Are Omega-3s a Myth?
In this episode, we dive into the murky waters of omega-3 supplements with the esteemed Dr. JoAnn Manson from Harvard MEdical School. Are fish oils the miracle cure they’re hyped up to be, or are we all just falling for another health fad? We’re breaking down the biggest myths, diving into what the research actually says, and figuring out who really benefits from these supplements. Plus, we’re answering your burning questions: Are plant-based omega-3s just as good? Do you really need to refrigerate that pricey bottle? Find out in today's episode.
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Juna Well, today is going to be a very fishy episode.
Eddie Fishy. I haven't had a tuna sandwich today. What are you talking about?
Juna Eddie, I'm sorry. No offense to you, but if you had a tuna sandwich, I would not let you destroy.
Eddie The studio is pretty small, so.
Juna Studio is, like five by five feet. Guys, if somebody brought 200 here, I'm sorry. They're out. But anyways, Eddie, today we are going to do our episode on omega threes.
Eddie You know, we've been doing this podcast for what is it more than five years. And I don't think we've ever had a real conversation about omega threes.
Juna Isn't that crazy. And you know what? It could not come at a better time because I have wasted so much money on omega three supplements. And I'm so confused because it's like, what do I even buy? There's salmon fish, krill oil. There's cod liver oil.
Eddie So just for the listeners, understand once again that this podcast is about Juna. And I know now, but they know these things can get pretty expensive.
Juna Yes, they can get very expensive. They can be like anywhere from 20 to $50 $60 a bottle.
Eddie Fish is also expensive.
Juna Fish is also very expensive. I don't eat fish, so I, you know, thought to myself, if I don't eat fish, I should try to get these omega three supplements because that's going to be healthy for me. And basically I'm just always confused by all the information online because everybody is saying different things. And I've spent so much money on omega three supplements that it's really hard to tell what I should actually be doing.
Eddie So hopefully by bringing in the world's expert on this, doctor, Joann Manson, we will have a very enlightening and, maybe less expensive solution for you.
Juna On today's episode. What are omega threes? Do they matter for our health? And what do you need to know about omega three supplements? I'm Juna Gjata.
Eddie And I'm Doctor Eddie Phillips, associate professor at Harvard Medical School.
Juna And you're listening to food. We need to talk. The only podcast scientifically proven to give you your daily dose of omega threes without any fish burps. First, we want to shout out one of our favorite reviews. Eddie, this has to be one of my favorite reviews that we've read of all time, because it has to do with the recent episodes we did and what we personally have changed from the podcast.
Eddie Again, it's about us. This one comes with six stars. I don't know, I'm just counting five stars. It would have been six from European Starling.
Juna Okay.
Eddie This title changed my life for the better. After hearing the recent episode where Yoona and Eddie shared what lifestyle changes they've made using the knowledge that they gained from the podcast, I thought it'd be fun to leave a review during the same exclamation point. This podcast has inspired me to get over my fear of the gym and start strength training.
Juna Sorry, I.
Eddie Do cardio training more often. Went from one time a week to 3 to 4 times a week. Incredible. And she is actually seeing improvements.
Juna Incredible.
Eddie Cut down on supplements and processed foods in general. And eat more. Yes. Real food.
Juna Yes.
Eddie I love this is just this litany of I know right? Learn from food. We need to talk. It goes on. Drink less caffeine in the afternoon.
Juna Yes.
Eddie My sleep schedule is so much better now. Yes. Stop caring so much about the number on the scale and focus more on feeling fit and healthy.
Juna I'm snapping.
Eddie These were all changes I made specifically from listening to the podcast. It's an awesome resource and so fun to listen to also. It's also one of the few I have on auto download. A definite must listen for those interested in health, nutrition and improving their lifestyle. Oh I am. My heart is pattering away. This is why I'll talk personally. Why I do the podcasts. This is why I became a doctor. This is what it feels like to be a doctor with a megaphone. You're not. You can have the same enjoyment without having spent four years in medical school. Four years of training. And for those listening. If you've experienced even one of these things and you know someone who might benefit from the podcast, why not share it?
Juna Totally, totally. Oh my God, this is such a kind review. Thank you Europeans darling. So heartwarming. And also, if you are listening and you have also enjoyed the podcast, go ahead and leave us a five star rating in review because it not only makes us feel great, it helps other people find the show. And another thing I want to mention before we start today is that Eddie is going to be running a marathon. Oh, and I wanted to let the listeners know because Eddie is raising money for a charity called Achilles International. Eddie, I'll let you talk about what the charity is.
Eddie So the main themes of my life, several of them are staying physically active and kind of pushing myself and doing grand things like my third and final marathon, the Chicago Marathon in the middle of October. But Achilles International supports disabled athletes, runners. To a large degree, over 140,000 athletes have been helped. When I'm running the marathon, there will be teams of Achilles folks taking blind runners, people who otherwise would not be able to do 26.2 miles alone. That's what Achilles supports. There are chapters around the world. I know there's one in Boston and Chicago, in New York, etc. I won't I won't belabor this. Please go to food. We need to talk. And his little banner that says run, Eddie, run.
Juna On our website.
Eddie If you click there. All the support is greatly appreciated.
Juna And the link is also in our bio on Instagram, if that's easier for you guys. And also, I just want to say, because a lot of people don't know this and Eddie is too humble, embarrassed to say things like this. But I just want to say that Eddie has never made any money from the podcast. He has volunteered his time for the past six years. Like all the late nights, we've stayed up writing script, editing scripts, doing research, looking up our guests, listening to our guests, other material to prepare for the episodes, and then coming to the studio and then giving me a ride home every day after the studio.
Eddie Oh, and throw in the free book.
Juna Oh, yeah. And the writing? The books. Eddie has volunteered his time this entire time, and it's like he has a lot of time because he's a doctor and a professor at Harvard Medical School. Right. So he has been so generous with his time over the past six years. So I think you would just be so awesome for us to all come together and support his marathon bid.
Eddie Thank you so much, Gina. And now on to the show.
Juna Today we're speaking to Doctor Joann Manson, professor of medicine at Harvard Medical School and chief in the Division of preventive medicine at Brigham and Women's Hospital. So the first question we have for you is, what are the biggest misconceptions about omega threes and the myths and exaggerations that you've seen in the media about mega threes?
JoAnn Well, I think a big misconception is that taking fish oil supplements or omega three. Supplements is a substitute for having fish in the diet and having a healthy diet. I really want to emphasize that taking omega three fish oil, or any other dietary supplement will never be a substitute for a healthy diet and healthy lifestyle. And when you have a diet with one, at least 1 or 2 servings of fish per week, the fish itself is providing omega three as well as replacing other components of the diet in some cases, such as red meat or processed foods. Therefore, the dietary pattern, the overall diet is healthier. So we certainly encourage the public to have adequate omega three from the diet. Having a minimum of 1 to 2 servings of fish per week. And if people don't eat fish using plant based omega threes such as flaxseed oil and, various vegetable oils that are high in alpha linolenic acid and other plant based omega threes.
Eddie If we stay with the fish, which I do like, and many of our listeners do. Any difference from one kind of fish to another? Should they be cold water fish or the sardines and anchovies actually better or higher in omega threes?
JoAnn There are fish that are higher in the omega threes. They're generally the darker fatty fish. And sardines and herring are excellent examples. Salmon and mackerel are good examples. The lighter fish are also very good for you, but not as high in the marine omega threes.
Juna And then can you explain what omega threes are. And also does the balance of omega threes and omega sixes matter. I feel like a lot of what I hear on social media now is that you have to also watch the balance between those two.
JoAnn Well the omega threes are long chain poly unsaturated fatty acids. And they're both the marine sources such as fish and other marine animals and plants, as well as the plant based omega threes that as I mentioned, you know, flaxseed oil and some of the other vegetable oils. There are some differences. There's increasing evidence that the EPA may confer even more heart, cardiovascular disease benefits than combination of EPA plus or DHA for alone and greater benefits than the plant based omega threes such as alpha linolenic acid. So there are some differences. And we can talk further about what some of the randomized trials show.
Eddie And I think over the years, like we were looking at what has been in the social media and what people believe out there. The hope or the thought was that the omega threes would protect against cardiovascular disease, support brain health, reduced risk of cancer, and the reason why we asked you to come on to food we need to talk is because you've conducted, well, many studies. But one particular that I'm thinking about is the vital study. It was only years and years, but can you summarize what what you're found and what we learned from the vital study and what benefits we could look to the evidence in terms of our our overall health?
JoAnn Yes. So the vitamin D and omega three trial vital is the largest randomized trial of the marine omega three EPA plus DHEA ever done. You know, in the world, it's also the only truly primary prevention trial of omega three large scale trial of omega threes, meaning it was done in a population at usual risk, not selected for prior cardiovascular disease or having specific risk factors. The other trials of omega threes have been generally high risk populations with prior cardiovascular disease, or they already have high triglycerides or multiple risk factors for CVD. So this is more of a usual risk population in midlife and older ages. And what we found in vital was that the omega three fatty acids led to only a small but statistically not significant reduction in overall cardiovascular events. However, we did see a statistically significant 28% reduction in. Heart attacks, which was a prespecified secondary outcome, no reduction in stroke. And so overall, the results for major cardiovascular events which included heart attacks, strokes and cardiovascular death were only modestly reduced. Overall, the randomized trials of omega threes and there have now been about 15 trials and at least as many meta analysis of these trials of omega threes have shown that overall, the omega threes reduce heart attacks and coronary events. But they do not reduce stroke. And so the effects on the composite outcome of heart attack plus stroke perceived death tends to be not significantly reduced. But there are those cautionary benefits. Now the one trial, the one randomized trial that had really different results and is considered an outlier trial was the Reduce-it trial, which tested high dose EPA only. So this was not a combination of EPA plus DHEA. It was a purified form of EPA, four grams a day of icosapent ethyl, and they found a 25 to 30% reduction in both coronary events and stroke. And so overall major cardiovascular events were significantly reduced. However, some concerns have been raised about the Reduce-it trial because the placebo used was mineral oil, and this was a population where everyone was on statin medications. It was high risk population with either prior cardiovascular disease or having diabetes plus other cardiovascular disease risk factors. They also had to have triglycerides of at least 150mg per deciliter. So they had to have at least moderately elevated, triglycerides. And the concern was that the mineral oil placebo may have adversely affected some of the biomarkers, like, inflammatory markers and others, as well as interfered with absorption of the statin medication in the placebo arm, which could have made the icosapent ethyl look better than it would have with an inert placebo. There really needs to be a replication trial of reduce-it using an inactive placebo, something like corn oil, where there wouldn't be concerns about the absorption of statins or adverse effects on CVD biomarkers. That trial has still not been done, but there are many, clinicians and researchers who have tried to get funding for the trial and clinicians waiting for those results.
Juna So doctor mentioned we have a membership where we will often ask people for questions. And we got so many questions from people about omega threes and vitamin D. And related to the 15 trials you were talking about. We got questions from Rachel and Cynthia asking if there is a difference between fish and omega three supplementation, which you kind of talked about a little bit earlier. But in these 15 trials, was it always omega three supplementation, or were some of them done with natural sources like fish? And do you think the average person should be supplementing with omega threes if they don't eat fish? If they do eat fish, what populations should be using it to supplement?
JoAnn So all of these trials were of omega three supplements okay. Were not trials of fish specifically. And that's because it can be blinded. You can have a randomized clinical trial with a placebo comparison group control group. And these trials were generally testing a combination of EPA plus DHEA, which is found in fish. You know, as I mentioned, fish also has the advantages of replacing unfavorable components of the diet, such as red meat or, you know, heavily processed foods. So it has those additional advantages we found in the vital trial that people who started out with low intake of fish, those who had less than the average, we just split it at average intake of. Fish, which was one and a half servings of fish per week. Those who have lower than average intake did significantly benefit from the Omega three supplement. This was one gram a day of combination EPA plus and reduce the primary outcome of major cardiovascular events by about 20%. If they had low fish consumption at baseline and those who were already at one and a half servings of fish per week did not benefit from this one gram a day of omega three, suggesting, I mean, this seemed highly plausible biologically, that there was a threshold effect, especially when you're using a relatively small to moderate dose of one gram a day of omega threes that if you're already getting adequate omega threes from the diet, and fish as the major source of omega threes, that there may be little benefit from taking a moderate dose supplement.
Eddie So let me pick up on two points there. One of them is are there ill effects of taking too much. And if so what's the limit. And then other examples of people taking, as I seem to remember, people taking way above four grams a day if they were trying to improve their mood or help their their mental health. So sorry for two questions at the same time, but that's okay.
Juna I was like five.
JoAnn Really good questions, Eddie. So there are adverse effects of high dose omega threes. In fact, we did a meta analysis of seven randomized trials that looked at the development of atrial fibrillation that had atrial fibrillation as an outcome. And there was an increased risk of atrial fibrillation with doses above one gram a day, but not a material increase with one gram a day or less. So we did not see a significant increase in atrial fibrillation in the vital trial with one gram a day. But trials testing higher doses, especially four grams a day, were finding 30 to 50% increase in risk of atrial fibrillation. Also, those trials find an increased risk of bleeding. So the omega threes in high doses can lead to some anticoagulant type effects and increased risk of bleeding. But generally, it is believed that the benefits will outweigh the risks, with doses up to four grams a day under the supervision of a clinician. We are not recommending that people just go out and start taking four grams a day without some supervision.
Eddie Professor Manson Joann, I am learning so much from this conversation, but we need to take a quick break. Before we do, I just want to say to our listeners, please share this episode. Send it to someone who you think needs this information.
Juna I'm going to turn to my dad because he's always ask me questions about omega threes, and then I'm gonna send in the bonus episode because my dad is obsessed with vitamin D, so this whole episode is being sent to my dad.
Eddie And we'll see you right back after this short break. And we're back with doctor Joann Manson from Brigham and Women's Hospital and Harvard Medical School.
Juna We had a question from one of our members, Katrina, who asked, are there other food sources of omega threes besides fish? And are they the same or inferior or superior?
JoAnn There are other sources, and in fact, for people who are vegetarian or allergic to fish, there are algae based omega threes that are on the market. They've not been tested in large scale, rigorous randomized clinical trials, but it would be expected that they may have, you know, similar coronary benefits, but probably not stroke benefits unless there is a very high dose, such as in the Reduce-it trial. They're also plant based omega threes, flaxseed oil, the vegetable oils, alpha linolenic acid that have been tested in a small number of randomized clinical trials have not shown clearly significant reductions in cardiovascular events or heart attacks, but at least had suggestive patterns for some benefit. I think generally they don't confer the same benefits as the marine. Omega threes is giving EPA or DHA because there's only a low rate of conversion of alpha linolenic acid, or these plant based long chain omega threes into EPA or DHEA.
Juna So in other words, is that that plant based omega threes are not as bioavailable as marine based omega threes.
JoAnn Well, in terms of having the conversion to EPA and having some of these cardiovascular benefits. But that said, if you're a vegetarian you're not going to eat fish. You're not going to take a fish oil supplement or a prescription omega three made of EPA. And I think we should come back to the difference between prescription medications and over-the-counter omega three supplements. Then it is important to get adequate omega threes from the diet. And this would be flaxseed oil, vegetable oils, alpha linolenic acid, which even though have not been shown in rigorous randomized clinical trials to reduce risks, do show a pattern of risk reduction in those trials.
Juna Great. So I'm really curious to hear about the prescription omega threes, because I actually have never heard of that before. So if we could start with that and then go into omega three supplements, that would be great.
JoAnn So first let me say for prescription omega threes. They have been approved by the FDA for people who have specific indications. And so, you know, your doctor clinician would talk with you about your triglyceride levels are very high, such as above 500mg or you have a history of cardiovascular disease or diabetes, plus other risk factors and a moderately elevated triglyceride level. You would then qualify for icosapent ethyl high dose EPA that was tested in Reduce-it, and that is a prescription omega three. Also in vital. We tested a prescription high quality omega three that had been used to treat high triglycerides and have been tested in some other randomized trials. Looking at people who already had a history of cardiovascular disease, we tested it in primary prevention. So very importantly, you know, see if you have indications for getting a prescription product. And not everyone is a candidate for getting a prescription product. And that's where over-the-counter come up. Now in vital, we saw people who had low intake of fish, as well as those who had two or more risk factors for cardiovascular disease. And in our study population, the African-American or black participants really benefited in terms of reduction in heart attack. So for heart attacks, specifically in the overall study population, we saw a significant 28% reduction, but it was more than 40% reduction in heart attack among those with low fish consumption. The African-American or black participants, and those who had two or more risk factors for cardiovascular disease. So those were groups who really seemed to benefit, and groups who may want to talk with their clinician about whether they should take over the counter fish oil supplements. Now, if you're going to take over the counter, do always check for a seal of quality control auditing. And this would be the USP, Pharmacopeia, the USP seal. The NSF National Science Foundation seal or it says tested by Consumer lab.com. You have some indication that the product has been tested for quality control, gone through a quality control audit where they check that the dose of the pills is actually what's listed on the label, that it's free of heavy metals, free of microbes, and that you can trust the, quality. There are omega three products, fish oil products on the market that don't have that, quality control auditing. So you need to select the products that do have indicators, the seals of a third party auditing.
Juna Can you talk about does the source matter whether it's called liver oil, krill oil or salmon? Is there any one that's better than another?
JoAnn Can you clarify? Do you mean for the supplements or for the diet?
Juna For the supplements? Yeah.
JoAnn So what's really important is to look at the contents in terms of the amount of marine omega threes. Okay. As I mentioned, there is some benefit from Reduce-it that EPA may be even more important than combination EPA plus DHEA for reducing cardiovascular risk. However, I think we need that replication trial of EPA alone. So I'm not going to make a recommendation to avoid combination EPA plus DHEA. I think look, to be sure that the content that you're taking is generally at least one gram a day, because it probably will not be too much benefit from the smaller doses. And this is particularly for people who have low fish consumption. Again, to get at least one gram a day of either EPA alone or combination EPA plus DHEA, and also look for the USP seal or other quality control seals, whether it's salmon, sardines, algae, or krill oil. You know, krill oil usually will require more capsules. I think it's really more what the dose is and the quality control of the over-the-counter product.
Juna So it'll say on the back, EPA plus day one gram or whatever.
JoAnn It usually will tell you the amount of each as well as the total.
Juna And then does it need to be refrigerated once you buy it? Or can you leave it in your cabinet?
JoAnn It can be left at room temperature, but you need to avoid temperature higher than room temperature. So if you're leaving it right next to a window, that's getting a lot of sun and it gets really hot, that can make it go rancid. Also, if there's a lot of humidity around, you want a kind of climate controlled room? Room temperature, but low humidity that it can be kept at room temperature.
Juna Okay. And then I'm guessing that you're not going to be able to answer this question, but are there any brands you recommend or are you not allowed to say?
JoAnn All I will say there because I don't want to promote a specific brand. Look for the seal of quality control testing, okay. And look for that USP or an A for other seal of third party auditing for quality. And then I think it will be a higher quality over the counter product. Or talk with your clinician about whether you're a candidate for prescription omega threes, which undergo very rigorous quality control testing. And many people will be candidates based on having a very high triglyceride level or having multiple, you know, risk factors being at very high risk of cardiovascular disease.
Eddie Before we break off, I just wanted to bring you back to, questions about brain health. So, mental health and dementia, cognition more broadly. What's the evidence?
JoAnn So the evidence for omega three is being of benefit for cognition. Mood or depression has been very mixed. The studies have been very mixed. And there isn't a consistent message now in the vital trial with the one gram a day of EPA plus DHEA. We looked in detail at cognitive change, mood, depression, and we found very neutral results for the omega threes. Now, I do want to contrast that a little with the vitamin D in the vitamin D omega three trial vital. We found no clear benefits of vitamin D for cognition or mood depression. However in our African-American and black participants. And we did actually make a point of having a large percentage of our study population in that group because we thought that vitamin D could be of greater benefit for black and African-American adults. We found that the vitamin D did have some benefits for slowing cognitive decline in the African-American and black participants, but we saw neutral results for omega threes across the board for both cognition and mood depression. But no worrisome findings. Just generally neutral absence of benefit or risk.
Eddie And you know, we're going to be speaking all about vitamin D in the bonus episode. Excellent.
Juna Yes. And Doctor Manson, thank you so much for your such straightforward and information rich way of talking, because I feel like we entered so many questions from our listeners in a pretty good amount of time, and we are going to be diving into that vitamin D in our bonus episode. But I just want to say thank you so much, because this has been so helpful.
Eddie And, you know, other than just the hour you spent with us, thank you for your decades of work in this area and being the the voice of reason and the evidence based person that I've read your work for years to just answer some of these basic questions. And thanks for coming on. Food. We need to talk.
Juna And as someone who super grossed out by fish, I, I like I really don't like the smell. But honestly, your your first answer is really making me reconsider trying to eat it because. Yeah. I just think you were very convincing.
JoAnn Well, thank you for inviting me. It's been a pleasure talking with both of you.
Juna Thank you so much to Doctor Joann Manson. We will link to her work on our website. And if you want to hear our bonus episode where we debunk vitamin D supplements and Doctor Manson tells us what is in her medicine cabinet, what kind of supplements she takes, you can go to food. We need to talk.com/membership or click the link in our show notes. You can find us on Instagram at food. We need to Talk. You can find me on Instagram at the official USA and Unita on YouTube and TikTok. You can find.
Eddie Eddie reference above. Running.
Juna Preparing for his marathon. Food. We Need to Talk is produced by me and is distributed by PRX.
Eddie Our mix engineer is a Rebecca Seidel.
Juna We were co-created by Carey Goldberg, George Hicks, Eddie Phillips and me.
Eddie For any personal health questions, please consult your health provider. To find out more, go to food. We need to talk.com. Thanks for listening.
Juna The more you know. Did you like that?
Eddie What's that?
Juna Moving.
