Fish Oil

Uses and Choosing the Best Product

There is much to know about fish oil. Why should I take it and what is the correct dose? What should I look for when purchasing a product? How do I know it is safe? Let's start from the beginning.

Why take fish oil?
Long-chain polyunsaturated fatty acids are an essential part of our diet. Marine vertebrates are the main source of omega-3 fatty acids which contains EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid). EPA and DHA are eicosanoids (signaling molecules) that are known to decrease inflammation throughout the body and have overall health benefits due to their involvement in many bodily processes. Inflammation is a well-researched cause of many types of illness, thus reducing it can be one of the best methods of preventing disease (1).

Heart disease has been the most well researched area for use of fish oil. Studies have shown that fish oil can reduce risk of arrhythmias, decrease triglycerides, lower blood pressure and slow growth rate of atherosclerotic plaques (2).

Joint health is affected by inflammation thus fish oil has been found to be beneficial in reducing pro-inflammatory elements in white blood cells and improving pain from rheumatoid arthritis (3) and osteoarthritis (4).

Skin conditions including psoriasis, acne, eczema, dermatitis all are improved with use of essential fatty acids. Often the body is deficient in these important skin nutrients and once increased in the diet along with other dietary adjustments can resolve or greatly improve the condition. Hallmark signs of deficiency include dry, scaly, itchy skin (5).

Mental health is one of the newer promising areas of study with the utilization of fish oil. Bipolar disorder and depression have both been studied and mood and mood swings have both shown improvement with use of fish oil (6,7).

Other areas that essential fatty acids support the body are immunity including allergies, eye health and fetal development.

Dosing
Dosing varies based on condition and body weight. Generally I recommend a total of EPA/DHA 1000mg-4000mg daily. This is not the Total omega-3 or total fish oil dose you see on the label. Always look to see how much EPA and DHA are in the fish oil and take enough of the liquid or capsules to ensure you get the recommended dose. (See Nordic Naturals liquid fish oil label below. The total EPA/DHA is 1375mg per 1 Teaspoon.)

Capsules or Liquid
Either are fine. The capsules will dissolve and are as available to your digestive tract as the liquid. The capsules are easier to take for some people who don't like the fishy taste or texture of the liquid. I often recommend taking your oil at night before bed if burping of fish flavor is an issue for you. You won't notice this in your sleep!

Storage
Always keep your fish oil in the refrigerator once it is opened to prevent your oil from going rancid. If the oil smells rancid do not use it as it has oxidized and you don't want to add oxidative stress to your body.

Safety
It has become clear that sourcing quality fish to make fish oil is of paramount priority. As our oceans have become more polluted with chemicals and metals, which fish then contain in their body and organs, having a high standard of choosing fish and processing the oil is necessary. Knowing the practices of the company you choose your fish oil from is the first place to start. High quality fish oil generally comes from cod liver and fish that are small such as sardines and anchovies as they are abundant in EPA and DHA and low in heavy metals. Companies that test every batch of their product assures to a greater extent that the fish oil is free of harmful chemicals and metals. Also, companies that have third-party testing outside of their own facility assures proper data for the product.

Sustainable fishing practices are also an important area with regards to production. The supply of fish in our seas is threatened due to overfishing, thus purchasing a high quality fish oil from a company that also focuses on sustainable fish harvesting supports the ongoing availability of this source of essential fatty acids.

Companies I recommend are Nordic Naturals, Vital Nutrients and Carlson's.

For more information on sustainable fishing practices and safety check the International Fish Oil Standards Program (IFOS) http://www.iffo.net/.

Side Effects
Fish oil is safe for most people including pregnant and breast-feeding women. At low doses (1-3mg) side effects are generally not noted aside from the possibility of digestive upset. At higher doses >3g blood clotting may be affected and there may be an increased risk of bleeding. Discuss taking fish oil with your doctor if you are on a blood thinning medication such as coumadin, have a clotting disorder or are having surgery.

References

1. Am J Clinical Nutr. 2008 Jun;87(6):1978S-80S.

2. http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyDietGoals/Fish-and-Omega-3-Fatty-Acids_UCM_303248_Article.jsp

3. Arthritis Rheum. 1995 Aug;38(8):1107-14.
4. Osteoarthritis and Cartilage. 2011 Sept;19(9):1150-1157.
5. Dermatoendocrinol. 2009 Sep-Oct; 1(5): 262-267.
6. Curr Opin Psychiatry. 2013 Jan;26(1):33-40.
7. Translational Psychiatry (2001)1.

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Inflammation

A Silent Cause of Chronic Disease

Inflammation seems to be a popular word in current health literature and for good reason. Evidence now supports chronic inflammation as a root cause of several of our common diseases such as cardiovascular disease, Alzheimer's, type II diabetes and cancer. The burden of inflammation on our health status has been recognized by the health industry and measures to address the underlying cause has become a topic of focus.

Low-grade chronic or systemic inflammation, unlike acute inflammation, acts as an underlying constant irritant to the body and its cells. Acute inflammation resolves as an injury heals whereas chronic inflammation resides in the tissues on a constant basis leading to dysfunction of cells and eventually organs and vessels.

There are a milieu of immune cells active in the body including macrophages and lymphocytes as well as proteins called cytokines and chemokines directing cellular inflammation(1). Other pro-inflammatory instigators include oxidized LDL, prostaglandins and NF kappa-beta.

Chronic inflammation can be triggered by cellular stress or dysfunction such as from free radicals causing oxidative stress (ie from smoking, stress or pollutants) or elevated blood sugar levels. It is now known that this chronic stress on the cells leads to a silent degeneration and loss of physiologic function.

Assessing your risk
Good markers that are inexpensive to test for inflammation risk include:

• CRP-hs 
• Fibrinogen 

Cytokine testing can also be done which is more expensive but provides information on specific factors causing systemic inflammation.

• Tumor necrosis factor alpha 
• Interleukin-1 beta 
• Interleukin-6 
• Interleukin-8 

Additionally, testing glucose, lipid panel and homocysteine will add additional information.

Preventing and managing inflammation

Diet

It goes without saying that a healthy diet is mandatory in order to prevent low-grade chronic inflammation in the body. An anti-inflammatory diet has been described in several ways but mainly consists of a whole foods diet, focusing on lean meats, fish, legumes, nuts, seeds, fruits, vegetables and whole grains. It is wise to avoid processed foods, cured meats, sugar, excessive alcohol, caffeine and fried foods. Additionally, an anti-inflammatory diet recommends avoiding foods that may be allergens to you as an individual such as gluten, dairy, soy, nightshades (tomatoes, potatoes, peppers etc), eggs or citrus. 

Dr. Jessica Black's: The Anti-inflammation Diet and Recipe Book is an easy to use reference book to help you get started.

http://theantiinflammationdiet.com/

Environmental toxins
The environment contains ever increasing pollutants in the air we breathe, water we drink and soil we grow our food in. Many of these harmful chemicals have been found to be endocrine disruptors and neurotoxins. There are methods to help protect yourself from these harmful chemicals. Make your home a chemical free zone. Choose household products that are chemical free, drink filtered water, choose whole, unprocessed organic or pasture-fed foods and avoid pesticides in your garden and yard.
See the CDCs Healthy House Reference Manual for more details on how to support a healthy home environment and the Multipure water filter which I recommend.
http://www.cdc.gov/nceh/publications/books/housing/housing.htm
http://www.multipure.com/

Obesity
Obesity is associated with low grade chronic inflammation which is predominately driven by adipose tissue macrophages(2). Maintaining a Body Mass Index/BMI (a calculation using weight and height to measure body fat) below 25 is a general guide to use for a healthy body weight.
Calculate your BMI here: http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html

Sleep
Alterations in sleep due to lifestyle factors, the aging process, and disease states have all been associated with increases in a range of inflammatory markers including monocytes, C-Reactive Protein, Natural killer cells (NK), and IL-6(3). Adults need 7-9 hours of sleep per night. See my article on The 4 Pillars for sleep support.

Smoking
Smoking increases inflammation as reflected by the elevation of serum inflammatory markers such as fibrinogen, white blood cells and CRP(4). Smoking is the single largest preventable cause of disease and premature death according to the World Health Organization. Data gathered on over 15,000 smokers in one study showed smoking-associated inflammatory response returned to normal within 5 years after smokers quit thus reducing health risks associated with smoking(5).
View this article for using acupuncture to support smoking cessation.
https://www.acufinder.com/Acupuncture+Information/Detail/Quit+Smoking+with+Acupuncture

Make the Change
Reducing risk factors with lifestyle modification is the best method to decrease inflammatory load in your body. In addition, supplementing with a high quality fish oil, eating or supplementing with spices such as tumeric, ginger and boswellia are a great adjunct to managing chronic inflammation. Make the necessary changes to your lifestyle to affect the inflammatory process and potentially live a longer and healthier life free of chronic illness.

References
1. Chronic inflammation and oxidative stress in human carcinogenesis. Int J of Cancer. 2007 Dec 1;121(11):2381-6.
2. Obesity, Inflammation, Insulin Resistance. A Mini Review. Gerontology 2009;55:379-386.
3. Sleep and Inflammation. Nutrition Reviews. Dec 2007;65:S244-S252.
4. Immunotoxicity, Immune Dysfunction, and Chronic Disease. Arnson et al. 2010;p198-199.
5. PLos Med 2005. June; 2(6):e198.
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Foundations of Health

The 4 Pillars 

Our health seems to have become a complicated subject. With endless information and education that's available, where do we start with applying it to maintaining wellness? From the latest research to fad health claims and internet suggestions, matters can be quite confusing as to what to do for preventative health and maintaining a healthy lifestyle. 

The foundation of our health depends on us engaging in activities that promote well being and diminish harmful effects on the body. Promotion and diminishing effects are simply two sides of one coin. When you engage in a healthy behavior it often coincides with stopping a harmful one. The basis of health really comes from 4 fundamental practices. Engaging in these 4 practices is health promoting and when we don't can be harmful to maintaining our health.

1. Proper Nutrition

2. Adequate Sleep

3. Exercise

4. Stress Management

NUTRITION

We all know we need to eat well but the definition of "well" or "eating healthy" isn't always so simple. 

You are what you eat has some merit as it so happens. With obesity on the rise as well as diabetes and heart disease, we have learned that eating a diet high in sugar, unhealthy fats, processed foods, and excess total calories leads to detrimental effects on our body. The USDA and US Department of Health and Human Services updates the Dietary Guidelines for Americans every 5 years. 

Current guidelines recommend monitoring dietary intake and replacing foods high in calories with nutrient-dense foods and beverages relatively low in calories. Specific examples of this include(1):

• Increase intake of whole grains (particularly those high in fiber), vegetables and fruits 
• Reduce intake of sugar-sweetened beverages
• Monitor intake of 100% fruit juice for children and adolescents, especially those who are overweight or obese
• Monitor calorie intake from alcoholic beverages for adults

Well researched and established diets that promote good nutrition and prevention of chronic illness are the DASH diet (Dietary Approaches to Stop Hypertension) and the Mediterranean diet. See links below for more information about these diets, recipes and a comprehensive paper on the 2010 Dietary Guidelines for Americans.

http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf

http://www.mayoclinic.com/health/mediterranean-diet/CL00011

http://www.mayoclinic.com/health/mediterranean-diet-recipes/MY02229

http://www.mayoclinic.com/health/dash-diet/HI00047

SLEEP

Inadequate sleep due to lifestyle, shift work, medications, insomnia, light pollution and other causes has become an epidemic in our society and not without consequences. In 2007 the Journal of Pediatrics reported 15 million American children are affected by inadequate sleep. It was noted that these children and adolescents experienced more problems in school, had an atopic skin condition, frequent or severe headaches and depressive symptomology(2). 

The National Sleep Foundation indicates 48% of Americans report insomnia occasionally while 22% experience insomnia every or almost every night. A lack of sleep can increase your risk of chronic disease such as diabetes, high blood pressure, heart disease and obesity. Physiologic changes that have been studied using sleep deprivation show increase in blood pressure, impaired blood glucose control and inflammation, all precursors to chronic illness(3). 

How much sleep do I need?(4)

Children ages 5-10 require 10-11 hours daily

Adolescents ages 11-17 require 8.5-9 hours daily

Adults 7-9 hours daily.

To aid in sleep consider sleep hygiene such as a very dark room, minimal noise, comfortable room temperature, and no pets in the bedroom. Building a routine around bedtime can assist in falling asleep. Go to bed at the same time each night, by 10pm is optimal, avoid stimulating activity such as work and watching certain TV shows one hour before bedtime. Avoid alcohol, caffeine, large meals and nicotine before bed. Instead try listening to calming music, taking a warm bath, reading or meditation.

EXERCISE

Some physical activity is better than none, and participating in any amount of physical activity results in gaining some health benefits. The US Department of Health and Human Services Physical Activity Guidelines for Americans recommends the following for substantial health benefits(5):

Children and Adolescents

• 1 hour or more of moderate to vigorous intensity aerobic activity with at least 3 days of vigorous activity a week.
• Included in this 1 hour should be muscle-strengthening activity at least 3 days of the week.
• Included in this 1 hour should be bone-strengtheing activity at least 3 days of the week.

Adults

• 2.5-5 hours per week of moderate-intensity to vigorous-intensity (or an equivalent combination) exercise divided throughout the week.
• Muscle-strengthening activities of moderate-high intensity involving all major muscle groups on 2 or more days a week.

STRESS MANAGEMENT

Not all stress is bad but the management of routine stress cannot be underestimated. The National Institute of Mental Health explains routine stress such as work, home life and daily responsibilities can have health risks related to cardiovascular disease, hypertension, diabetes, depression and anxiety disorders(6). When our body continues to react as if a threat is always there then a constant presence of hormones in our body exists such as elevated cortisol and adrenaline. 

Chronic elevation of these and other hormones over time is what causes the risk of the above mentioned health concerns as well can contribute to insomnia, weight gain, digestive issues and memory impairment.

Consider the following suggestions to help decrease your stress load:

• Attend a weekly yoga, tai chi or qi gong class.
• Take 100 slow deep breaths daily. See video on belly breathing. http://www.youtube.com/watch?v=H5H_Qrcmxdg
• Try to do a 5 minute meditation before you get out of bed in the morning and before you fall asleep at night. 
• Go for a 10-15 minute walk during your lunch break.
• Take a 1 minute stretching break every hour while at your computer.
• Phone a friend or family member.
• Remember to laugh everyday!

References

1. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf

2.. http://www.pediatricsdigest.mobi/content/119/Supplement_1/S29.full

3. http://www.sleepfoundation.org/article/sleep-related-problems/sleep-aids-and-insomnia

4. http://www.cdc.gov/features/dssleep/

5. http://www.health.gov/paguidelines/guidelines/default.aspx

6. http://www.nimh.nih.gov/health/publications/stress/fact-sheet-on-stress.shtml

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Primary Care Screening

                                                  

An ounce of prevention

Screening recommendations are made to assist us in assessing our risk of developing disease and identifying pathology that has arisen in our bodies. The goal is to "catch" any abnormalities in early stages or before the body develops physiologic changes into disease. For instance by monitoring a cholesterol panel we can see if levels are starting to elevate and address this with simple changes such as diet and exercise. Maintaining normal cholesterol levels and addressing changes early may prevent the development of coronary heart disease, heart attack or stroke later on. Identifying abnormalities early allows for better opportunities for most effective treatments with fewer side effects and generally better outcomes.

Screening recommendations can be confusing at times. They may vary based on gender and age as well by which association is making the recommendation. For best insight I make comparisons between some of the leading organizations including:

American Cancer Society                    
American Gastroenterological Association
American Heart Association
American Medical Association
Center for Disease Control and Prevention
National Institutes of Health/National Cancer Institute
National Osteoporosis Foundation

Primary care screening should include the following: (Variations in screening recommendations vary with a current or past history of disease. Discuss screening guidelines with your doctor.)

Breast

• Starting at age 40 yearly mammograms continuing until a woman is in good health.
• Clinical breast exam every 3 years for women 20-39 years old and annually thereafter.
• MRI in addition to mammogram may be recommended for women at higher risk due to genetic alterations, family history or other factor. Discuss this with your doctor.

Cervical

• Women ages 21-29 should have a pap every 3 years. HPV test should be added if there is an abnormal pap.
• Women ages 30-65 should have a pap test plus an HPV test every 5 years. A pap alone can also be done every 3 years.
• Women over age 65 who have had regular cervical cancer testing with normal results should not be tested for cervical cancer. Women with a history of serious cervical pre-cancer should continue to be tested for at least 20 years after that diagnosis, even if testing continues past 65.

Endometrium 

• By age 35, if high risk, a woman should be offered an endometrial biopsy.
• Each year a woman should be informed about the risks and symptoms of endometrial cancer, and about the potential benefits, risks, and limitations of early endometrial cancer detection. 
• At menopause women are strongly encouraged to report any unexpected bleeding or spotting to their doctor. 

Prostate

• Starting at age 50, men should talk with their doctor about the pro's and con's of testing. 
• Testing includes a PSA blood test with or without a rectal exam. Frequency of testing will depend on their PSA level.

Colorectal

Beginning at age 50, both men and women should follow one of the following:

• Flexible sigmoidoscopy every 5 years, or
• Colonoscopy every 10 years, or
• Double-contrast barium enema every 5 years, or
• CT colonography (virtual colonoscopy) every 5 years
• Yearly fecal occult blood test or fecal immunochemical test

Lung

Discuss with your doctor the benefits, limitations, and potential harms of lung cancer screening with:

• Individuals ages 55-74, in fairly good health, with at least a 30 pack-year history of smoking (estimated by number of packs per day x number of years smoked), and are still smoking or have quit within the last 15 years.
• If screening is indicated, a low-dose CT scan of the chest yearly through age 74 as long as you remain in good health is recommended. 

http://www.cancer.org/healthy/findcancerearly

Type 2 Diabetes

Clinical judgement and patient preference will determine diabetes screening.

• Beginning at age 45, every 3 years particularly in those with a BMI >/=25kg/mg2  
• Consider testing at a younger age or be carried out more frequently in individuals that are overweight and have one or more other risk factors.      

http://www.care.diabetesjournals.org/content/27 

Osteoporosis

Bone Mineral Density (BMD) should be performed:

• In women age 65 and older and men age 70 and older.
• In postmenopausal women and men age 50-69 based on risk factor profile.
• BMD and vertebral imaging to those who have had a fracture, to determine degree of disease severity.
• At DEXA facilities using accepted quality assurance measures.

http://www.nof.org/files/nof/public/content/file/950/upload/523.pdf

Cholesterol

• Adults aged 20 years and older have their cholesterol checked every 5 years.

http://www.cdc.gov/features/cholesterolawareness/ 

General Screening

Additional screening includes blood pressure, weight, dental, vision, hearing, immunizations, infectious disease, tobacco, alcohol, depression and physical exams. Based on age, gender and risk factors recommendations vary.
For more details go to:  http://www.nlm.nih.gov/medlineplus/ency/article/002125.htm

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