COLORADO SPRINGS — Omega-3 fatty acid capsules are an excellent alternative to the traditional fibrates or niacin for triglyceride lowering, John A. Merenich, M.D., said at a meeting of the Colorado chapter of the American College of Physicians.
“I am a huge advocate of the omega-3 fatty acids. If you haven't been using them, you've really got to try it,” asserted Dr. Merenich, an endocrinologist who directs population-management programs for Colorado Kaiser Permanente in Denver.
The American Heart Association recommends consumption of at least 1 g/day of the omega-3 fatty acids docosahexaenoic acid (DHA) and/or eicosapentaenoic acid (EPA) to reduce cardiovascular risk in patients with established coronary disease, and at least 2 g/day to treat hypertriglyceridemia. It's tough to get that much by eating fish. Besides, there is growing concern regarding the adverse health effects of eating large quantities of fish possibly contaminated by mercury, polychlorinated biphenyls (PCBs), and other toxins.
In nature, fish obtain omega-3 fatty acids by consuming large quantities of DHA/EPA-producing algae and plankton. When cost isn't an issue, Dr. Merenich's preferred source of omega-3 fatty acids is the DHA oil capsules produced by Martek Biosciences Corp. Martek has developed proprietary technology to grow large quantities of a DHA-rich microalgae, bypassing the middleman—that is, the fish—altogether.
“You don't have to kill the fish, you don't have to worry about the organic solvents, the mercury, dioxins, whatever. The PETA [People for the Ethical Treatment of Animals] people are happy. Everybody's happy,” he said.
It's a very well-tolerated product. The downside is it's quite expensive, at a cost of about $2/day.
Fish oil capsules are much cheaper. But it's important to understand that a 1-g capsule of fish oil typically contains only 300 mg of DHA/EPA. So to obtain 2 g of the triglyceride-lowering active ingredients, a patient has to swallow 6 or 7 capsules per day. Still, Dr. Merenich has found most patients are much more willing to do that than to take conventional, side-effect-laden niacin for triglyceride lowering.
“Niacin is a pain in the rear end,” he declared, noting that he is successful in keeping patients on long-term niacin therapy only about 60% of the time.
Fish oil supplements are distilled to achieve purity. Concerns about contamination by mercury, PCBs, or dioxin haven't been borne out in lab studies conducted by Consumer Reports and ConsumerLab.com.
Consumer Reports evaluated 16 brands of fish oil supplements in its July 2003 issue. None were contaminated. All contained the claimed quantities of omega-3 fatty acids. The review concluded it's reasonable to choose a product based upon low cost and listed two as “best buys”: Kirkland Signature Natural Fish Oil, available at Costco, and Member's Mark Omega-3 Fish Oil, sold at Sam's Club.
More recently, ConsumerLab.com tested 41 commercially available fish oil products. Again, none were contaminated by the environmental toxins that are increasingly concentrated in many fish species.
“The GNC and Vitamin Cottage products are very, very good and priced reasonably. I refer patients there,” said Dr. Merenich, who disclaimed financial interest in the products he discussed.
He added that the omega-3 fatty acids lend themselves particularly well to combination lipid-lowering therapy with statins. Many patients like the idea of taking a nonprescription 'natural' product along with their prescription drug. While statins primarily target LDL, in higher dosages they can also lower elevated triglycerides by 25%-35%.
Another reason to consider combination therapy is that a patient's LDL level often increases after initiating triglyceride-lowering therapy. “That's a common clinical situation. I probably get this question more than any other,” he said.
Even if the LDL does go up, the cardiovascular risk as reflected in the non-HDL cholesterol level is often reduced by effective triglyceride lowering. And non-HDL cholesterol is an even better indicator of risk than LDL, particularly in patients with metabolic syndrome.
Consider, for example, a patient with metabolic syndrome who has a baseline total cholesterol of 186 mg/dL, a triglyceride level of 258 mg/dL, an LDL level of 98 mg/dL, and an HDL level of 36 mg/dL. After 3 months of triglyceride lowering, total cholesterol is 179, triglyceride is 142, LDL is 113, and HDL is 38 mg/dL. That patient's baseline non-HDL cholesterol was 150 mg/dL; after treatment, it has dropped to 141 mg/dL.