New Form of Secondary CHD Prevention
Heart Association Advocates Fish Oil Supplements
by Mitchel L. Zoler, Philadeophia Bureau - Family Practice News

CHICAGO - How much fish can you eat? Or would you rather take these capsules?

Those are the questions that primary care physisicans should start asking patients with documented coronary heart disease (CHD) now that the American Heart Association (AHA) has recommended that thesee patients consume about 1g of omega-3 fatty acids per day.

The AHA's new fish oil guidelines say that patients with documented CHD ideally should get their daily fish oil fix from an approximately 3-ounce serving of a fatty fish such as salmon, herring, trout or sardines. Somewhat leaner fish, such as canned tuna, halibut, and flouder also are fine but must be consumed in larger portions, according to the guidelines.

In a major departure, the AHA also said, for the firt time, that a recommended nutrient could alternatively be consumed as a supplement -in this case that would most commonly mean 1-g fish oil capsules that are widely marketed and contain 180 mg of eicosapentaenoic acid and 120 mg of docosahexaenoic acid. To get their daily doe, patients should take three of these capsules.

"This is the first pill supplement ever recommended by the AHA," William S. Harris, Ph.D., said in an interview at the AHA's annual scientific sessions. the AHA's nutrition committee found compelling evidence from controlled studies reported since 1999 that daily intake of about a gram of omega-3 fatty acids can significantly reduce the incidence of new CHD events in patients with established disease. The committee also realized that many Americans would find it difficult to eat sufficient amounts of fish on a daily basis. Accomulated evidence also has shown that fish oil capsules provide a similar benefit, and that they appear to be safe, said Dr. harris, coauthor of the recommendations and co-director of the Lipid and Diabetes Research Center at the Mid-American Heart Institute, Kansas City, Mo.

The major downside to heavy fish consumption is that some species may contain significant levels of mercury or other environmental polutants. Mercury intoxication is primarily an issue for children and women who are pregnant or breast-feeding, according to the guidelines. "For middle-aged and older men and for post-menopausal women, the benefits of fish consumption far outweigh the risks with-in the guidelines established by the FDA and the Environmental Protection Agency," the recommendations said.

Fish oil capsules should be "high quality" and free of contaminants, the guidelines stated. Currently, there are few mechanisms in place that allow the public to be sure of these characteristics, Dr. harris said.

The U.S. Pharmacopeia has recently developed a program that certifies nutritional supple4ments for purity and potency. Another possibility is that the AHA may start certifying fish oil supplements.

Until then, patients should look for 1-g fish oil capsules that each contain 180 mg of eicosapentaenoic acid and 120 mg of docosahexaenoic acid. This content provides some reassurance that the oil has been thoroughly processed and that contaminants have been removed, Dr. Harris said. A Norwegian company produces an ultrapurified 1-g capsule that contains 850mg of omega-3 fatty acids, and it is now seeking a partner for U.S. marketing, he said. But these capsules will probably be more expensive than the ones now sold in the United States, which can retail for as little as 5 cents a capsule.

The new guidelines also recommended that people without cardiovascular disease eat at least two servings of fish a week and also include oils and foods in their diet that are rich in a-linoleic acid, such as flaxseed, canola, and soybean oils; walnuts; and flaxseed. but fish oil supplements are generally benign, so there is no known downside if people who are in a primary prevention setting also use them, he said.

The recommendations also say that people who need to lower their serum triglyceride level -- usually when the level exceeds 200 mg/ dL - can accomplish this by taking 2-4 g of omega-3 fatty acids a day. For most people, the intake would need to be at least 3 g a day to have a triglyceride lowering effect, Dr. Harris said.

physicians shouldn't misconstrue this recommendation as a knock against drugs such as fibrate or niacin, which are the established agents for lowering triglyceride levels. But omega-3 fatty acids have some efficacy for lowering triglycerides and are an option for patients, he said.

© 2003 Wayne Hollopeter, M.D. All Rights Reserved
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