Omega-3 Dose, Bleeding, and Eye Health: Ask Us Anything | Part 2
OmegaMatters: Episode 38 – Part 2
Hosts: Drs. Bill Harris & Kristina Harris Jackson
About this episode:
In this episode Drs. Harris & Jackson address several audience questions, including how to interpret an omega-3 supplement label, concerns around omega-3 and bleeding, and how omega-3 supports eye health. For more information on OmegaMatters, visit: https://omegaquant.com/omegamatters-broadcasts/
SHOW TRANSCRIPT
Dr. Bill Harris: So Theresa S, Theresa actually is in Sioux Falls, our hometown, so hello, Theresa.
Dr. Kristina Harris Jackson: Wow.
Dr. Bill Harris: She says, “I often see supplements with high amounts of omega-3 on the label but relatively low amounts of EPA and DHA. Is all DHA and EPA omega-3” yes, they’re all omega-3, “but not vice versa? In other words, can there be other omega-3s besides them? What ingredients make up the difference? Can you explain for the purchaser the interplay between these components?”
Dr. Kristina Harris Jackson: Oh, it’s so confusing to get a supplement. So EPA and DHA are omega-3s. There are more omega-3s than EPA and DHA, including ALA and DPA, which you may have heard of. And so the total omega-3 level on the supplement facts panel can be 1000 and then EPA could be just 300 and DHA just 300. That’s possible. So what we always say is look at the EPA and DHA content on the supplement facts label, knowing what the serving size is also. Always note that. And that difference is all the other omega-3s and so you really only care about the EPA/DHA content. We don’t know how they’re measuring these or what they’re putting in the total omega-3 bucket, or maybe it’s something else, but there’s a lot of proprietary blends of things.
We have no idea what’s going on in that. But you’re just looking for the actual value of EPA and DHA separated out, you don’t want a combined metric, on the supplement facts panel, and that’s what you’re going to use. If you’re using our calculator, we are talking about EPA and DHA specifically and amount of that, and not total omega-3s. So always flip it around, look at the back panel, and that’s where you’re going to get the most clear information, but it’s confusing.
Dr. Bill Harris: Great. Well, we’ve got a lot more questions and not much more time, so why don’t we wrap up this AUA and do another one soon and we’ll pop up AUA number two and deal with these other questions.
Dr. Kristina Harris Jackson: Sounds great. Thanks so much.
Dr. Bill Harris: Okay, thank you too.
Dr. Kristina Harris Jackson: Bye-bye. All right, so do you want to come back to this later?
Dr. Bill Harris: Yeah, or we could even record it now if you want to.
Dr. Kristina Harris Jackson: We could record it now if you’re still feeling good.
Dr. Bill Harris: Yeah.
Dr. Kristina Harris Jackson: We’d go bleeding, dry eye, high omega-three and [inaudible 00:02:41].
Dr. Bill Harris: There’s quite a few left so I just thought, yeah.
Dr. Kristina Harris Jackson: Natural breaking point.
Dr. Bill Harris: Seemed like a good breaking point.
Dr. Kristina Harris Jackson: I think so. Just a minute. Okay.
Dr. Bill Harris: Do you think we need to sign out and sign in again if we’re going to record a second one?
Dr. Kristina Harris Jackson: No, I don’t think so. I mean don’t think [inaudible 00:03:16].
Dr. Bill Harris: Oh, that’s right, they can edit it anyway to look at it. Okay. Is my screen… you’re very fuzzy.
Dr. Kristina Harris Jackson: No, I shouldn’t be because I’m using my camera.
Dr. Bill Harris: I know you’re very pixelated on my screen, but I think that’s okay.
Dr. Kristina Harris Jackson: I think it’s okay.
Dr. Bill Harris: Okay, wait a minute. Should I change my shirt? Maybe not.
Dr. Kristina Harris Jackson: Nope, we’re just same day. Okay. Bleeding and blood… we’re going to start the bleeding and blood thinning. All right, ready-
Dr. Bill Harris: Go.
Dr. Kristina Harris Jackson: Hello, welcome back to part two of our AUA, Ask Us Anything. In the last AUA, we covered more about C-15 and atrial fibrillation and questions about fish and algal oil and things like that, so check that out. But we have a lot more questions so we wanted to keep answering them. And our first general topic is about bleeding and blood thinning. We have done a nutrition talk on this previously so you can go check that out for the real detailed look at all the studies that we might talk about here. So the first question, which was anonymous, is will omega-3 increase bleeding risk for people with low platelets and not on medication.
Dr. Bill Harris: Good question. There were studies from the 1980s, particularly from our group, where we were giving 10 to 20 grams a day of EPA and DHA to normal volunteers. And on average there was a small decrease in platelet count. One particular person had a big dive in platelet count, but on average a small decrease. Now whether you’re taking doses of omega-3 that’ll give you an omega-3 index of 8%, which we think is optimal, which is around a gram and a half, really has no effect on platelet counts. If you have a low platelet count, that’s a matter for you and your doctor, but I would not be particularly concerned about taking, again, amounts of omega-3 that would get you an 8%, one to one and a half grams is fine.
Dr. Kristina Harris Jackson: So you’re saying omega-3s at a very high dose in that one study did seem to affect platelet levels?
Dr. Bill Harris: Mm-hmm.
Dr. Kristina Harris Jackson: But generally omega-3s do not lower platelet count?
Dr. Bill Harris: Not at the standard supplementation doses, no.
Dr. Kristina Harris Jackson: Okay. Jillian W. asks, “Can krill oil be a good blood thinner instead of drugs? And if so, how much should you take?” And again, we are not medical doctors so this is general.
Dr. Bill Harris: I would say no, you would not want to depend… if your doctor thinks you ought to be on a blood thinner, you better be on a blood thinner. And I would not count on krill oil, fish oil, algal oil, anything, any omega-three to be the substitute. You can take them together and that’s probably a good thing to do from our bleeding discussion during the nutrition talk, but it’s certainly not a substitute for anti-coagulant drugs.
Dr. Kristina Harris Jackson: That’s good. All right, Ed D. has a very complicated question. Let’s see if you can answer it. Any knowledge of research or thoughts about the possibility of fish oil or SPMs mitigating potential negative effects of the enhanced clotting effects and /or endothelial damage of LP(a)?
Dr. Bill Harris: Okay, yeah, a lot of terms to define there. Let’s start with the end. LP(A) is lipoprotein little a, which is a form, a derivative of low density lipoproteins, LDL, and it’s a fairly strongly genetically determined risk factor. Most people have pretty low levels of LP(a) but some have pretty high. And I think now there’s a drug finally devised to lower the levels of that. One of the adverse or one of the mechanisms by which a high LP(a) level operates as it can increase blood clotting for some chemical reasons. And so we and others looked at, years ago, at the effects of omega-3 fatty acid supplementation on LP(a) levels, now not on LP(a) impacted coagulation per se, but looking at just LP(a) levels and there was a small but not substantial change, so it’s not really a good treatment for high LP(a). Nobody is actually, to my knowledge, ever studied whether increased omega-3 would reduce the coagulation tendency of accompanying high LP(a). So it’s a good question, a good research question for the future. Oh, and the SPMs, okay. So specialized mediators of… SPM.
Dr. Kristina Harris Jackson: Pro-resolving mediators.
Dr. Bill Harris: Pro-resolving mediators, right, I’d rather just call them PRMs, pro-resolving mediators, which are metabolites of EPA and DHA and arachidonic acid and linoleic acid. These pro-resolving mediators are made from particularly EPA and DHA. And so the question is, are the effects of taking EPA and DHA as fish oil or krill oil or algal oil, you do increase levels in your blood… when you provide more EPA and DHA you get more of these 20 or 30 different metabolites of EPA and DHA are produced. If you give them more substrate they make more product. Not surprising. And some of those molecules that are produced may have effects on coagulation and bleeding. I’m not aware that’s the effect. They’re more anti-inflammatory than they are anti-coagulant. So it’s an interesting question. Again, something else for research.
Dr. Kristina Harris Jackson: Yeah, that’s great. So that’s everything on bleeding that we have. Again, we have a whole nutrition talks on that that goes deep dive. So check that out. Next is dry eye. I’ll make it through some dry eye. What’s the current evidence that fish oil supplements do or do not contribute to eye health? Specifically glaucoma and macular degeneration, which is different than dry eye.
Dr. Bill Harris: Very different than dry eye.
Dr. Kristina Harris Jackson: But Sue G. asked this because she started supplementing years ago after seeing evidence that it may help with dry eye. So that’s a lot.
Dr. Bill Harris: It’s a lot, yeah. And so it’s all eye health in general. Just to back up, a little background, certainly the retina of the eye is one of the richest tissues in the body when it comes to DHA levels. So that tipped people off decades ago that there’s something about omega-3 in the eye that’s important because if the retina wasn’t enriched with DHA that wouldn’t be a concern. But obviously it’s there for a reason. And people have studied the eye a lot and particularly in early childhood development looking at visual acuity seems to be a function of how much omega-3, at least for a few weeks after birth, it’s important. It seems to settle down later.
Macular degeneration, glaucoma are two very different eye conditions and there are some evidence that omega-3s can slow the development of macular degeneration and glaucoma, intraocular pressure. That’s been documented. It’s not been well studied, but to some extent it’s been studied and looks favorable. Dry eye has been studied more. It’s easier to do randomized trials on dry eye because it acts quickly and there are some very positive omega-3 intervention trials apparently but there’s also mixed data. There’s other studies that one could criticize and have been criticized as to why they were neutral. No adverse effects of course on dry eye, but the anti-inflammatory effect of omega-3 should play a role in improving dry eye symptoms.
Dr. Kristina Harris Jackson: Good. So I guess sort of related, what omega-3 dosage would you recommend to a senior who’s experiencing very dry mouth and eyes at night?
Dr. Bill Harris: Well, whoever asked that question…
Dr. Kristina Harris Jackson: Leslie.
Dr. Bill Harris: Leslie, yeah, Leslie. I immediately thought of my grandfather when she said that because he had dry eyes and he had very dry mouth and he was diagnosed with a thing called Sjogren’s syndrome, which is immunologic. Kind of a, what do you call it, autoimmune type condition. Of course we never heard of fish oils when my grandfather was alive so that was not an appropriate study. So whether that’s the thing she’s describing is actually clinical standard dry eye from after having LASIK and that kind of thing or not, it may be a condition that’s more serious and whether omega-3 would help or not, I don’t know. But it’s back to the if it’s standard run-of-the-mill dry eye I think omega-3 does help. I’m not sure about the dry mouth.
Dr. Kristina Harris Jackson: Yeah, yeah, definitely.
Dr. Bill Harris: And I’m not a doctor.
Dr. Kristina Harris Jackson: And check in with your doctor.
Dr. Bill Harris: I’m a doctor but the kind that can’t help anybody.
Dr. Kristina Harris Jackson: Exactly, exactly. Okay, yes. There’s also a question on whether or not gamma linoleic acid for a dry eye supplement is necessary.
Dr. Bill Harris: Let’s try that one again, gamma linolenic acid.
Dr. Kristina Harris Jackson: Oh, sorry. There’s also a question about whether gamma linolenic acid is a necessary part of a dry eye supplement.
Dr. Bill Harris: Okay, yeah. So that’s called GLA, gamma linolenic acid, it’s an omega-6 fatty acid at 18 carbons, 3 double bonds, so it’s very similar to alpha linolenic acid except it’s gamma. It’s a different place to double bonding. It’s found in a few kind of obscure plant oils and there have been some, at least one or two studies, looking at giving GLA for dry eye symptoms and they reported some good effects. I am not going to pretend that I know that that’s a good thing or not. I guess if I had dry eye I’d just try it and see if it works. If it works, great. If it doesn’t work, I’d just go back to regular fish oil.
Dr. Kristina Harris Jackson: Yeah. I don’t know if we touched this specifically, but they’re also asking the best dose and duration for treatment of dry eye for benefit.
Dr. Bill Harris: Yeah, best doses, again I always come back to hitting in that 8% target and that’s about roughly a gram and a half of EPA and DHA for the typical person, which should get you up to an omega-3 index of eight or so and keep you there if you keep taking it. So that’s what I’d go for.
Dr. Kristina Harris Jackson: And it probably would take?
Dr. Bill Harris: It takes 12-ish weeks, three, four months to really reach the peak, a new steady state of omega-3.
Dr. Kristina Harris Jackson: And eye conditions could be changing any time in between there. I’m not sure how fast the eye responds.
Dr. Bill Harris: It certainly could theoretically happen faster than achieving that 12-week thing, yeah.
Dr. Kristina Harris Jackson: Yeah, okay. That’s everything on eyes. Let’s go to high omega-3 index levels, what’s going on there. So this person, they initially tested, they were doing a lot of supplementation and they had a 15% omega-3 index. But she’s wondering, Kathleen K., since her level is high, is this something I just need to test once a year if I keep my same regimen or more often? I think she feels okay being at 15%. What do you have to say about 15%?
Dr. Bill Harris: 15% is fine, probably unnecessarily high. There is certainly a point beyond which having higher and higher levels you cease to have benefit, although that is a range of omega-3 index levels that there’s very little data to say it’s good, bad or indifferent. So it’s very hard to say. I think you probably can’t get much over 20% in humans, or dolphins as a matter of fact, we studied them as well. That’s about the max. And red cells are made in a certain way and they have to have certain physical properties and the body designed to know how much omega-3 you can get in and not make the cell dysfunctional. So C-15, back to that again. 15% omega-3 index is, I’d say, higher than needed. I’d keep it between 8 and 12 if it were me.
Dr. Kristina Harris Jackson: Well, Mary Beth also had a question on this. She also had a 15% omega-3 index recently. Before that it was 19%.
Dr. Bill Harris: There we go, dolphin.
Dr. Kristina Harris Jackson: So, she’s two years older, she’s got a lot of it. So she purposely reduced supplementation to go from 19 to 15%, and she just also was wondering if she needed to do that, should she be reducing that level even more? Are there any consequences?
Dr. Bill Harris: I think it’s prudent to not really get beyond that 9 to 12%. That’s sort of an area where almost no humans have ever lived. So we really don’t know what happens out there. But 9 to 12% is high, but it’s probably not high for some Japanese people, and they’re doing okay.
Dr. Kristina Harris Jackson: Yeah, yeah, and some potential things people run into when they’re at very high levels are sometimes more bruising. Sometimes you have a longer bleeding time, but it’s not a severe amount of bleeding. This is part of that bleeding controversy that we talked about. So when you do see that, that is evidence the omega-3s are doing kind of what we think they should be doing. And there’s some thought that it’s potentially depressing our immune system’s ability to react to things because we’re maybe messing with the balance a little bit too much when we get that high on the omega-3s. But what was it from some of the original Inuit recordings, they noticed some things eating an extremely high diet of fish.
Dr. Bill Harris: Yeah, if you eat 10 to 13 grams a day of EPA and DHA there was increased risk for bleeding. Okay, but just don’t do that.
Dr. Kristina Harris Jackson: Yeah, it’s too high.
Dr. Bill Harris: You don’t need that much.
Dr. Kristina Harris Jackson: It’s too high, but those are what you would expect to see if you got really, really high. But we don’t have a toxic level. We don’t have a clear cut point where it’s like this is safe and this is not. We think being a little more prudent, staying 8 to 11 or 12% you should be getting most of your benefit and you’re not going way above and not spending a bunch of extra money on supplementation. It’d be very hard to get to those levels on fish intake alone. It would be taking 11 to 13 grams a day. So that is the end of the questions.
Dr. Bill Harris: No, you’ve got a bunch of miscellaneous, don’t you?
Dr. Kristina Harris Jackson: Oh, we’re still going for… Oh, oh, oh, oh, yes, yes, yes, yes, yes, okay. Some random ones. Stephen T. asks, “What is DPA? Can you explain its function?”
Dr. Bill Harris: DPA, docosa, let’s see, 22 carbons, penta, five double bonds, enoic acid, so it’s a intermediate between EPA and DHA. EPA is 20 carbons and five double bonds. DPA has got two more carbons still five double bonds. And DPA is a much less studied omega-3. It’s not present particularly in high levels in fish like EPA and DHA are. Some people think it’s kind of a reservoir repository in a way because you can fairly easily make EPA out of DPA as needed. And you could also theoretically go on to make DHA from DPA. Effects on health, higher levels are associated with good health outcomes. That’s a good thing. But that doesn’t mean that it’s necessarily doing the activity that’s required or what EPA and DHA are doing it may not be replicated by DPA. So we don’t necessarily recommend supplementation with DPA. We don’t know what levels would be healthy. We don’t really know a whole lot about DPA at this point other than it’s there in the blood and it’s there for a reason. We just haven’t really figured out the reason yet.
Dr. Kristina Harris Jackson: Kind of along these lines on kind of pathway questions, can a vegan create enough omega-3 EPA and DHA by consuming flax, walnut, chia, or is the conversion process too limiting? That’s from Bernie K.?
Dr. Bill Harris: Yeah, a common question, good question. The question is enough. Can just eating ALA, basically a vegan, not eating EPA and DHA, which only come… except for certain microalgae theoretically… EPA and DHA only come in the human diet in fish, animals. So there certainly is enough EPA and DHA made by vegans to allow them to develop normally to grow up, become adults, have children, et cetera. So you can make enough of EPA and DHA to support health. There’s been recent concerns that vegans might have, because of their low omega-3 status, which roughly is about 3.5% omega-3 index from a study we’ve recently done, which is quite low and so three and a half percent is not good we would think for a lot of reasons.
And of course a vegan diet, it can be a very healthy diet from a cardiovascular point of view. But the concern I think nowadays is more about cognitive function and dementia and whether there’s enough DHA made to actually give optimal cognition. There have been problems in vegans of cognitive decline that’s raising concerns now. So that’s, I think, a caution in that regard. If I was a vegan I’d be taking an algal EPA/DHA supplement.
Dr. Kristina Harris Jackson: And probably some B-12.
Dr. Bill Harris: And B-12, right. And maybe choline, whatever, and a bunch of other things too probably.
Dr. Kristina Harris Jackson: Yeah, kind of related to this, what effect does Vascepa have on the omega-3 index?
Dr. Bill Harris: So Vascepa is the trade name for the EPA-only ethyl ester product that’s made by Amarin and was used in a big study called the REDUCE-IT study. Vascepa is, again, because it’s EPA it really doesn’t have as much of an impact on the Omega-3 index as you might think, even in the REDUCE-IT study we’ve calculated from a couple of angles that the omega-3 index has not been measured in a major trial but we assume based on some other factors that give you an Omega-3 index of about 7%, very rich in EPA. So that’s back to what you were talking about earlier, Kristina, about if you’re taking a lot of EPA the Omega-3 index is going to be maybe 50/50 EPA and DHA. So roughly about 7% from taking four grams a day of EPA ethyl ester Vascepa.
Dr. Kristina Harris Jackson: Well, I think that is actually the end of our omega-3 questions.
Dr. Bill Harris: Great.
Dr. Kristina Harris Jackson: Well, there is one that’s kind of about vitamin D.
Dr. Bill Harris: Oh yeah, I’m not sure we can go there.
Dr. Kristina Harris Jackson: We can’t answer that, Colleen S., higher omega-3 affecting the conversion of sun exposure to vitamin D and that whole process. I don’t think we have any knowledge of that.
Dr. Bill Harris: No. So you’ve been on the receiving end of a lot of questions just in the clinical work you do with OmegaQuant. Anything that always pops up in your mind that maybe these folks didn’t ask that it’s always good to get out there?
Dr. Kristina Harris Jackson: That we haven’t already talked about? I think there’s kind of the question that was why if a lot of people take fish oil some people benefit, some people don’t, which has a lot of definitions that need to be made there. What benefit are you talking about? But I do think there’s a lot of places, simple fixes, simple ways that you can be pretty sure you’re getting a good bang for your buck if you’re going to take a supplement. And the first is really testing your blood is the ultimate way to know if you’re actually absorbing it. And that’s what you need for it to have benefits in your body. So if you’re really great you do a pre and post-test when you start a new supplement take it at the beginning, take the supplement for three months and retest. And then if your blood levels are going up then know it’s working and then you know it’s worth the buy.
I’ve talked to people who have done that and not seen their blood levels go up when they’ve been taking their supplements. Typically if it’s not going up as much as they expect it’s because they didn’t look at the dosage and they aren’t taking an appropriate dose for the benefit for the levels they want. Maybe the back of the panel said it’s three pills per serving size and they’re just taking one per day. That means anything on the back panel divide by three and you’re getting that. The other thing is if you’re taking something and it’s not with a meal or fat, and some people need that extra kick with the absorption process to have more food getting the fat more well absorbed so they need to take their fish oil with a fatty meal. If they don’t, if they take it on an empty stomach in the beginning of the day they might not absorb it at all.
So that’s important. That’s what you would find out also if you were doing testing. And a lot of times other people will take a certain dose, retest at three months, everything’s going great, and then they will stop taking that dose. Your levels will decrease to the level you’re taking. So those are the main pitfalls you can see with whether or not you’re going to get a benefit, it really depends on whether or not it’s getting in your body consistently. And if you take a super, super high dose but it’s too expensive, you don’t like it, too hard to take, that’s not ideal. You’d rather not have a really high level at 12%, let’s say, but you don’t like the process, you can’t sustain the process, it’s better to have a more sustainable long-term type of intake either through more fish intake or a fish oil dosage that is, I would think, two pills or the liquids are easier to swallow. That whole process has to be sustainable for this to be a lifelong habit, which is kind of what we see as the most effective thing.
Dr. Bill Harris: Good. Good point, okay.
Dr. Kristina Harris Jackson: That’s that. Thanks so much. We’ll do this again sometime. So send us your questions and maybe those will help us determine what we do for nutrition talks where we get really deep into this stuff so you can see what studies we’re actually talking about instead of just trusting us. You can just see for yourself. All right, thanks so much.
Dr. Bill Harris: Thank you.
Dr. Kristina Harris Jackson: We’ll see you next time.
Dr. Bill Harris: Bye-bye.