Fish oil has a wide range of proven medicinal benefits. It contains omega-3 fatty acids in the form of EPA and DHA which the body is unable to produce on its own. Omega-3 fatty acids are available in over the counter supplements and as prescription medications.
Several recent studies have found that prescription omega-3 fatty acids can reduce triglyceride levels in people with very high or high levels of triglycerides.
It is estimated that 25% of all adults in the U.S have high triglyceride levels. This is a cause for concern because of the evidence that high triglycerides increase the risk of cardiovascular disease.
In August 2019, the American Heart Association released a science advisory endorsing the use of prescription Omega 3 fatty acids to treat high triglycerides. The AHA states that they are a safe and effective option to reduce triglycerides. However, they have not endorsed over the counter omega 3s and caution against their use in managing high triglycerides. (1)
The highlights of the advisory are as follows :
- A dose of four grams a day of prescription omega-3s can effectively reduce high triglycerides.
- Identification of underlying causes like hypothyroidism or poor type 2 diabetes management should be done before prescribing medication.
- There are two types of omega-3 fatty acid medications available by prescription. Medications containing only EPA or drugs containing both EPA and DHA. Neither formulation is recommended above the other due to the absence of head to head studies.
- People should not treat high triglycerides with non-prescription omega-3 supplements because they have not been approved by the FDA.
What are Omega-3 Fatty Acids?
Omega-3 fatty acids are a family of ‘good’ fatty acids known to play a number of important roles in the body and to provide various health benefits.
Your body is unable to produce fatty acids on its own so you need to get them from the food you eat or from supplementary sources.
The three main types of omega-3 acids are :
- ALA – alpha-linoleic acid
- DHA – docosahexaenoic acid
- EPA – eicosapentaenoic acid
ALA is found in certain plants like flax seeds, chia seeds and hemp seeds. EPA and DHA are mostly found in algae and animal food especially fatty fish.
Fatty fish like mackerel, herring, salmon and tuna are a good source of EPA and DHA. The AHA recommends eating these fish twice a week at least.
The vast majority of people fall short of the recommended levels of dietary omega-3s, so omega-3 supplements like fish oil is often recommended.
Studies have found that omega-3 fatty acids have a wide variety of health benefits. As well as their heart health benefits, studies have found they may have a number of other positive effects on your health.
Omega-3s have been extensively studies and to date, there is evidence that they can have a positive effect on various conditions including the following :
- Heart health
- Inflammatory diseases
- Bone and joint health
- Metabolic syndrome
- Depression and anxiety
- Brain health
- ADHD
- Eye health
- Auto-immune diseases
- Cancer
- Menstrual pain
You can read about the various health benefits of fish oils if you click the following link. 10 Proven Benefits of Fish Oil.
This article will look at the effects of omega-3 fatty acids on cardiovascular health and in particular on their proven ability to reduce triglyceride levels.
Omega-3 Fatty Acids and Heart Health
Heart disease is one of the greatest causes of mortality. In fact, heart attack and strokes have remained the leading causes of death around the world for the past 15 years. (2)
Back in the late 1980s, observational research revealed that communities who ate large amounts of fish had far lower rates of heart disease. (3) This relationship has since been linked to the consumption of omega-3 fatty acids. (4)
Studies into the effects of omega-3 fatty acids have consistently linked them to am number of heart health benefits.
These include :
- Lower triglyceride levels
- Raised HDL cholesterol (the good kind)
- Reduced inflammation
- Reduced blood pressure
- Plaque prevention
Omega 3 Fatty acids and Triglycerides
Studies have consistently revealed that omega-3 fatty acids can reduce triglycerides. According to the American Heart Association, a dose of 4 grams a day can be used wither as an individual treatment or used along with other treatments for high triglyceride levels.
Note again that the AHA only endorses the use of prescription omega-3 fatty acids.
To date, no head to head studies have been conducted into the comparative effects of DHA and EPA. The majority of studies have looked at the effects of supplements that contain a combination of both acids.
However, in 2015, a review of the comparative benefits of prescription omega-3s was published. This review is highly informative and affords us an opportunity to examine the relative merits of the main types of fatty acid. (5)
Furthermore, the review involved only the analysis of prescription omega-3 fatty acid medications :
- EPA only : Vascepa
- Combined EPA and DHA : Lovaza, Epanova and Omtryg
Studies have found that omega-3 fish oil supplements containing EPA and DHA at the recommended dose of 4 g a day can reduce the level of triglycerides by 30% or more in patients with very high triglycerides (defined as 500 mg/dL).
In this group, vascepa – the EPA only formulation did not raise LDL cholesterol levels, However, the combination medications containing both DHA and EPA did cause an increase in LDL cholesterol.
The same dose is also effective in people with triglyceride levels in the range of 200-499 mg/dL. Researchers have typically found that prescription omega-3s can reduce triglyceride levels in this group by between 20 and 30%.
In this group, the EPA only formulation medications did not cause a significant increase in LDL cholesterol.
What the Studies Tell Us
High levels of triglycerides (hypertriglyceridemia) is a common condition linked to an increased risk of heart disease and other adverse cardiovascular effects.
Prescription Omega-3 fatty acids can produce significant reductions in triglycerides in people with very high or high triglyceride levels. Prescription formulations whether EPA only or a combination of EPA and DHA have a similar effect on triglyceride levels.
While the effects of these products are similar in terms of triglyceride reduction, they differ in several other parameters. In particular, omega-3 products which contain DHA may increase LDL cholesterol levels in patients with very high triglyceride levels.
Products containing only EPA do not raise LDL cholesterol levels and are typically well-tolerated.
Products containing both DHA and EPA produced a slight increase in HDL cholesterol (the good kind) while the EPA only formulation – Vascepa produced a slight decrease.
Vascepa (EPA) and Coronary Disease
In November of 2018, the results of the REDUCE-IT trial were presented by the American heart Association and simultaneously published online. (6)
The AHA revealed that treatment with Vascepa (an EPA only Omega-3 formulation) significantly reduced major cardiovascular events. These included combined cardiovascular death, unstable angina, non-fatal stroke and myocardial infarction over a 4.9 year period.
Treatment with Vascepa resulted in a 20% decrease in cardiovascular death alone prompting doctors to declare the results as ‘truly extraordinary’.
According to the authors of the study, the findings are extremely significant and stand them apart from other studies into triglyceride-reducing agents.
Experts are uncertain of the exact reason that the results were so impressive compared to previous studies. They speculate that a lower dose of EPA or a lower ratio of EPA to DHA in previous trials may be responsible.
In this study, Vascepa (a highly pure form of EPA ethyl ester) was used at a dose of 4g a day. Most previous studies used combined formulations of DHA and EPA.
It is also worth noting that this highly purified form of EPA does not cause an increase in LDL cholesterol levels seen with combination fish oil supplements.
What about OTC Fish Oil Supplements?
It is important to distinguish the prescription formulations from over the counter fish oil products. The studies we have discussed used a high dose of prescription omega-3 fatty acids.
These days, there is a huge range of fish oil products available online and at health stores. It is important to know how much fatty acid they contain and in what ratio. A product that contains 1,000 mg of fish oils may only contain 300 or 400 mg of omega 3s.
To put that in perspective, you would need to take 14 or 15 capsules a day to get the 4 grams of active ingredients recommended by the studies.
Taking so many capsules is not only unpractical but may also cause adverse gastrointestinal effects.
Although over the counter fish oil products are not regulated in the same way as prescription omega-3s, that does not mean you can not get a quality product. It is also worth noting that the 4 grams a day recommendation relates to triglyceride levels and cardiovascular benefits but fish oil has a wide variety of potential benefits in lower doses.
The Best Over The Counter Fish Oil Supplements
When it comes to fish oil supplements, the quality and concentration of the products available varies widely. Consumer labs has tested a number of products and given many their seal of approval.
Of the 17 products tested by ConsumerLab.com, 14 were ultimately approved for their quality. Some over the counter supplements actually contain nearly as much EPA or DHA as the prescription omega-3s but can be bought at a cheaper price.
Various forms of supplements were tested including capsules, chews or softgels. The level of omega-3 fatty acid contained in these products ranged from as little as 60 mg (ChildLife Pure DHA) to 1420 mg. (Nordic Naturals Ultimate Omega)
When choosing a fish oil supplement, it is important to focus more on the amount of active ingredients in the oil rather than the total amount of oil they contain.
Some supplements are also much more highly concentrated than others. More concentrated products allow a person to consume smaller capsules but get more omega-3s into their system.
For example, both Spring Valley Fish Oil and Minami garden of Life Fish Oil contain 1000 mg of fish oil. However, the Minami softgel provides over three times more omega-3s as the Spring valley softgel.
OTC Fish Oils
The following are some of the fish oil products approved by ConsumerLabs.com.
GNC Triple Strength EPA
Earlier in the article, we looked at the impressive recent findings related to Vascepa – the prescription, EPA only drug. Vasecepa contains 96% EPA and provides around 960 mg of EPA in each capsule. For triglyceride reduction, 4 capsules are taken each day and the price works out at around $10 dollars a day.
DNC Triple Strength EPA provides around the same levels of EPA as Vascepa but works out at less than a third of the cost.
OmegaBrite
This is another product containing a high ratio of EPA. However, you would need to take 12 softgels to provide the same dose as Vascepa. The cost of this dose would be around $8 a day representing only a moderate saving.
Minami Garden of Life® Platinum Omega-3 Fish Oil
This is a highly concentrated formulation. Each softgel contains 984 mg of omega-3s with the majority being in the form of EPA.
The concentration levels are similar to Lovaza and Epanova -the prescription fish oil used in the studies referenced earlier in this article. Each capsule costs around 70 cents which is relatively expensive but considerably cheaper than the prescription versions.
Nordic Naturals Ultimate Omega
For those who prefer not to swallow large capsules, this is a highly concentrated fish oil liquid that you can take from the bottle. Half a teaspoon of this product provides 1,235 mg of omega-3 fatty acids.
The cost for half a teaspoon dose will be around 75 cents and works out to around $3 a day for a dose similar to the one recommended for triglyceride reduction.
Are Fish Oil Supplements Safe?
Omega-3 fatty acids are generally regarded as safe, however some adverse side effects have been observed in trials using prescription Omega-3s.
Espanova has been linked to adverse gastrointestinal effects including nausea, diarrhea and vomiting. The EPA only medication – Vascepa has not been linked to adverse gastrointestinal effects. The most commonly reported side effect in people using Vascepa was joint pain. (5)
Because of the potential adverse side effects, the AHA recommends taking omega-3 supplements with a meal.
Final Thoughts
Studies have revealed that fish oil has a number of excellent health benefits. Fish oil contains high levels of omega-3 fatty acids in the shape of EPA and DHA.
According to studies, these fatty acids can have a positive effect on a wide variety of conditions including heart disease, inflammatory disease, anxiety and depression, autoimmune conditions and metabolic syndrome.
Recent studies have revealed that omega-3 fatty acid can have a significantly positive effect on heart health. a number of studies have found that a combination of DHA and EPA can significantly reduce triglyceride levels.
The studies discussed in this article have used prescription omega-3 drugs. These drugs are regulated by the FDA and approved for the treatment of high triglycerides.
While over the counter omega-3 supplements are not officially recommended and are not as strictly regulated, there are many quality brands available. Some can provide as much EPA and DHA as the prescription options but at a much lower cost.
The research into the effects of omega-3 fatty acid on heart disease is still in its infancy. Ongoing studies are expected to tell us even more about their potential.
(1) https://newsroom.heart.org/news/prescription-omega-3-fatty-acid-medications-effectively-lower-high-triglycerides?preview=61b7
(2) https://www.who.int/en/news-room/fact-sheets/detail/the-top-10-causes-of-death
(3) https://www.ncbi.nlm.nih.gov/pubmed/18541598
(4) https://www.ncbi.nlm.nih.gov/pubmed/12848280
(5) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4671468/
(6) https://www.nejm.org/doi/full/10.1056/NEJMoa1812792
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