Should You Try Prescription Fish Oil?

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The final marketing point that the prescription fish oil supplement makes is that the DHA omega-3 fatty acid found in many heart healthy fish oil blends may raise LDL-cholesterol. That’s the cholesterol, known as the lousy cholesterol, associated with an increased risk of cardiovascular disease.

Based on the studies I read, there may be a small increase in LDL-cholesterol in some studies. What they fail to mention is that there’s more than one type of LDL-cholesterol. The small, dense LDL cholesterol has been shown to be associated in CVD even when LDL-cholesterol is in the normal range; the large and fluffy LDL-cholesterol seems to have no relationship with CVD. The supplement fish oils that contain DHA seem to raise only the large LDL-cholesterol. That has led other researchers to call the effect of fish oil on LDL to be cardioprotective at best and benign at worst.

The Issues with the Marketing of Rx Fish Oil

Every company wants to put their best foot forward and prescription fish oil is no different. In reviewing the marketing materials as well as the research, here are my concerns:

  • The results of the studies they cite show a decrease in triglycerides of 33%. The mean level of triglycerides in one of the studies was about 660 mg/dl. That means it dropped the mean level to 440 mg/dl. While statistically significant, there’s no way to know whether that’s clinically significant in reducing the overall risk of CVD because the studies were so short.
  • The company clearly states that this medication is clinically relevant only to people with triglycerides greater 500 mg/dl; that’s a very small percentage of patients who may have familial high cholesterol. For the typical person with high triglycerides, this medication is not appropriate. That doesn’t mean it’s illegal to prescribe it for people with triglycerides between 250 and 500, but there’s also no evidence that it’s better than a change in diet or exercise. Will it be prescribed only for people with high triglycerides? We’ll see.
  • The company did not run comparative studies against fish oil supplements or with diet and exercise alone. Seems like that would be obvious.
  • Finally, while there are programs to get this medication for lower prices, I checked with my prescription plan and the cost would be $375 per month. For that kind of money, you can have someone prepare healthy meals specifically designed to reduce your triglycerides or take a class to learn to prepare them yourself; you could definitely join and inexpensive gym and buy more fresh fruits and vegetables.

The Bottom Line

Similar to statin medications when they were introduced decades ago, prescription fish oil should be limited to a very specific part of the population with familial high triglycerides. That’s all—no one else.

As for fish oil supplements, the issues they point out in their marketing material are not significant. You never use dietary supplements to treat any disease, but that doesn’t mean they can’t help you compensate for nutritional deficiencies. There will be a difference in the quality of any supplement so make sure you choose a quality manufacturer.

For the bulk of the population to reduce their triglycerides, reducing refined carbohydrates, saturated fats, and alcohol, increasing vegetable and fruit intake, and getting some exercise will help most. Like I always say: Eat better. Eat less. Move more.

What are you prepared to do today?

        Dr. Chet

References:
1. http://dx.doi.org/10.1016/j.atherosclerosis.2016.08.005.
2. J Clin Endocrinol Metab. 2018 Aug 1;103(8):2909-2917.
3. Am J Clin Nutr. 2004 Apr;79(4):558-63.

Fish Oil: Medication versus Supplements

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Before I address the concerns about fish oil supplements put forth by the Vascepa® prescription omega-3 website, it’s important to understand that all prescription and over-the-counter medications have been approved by the U.S. Food and Drug Administration (FDA). That means they have spent a significant amount of money—sometimes over $1 billion—to prove that the treatment claims are significant, and you can’t take that away from them. But marketing is a different story, so let’s look at what they say.

“Fish oil supplements are not FDA-approved.” True; no dietary supplement is FDA-approved, but that doesn’t mean they’re not regulated. They also can’t make claims about curing diseases.

“Daily dose could require 10 to 40 capsules to equal the prescription EPA omega-3.” That depends on the brand purchased, so that critique is weak.

“Fish oil supplements can leave a fish-y aftertaste.” Really? It’s fish oil, what would you expect? (Keeping the supplements in the refrigerator may help with that as well as taking fish oil before meals.) They suggest that the oils turn rancid and that causes the taste, but they offer no proof of that claim.

The last critique they make of fish oil supplements is that “Many contain another omega-3 fatty acid called DHA.” They say DHA can raise LDL cholesterol. I’ll address that claim and provide some concerns I have with the prescription omega-3 and how it’s being marketed on Saturday.

What are you prepared to do today?

        Dr. Chet

Treatment for High Triglycerides

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Hypertriglyceridemia, the medical term for high triglycerides, is a risk for cardiovascular disease. Recently I spotted a health headline from a medical newsletter that read “Omega-3 Fatty Acid Medications Can Boost Cardiovascular Health.” The word that caught my attention was “medications” so I checked it out.

The article described the benefits of recently approved medications based on marine omega-3 fatty acids. I checked out the latest one called Vascepa®. This is a purified form of fish oil that, according to the data on its website, can lower triglycerides up to 33%. Sounds impressive.

Back to the newsletter article: the author interviewed the lead author of a review paper that stated that prescription omega-3s are effective in lowering high triglycerides. Then she went on to say to avoid omega-3s from dietary supplements because they haven’t been proven to lower triglycerides as the prescription omega-3s have.

The website for Vascepa went a lot further in criticizing omega-3 supplements. What were their objections? Is a prescription the best way to go to treat hypertriglyceridemia? That’s what I’ll cover the rest of this week.

What are you prepared to do today?

        Dr. Chet

Reference: https://www.medicalnewstoday.com/articles/326146.php

The Bottom Line on Vaping Today

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Recent reports indicate that in addition to fruit juices and flavors such as menthol and bubble gum, two natural products may be contributing to the issues with vaping: vitamin E and CBD oil. Vitamin E has been found in some vaping cartridges that contain CBD oil. CBD, short for cannabidiol, is the second most abundant cannabinoid found in the cannabis plant. It has levels of THC (tetrahydrocannabinol) below the legal limit and is often used for pain relief and psychological distress such as anxiety. I can’t comment on CBD oil; it’s not my area of expertise.

What I do know is that while cannabis is typically inhaled, CBD oil can be administered orally or topically and that’s probably a better delivery system. When any oil is produced, vitamin E is typically added so the oil doesn’t go rancid. In addition, there may be other additives so the CBD doesn’t break down. There’s no research to suggest that the oil or the vitamin E are safe when incinerated. Even if a cold aerosolized process is used, the ingredients are not designed to be administered that way.

Lung tissue is very sensitive. Think of the aerosolized droplets thousands of times larger than individual molecules of vitamin E or omega-3 fatty acids that would be found in blood. Those droplets would create a barrier, making it tough to breathe, whether natural or not. The benefit relies on the absorption and while some would be absorbed quickly, how long would the residue remain? Could it even be removed?

The Bottom Line Today

As I said in the Tuesday Memo, the governor of Michigan banned the sale of flavored vaping products; I think she made the right decision even though she is taking political heat for it. Business interests have interfered in public health initiatives for too long. Do I even have to mention the tobacco industry? And that it has heavily invested in the vaping industry? With the health of a generation at stake, I think taking time to examine the safety and marketing of these products is warranted.

I wish I could say this is the last word on vaping, but this is a rapidly changing health topic. The only vaping that should be allowed is as a method for quitting smoking—not to replace smoking, but as part of a strategy to quit smoking. It should be regulated by the Food and Drug Administration because nicotine is a drug.

As for the rest of what’s being used in vaping products, I think everyone should take a pass. If the industry actually conducts safety testing to discover any health issues for vapers, maybe, but I just don’t see that happening. The burden shouldn’t be on the health industry to prove vaping is bad; the burden should be on the vaping industry to prove it’s safe. We do enough to ourselves already to impair our health. We don’t need to add any more habits that we’ll need to break in the future. If you smoke, there’s no question you should quit. Talk with your doctor about the best way to accomplish that before you start vaping.

What are you prepared to do today?

        Dr. Chet

Is Vaping Healthy?

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Two years ago, I wrote this about vaping’s potential negative effects: “We won’t know how harmful it is for years, possibly decades, when those who began vaping years ago are tested and found to have higher rates of lung disorders.”

I was wrong; we’re seeing serious lung issues now and even a few deaths. Reports of respiratory illnesses include pneumonia and asthma-like symptoms that impede breathing. Another issue appears to be seizures in some cases. The problem is that no one can identify what’s causing the problem.

One cause might be heavy metals that are aerosolized from the vaping devices as well as metal juice cartridges such as chromium, nickel, and lead. They may be irritants to lung tissue. Lead could also explain seizures in some vapers.

I think that the juices targeting young vapers could be a major source of contaminants. Juices may be natural or synthetically produced, and we might point the finger at synthetic flavors. However, there’s no research on what incinerating natural juices would produce. Phytonutrients are meant to be eaten; what could happen to them when they’re burned? They may end up being toxic due to the change in chemical structure caused by exceeding normal cooking temperatures.

There are still other possibilities so I’ll finish this up on Saturday.

What are you prepared to do today?

        Dr. Chet

Flavored E-cigs Banned in Michigan

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If you’ve been paying attention to the health news at all, you know that there have been some serious respiratory issues and deaths related to vaping. Because the majority of patients were young and were using flavored juices in the vaping products, Michigan Governor Gretchen Whitmer placed a temporary ban on the sale of all flavored e-cigarette products in the state. I applaud the governor’s action. It gives the legislature six months to come up with reasonable legislation governing vaping and vaping products.

This is not a simple issue. Health is the primary concern, especially the health of teenagers and young adults. But because of the prior lack of regulation, the vaping industry has grown to be a multi-billion dollar industry. They’re firmly entrenched, much as the tobacco industry was. They’re not going to go quietly.

The products are being pitched as healthier alternatives to cigarettes. They contain nicotine but none of the other noxious chemicals in cigarettes. They may be useful in helping adults quit smoking, but I’m skeptical of that one. Why create a billion-dollar industry that’s sole purpose is to lose customers? But the operative word was adult.

The concerns are that vaping devices use flavored juices that make them appealing to teens. Even those sold to kids without nicotine set the stage for taking the next step to a nicotine product. But are juices or flavored liquids safe to vape? I’ll update what I wrote two years ago on Thursday.

What are you prepared to do today?

        Dr. Chet

Can Fasting Reduce Inflammation?

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In this Memo, I’ll review the third paper from the recent journal Cell on fasting and summarize what this all may mean for the use of intermittent fasting.

Researchers used both mice and humans as subjects in a series of studies. The objective was to examine how the immune system responded to a fasting protocol. For the study in humans, the subjects fasted for 19 hours after eating, with blood samples taken before and after the fast. In the mice, a variety of protocols were used. The most common was mice were fed for a short time before food was withheld for the remainder of 24 hours.

In mice and humans, circulating monocytes were reduced. This was important because they were pro-inflammatory in nature; thus inflammation decreased in response to the fasting protocol. In some of the studies, this reduction was maintained even with exposure to pathogens. That means the immune response was not compromised even in animals with induced autoimmune diseases.

Fasting Protocols

Three different studies used at least three different approaches to fasting. In the first study, food was withheld completely for 36 hours. In some phases of the second study, calories were reduced by 50% although the vitamins, minerals, and protein were maintained at normal levels. The final study used a fasting protocol we’re most familiar with: eat within a few hours and liquids only the remainder of the day.

The results were similar in sustaining and perhaps improving the immune system of the animals when placed under pathogenic stress. The only issue is what form of dietary restriction worked best? You can’t ask mice how they felt; you can only check immune system markers. In one of the approaches, the skin of the mice was injured at different times of continued fasting. The healing ability continued until the fast went beyond 48 hours; after that wound-healing was impaired.

The Bottom Line

These studies haven’t changed my approach to fasting. If you’re going to fast to rejuvenate your immune system, don’t play games. Reduce caloric intake to 500 to 800 calories per day for two to three days; those studies show the best benefit. Be sure to select small quantities of the healthiest foods.

Fasting is not abstinence. The current approaches to intermittent fasting are really intermittent abstinence. The idea is to abstain from food completely for 12 to 18 hours while still drinking liquids. That may not be possible for everyone. Some medications have to be taken in relation to food intake. Pre-diabetics and type 2 diabetics should still monitor blood sugar, especially if exercising during the fasting times. The current intermittent fasting approach is more about controlling when you eat than anything else, and that’s something you should do anyway.

I believe in fasting. That’s why I wrote Real-Life Detox—so you could do it right and gain the most benefit. The critical thing is to find a way to eat that you can sustain for the rest of your life, and that includes occasional fasts.

Eat less. Eat better. Move more. That’s always the goal.

What are you prepared to do today?

        Dr. Chet

References:
1. Cell. 2019. DOI:https://doi.org/10.1016/j.cell.2019.07.047.
2. Cell. 2019. DOI:https://doi.org/10.1016/j.cell.2019.07.049.
3. Cell. 2019. DOI:https://doi.org/10.1016/j.cell.2019.07.050

Fasting and Memory T Cells

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The second paper from the journal Cell on fasting examined the longer term effects of fasting on memory T cells. Several species of mice were used in a variety of studies; these were complex experiments to say the least. Before I go further, a little about memory T cells.

Memory T cells are a class of T cells that remain after responding to a prior infection; they’re also created in response to vaccinations. The benefit is that if someone is re-exposed to the same or similar pathogen or toxin, the memory T cells mount a more vigorous attack than after the first exposure.

The mice were monitored for two weeks to establish a baseline caloric intake, then they were maintained on 50% of their caloric intake for three weeks or longer. There were several experiments. In some, while the calories were reduced by 50%, protein, vitamins, minerals, and essential amino acids were maintained at 100%. Therefore, there were no micronutrient or protein deficiencies, just calorie deficits.

The researchers found that stress hormones increased in response to caloric reduction. The memory T cells were transported and stored in the bone marrow. When the diet was returned to normal, the memory T cells were returned to their typical locations in the immune system. Other experiments showed that the memory T cells had an enhanced ability to fight pathogens.

One more study to examine on Saturday.

What are you prepared to do today?

        Dr. Chet

References:
1. Cell 2019. DOI:https://doi.org/10.1016/j.cell.2019.07.049.
2. Translational Biology in Medicine, 2014.

Fasting and Immune Function

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Intermittent fasting is the latest health fad. When I say fad, I mean there are as many definitions of what it means as there are experts. In a recent edition of the journal Cell, three papers were published that provided some insight into the effects of three different types of intermittent fasting on three different systems involved in immune function. That’s our topic of the week. I’ll present each study and comment on the implications on Saturday.

In the first paper, researchers used juvenile mice to examine changes in immune function in sections of the intestine called Peyer’s patches (PP). These patches form an important part of the immune system by monitoring intestinal bacteria populations and preventing the growth of pathogenic bacteria in the intestines. The mice were fasted for 36 hours. Results were compared with normally fed mice that served as controls.

During fasting, immune cells were disrupted and thus compromised the typical immune response; specifically, B cells were sent to bone marrow. It’s difficult to say whether this is a protective mechanism or not. The B cells were returned to the PP during re-feeding. There were many more parts of the study, but the bottom line was that the immune system was compromised during fasting and remained impaired for a time after re-feeding.

We’ll take a look at the second study on Thursday.

What are you prepared to do today?

        Dr. Chet

References:
1. Cell. 2019. DOI:https://doi.org/10.1016/j.cell.2019.07.047.
2. http://bit.ly/2lxYIRa.

All Research Matters

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As we enter the final holiday of summer, I want to challenge you to listen to a podcast over this long weekend. Before I get to the details about the podcast, I want to tell you why research matters.

I spend a considerable amount of time examining nutrition research. If you read what I write, you know I’ve criticized who nutrition research is done by as well as how nutrition research is done. That doesn’t mean that the research is not worthwhile. The interpretation of what any given study means can be debated and methodologies can always be better. It doesn’t mean that the research isn’t important; if nothing else, it can show how not to do something.

Take a different topic such as climate change or vaccinations. These topics are a great way to start an argument because people have strong opinions on them. Pick either side and you can find research to support your position. Again, that’s due to the interpretation of research on highly complicated topics, but it doesn’t mean that the research shouldn’t have been done in the first place. It absolutely has to take place.

We seem to be entering an era where government-sponsored research is being attacked, and that will be harmful to us in ways we can’t imagine. Think about it. Do you want research funded only by the sugar industry to set dietary guidelines? How about climate research funded only by the gas and oil industry or energy research funded only by the windmill industry? That’s where basic science research is critical to bring balance to the equation. No research should be avoided because it offends one industry or another.

Now to the podcast: listen to Malcolm Gladwell’s podcast called Revisionist History on your favorite podcast platform. The episode is titled The Obscure Virus Club. It’s the story of a small number of scientists who persisted for decades in researching obscure viruses and whose findings were ignored for way too long; I’ll tell you that Paula was in tears as she figured out the life-or-death consequences of those delays. Think of the implications if even more research were unfunded and unpublished. Just because it’s a holiday weekend doesn’t mean our brains shouldn’t be engaged. Send me your thoughts after you listen to it.

What are you prepared to do today?

        Dr. Chet

Research: http://revisionisthistory.com/episodes/40-the-obscure-virus-club