Counting back from omega

If you are a human being living on Earth, you know by now that omega 3 fatty acids are some of the most sought-after supplements on the planet. I have no affiliation with any of the industries producing them, however, I am well acquainted with the options available to choose from in many markets in the world. I do not endorse the sale of any of the omega 3 prescription drugs mentioned in this post. They are presented solely with the purpose of comparison as the identification using the generic names would have been too confusing.

If you want to make an idea about the potential for confusion associated with selecting the right omega 3 supplements, go ahead and search “omega 3” on Google and over 1.5 million results will display for you in the blink of an eye. I dare you to develop an original strategy to pick the right omega 3 supplements without reading them all! Amazon alone will report the availability of 4,000 different omega 3 containing over-the-counter products. Is it all noise? The cost of a capsule ranges anywhere from 10 cents to over $3 each. How many of these are a scam? How many pose a health risk and how many won’t have an effect at all? Hopefully, none of them would hurt someone but, as far as I am concerned, not doing any good isn’t something I am willing to ignore either.

Aside from the OTC options, one’s search may encounter a handful of omega 3 based prescription drugs. They include either a combination of the purified carboxylic acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) – such as Epanova® – or omega 3 esters enriched in EPA/DHA – such as Lovaza® on the US market, Omacor® on the non-US markets, and Lotriga® in Japan – or, at the very least, an EPA derivative alone – such as Vascepa®. What do they do and how do they differ from each other?

Fish oil – such as cod, herring or salmon – does contain omega 3, including each of the esterified EPA and DHA. Why don’t we use fish oil? What made us move away from it after all? There are three bold reasons that kept humans searching for better alternatives to fish oil:

  1. contaminants (mercury and polychlorinated biphenyls – PCBs)
  2. risk of vitamin A toxicity
  3. minimal effectiveness in elevating EPA blood levels
  4. fishy taste

Of all, #3 seemed to defeat the purpose of supplementing omega 3 in the first place. While DHA has many anti-inflammatory benefits, it is the EPA that is the main active ingredient responsible for the lowering of bad cholesterol, particularly triglycerides (TGs). How little would the fish oil increase the much needed EPA levels? Well, put it this way: the best information we have access to comes from the ECLIPSE-II trial which compared Lovaza® – call it an EPA/DHA “enriched fish oil” – and Epanova®, a drug delivering a mix of purified and de-esterified EPA/DHA. This study demonstrated that taking 4grams of Lovaza® increases the blood EPA level from 9.5µg/mL to 34µg/mL after 2 weeks of treatment, while the same dose of Epanova® increases it from 13µg/mL to 143µg/mL after 2 weeks.

Do I play the Pharma cheerleader here? Not at all. I am, in fact, trying to make a point about how much fish oil (which contains considerably less EPA/DHA than Lovaza®) should be expected to improve blood levels of EPA. Let’s do some math! We know that 4grams of Lovaza® increased the blood EPA level from 9.5µg/mL to 34µg/mL. One of the products with the highest omega 3 sales rank on Amazon-US is Icelandic Ultra Pure Omega 3 Fish Oil from Bio Schwartz. The product lists a total of 900mg EPA and 150mg DHA per serving. This means that one would need four to five servings to reach the Lovaza® performance – which I can’t even call “performance”. The worst is yet to be discussed, however! Bio Schwartz is fair to mention it but how many clients know to read the label that states “Serving Size: 3 Softgels”?? That means that you need 3 softgels to achieve the 900mg EPA in the serving size. This equates to taking 12 to 15 softgels per day (4 to 5 per meal) in order to reach a potential under 50µg/mL EPA in the blood. How much protection is that?! This is the reason why I did not recommend this product in Dr. Alice’s Shop.

The situation is fishier for omega 3 supplements sold on Amazon in Europe. A concerning proportion of the OTC products do not show the ingredient list. For these the decision is easy: don’t buy them! For the few for which I could read the ingredient list, here are a few examples:

  • From Amazon UK no sales rank was available but here is one that had over 1,000 FIVE STARS customer reviews: Omega 3 Fish Oil by Nu U Nutrition. Each capsule contains 180mg EPA and 120mg DHA. In order to approach Lovaza® effect (which is nearly nothing), one would need to take no less than 22 softgels per day – thus about 6 to 7 per meal! This is the reason why I did not recommend this product in Dr. Alice’s Shop, despite the “overwhelming” five start review form over 1,000 customers. It must have been a really good placebo – that’s all I can say.
  • From Amazon Germany, same as above although with only 700 reviews here. I picked another 700+ FIVE STARSs reviewed as an example anyway: Omega-3 Kapseln Fettsauren aus Krillol by Livoa Vital. Each capsule contains 100mg EPA and 56mg DHA. Choose this and you will “only” need 40 softgels per day to reach minimal to no effectiveness what-so-ever. Not sure what they wanted to develop – maybe a homeopathic product?? What in the world?? Who pays 30 Euro for that?? I guess 700+ happy customers! I do not recommend this product – period!
  • From Amazon Canada, I could find minimal reviews comparing to the rest of the world. So, instead of picking one of the many low-dose EPA products with under 100 reviews (ineffective, of course), I picked one that I believe is very effective but prohibitively expensive. I do not recommend it in my shop because of the bad ratio quality/price. However, it was worth mentioning to give you an idea of how you should read the label. Viva Labs is marketing an Omega 3 Fish Oil supplement that delivers 700mg EPA and 240mg DHA per softgel. Five to 6 softgels are still needed daily to approach Lovaza® effect (again, minimal anyway) but you did not hear the price: CDN$103.98.
  • From Amazon Italy, same as Germany and UK, I found hundreds of customers happy to buy a placebo pill with minimal effect. I am really curious what is the satisfying part of that softgel… With much fewer reviews, but way better content (still don’t recommend it due to poor quality/price ratio) comes Omega 3 SYW by See Yourself Well. For 44.10 Euro, each softgel delivers 400mg EPA and 200mg DHA – you need 10 softgels daily to reach the same (minimal!) effect of Lovaza®. The amount may be ok for daily supplementation WITHOUT the goal of lowering triglycerides, but if I am to do that I want a better price.
  • On Amazon Spain, the Nu U Nutrition product dominates again although here it does not reach hundreds of reviews. Remember, you are paying for 180mg EPA per softgel and need 22 of those. Moving to the next most reviewed omega 3 product: Omega 3 + Krill by Salud Plastimea Nutri. It took me a while to read the ingredient list but, nevertheless, here is what it seems to say: 264mg EPA and 170mg DHA. Should you go for it, about 15 softgels daily would give you a minimal EPA improvement.

With these examples covered, now let me tell you why I make such a big issue out of the circulating EPA that one should reach if targeting to lower TGs. Individuals with elevated TGs and less than 87µg/mL blood EPA had the highest risk for major coronary events. Individuals with an EPA higher than 150µg/mL had a 20% lower risk for major coronary events. That is an impressive improvement! However, could you tell me how would one be able to reach 150µg/mL with an OTC product delivering 100mg EPA per capsule when the minimum needed daily dose is 4grams EPA?!

Be mindful when selecting your omega 3 supplements and account for the fact that your stomach won’t thank you for taking 3 or more softgels at a time. Should you find the right product for you based on the rationale described here, remember that esterified omega 3 has to be administered with oily food as the pancreatic lipase is needed for their absorption and this enzyme is only produced in response to fat reaching the gut. Of course, that should be modest enough not to defeat the purpose of the pill. Don’t take it with two spoons of mayonnaise!

Last, not least, remember to look for an EPA/DHA ratio equal to or higher than 1.5 as that was shown to achieve the maximum effectiveness. Let me know if you have any questions about any of the above or about the products that I recommend in Dr. Alice’s Shop. I also invite you to comment below and post pictures of the omega 3 ingredients list that you have at home.

Stay healthy until next time!

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Dr. Alice

I teach people how drugs work, when they are needed, and why. My expertise as a pharmacist and researcher allows me to determine whether taking or not taking a drug will pose any risk given all current circumstances that apply at this moment. Many times we don't know unless we try, but other many times walking the extra mile pays off giving in return more wonderful moments and more to give to others.

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