which is thought to be the mechanisms of neuroprotection and further thought to be synergistic with Uridine supplementation.[241][242]
Animal evidence appears to support the role for DHA in high doses (300mg/kg in rats, which is an estimated human dose of 48mg/kg or 3.2g DHA for a 150lb person)
In persons with Alzheimer's, 2,000mg DHA (no EPA supplementation) from algae over 18 months has failed to benefit cognitive decline[229] and another study using 1,700mg DHA and 800mg EPA in persons with Alzheimer's for 6 months has failed to significantly attenuate the rate of cognitive decline as assessed by MMSE[243] and failed to alter neuropsychiatric symptoms (both citations are the same trial).[244]
In human studies on age-related cognitive decline that are not Alzheimer's patients, it appears 900mg DHA may reduce the rate of cognitive decline[245] but 500mg DHA and 200mg EPA over 24 months has failed to do so.[246] The latter study, however, failed to find any rate of cognitive decline in either group and may not accurately represent fish oil.
Studies using practical and high levels of fish oil supplementation in persons with Alzheimer's Disease have failed, but studies in older adults without AD have suggest that DHA may be able to attenuate the rate of cognitive decline. The reason for this disparity, if it exists, is not known
Resolvin E1 (RvE1) signals for analgesia via the Chem23 receptor, and is active independent of fish oil supplementation (injections of 0.3-20ng RvE1; more potent than 10mcg of the COX2 inhibitor NS-398);[75] its metabolic inactivation by oxidation (oxo-RvE1[247]) is metabolically inactive.[75] It appears that activation of the Chem23 receptor via RvE1 inhibits ERK[248] and more specifically TNF-α induced activation of ERK[75] which would signal to TRPV1[249] to mediate the perception of pain. Overall, it is hypotheiszed that RvE1 siganllings for pain releif primarily by dysregulating TNF-α and its normal induction of glutamate release form neurons, which activates ERK to induce pain via TRPV1.[75]
Although RvE1 was researched above, RvD1 (from DHA) appears to also activate the Chem23 receptor[75] and the parent fatty acids of EPA and DHA were also tested but were approximately 10,000-fold weaker.[75]
Resolvin E1 (from EPA supplementation) and Resolvin D2 (from DHA) appear to act via a novel receptor to prevent the proinflammatory cytokine known as TNF-α from inducing pain. On a molecular level (how much of a molecule is required to induce effects), RvE1 and RvE2 are remarkably potent
For human studies, supplemental fish oil has been found to reduce pain in persons with inflammatory joint pain as assessed by patient reports and NSAID consumption (rescue medication, which was reduced) but not by physician reports.[250]
CETP is a transport protein that transports cholesterol from HDL to either vLDL or LDL (apolipoprotein B containing lipoproteins[251]) in exchange for triglycerides,[251][252] and reducing the activity of CETP increases HDL-C[251] possibly in hyperlipidemics only[253] while CETP activity itself is positively correlated with LDL-C.[252][254] Due to this and associations between CETP and high cholesterol[255][256] increasing the activity of CETP is seen as pro-artherogenic (increasing LDL-C while reducing HDL-C, opposite of the desired therapeutic intervention) and its inhibition seen as desirable.
The inhibition of CETP is further desired as a triglyceride reducing treatment[257] as the exchange for cholesterol from vLDL/LDL towards HDL-C is a 1:1 exchange with triglycerides;[258][251] a depletion of triglycerides from LDL and vLDL cholesterol (rather than placebo per se) has been confirmed in humans following supplementation of fish oil.[259][260][261]
Fish oil has been noted to increase CETP activity in animals[262] due to DHA and not EPA,[263] which is thought to underlie the selective induction of LDL-C seen with DHA and not EPA although it does not explain the increase in HDL-C seen with DHA.[264]
It is plausible that one of the mechanisms underlying the benefits of fish oil is CETP inhibition, which is able to reduce triglycerides and increase HDL-C (however, this pathway alone does not explain the effects on LDL-C)
In regards to fasting triglycerides (TGs; risk factor for cardiovascular disease when elevated), fish oil appears to be both a potent and reliable triglyceride reducing agent for persons with hyperlipidemic (high blood TGs).
The meta-analyses that have been published indicate that fish oil is effective for general dyslipidemia (0.34mmol/L reduction[265]) HIV related dyslipidemia (7 trials of 372 persons reducing TGs 1.12 mmol/L[266]), dyslipidemia associated with renal failure (10 trials of 337 persons reducing TGs by 0.78mmol/L[267]), and diabetic dyslipidemia (24 trials of 1530 persons reducing TGs by 0.17mmol/L or 7%[268]). The range of reduction has been cited to be as high as 25-30% with 4g of EPA ethyl ester daily,[269] but more recent evidence suggests that the reduction is a tad more modest (estimated 15-20% reduction, as the magnitude does depend on baseline triglycerides).
Both EPA and DHA are able to reduce triglycerides[264] and these benefits extend to other sources of DHA including algae oil (meta-analysis[27]) and Krill Oil with comparable potency. When comparing the effects of EPA against DHA when they are used in isolation (separate trials), EPA appears to be a tad more effective (meta-analysis[264] concluding a 25.1mg/dL reduction with DHA in isolation[270][271][272][273][28][274][275][276][277] as average but a 45.8mg/dL reduction with EPA in isolation[278][279][280][281] are similar doses and baseline TGs). However, studies that assess direct comparisons between DHA and EPA[282][283][284][285][286] note superiority with isolated DHA (when doses are similar in weight; ie. 4g versus 4g[264]). It is plausible that this difference is due to EPA traditionally being dosed at a higher quantity than DHA, with fish oils typically following dose-dependence.[265]
Fish oil reliably and potently reduces triglycerides following supplementation for a few weeks and this can be traced back to both the EPA and DHA components with comparable potency. The reduction in triglycerides follows dose-dependence and is more significant in persons with high baseline triglycerides, and is quantified in the 15-30% range (pharmaceutical grade potency, hence fish oil being patented into Lovaza as ethyl ester for the reduction of triglycerides)
Supplemental fish oil does not appear to influence postprandial triglycerides when acutely supplemented (one dose at mealtime)[287] but has been noted to reduce postprandial triglycerides in hyperlipidemics following prolonged supplementation (27% with 4g ethyl EPA[288] or 19% with 4g fish oil[289]).
The reduction in postprandial triglycerides occurs following repeated supplementation and may be more reflective of the triglyceride reducing effect per se. Single dosages of fish oil fail to benefit postprandial triglycerides
It is thought that DHA mediates the cholesterol increasing effects of fish oil supplementation[264] as supplementation with DHA increases HDL-C by 4.49mg/dL (95% CI of 3.50-5.48mg/dL) and LDL-C by 7.23mg/dL (95% CI of 3.98-10.5) whereas EPA nonsignificantly increases HDL-C by 0.20 mg/dL (95% CI of -0.82 to 0.41) and insignificantly influences LDL-C by 1.85mg/dL (95% CI of −3.01 to 6.71) with the sporadic instances of EPA increasing HDL-C and LDL-C[290][278][282][286][284][285] possibly being explained by conversion of EPA into DHA in the body.[264]
Fish oil supplementation, secondary to the DHA component, can increase both HDL-C and LDL-C lipoproteins in the body. It appears to increase LDL-C a bit more than it does HDL-C, and thus large doses of fish oil may not be advisable for persons with high LDL-C cholesterol (unless the reduction in triglycerides seen is more important, or if a statin drug or similar cholesterol reducing agent such as Berberine is taken alongside the fish oil)
It is possible for fish oil to reduce LDL cholesterol, but infrequent; it requires the user to not have disturbances in LDL cholesterol in the first place (normocholesterolemic)[291][292] or otherwise augments the LDL-C reducing effects of statin drugs (Nutrient-Nutrient Interactions section).
Possible LDL-C reducing effects with statin drugs, where fish oil and statins appear synergistic in reducing LDL-C (which appears to negate the adverse LDL increase of fish oil that is possible in hyperlipidemics)
In secondary prevention of cardiovascular disease, a membrane ratio of 4:1 omega6:3 (average with a standard western diet is 15-16.7:1[64]) or lower is associated with a 70% decrease in total mortality[64] as assessed by a single blind prospective study.[293]
Somewhat normalizing the omega 3 to 6 ratio appears to be associated with cardioprotection
The mechanistic basis for the improved endothelium-triggered relaxation with n - 3 PUFAs may include the suppression of thromboxane A2 or cyclic endoperoxides, a reduced production of cytokines, the augmented endothelial synthesis of nitric oxide, an improvement of vascular smooth muscle cell sensitivity to nitric oxide, and a reduced expression of endothelial adhesion molecules[294].
Note: For a complete overview on how fish oil supplementation interacts with glucose metabolism the pancreas and liver sections under "Interactions with Organ Systems" would be useful to read in addition to the following information in this section
Diabetic nephropathy and retinopathy can be read up in the organ systems section as well, although diabetic neuropathy is under the Neurology header for nerve health
Fish oil supplementation (following studies using ethyl ester EPA) note that fish oil consumption can somewhat reliably increase fasting glucose in the range of 2–6mg/dL, this applying to both diabetics and nondiabetics and conclusions being drawn from multiple meta-analyses(most positive[295][296][297] and some counter evidence[298]) and a trend to increase glucose is still seen in hyperlipidemic patients.[288] This increased glucose concentration is not usually met with increases in biomarkers of diabetes seen as adverse (HbA1c[296][285][297] and fructosamine[271][299]) suggesting that it may not further pathology of diabetes.
It should be noted that the increases in glucose are not observed at low doses of fish oil supplementation (6g of fish oil conferring 1,080mg EPA and 720mg DHA[300]) and appear to follow dose-dependence, with one study failing to find an influence of 4g fish oil finding an adverse increase with 7.5g (2,600mg EPA and 1.4mg DHA).[301]
There appears to be a small increase in fasting blood glucose seen with fish oil supplementation that is independent of disease state (affects diabetics, hyperlipidemics, and healthy controls) but is small (2-6mg/dL) and not associated with an increase in diabetic parameters HbA1c and fructosamine. The increase in glucose appears to occur at higher fish oil doses, and so for diabetics wanting to use fish oil using the lowest effective dose may be prudent
In healthy persons, fish oil may not increase insulin sensitivity with a high fat (37%) diet when weight loss or gain prevented, at a dose of 3.6 EPA+DHA daily.[302] This study did note nonsignificant trends of improved sensitivity in individuals who had higher 6:3 ratios at baseline. Other studies note similar results in healthy persons[303] but did not record phospholipid ratios.
In otherwise healthy males, even pairing exercise with fish oil did not yeild any changes to insulin sensitivity that were attributable to the fish oil.[304] Fish oil seems to be additive to but not synergistic with exercise.
Other studies suggest improvement in insulin sensitivity in populations who typically have worse 3:6 ratios, such as the elderly[305] the metabolically unhealthy,[288][306] and the obese.[307] It should be noted that this body of evidence is not bullet-proof, and notable studies do detect no changes in insulin sensitivity even in the above populations.[308][309][310][311] Furthermore, information from our rubric show that a large amount of systematic meta-analysis' show no significant ability for fish oil to change fasting glucose or fasting insulin in type II diabetics.[312][298][295][296]
The above mechanism of increasing insulin sensitivity may be by preserving cell fluidity and rheology, or bringing an aberrant omega3:6 ratio back to a normal range (or preventing aberration in the first place) with no therapeutic benefit beyond that. This is supported by Haugaard et al. who demonstrate a correlation between membrane PUFA content (independent of being omega 3 or 6) but additionally the 3:6 ratio, and insulin sensitivity.[313] Finally; in those who develop insulin resistance from fructose overfeeding, fish oil appears to be ineffective at alleviating the insulin resistance (although it still reduces triglycerides).[314] This lends credence to the notion that fish oil's insulin sensitizing effects are at the level of the cell, as fructose causes insulin resistance at the level of the liver and pancreas.[315]
Another possible mechanism is merely negating the negative effects on some saturated fatty acids on insulin sensitivity. Palmitic acid is known to induce muscular insulin resistance,[316] and polyunsaturated fats (either omega-3 or 6) can reduce the negative effects of palmitic acid.[317]
Fish oil has some evidence that it might increase insulin sensitivity, but these studies are isolated and are dependent on pre-existing conditions that hinder insulin sensitivity. As a general statement, fish oil supplementation does not increase insulin sensitivity or reduce fasting glucose (a long-term marker of glucose metabolism; fish oil can reduce blood glucose acutely though).
That being said, it does seem to induce some changes in glucose consumption that may appear to be like insulin sensitivity. See the section on 'Muscle Bioenergetics' for more details.
There appears to be a reduced risk of diabetes associated with a somewhat normalized omega3:6 ratio.[318][319][320]
In mice, high doses (15% of diet) of fish oil have been noted to induce CPT-1, Nrf1, and PPAR-α expression in adipose tissue;[321] the latter of which tends to be antiobese when activated[322] and the former the enzyme that mediates carnitine transport into the mitochondria and serves as the rate-limiting step of fat oxidation.[323]
PGC1α has also been noted to be induced in adipose of mice[321] but although activation of PGC1α may increase energy expenditure via UCP2 expression it is possible this is just downstream of PPARα activation as there are similarities in this regard between fish oil and fibrates (pharmaceutical PPARα activators).[324][325]
Beyond that, DHA is thought to be the active ingredient as it is better correlated with weight loss in humans.[326]
Fish oil can technically activate the PPARα receptor to induce mitochondrial biogenesis and increase the metabolic rate. Although it is confirmed in rodent models, it requires a high oral dose and rodent models have been noted to be genetically different when it pertains to PPAR metabolism (see: Conjugated Linoleic Acid)
In studies that assess metabolic rate, it is found to not be significantly influenced (despite increased fat oxidation) in otherwise lean men.[327]
Does not reliably increase metabolic rate
There may be antiinflammatoy effects at the level of the adipocyte as evidence by less cytokine secretion under the influence of fish oil fatty acids.[328]
May exert a localized antiinflammatory effect, which could indirectly aid fat metabolism in persons characterized by excessive inflammation (ie. metabolic syndrome)
Through these agonisms, fish oil can increase adiponectin secretion from fat cells.[329][330] Surprisingly, though, it seems to take up to 6 weeks for this effect to be physiologically relevant in humans at a dose of 2g fish oil daily.[331] Higher levels of circulating adiponectin are seen with diets higher in fish oil omega-3s.[332]
EPA is more potent at increasing adiponectin relative to DHA, and this increase in mediated mostly through PPARy activation.[333][329] Fish oils can also positively regulate leptin in the same manner.[334]
It has been noted that the anti-obese effects of fish oil on body weight gain in high-fat fed rats is reversed in diabetic rats[335] and that inclusion of large amounts of sucrose into the diet reduced the anti-inflammatory and weight loss effects of fish oil.[336]
In rats that are fed a high fat obesogenic diet, fish oil ingestion (without exceeding caloric intake) appears to attenuate the rate of fat gain over time when consisting of 20-40% of overall calories[337][338][339][340][341] with some studies using more reasonable doses (1-12%) noted the same result but to a smaller degree, with some indication that DHA was more relevant than EPA.[342] It is not sure if this effect is similar in diabetics, as one study has found an augmentation of weight gain (without measuring fat mass)[335] but appears to still persist in already obese animals who are subject to further weight gain.[343]
In general, high doses of fish oil in rats (to a level inpractical for human consumption) are able to reliably reduce weight gain in rats fed an obesogenic diet; it appears to occur to a smaller extent with smaller doses which may be more relevant to human ingestion
Fish oil is known to suppress the adipogenic receptor PPARy[344] and its mRNA levels.[345]
Fish oil has been noted to increase the expression of the Carnitine Palmitoyltransferase-1 (CPT-1) enzyme in muscle cells[346] (possible secondary to PPAR activation[347]) and increased both peroxisomal acyl-CoA oxidase and UCP3 expression at very high dietary intake in rats (40% of dietary intake).[337]
Some interactions at the level of skeletal muscle may mediate fat loss via caloric expenditure
When looking at survey research, there appears to be an inverse correlation with dietary fish oil intake and obesity rates (suggesting a protective effect)[348] or no significant relation at all.[349]
When looking at interventions, one study in otherwise healthy lean men has noted that replacing 6g of fatty acids with fish oil for 3 weeks resulted in a fat loss of -0.88+/-0.16 (relative to placebo with -0.3 +/- 0.34kg) which was associated with an increase in fat oxidation but not metabolic rate.[327]
May increase fat loss in otherwise lean individuals, although the evidence that supports this hypothesis is less robust than other evidence
In obese sedentary persons, 6g of fish oil has failed to outperform 6g of control oil (sunflower) either with or without aerobic exercise although there was evidence of slight synergism with fish oil and exercise.[350] The lack of benefit of fish oil to reduce fat mass in obese persons has been noted elsewhere with insulin resistant women given 2.9g DHA and 1.3g EPA for 24 weeks.[309]
Elsewhere, it has been noted (hyperlipidemics) that the decrease in body fat seen with fish oil supplementation is only significant when paired with exercise with no inherent loss being noted at similar doses[351]
In studies that enforce a caloric restriction, fish oil (2,800mg omega-3) ingestion in obese women is associated with greater losses of body fat and weight (24%) than is control oil (saline) which is thought to be related to higher ketone levels detected in the blood.[326] Some degree of fat loss has also been noted with fish oil when it is paired with the Zone diet (Zone diet alone in this study also effective) while it alone was ineffective.[188]
There may be a role for fish oil in reducing fat mass in obese persons, but it appears to not be an inhernent fat loss effect but rather dependent on other fat loss inducing habits (such as exercise or caloric restriction). Even then, the magnitude of effect in obese persons does not appear to be overly remarkable
Fish oil supplementation has been noted to augment muscle protein synthesis that is induced by Leucine in both young[352] and old adults.[353]
A possible mechanism is supressing SMAD2 and inducing SMAD7 (noted in renal cells[354] and cardiac cells[355]) which is known to suppress the signalling of Myostatin, as myostatin is depedent on nuclear translocation of SMAD2/3 (complex) and this has been noted to be inhibited with fish oil.[355]
Theoretically plausible that there are interactions with fish oil and Myostatin, but this has not directly been assessed and is currently not established
A very high dose (1g/kg bodyweight; about 28% EPA+DHA content) fish oil in rats shows increased glycogen resynthesis rates and increased glucose oxidation independent of insulin,[356] and 14% increase lactate concentration that was dependent of insulin stimulation. The increased glucose oxidation and uptake may be downstream effects of increasing transcription of AMPK.[357] Activation of AMPK has been noted in other tissues by DHA, such as the intestines[121] and can do so vicariously though adiponectin.[332] This increase in glucose oxidation (possibly by AMPK) was also noted at intakes of 1.8g omega3 (1.1 EPA, 0.7 DHA), which quantified the same glucose oxidation rates despite a 17% lesser AUC for insulin.[358]
Fish oil seems to upregulate mRNA for uncoupling proteins (heat production) in mouse muscle UCP3, brown adipose tissue UCP2, and liver UCP2[325][359] although a drop is seen in white adipose tissue UCP2. Muscle upregulation is seen in bovine as well.[360] Although increased UCP expression is correlated with decreased energy efficiency, a dose of 7.2g fish oil (1.1g EPA, 0.7g DHA) does not significantly impair energy efficiency in otherwise healthy males.[304] This study did not a trend of increasing fat utilization over carbohydrates, however; uncoupling proteins were not measured. This may be a dose issue, as metabolic efficiency is greatly reduced when fish oil is superloaded at 40% of energy intake in rats.[337]
Fish oil (technically, EPA) incubation in muscle cells is associated with a greater ability for the muscle cell to switch from glucose to fat as primary substrate for oxidation, a phenomena known as 'bioenergetic flexibility' of 'metabolic switching'.[361]
In mice subject to immobilization, fish oil supplementation has been implicated in decreasing the rate of muscle degeneration.[362] However, it also hinders recovery after the fact for a few days via the same pathway.[363]
Some studies in post-surgery situations note increased retention of lean body mass when EPA is added to enteral nutrition.[364][365] Its still under investigation, however, as some studies note no difference.[366]
Fish oil appears to most significantly influence glucose metabolism in muscle cells, but beneficially influences both fat and glucose metabolism and the flexibility between the two. In moderate doses, it appears to beneficially influence bioenergetics through a combination of nutrient uptake (AMPK, membrane rheology) and mitochondrial enzymes. Many of the anti-diabetic effects seen with fish oil can be indirectly linked to increased muscle cell uptake of glucose and increased insulin sensitivity. The evidence of it increasing hypertrophy is promising, although limited.
In mice and over longer periods of time, fish oil can preserve the effects of some hormones (insulin, adiponectin) on muscle cells when normally exposed to an obesogenic diet.[367][332] This may be due to the fish oil component DHA being able to partially reverse the reduction seen in muscle glucose uptake with Palmitic Acid, a saturated fatty acid.[357] Normalizing the phospholipid ratio (independent of fish oil) does seem to increase adiponectin secretion, however.[368] It is not clear whether the means to the end (fish oil) or the end (ratio) are the cause of health benefits seen.
In muscle cells, fish oil can also increase AMPK mRNA levels, particularly the AMPKa2 subset.[357] It has been implicated in doing so in white adipose tissue as well.[125]
High doses of EPA (500mg/kg) have been shown to reduce PPARd and PPARy expression in muscle cells, and interfere with the production of pro-inflammatory TNF-a and IL-6, which lend credence to its anti-inflammatory claims.[125] Increased GLUT4 expression was seen at this dose, although lower doses show only increases in GLUT1 translocation.[369]
Possibly through AMPK, a decreased n6/n3 ratio (more omega 3 relative to omega 6) in muscle cells is associated with increased glucose uptake and better whole-body glucose tolerance independent of mitochondria.[47] The ratio was approximately 0.5:1-1.5:1 (fish oil) relative to 17.5:1-29.7:1 (control), as measured in the cell membrane.[47] The muscle cell membrane seems highly response to dietary changes in omega fatty acid intake[370] and has been associated in vivo with human insulin sensitivity.[371]
Interleukin-2 (IL-2) secretion from lymphocytes has been noted to be reduced when murine splenic cells are incubated with fish oil fatty acids[372] which has been noted to affect persons regardless of disease state (lymphocytes in this study isolated from diabetics and controls[373]). As IL-2 is a cytokine that positively influences T-cell proliferation[374][375] and is a stimulator of TNF-α[376] and IL-1 (alpha and beta)[377] secretion, it is likely the suppression of IL-2 underlies other immunological effects of fish oil supplementation.
Mechanisms are not fully established, as a suppression of IL-2 signalling (assessed by T-cell cycle progression) has been noted with fish oil[378] and a reduction in Diacylglycerol (DAG) and ceramide has been noted,[372] with both of those being positive regulators of T-cell proliferation.[379][380] Although the receptor itself appears unaffected in content,[381] a decreased signalling potential (as assessed by ERK1/2 phosphorylation) has been noted in T-cells incubated with fish oil[382][383][384] which may be related to reduced recruitment of PKC isomers (alpha and epsilon) to the cell membrane;[385] this would result in the immunosuppressive effects of fish oil being dependent on membrane rheology and the omega-3:6 ratio.
3.5g fish oil for 12 weeks (otherwise healthy 50-70yrs) has failed to significantly influence IL-2[386] and failed to influence with 2g daily in persons with isolated hypertriglyceridemia.[387] However, 18g of fish oil (2,754g EPA and 1854mg DHA) daily in otherwise healthy youth has been noted to reduce secretion of IL-2 in stimulated PBMCs by a variable 23-52%[374] and in type II diabetics, IL-2 has been reduced following fish oil supplementation (1,548mg EPA and 338mg DHA for 8 weeks) by 17.1%.[388] The efficacy of fish oil in suppressing T-cell activity and IL-2 does not appear to depend on disease state.
Athletes undergoing exercise given fish oil (6 weeks of 1,300mg EPA and 300mg DHA) have noted an increase in neutrophil (PBMC) produced IL-2 when measured 3 hours post exercise relative to placebo,[389] which due to IL-2 normally being suppressed after exercise[390] this was interpreted as a reduction in immunosuppression. This has been noted elsewhere in elite swimmers,[391]
Interleukin-2 appears to be (somewhat unreliably) suppressed following supplementation of fish oil, which may be due to the dietary ratio of omega-3 and omega-6. Suppression of IL-2 results from impairing signalling on a T-cell, and the ultimate result is less IL-2 (which in and of itself results in less T-cell proliferation, TNF-α, and IL-1β)
Tumor necrosis factor alpha (TNF-α) is a pro-inflammatory cytokine that appears to be negatively correlated with omega-3 status.[392] This cytokine is positively influenced by IL-2 stimulation[376] and a reduction in IL-2 would result in a reduction in TNF-α. Similar to IL-2, the receptors for TNF-α are unaffected following fish oil supplementation[393] but unlike IL-2 the stimulation of TNF-α from a stimulated immune cell (in this case, monocyte) does not appear altered.[394]
Reductions in TNF-α have been noted in otherwise healthy men,[395][192] and youth (offspring of type II diabetics[396] or obese youth[397]) and has been noted with high doses (18g) in young adults[398] and more moderate doses in persons on hemodialysis.[399] However, similar to IL-2 there are several null effects suggesting no change[386][400][401] and the demographics of the positive and negative studies overlap including disease states or medical conditions such as hemodialysis[399][400] and thus it is unlikely that this conditionally works in a certain demographic.
TNF-α concentrations in serum appear to be unreliably reduced following supplementation with fish oil, and due to the high correlation with reductions in IL-2 and TNF-α paired with a plausible mechanism it is thought that the reductions in TNF-α are merely due to less circulating IL-2
C-reactive protein normally is inversely related to serum omega-3 fatty acids[402] or noted to be positively correlated with omega-6 fatty acids.[403]
C-Reactive protein has been noted to be reduced at rest in otherwise healthy men following 6 weeks consumption of 2224mg EPA and 2208mg DHA[395] and women on hormone replacement therapy have experienced a decrease in C-reactive protein with 7-14g fish oil daily (35% and 10.7%, respectively).[404]
1.5g of fish oil, with or without 800mg Vitamin E has failed to reduce C-Reactive protein.[394] In stroke recoverers (65+/-10yrs) given 1.2g fish oil daily, C-reactive protein is unaffected,[405] youth given 0.6g EPA with 0.26g DHA fail to find a reduction,[393] and in persons with mild hypertriglyceridemia it is also unaffected.[406]
C-Reactive protein appears to be reduced following ingestion of fish oil supplementation, although it is somewhat unreliable and usually no significant influence is seen. It is possible that very high doses of fish oil force a reduction in CRP
3.5g fish oil for 12 weeks (aged 50-70) has failed to influence IL-6 along with 12 other parameters measured (IL-1α, IL-1β, IL-2, IL-4, IL-5, IL-6, IL-8 (or CXCL8), IL-10, IL-12p70, IL-13, IFNγ).[386] IL-1β and IL-6 have elsewhere been unaffected in persons on dialysis (2,400mg fish oil[400] and 3,400mg[406]) as well as healthy persons (775mg EPA[401]) but IL-6 has been reported to be decreased in otherwise healthy older men given 1.5-2.5g fish oil daily to a magnitude of 10-12%[192] and in women on hormone replacement therapy with 7-14g fish oil daily.[404]
The levels of IL-6 secretion in response to LPS stimulation have been seen to not be significantly influenced by 7-14g fish oil in postmenopausal women[404] but has been noted to be reduced (14%) in medical students in response to LPS.[407] When assessing neutrophil function, although IL-1β, IL-10, and IL-23 appear to be suppressed (IL-5 and IL-17 trending) IL-6 was not.[401] IL-1 (both subunits) have elsewhere been noted to be reduced with fish oil supplementation.[398]
Other interleukins tend to not be significantly affected, although IL-6 appears to be reduced in some instances. The instances where IL-6 are reduced correlate well with instances where C-reactive protein are reduced
Chemotaxis is the process by which immune cells are recruited to a specific site in the body in response to secreted cytokines and involves the immune cell rolling along the endothelium until it attaches to cellular adhesion factors (E-Selectin, ICAM-1, and VCAM-1 being most researched) and is pulled into tissue.[408][409]
The arachidonic acid metabolite known as Leukotriene B4 is a potent chemoattractant (promoting chemotaxis) and it appears that following supplemental fish oil this chemoattractant is reduced and ultimately less chemotaxis occurs for both neutrophils and monocytes in both diseased and healthy populations.[410][411][412][413][398]
There appears to be less chemotaxis associated with fish oil supplementation, which reduces the rate immune cells (neutrophils and monocytes) can penetrate tissue. This is an immunosuppressive action due to lowering levels of the immunosupportive omega-6 fatty acid metabolite (Leukotriene B4) and can reduce immunity and inflammation independent of circulating cytokines
In animal studies or in vitro, decreased expression of cell adhesion factors have been noted on monocytes,[414] macrophages,[415] lymphocytes,[416] and the endothelium;[417][418][419] This has been noted with both EPA[419] and DHA[418] in isolation.
In human studies, supplemental fish oil is able to reduce the ability of isolated immune cells to express cell adhesion factors in response to immunostimulatory agents when tested outside the body[420][421] and serum levels of soluble adhesion factors have been noted to be decreased[422][419] There appears to be some associated with age, having this immunosuppressive reduction of adhesion factors occuring in elderly persons but not youth[422] but even then it is somewhat unreliable.[386]
Cell adhesion factors are reduced with EPA and DHA technically, although human studies as somewhat various in concluding what supplemental fish oil does. As omega-6 fatty acids confer the opposite effect, it is plausible that increasing the omega 3:6 ratio confers immunosuppression while the reverse confers immunopotentiation
Neutrophil EPA and DHA are both reliably increased following supplementation of fish oil.[423][424][401] Supplementation of EPA in isolation is able to increase DHA levels in neutrophil membranes[401] although very high doses (1600mg) of DHA are required to increase EPA concentration.[424]
The suppression of Leukotriene B4 seen in vitro[425] and following oral ingestion in humans[423][424] appears to be related to a reduced ability of stimulated neutrophils to produce it,[425] which has been confirmed in humans consuming fish oil (31% reduction with 775mg EPA).[401] When looking at genes affected by fish oil ingestion in neutrophils, a decrease in protein content of PI3Kα and mRNA content of PI3Kγ (PI3Kβ and PI3Kδ unchanged) has been noted and the reduction in signalling via Akt/nF-kB thought to play a role.[401]
Fish oil supplementation, due to association with fish oil fatty acids with the neutrophil membrane, appear to reduce the ability of neutrophils to secrete the proinflammatory Leukotriene B4. This may be related to PI3K/Akt signalling being suppressed
In regards to oxidative function (neutrophils use oxidation to destroy pathogens via a process known as oxidative burst,[426] mediated by NADPH[427]) superoxide production appears to be increased following fish oil ingestion at 2g daily (300mg EPA and 400mg DHA)[428]
2g fish oil (300mg EPA, 400mg DHA) daily in cancer patients for 8 weeks reversed the chemotherapy-induced reduction in neutrophil count and phagocytosis (neutropenia[429]) to a 29% increase (all PMBCs) and 14% increase respectively; superoxide production of neutrophils was enhanced 28%.[428]
Monocytic secretion of IL-1β, IL-6, and TNF-α appears unaffected (MCP-1 activation) following ingestion of fish oil at the dose of 1,500mg daily for 12 weeks with or without 800mg Vitamin E.[394]
3 weeks of 4g fish oil has failed to significantly influence parameters of monocytic activation or adhesion in healthy persons and those with coronary artery disease.[289]
Natural Killer (NK) Cells are immune cells that aim to induce cellular death, and are important in cancer prevention. Fish oils at 10% of the diet by weight in rats are able to preserve NK levels closer to pre-operation levels than when compared to a normal feed diet, with no apparent effect in pre-operation (healthy) levels.[430]
At rest in older individuals (55yr or above), supplemental fish oil (720mg EPA, 280mg DHA) for 12 weeks has noted a 48% reduction in NK cell activity which was not replicated by supplemental DHA (720mg) or other tested fatty acids (arachidonic acid, GLA, alpha-linolenic acid)[431] despite other studies noting that supplemental DHA may reduce NK cell activity in young men (albeit at 6,000mg daily)[432] and EPA between 1,350-4,150mg daily for 12 weeks in youth failed to note an increase.[433]
NK cell activity has been found to be enhanced in otherwise healthy young men subject to exercise (accreddited to an increase in NK cell content that was induced by exercise[389]) which is thought to be due to decreasing PGE(2) concentrations which naturally retard NK cell activity.[434] An increase in IL-2 was also noted,[389] which is known to stimulate NK cell activity.[435]
There is currently mixed evidence as to the role of fish oil supplementation on NK cell activity, with both increases and decreases having been detected. The reasons for the discrepancies are speculated but not known
B cells are a subset of lymphocytes with prominent effects in lung and intestinal tissue that serve to secrete antibodies and some cytokines to act as support cells in defense against pathogens.[436][437] B-cells have been confirmed to incorporate fish oil lipids into their membranes ex vivo[438] and following oral ingestion.[439] It is thought that the mechanism by which fish oil acts is via supporting formation of lipid rafts.[439][440]
Mice ingesting fish oil (12-14.5% of diet by calories) appear to have increased CD69[438] and CD40[439] receptor expression with no influence on CD80, CD86, nor MHCII;[439] B-cell secretion of IFNγ and IL-6 appears to be enhanced up to 50% ex vivo when stimulated by LPS[439] and has been noted to occur in vivo.[438][440] The response of B-cells to antigens appears to not be significantly influenced,[439] yet higher IgA concentrations have been detected in mice.[440]
In humans, studies have failed to find alterations in serum concentration of B cells (not activation thereof) with doses of DHA ranging from 720mg to 6,000mg.[431][432][433]
Supplementation of fish oil has not yet been found to alter the concentration of B-cells in the body, and the binding of B-cells to antigens appear to be unaltered. However, overall the B-cell appears to be more responsive to inflammatory stimuli and may secrete more antibodies which would suggest that fish oil may enhance adaptive immunity
B-Cell activation may underlie increases in serum IL-6 and IFNγ
T cells are lymphocytes that can be divided into helper T cells (depending on whether they express the receptor known as CD4, in which case they are referred to as CD4 positive) and cytotoxic T cells (same idea but with a receptor known as CD8). CD4+ and CD8+ are shorthand for helper and cytotoxic T cells, respectively.
CD4+ T-cell activation occurs when T cells are met with antigen presenting cells (dendritic cells) and is mediated by receptors (TCRξ/CD3) and costimulators (ICOS and CD28 as positive modulators, CTLA-4 and CD152 as negative).[441] It appears that the signalling cascade that results in expression of the T-cell receptor (TCR) is suppressed when fish oils are incorporated into the cell membrane[442][443][444] and the ultimate result is less associated with T-cells and dendritic cells and an immunosuppressive effect[445][446] which has been confirmed in mice at 1.5% of the diet as omega-3[447] or 200mg/kg.[446]
Incorporation of fish oil fatty acids into the T cell membrane appears to be associated with less association with dendritic cells and thus less activation
When looking at human interventions fish oil supplementation has repeatedly failed to negatively influence T-cell function with 4,050mg EPA for 12 weeks in young and middle aged men,[433] 6,000mg of DHA for 90 days,[432] or their combination at 720mg EPA and 280mg DHA.[431] However, one trial in healthy older adults with similar doses as before (720mg EPA and 280mg DHA) has noted a suppressive effect associated with EPA (and the omega-6 fatty acid GLA) but not DHA.[448] This suppressive effect was partially reversed 4 weeks after supplement cessation.[448]
Interestingly, dietary alpha-linolenic acid (parent omega-3 fatty acid) has been reported to reduce the rate of lymphocyte proliferation at 18g a day[449] and in vitro arachidonic acid has also shown immunosuppressive effects on lymphocyte proliferation.[450][451] It is possible that overall polyunsaturated fatty acids play a role (it has been noted elsewhere that T cell suppression is abolished not by COX/LOX inhibitors (eicosanoids) but by lipid antioxidants[452]), although this does not explain the lack of efficacy of DHA in the same study that noted EPA was immunosuppressive.[448]
There is mixed evidence as to whether this immunosuppression is a concern in otherwise healthy humans. It is possible that the interaction with fish oil and T lymphocytes is related more to total membrane PUFA than it is to the omega 3:6 ratio but it is not certain
Fish oil EPA and DHA are both polyunsaturated fatty acids, and each unsaturated bond (double bond) can possibly be oxidized; this would convert the lipid itself into an oxidant capable of producting other oxidants[453][454][455] and is a phenomena common to any unsaturated fatty acid including arachidonic acid.[456] Although this is sometimes required for bioactivity (first stage in eicosanoid production from DHA requires a free radical), it is desirable to avoid fish oil oxidation ex vivo (prior to supplementation) and is a reason why Vitamin E (reference lipid antioxidant) is almost always included alongside fish oil products (with somewhat lacklustre results, actually[457]).
Lipid peroxidation can be measured in the blood by either TBARS,[458] Malondialdehyde (MDA),[459] 4-hydroxy-2-nonenal,[460] or oxidative metabolites of eicosanoids (notable 8-iso-PGF2α);[461] sometimes serum Vitamin E is also measured, and a decline is thought to be due to being sacrified to prevent lipid peroxidation. Of these measurements, MDA and 4-hydroxy-2-nonenal may be more reliable as 8-iso-PGF2α has been noted to be decreased in the urine following fish oil consumption[462][463][464] (indicative of antioxidant effects) and fatty acids such as Conjugated Linoleic Acid (CLA) have been noted to interact with 8-iso-PGF2α indepedent of oxidation before.
Technically speaking, polyunsaturated fatty acids can be oxidized to form lipid peroxides and then can produce a variety of intermediates (4-hydroxy-2-nonenal and malonyldialdehyde for example) that are pro-oxidative
8g of fish oil (1,600mg EPA+DHA) that has already been oxidized prior to consumption in otherwise healthy subjects for 7 weeks has failed to show evidence for lipid peroxidation (Vitamin E, isoprostane, and hydroxy-nonenal measurements)[465] and makes note of other studies using nonoxidized fish oil failing to find an increase of urinary isoprostane or serum biomarkers (MDA) following fish oil consumption[466][462][467] which seems to be the consensus.[468]
When selectively looking at evidence that does support a change, the direction is mixed; some studies have reported increases in 4-hydroxy-2-nonenal following DHA consumption in humans[469] and the combination of fish oil and exercise (although quelled with Vitamin E)[470][471][472] and may increase lipid peroxidation in animals via TBARS.[473]
Despite the theory, there is currently weak evidence to support an increase in lipid peroxidation following fish oil consumption (even oxidized prior to ingestion) and ample evidence to suggest such an increase does not occur in otherwise healthy adults
DNA damage can easily be induced by oxidative stress and lipid peroxides are capable of damaging DNA,[474] and is a mechanism by which oxidation and cancer risk are linked (with inducing damage to DNA being negative).[475]
Studies in research animals that measure DNA damage note less damage with fish oil supplementation relative to safflower oil as reference[476][477] (assessed by urinary 8-oxo-7,8-dihydroguanine[478]) and fail to find induced damage with intakes up to 3,305 and 3,679mg/kg isolated DHA in otherwise healthy rats (male and female respectively; human equivlance of 529mg/kg and 588mg/kg)[479] although DHA has been noted to increase DNA damage in older rats at 300mg/kg.[480] One study that confirmed an increase in urinary 8-oxo-7,8-dihydroguanine with a normalized omega-3:6 ratio (relative to high omega-6) also noted enhanced DNA repair enzymes[481]
Human evidence suggests (epidemiology) that higher serum omega-3 fatty acids are associated with higher rates of DNA damage relative to higher omega-6 fatty acids[482] but interventions have found no significant influence on DNA fragmentation during a marathon race,[483] and during pregnancy.[484]
It is theoretically possible that high doses of fish oil (lowest dose noted being 300mg/kg in rats or 48mg/kg DHA in humans) in a susceptable population such as older subjects can enhance the rates of DNA damage, but it is unsure how relevant this is to supplementation due to enhanced DNA repair also being noted. Based on human evidence, fish oil causing DNA damage does not appear to be a concern
In regards to human studies that measure antioxidant enzymes (notably glutathione peroxidase, catalase, and superoxide dismutase) there do not appear to be significant changes in either a protective nor harmful manner[465][485][486] although limited evidence suggest a small (likely not clinically relevant) increase in glutathione in overweight women.[487] An increase has been noted in rodent studies when investigating populations that normally have suppressed glutathione (the increase thought to be secondary to preservation of glutathione[488][489]) but human evidence does not yet replicate this.
Although increases in antioxidant enzymes have been noted sporadically, there is likely no significant effect of fish oil supplementation on the most commonly measured ones
Studies that have failed to find a significant influence of fish oil consumption on VO2 max include 3,000mg fish oil (1,300mg EPA; 300mg DHA) for 6 weeks.[389]
In response to exercise in trained men, high dose fish oil (2224mg EPA and 2208mg DHA) for 6 weeks was able to reduce inflammatory cytokines (CRP and TNF-α) at rest but failed to alter the exercise-induced changes in immune parameters.[395]
Natural Killer cells appear to have enhanced cytotoxicity for 2 hours after exercise (afterwards they return to baseline)[490][491] and 3,000mg of fish oil (1,300mg EPA and 300mg DHA) daily for 6 weeks in otherwise healthy men is able to augment the exercise-induced increase in NK cell activity alongside an increase in IL-2 (no changes in IL-4, IL-6, cortisol, or IFN-γ).[389] This is somewhat different than other anti-inflammatories, as indomethacin has been noted to abolish NK cell activity from exercise[491] and is thought to be due to increasing NK cell count rather than individual activity (as no evidence for increased activity was noted when cellular concentration was controlled for).[389] Possible explanations for this include an increase in IL-2 (noted[389] and known to stimulate NK cell activity[435]) and a reduction in PGE(2) concentrations, which would be attenuating a negative regulator of NK cell activity.[434]
Preliminary evidence suggests that fish oil can augment the NK cytotoxic response to exercise, but due to the variability seen with natural killer cells in general it is not known how reliable this information is
Note: Any intervention for increasing fish oil consumption during pregnancy needs to be met with a concomitant avoidance of mercury, as infants appear to be at high risk of cognitive impairment from excessive mercury consumption (relative to adults). Advice for mercury avoidance can be found in the first section of this article
It is thought that supplemental fish oil can benefit the mothers due to the fetus sequestering EPA and DHA for development, which is thought to underlie the reduction in plasma EPA and DHA seen in pregnant women.[492]
One study in pregnant women who also had major depressive disorder found that 2,200mg EPA and 1,800mg DHA was able to reduce depressive symptoms during the perinatal period and postpartum[169] although to counter this intervention is a fairly large amount of trials using a range of EPA or DHA supplementation reporting null effects.[493][494][165][166][167][168] It is possible that fish oil merely acts in pregnant women the same as in all depressed persons (EPA being more anti-depressive in persons with worse depression) and that perinatal and postpartum related depression that is not to the magnitude seen in major depressive disorder is unaffected.
Fish oil, particularly EPA, does not appear to have any special effects in regards to depression associated with the perinatal and postpartum period. EPA is antidepressive in the most depressed cohorts, and this has been noted in pregnant women who also had major depressive disorder; many trials with depression of a lesser magntiude have reported a failure of fish oils to benefit depression
Gestational diabetes is a transient state of diabetes occurring in 3-8% of pregnancies[495] with mixed survey evidence as to whether dietary fat from fish is associated with gestational diabetes risk.[496][497][498]
800mg DHA daily in pregnant women has failed to significantly alter risk for gestational diabetes.[499]
Does not appear to significantly reduce the risk for gestational diabetes
Pre-eclampsia is a pregnancy complication associated with vasoconstriction and endothelial damage, and its pathology appears to involve prostaglandins.[500][501] One meta-analysis[502] has claimed insufficient evidence to support an effect of fish oil (using mostly underpowered studies) and a more robust trial of 2399 women has failed to find a protective effect with 800mg DHA supplementation (1.5g omega-3).[499]
Insufficient evidence to support a role for fish oil in reducing the risk of pre-eclampsia
There may be less death in infants associated with maternal DHA consumption, with one study noting that while control experienced 12 and 5 neonatal deaths and convulsions (respectively) 800mg DHA reduced this to 3 and 0.[499] This trial stated that further research is needed.
Infant weight has been noted to be increased with supplemental fish oil to a moderate degree (47g, 95% CI of 1-93g) and a slightly increased time to birth (2.55 days; 95% CI of 1.03-4.07 days), but despite the increased time to birth this analysis only found a protective effect against premature birth when measuring before 34 weeks (no effect at 37 weeks).[502] This increased time until birth resulting in greater infant weight has been noted elsewhere with 2,700mg fish oil.[503]
May reduce the risk of birth complications and the risk of premature birth (relative to not consuming any omega-3 fatty acids), with a moderate amount of evidence to support increased birth weights and prolonged time to birth but very preliminary evidence to suggest less neonate deaths
Consumption of omega-3 fatty acids (or any polyunsatuated fatty acid) is known to cross the placental barrier[504][505] via FATP transporters (particularly FATP4)[506] to regulate nervous system development.[507] Unlike adults, the fetus in not capable of inherently synthesizing sufficient omega-3 fatty acids and thus parental provision is mandatory[507] and supplemental DHA has been confirmed (in primeapes) to be approximately 8-22 times more effective at increasing neural DHA stores in offspring than the parent omega-3 fatty acid (ALA).[508] It should be noted that arachidonic acid (omega-6 counterpart to EPA) is also vital for cognitive development, but seems to be less responsive to the diet suggestive of better regulation.[509]
DHA plays a critical role in neural development of the fetus during pregnancy, and the fetus is dependent on parental provision of DHA (either through supplementation or the diet). It is for these reasons that supplemental fish oils are thought to increase cognitive development in unborn children, and it is unsure if the omega3:6 ratio plays any role here as arachidonic acid is also critical (rather than being negative like some other goals)
One review and meta-analysis (11 trials reviewed with a sample of 5272; 7 in meta-analysis) has been conducted assessing cognitive and visual performance of offspring of mothers who consumed omega-3 fatty acids during pregnancy[510] assessing the following trials[511][512][513][514][515][494][516][517][518] (two not found online) noted that no significant effect of fish oil on cognitive capacity could be reliably determined while the one statistically significant benefit on Developmental Standard Scores (3.92; 95% CI of 0.77-7.08) had a high risk for bias.[510] The bias mentioned in the review to be of most concern were high attrition rates (27–86%) and unclear and haphazardous randomization while publication bias could not be ruled out due to some studies not being fully published (but similar null results being reported in the abstracts).[510]
The evidence currently assessing how maternal fish oil supplementation affects offspring cognitive development is somewhat subpar, and although a benefit to cognition cannot be ruled out at this time the evidence does not support such a result
Dietary DHA intake is critical during the first three months of life, where it correlates greatly with neural DHA levels (as assessed by autopsy reports)[519][509][520] and due to this importance it is a mandatory additive to baby formulation[509] and provision to preterm infants highly recommended.[521] DHA is also a component of breast milk (and thus provided during breast feeding)[522] of which the concentration of DHA in breast milk is correlated with the mother's diet.[523][524][525]
Supplemental ALA (from flaxseed or plant sources of omega-3) is ineffective in raising breast milk concentrations of DHA, despite an increase in breast milk concentrations of ALA.[526]
DHA is somewhat critical for infants to consume during the first few months of life to support cognition. It is normally occurring in breast milk, and is a mandatory additive to any infant-based dietary formulation due to this importance
Maternal intake of salmon (3.45g of fish oil per week) during the 20 weeks of pregnancy prior to birth is sufficient to increase breast milk concentrations of EPA (80%) and DHA (90%) when the mothers normally did not consume fish.[527] Increase in breast milk have been noted with supplementation as well during both pregnancy[528][529] and during lactation exclusively[530] or both;[531] with some manner of dose-dependence being noted and highest levels being reached after 2 weeks supplementation.[530][531][528][529] Daily intake does not appear required, as supplementing fish oil (or consuming fish) repeatedly and then ceasing for 2-4 weeks does not normalize breast milk concentrations of EPA/DHA although a decline does appear present.[527][532][533][534]
One study (salmon twice weekly, giving 3.45g fish oil) has noted a reduction in breast milk IgA concentrations.[527]
Breast milk DHA concentration reflects dietary DHA concentration, and both fish intake and supplementation can elevate levels of breast milk DHA. Supplementation does not appear to be required as up to 90% increases have been detected with 3.45g fish oils per week (via salmon consumption), and daily ingestion of fish oil supplements or fish products does not appear to be required
Omega-3 fatty acids, particularly DHA, are known to be highly involved as modulators of retinal capillary integrity, neovascularization and inflammation[535] related to their protectins and resolvins.[88]
DHA has been noted to be decreased in the retina of diabetic rodents[536][537] (as well as plasma of humans[538]), and dietary provision of fish oil (5% of diet totalling 10.26% DHA and 14.16% EPA) is able to abolish the increase in angiogenesis and grealty attenuate inflammatory biomarkers in type II diabetic rats (relative to soybean oil)[539] as well as type I.[540] This protection actually seems to extend beyond diabetes (being noted in a mouse model of retinopathy of prematurity at 2% of the diet[541]) and seems to be related to increased eicosanoids (Neuroprotectin D1 and Resolvin E1/D1 being detected[541]) and a normalized omega3:6 ratio, as the Fat-1 mouse line (genetically altered to normalize the ratio) appears to have reduced risk of angiopathy.[542]
The increase of acid sphingomyelin (ASM) is also fully normalized relative to omega-6 (soybean) controls[539][540] and is thought to be involved in the pathology of retinal angiogenesis.[539]
Omega-3 fatty acids, specifically DHA and normalizing the omega 3:6 ratio, appear to be very protective against the development of retinal angiogenesis. This protection, in rodents, is near an absolute level with a reasonable intake of dietary fish oil and thus supplemental fish oil is likely to confer benefits to humans who supplement it
Eicosanoids derived from arachidonic acid (AA) appear to be involved in the destruction of pancreatic β-cell (insulin producing cells of the pancreas[543][544]) population,[545] with the PGE2 produced from COX enzymatic activity being most relevant[544][546][547] and related to COX2 specifically.[548][549] COX2 is overexpressed in pancreatic β-cell due to transcription factor NF-IL6,[549] and its increased activity by the cytokine IL-1β appears to link overall inflammation and PGE2.[550]
When PGE2 is elevated in a pancreatic cell, insulin secretion is suppressed[547][551] and proliferation of β-cells are suppressed.[552]
12-HETE (catabolite of arachidonic acid) is detected in pancreatic cells[553] and appears to also contribute to β-cell toxicity via NADPH oxidase-1 dependent mechanisms following conversion by 12-LOX (also expressed in pancreatic cells[553])[554] yet does not suppress insulin secretion[555] like similar structures (5-HPETE[556] and both LTB4 and 15-HETE[555]); although dietary inclusion of omega-3 fatty acids can reduce the arachidonic acid metabolite LTB4,[423][401][424] results in humans investigating 5-HETE suggest no suppression.[423]
There is limited evidence to draw connections between the above mechanisms and supplemental fish oil. One study in Fat-1 mice (with a normalized omega3:6 ratio) noted more protection against inflammation induced cell death[557] and seem to be resistant to the pancreatic toxin streptozotocin.[558]
Eicosanoid products of arachidonic acid are stimulated by inflammatory stressors (such as IL-1β) and then mediate pancreatic cell destruction and hinder insulin secretion, as they are negative regulators of pancreatic β-cell function. Although there is no human evidence to suggest a link between fish oil consumption and improved pancreatic cell functioning, it appears to be plausible and noted in some mouse models
Fish oil supplementation beneficially effects kidney function in those with diabetes (and at risk for diabetic nephropathy) at 4g daily,[559] whereas animal models with higher doses show more dramatic protection.[560] The mechanism may be through reducing pro-inflammatory cytokines in the kidney and through eicosanoid production.[561][562] There isn't the largest body of literature on this function exclusively, and at least one recent review suggests that a final conclusion on fish oil's effects on renal function is preliminary.[563]
There have been correlations established between dietary PUFA (Polyunsaturated fat) intake of omega3s and prevention of renal disease, suggesting a preventative role may also exist.[319]
There may be a protective role for omega-3 supplementation and the development of renal pathology associated with diabetes
High intake of dietary fish products are associated with reduced risk of skin cancer[564][565] (while higher omega-6 intake is associated with increased risk[566]) which is thought to be related to reduced sunlight-induced immunosuppression (noted in rats[567] and humans with 4,000mg EPA+DHA[568]) resulting in reduced tumor multiplicity and increased tumor latency.[569][570][571]
The mechanisms are thought to be related to membrane fatty acid content (and due to that, eicosanoid and prostaglandin signalling) as EPA is known to compete with arachidonic acid in the membrane[572] and higher dietary intakes of omega-6 in research animals augment solar radiation induced skin carcinogenesis secondary to immunosuppression.[567][573][569]
Fish oil appears to have protective mechanisms against skin cancer development, and the omega-3 to omega-6 fatty acid ratio in skin membranes appears to be important for this goal. The links between fish oil and skin cancer development are related to immunity, with higher fish oil intakes appearing to reduce immunosuppression induced by sunlight
In pancreatic cancer cells, both EPA and DHA induce apoptosis (not inhibited by COX inhibitors) via inducing reactive oxygen species and subsequent autophagy at a concentration of 10mM, which was abolished (in vitro) with the addition of Vitamin E; when mice are injected with pancreatic tumors (MIA-PaCa-2 cell line) and fed 5% of the diet as fish oil, it appears that fish oil was associated with a reduction of tumor volume to approximatley a third of control.[574]
Lupus erythematosus (Lupus) is a disease state characterized by arthritis, vasculitis, rash, and the involvement of the central nervous system that appears to be associated with reduced omega-3 (EPA and ALA) and GLA content in lipid membranes.[452] Fish oil is investigated for treatment of lupus as the first pilot study in humans noted full remission from symptoms associated with mixed EPA/DHA supplementation for 8 months or more (162mg EPA and 144mg DHA).[452]
Other studies note that 3g of omega-3 fatty acids from fish oil[575] or EPA in isolation[576] in patients with lupus (for up to 24 weeks of supplementation) appears to reduce general symptoms as assessed by the rating scales of SLAM-R (33-34% reduction[576][575]), BILAG (51% reduction[575]), and may benefit blood flow as assessed by flow-mediated vasodilation[575] and has mixed effects (55% of patients) on treating dyslipoproteinemia.[577] In rats, the progression of nephtritis is attenuated with fish oil supplementation which promotes lifespan[578][579] and this effect has been noted in humans (15g for 1 year) to a much lesser degree, where proteinuria is reduced nonsignificantly and glomerular filtration rate is unaffected.[580]
There is some counter evidence, with at least one study noting that the benefits observed at 3 months was no longer present at 6 months (200mg/kg bodyweight at 18.6% EPA and 12.1% DHA)[581] and benefit has been noted with superloading elsewhere (20g daily for 12 weeks; study did not proceed towards the 6 month timeframe).[582] Interestingly, the lone other study to use a prolonged high dose intervention (15g daily for 1 year) also noted lacklustre results in renal symptoms of lupus.[580]
Fish oil supplementation appears to have a role in controlling the symptoms associated with lupus, but there is suspicion to believe that long term dosing of high levels of fish oil eventually abrogates the benefit and that lower doses (the standard 180mg EPA and 120mg DHA dosage) may be more beneficial
As GLA/DGLA appear to be associated with symptoms of lupus as well (and these are an omega-6 fatty acid class), it is plausible that the ratio in lipid membranes is important and that high doses skews the ratio too severely in favor of omega-3
Dietary intake of EPA is known to increase skin levels of EPA following ingestion of 10g fish oil (1,800mg EPA and 1,200mg DHA[583]), 4g fish oil (95% EPA ethyl esters)[584] and 10g fish oil (1,800mg EPA and 1,200mg DHA).[583]
Solar radiation is known to transiently suppress the immune system[585] in a dose-depedent manner[586][587] and persons with contact dermatitis (a topical allergic reaction) can be used as research models to assess photoimmunosuppression.[588] Using this model, 5g fish oil (3,500mg EPA and 500mg DHA) has been demonstrated to reduce photoimmunosuppression by 6.9-11%.[568]
Sunlight induced erythema (reddenning) appears to be reduced following supplement ingestion for 3 months or so, with the time of exposure required to induce erythema increaasing 37-117%.[584][583] A reduced sensitivity to sunburns has also been reported.[584]
Appears to protect the skin against sunlight, with benefit seen on both sunlight induced immunosuppression as well as sunlight-induced reddening (erythema). A reduced risk of burns has been reported to be associated with fish oil consumption, and these mechanisms appear to be sensitive to the omega3:6 ratio
There are mixed reports on how oxidation is influenced in the skin following fish oil consumption, with one reporting no alterations in DNA damage per se but reduced sunlight-induced DNA damage[584] while elsewhere lipid peroxidation (TBARS) has been noted to be increased in skin tissue.[583]
It is possible that fish oil supplementation can increase lipid peroxidation in the skin, but this has not yet been linked to adverse toxicological effects such as DNA damage (which are, surprisingly, reduced following exposure to sunlight and fish oil relative to sunligt alone)
Fish oil was first thought to reduce pressure ulcers in critically ill persons in a study that was confounded with GLA and antioxidants[589] where the benefit was thought to be due to improved blood flow noted with this combination therapy[590] or changes in immunity;[591] fish oil in isolation has been noted to confer these properties by reducing pressure ulcer formation by 20-25%[592] although this study has been criticized for its lack of data.[593]
Theoretically possible that fish oil supplementation can reduce pressure ulcer formation in the critically ill, but this is not established by a large amount of robust evidence. This topic is preliminary
There is a surprisingly lack of literature investigating the link between fish oil and hair, despite the knowledge that prostaglandins are involved in hair growth regulation.[594] The machinery appears to be present, as phospholipase A2 has been detected in hair follicles on the outermost epithelium[595] and receptors for PGE(2) (EP3 and EP4) have been detected on the dermal papillae.[596][597] Drugs that act like PGE2 and PGE2α (Viprostol and Latanoprost) have been noted to induce hair growth[598][599] associated with promotion of hair follicles to anagen phase[600] while COX2 overexpression induces hair loss (restored with COX2 inhibitors[601][602]); both overexpressing and abolishing phospholipase A2 activity reduces hair growth.[595]
Both PGE2 and PGE2α have been found to be produced locally in hair cells[594] and theoretically can induce hair growth via their receptors (EP3 and EP4), although all prostaglandin receptors appear to be expressed in various areas of the hair follicle.[603]
There is furthermore a plausible link between prostaglandin receptors and androgen metabolism, via the receptors that respond to both classes of molecules (AKR1C1 to a lesser degree, and both CBR1 and AKR1C3[604] are expressed in hair follicles[594]); PGE(2) may not increase testosterone per se, however.[605] Additionally, the enzyme known as prostaglandin D2 synthase (which converts Arachidonic acid metabolite PGH2 to PGD2) is known to be induced by androgenic signalling[606][607] and the higher PGD2 is correlated with and has a causative role in suppressing hair growth in man;[608] EPA has been noted to suppress PGD2 in mast cells (immune cells) by competing with arachidonic acid at the COX enzymes[609] and has been noted to suppress PGD2 elsewhere in macrophages.[610]
PGE(2) production from eicosanoids appears to be a positive modulator of hair growth while inflammation appears to negatively influence hair growth via prostaglandins (and COX2), but the connection of this information to supplemental fish oil is not known (if anything, this information favors arachidonic acid supplementation).
Supplemental polyunsaturated fats to dogs (9.3g linoleic acid with either 3.3g or 0.42g of ALA per 1000kcal) has been noted to increase hair softness and glossiness but also greasiness and scaliness, which was thought to be associated with increased cholesterol esters found in hair cells.[611] This has been noted elsewhere, again in dogs.[612]
At least in dogs polyunsaturated fatty acids can interact with hair but a few problems exist when applying these studies to fish oil ingestion (ie. they used other sources of polyunsaturated fats and some omega-6) and did not explicitly measure hair growth, only glossiness.
There is not enough evidence to suggest how fish oil supplementation interacts with hair
In cellular membranes phosphatide subunits bind to fatty acids, uridine, choline, and some other molecules such as amino acids to form the components of the membrane.[613] Uridine is important in the body as it confers a pool of substrate[198][614] to make the molecule Cytidine-5'-triphosphate, the availability of which is the rate-limiting step[615] in transfering a Cytidine monophosphate from Cytidine-5'-triphosphate to phosphocholine, which would result in the production of CDP-choline. As CDP-choline highly interacts with DHA to form Phosphatidylcholine phospholipids in membranes,[616] supplemental Uridine (via CDP-choline) is thought to be synergistic.
Uridine provision is the rate limiting step in the body producing phosphatidylcholine (via CDP-choline) associated with DHA fatty acids, and provision of uridine accelerates production
Ingestion of choline, uridine, and DHA (constituents of phosphatidylcholine synthesis) in rats appears to increased brain membrane concentrations of phosphatidylcholine by 50% or more[241] and appears to be synergistic as any agent alone increased phosphatidylcholine by 13-22% in this study where combination of all increased PC concentration by 45%.[617] This positive influence on brain phospholipids also applies to other phosphatamides such as phosphatidylethanolamine, phosphatidylinositol, and Phosphatidylserine[617][242] and while DHA is less effective than combination therapy uridine in isolation tends to be inactive which rules out mere additive effects.[242]
Uridine and DHA appear to be synergistic in increasing phospholipid concentrations in the brain of research animals (Uridine augments DHA's ability to increase it seems). There may be further synergism with provision of choline (this suggests potency between Krill Oil, which is DHA complexed to Phosphatidylcholine, and Uridine supplementation)
Combination therapy with DHA (300mg/kg) and Uridine as 5’-monophosphate (0.5%) has been found to increase dendritic spine density (36%) in the adult gerbil hippocampus over 4 weeks; combination therapy appeared to be more effective than DHA alone (18%) and since uridine was inactive in isolation it appeared to be synergistic.[242] There was no influence on spine size, only density.[242]
Uridine has been implicated in augmenting dendritic spine density in the hippocampus induced by DHA provision, which is thought to underlie possible synergism in memory enhancement
Linoleic acid (LA) is the parent omega-6 fatty acid, which is bioconverted into arachidonic acid in the body and tends to antagonize the effects of fish oil supplementation.
One study that measured the triglyceride lowering effects of fish oil noted that while fish oil (3.1g daily) reduced triglycerides by 51% when paired with a low LA food product, but by increasing linoleic acid by 7.3g per day with a high LA food product the reduction in triglycerides was attenuated to 19%.[618] This possibly extends to food consumption as well, with fish having a higher omega 6:3 ratio having less benefits to artherogenesis (plaque in arteries) than do a similar amount of omega-3 with less omega-6.[619]
The effects of fish oil on immune cells may not be affected by linoleic acid consumption.[620]
The parent omega-6 fatty acid may antagonize the triglyceride lowering effects of fish oil even when supplemented or eaten acutely (more pronounced if daily), and if using fish oil for that purpose then coingesting the two would not be advisable
Astaxanthin is a carotenoid that serves as a lipid antioxidant, and is thought to in part contribute to the health benefits of consuming red fish (salmon) or Krill Oil.
A decrease in proliferative capacity of lymphocytes has been noted with fish oil (17mg/kg bodyweight) paired with astaxanthin (1mg/kg) which is thought to be either additive or synergistic since no reduction was seen with either agent alone;[621] said reductions have indeed been noted with astaxanthin (5µM[622]) and with PUFAs elsewhere,[623] but in higher concentrations/dosages.
Curcumin is the main bioactive of the curcuminoids derived from some spices (usually Turmeric but with a small content in Ginger).
The combination of DHA and Curcmin in isolated breast cancer cells (MDA-MB-231, MCF-7, and three others) appears to be synergistically antiproliferative, where although 30μM of either compound in isolation failed to act the combination (18μM DHA and 12μM curcumin) suppressed proliferation.[624] There was less genomic activity with the combination than with isolated curcumin, and proteins that were unaffected by either compound in isolation but affected by the combination include CXCR4 (suppressed), aromatase (induced), SERPINB5 (suppressed), PPARγ, and p53 phosphorylation.[624]
Fish oil and curcumin appear to be synergistic in suppressing breast cancer cell proliferation, which is associated with inducing some proteins not seen with either isolated compound
There may be synergistic anti-inflammatory effects in macrophages with curcumin and both fish oil fatty acids as assessed by LPS-induced PGE(2) production[625] and in a rat model of colitis (inflammatory bowel disorder) curcumin and fish oil have been noted to be synergistic.[626]
Possible synergistic anti-inflammatory effects
Brain derived neurotrophic factor (BDNF) is a protein that positively regulates synaptic growth and neuronal growth[627] and due to its positive influence on long term potentiation and synaptic growth[628] it is thought to be a molecular target of cognitive enhancement.
DHA is known to support neuronal membrane fluidity[629] and increase BDNF concentrations[630] and DHA (1.25% of diet) has been noted to augment the BDNF-induced learning that occurs from exercise in rats.[630] Due to the synergism present with DHA and exercise and the ability of curcumin to also support BDNF levels[631] it has been hypothesized that they are synergistic.[632]
Theoretically synergistic on increasing BDNF and thus learning, but this has not yet been demonstrated
The carotenoid from seaweed, Fucoxanthin, has been found to be slightly synergistic with fish oil for attenuating weight gain in obese and diabetic mice.[633] The addition of fish oil at 6.9% of the diet (quite a high dose) was found to make 0.1% dietary fucoxanthin as effective at suppressing fat gain as double the dose.[633]
The two may be synergistic for their anti-obesity effects, but minimal evidence for the combination
Interestingly, fucoxanthin can increase liver levels of DHA independent of fish oil consumption.[49]
When a Fenugreek oil (formulated with 15% fish oil by weight) was given to diabetic rats at 5% of food intake, it resulted in a 51% decrease in blood glucose levels after a meal due to decrease the activity of carbohydrate digesting enzymes in the pancreas (46% reduction in α-amylase, 37% reduction in maltase) and plasma (52% α-amylase, 35% maltase).[634] The combination 5% group was slightly more potent than the 5% Fenugreek group and much more than the 5% fish oil group.
A protective effect on pancreatic beta-cells was also noted with this combination[634] as well as decreases in triglycerides attributed to the fish oil component. Said infusion also normalized the increase in ACE that diabetic rats experience.[634]
Taurine is a sulfur-containing amino acid which is seen as anti-diabetic, it was investigated alongside Fish Oil fatty acids due to both being present in high amounts in seafood. The expected increases in body fat seen in diabetic mice subject to both taurine (at 4% of the diet) and fish oil was lesser with the combination than either nutrient alone, and the levels of insulin and glucose were lower with the combination than either molecule in isolation.[635]
Possibly additive benefits
Among statin-treated patients, a more normalized ratio is still associated with slower rates of atheroma progression when compared to a high omega-6 ratio[636] and intervening to reduce the ratio via delivering dietary omega-3 fatty acids reduces cardiometabolic risk factors.[637] Due to the benefit of a normalized ratio even in statin patients and the high level of safety seen with fish oil during statin therapy,[638] they are thought to be worthy combinations.
Several studies have suggested that the combination of a statin drug (usually simvastatin) and omega-3 fatty acids (2-4g EPA+DHA) is complementary on improving HDL-C while it can reduce triglycerides (inherent property of fish oil) and appears to synergistically reduce LDL-C (which is notable, as fish oil alone may increase LDL-C).[271][299][639][638] Potential synergism or additive benefit has also been noted in regards to vascular function in diabetics[640] and this synergism appears to apply to lovastatin (via its nutraceutical form of Red Yeast Rice[641]).
The synergism between omega-3 fatty acids and statin drugs appeared to be similar in result to but either outperformed[642][643] or similar in potency[644] to a statin and fibrate combination therapy (rosuvastatin and fenofibrate).
Fish oil supplementation appears to be synergistic with statin drugs on improving cardiometabolic parameters, as they inherently lower triglycerides (something statins do not normally do) and appear to augment the LDL-C reduction of statin drugs (fish oil alone may slightly raise LDL-C). It is not sure if this synergism has a role, however, in persons on both statins and fibrates already as fibrates may already be doing the role of omega-3 fatty acids except better
For the possible safety implications of lipid peroxidation from polyunsaturated fatty acids, please refer to the lipid peroxidation subsection of 'Interactions with Oxidation'
Although there are numerous toxins associated with fish consumption, mercury is the one at the forefront of concern due to its correlation with omega-3 intake in fish[645][1] and its adverse effects on child cognition when consumed by pregnant mothers, as mercury can pass the placental barrier[646] and reach the child; as assessed by umbilical cord exposure.[647] Other toxins do not have as strong a correlation in children, such as PCBs and Dioxins[648] and although a concern, are less of a concern relative to mercury.
Additionally, mercury just has an adverse pharmacokinetic profile. When fish is cooked, the methylmercury binds to meat proteins[649] and 95% of ingested mercury is absorbed within 2 days[650] where it persists in the body for 70-90 days.[651]
In some epidemiological research, high consumption of mercury is related to heart disease risk, mostly with whale meat[652] but related to the mercury intake itself.[653][654] The omega3s offer a protective effect though, and avoiding the highest sources of mercury reduces a lot of risk on cardiovascular disease.[655][656] Only the highest sources of mercury (shark and whale) seem to cause enough of an effect for significance to arise in this epidemiological research, although the effect of mercury per se may be dose dependent.
In food, one recent review noted that the safest fish in terms of "High omega3, low Mercury" were salmon, trout and shrimp.[654] They examined those three, as well as other common fish (cod, halibut, shark, three forms of tuna, mackeral, seabass, snapper, tilapia and swordfish) for mercury content. Their results were:
They[654] also averaged the omega-3 content of said species by doing a literature review of a few studies[657][658][659][660][661], their averages were:
In supplements, fish oil capsules and cod liver oil seem to be relatively low in mercury. Although products will vary in concentrations (depending on the fish used), one study noted a range of 0.013ng/g-2.03ng/g Mercury and no detectable methylmercury in capsules and 0.233ng/g in cod liver oil.[10] A study conducted in the US looking at three (unnamed) brands noted values of 9.89ng/g, 38.8ng/g, and 123ng/g in one salmon oil product.[662]
A letter to the Editors in which independent testing was done[663] mentioned that many popular fish oil products sold in North America have below 0.1mcg/g; TwinLab, Kyolic, Nature's Way, Natrol, Health from the Sun, and Nordic were cited in this letter.[663]
Organochlorines and PCBs are at a minute level in supplementation, below the detection limit of many studies looking at them.[664] Some studies do note detection, however, and tend to be by far highest in predatory oils like shark oil (usually supplemented for the Squalene content).[9]
Stick to supplements made from Cod, Sardines or Mackeral (non-predatory cold water fish). There seems to be a lot of variance on mercury levels in supplements, and the only leads at the moment is that reputable (popular) companies seem to uphold their promises for independent testing (as shown by the letter to the editor). Krill Oil is also an option if you want to low-ball the dose to avoid mercury contamination.
Food-wise; Salmon (Farm-raised is a bit better than canned), Mackeral, Cod, Trout and Shrimp are probably the best fish to consume to get the most omega-3 fatty acids with the least amount of mercury and other contaminants.
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