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FAQ (9)

Are Fish-Oil Supplements as Good as Fish?

Maybe not. They both contain the essential omega-3 fats, so you might think that the benefits would be the same. Recent research, however, suggests that may not be the case.

That comes as a surprise to many people (including me). Ten percent of us take fish oil caps, a group exceeded only by those taking multivitamins or calcium. After eating fish regularly (mostly salmon) for a long time, my HDL “good” cholesterol increased with the addition of fish oil capsules, from a very good  65 to a terrific 75. The benefits of adding fish oil seemed evident.

Health organizations from around the world recommend eating fatty fish several times a week. Moreover, the American Heart Association gives people with heart disease the option of taking fish oil supplements to meet the omega 3 intake it recommends.

Observational studies clearly show that people who eat fish regularly have fewer heart attacks and strokes. While the precise mechanism is unknown, research, mostly in the lab, has shown that the omega 3 fats in fish oil help prevent abnormal heart beat and blood clots, reduce inflammation, and make arteries more flexible. There are other benefits, but those are the main ones. 

Research in the last few years, however, has raised doubts about the benefits of fish oil supplements. While most of the earlier studies found benefits, the latest studies have not. The new research is summarized in the May 2013 issue of the UC Berkeley Wellness Letter.

In 2012, two large meta studies concluded that the evidence does not support claims that omega 3 supplements help prevent cardiovascular disease. Another large review study that year found that while 26 observation studies found that fish oil was associated with moderately reduced stroke risk, 12 clinical trails involving supplements found no benefit. Also in 2012, a large trial of people with diabetes or prediabetes who took omega 3 supplements daily for six years showed no reduction in heart attack or stroke or death. A British study in 2011 found that various doses of omega 3 did not keep arteries flexible in healthy people. Another British study found no vascular benefit in people with peripheral artery disease. However, another study in the same journal concluded that omega 3s can improve arterial functioning.

Why the inconsistency? What, if anything, has changed in the last few years?  

One factor mentioned frequently is the increasing use of state-of-the-art medications such as statins and blood pressure drugs. “That helps explain the apparent lack of effect of the supplements,” the Wellness Letter wrote. “Even if omega 3s provide benefits, these would be hard to detect against the back drop of much larger benefits of these drugs.”

Until the uncertainty is settled, the prudent thing would be to get your omega 3s from fatty fish, with supplements as a fall back option for those who, for whatever reason, can’t tolerate fish. If you want to go the supplement route, it would be wise to check with your doctor beforehand.

“The supplements have few, if any, serious adverse effects,” the Wellness Letter adds, “unless, that is, they lead you to think you can eat an unhealthy diet or avoid taking statins or other drugs you may need.” Supplements are rarely a good substitute for whole food.

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I’ve made some changes in my omega 3 intake, mainly due to a factor that may be unique to me, but also because of the new research.

I was eating salmon regularly and also taking a fish oil cap three times a day with meals. That may have been too much, because I started having a mild but persistent headache. After trying several other things, it occurred to me that overdosing on omega 3s might be causing my headache. I stopped taking the fish oil caps and within a day or so my headache went away. It may have been a coincidence, but it did seem to work. [Later investigation suggested that my headache was  due to an inflammation of the nasal passages, sinusitis; after addressing the problem, I added back one fish oil capsule at lunch, along with sardines as explained below.]

I also made another change. I  switched from salmon to sardines—for breakfast. Whoa! Hold on. I can see many of you recoiling at the thought of sardines for breakfast. Please hear me out before rejecting the idea.

I have 2 or 3 ounces of sardines with a sliced hard boiled egg, along with my “Old Reliable” breakfast mixture (whole grains, fruit, vegetables, mixed nuts, and non-fat milk). I eat the egg and sardine combo while I fix the Old Reliable.

My sardines come packed in mustard or tomato sauce, which is quite tasty with hard-boiled egg—better than the egg alone. We had a man and his wife here last month for a 2-day consultation and, after a bit of hesitation, they enjoyed the sardine-egg combination. They cleaned their plates on both days, and went home with photos of the brands we buy on their cell phones.

If you’re still hesitant, I have more news on sardines. The UC Berkeley Wellness Letter says that sardines are fast becoming the fatty fish of choice. Calling sardines “the top choice across the board,” the Wellness Letter explained that the little fish is one of the riches sources of omega 3 fats—richer than many fish oil supplements. They’re also a “good ecological choice.” Sardines are abundant in most parts of the world and contain far fewer contaminants than fish higher on the food chain, such as tuna, swordfish, farmed salmon, and most other fatty fish.

Eaten with the bones, sardines are also a good source of calcium.

Here's another reason to consider sardines for breakfast. Packed with protein and good fat, the sardine and egg (I eat the yolk) combination helps to stabilize your blood sugar, keeping you satisfied longer that the Old Reliable or other cereal mixtures alone. That's a fact. I guaranty it.

Finally, sardines are convenient, coming packed in water, oil, and tomato or mustard sauce. Just open the can and eat. I don’t care for the sardines packed in water or oil, but the mustard and tomato sauce turn sardines into a tasty treat, even for those who don’t much care for fish.

Let’s hear it for sardines!


This photo, taken by Carol, gives you an idea of my portion size. That's one egg.

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I'm scheduled for a blood test soon and will discuss the changes, if any, in my lipid profile with my doctor. It's always wise to discuss major changes in you diet with your doctor. Best practice is to talk to your doctor before making changes.

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Are Eggs Back In the Dog House?

A new study reported August 14, 2012, in the Journal Atherosclerosis found that eggs are nearly as bad for your arteries as cigarettes.

Earlier research from Harvard Medical School (1999) and elsewhere suggested that it’s not so much the cholesterol in foods that cause health problems, but the amount of saturated fat. Eggs are high in cholesterol, but relatively low in saturated fat. Both the cholesterol and fat are in the yolk. Many--certainly not all--doctors have been telling their healthy patients it’s okay to eat eggs in moderation. Eggs are an excellent low-calorie, low-fat source of high-quality protein and other important nutrients.

The advice on eggs may be changing--once again. (Please hear me out before deciding whether to act on the basis of the new study.)

I've been all over the map on egg consumption, eating six or more raw eggs daily early in my life, none for a time, and than gradually putting them back into my diet. I currently eat two hard boiled eggs a day, one with breakfast and another later in the day--with no adverse effects on my cholesterol profile.

Let's review the new study, and then see where we stand.

Researchers led by Dr. J. David Spence of Western University in Canada used information on 1,231 men and women, average age 62, gathered at a vascular prevention clinic; many of the patients had been referred after suffering a stroke or transient attack. Ultrasound was used to measure the atherosclerotic plaque in their carotid arteries, and a lifestyle questionnaire was used to document their smoking and egg consumption. Smoking was measured in pack-years (number of packs per day times the number of years), and the number of egg yolks consumed per week times the number of years consumed (egg yolk-years).

An analysis of this information found that smoking and egg consumption were each independently associated with increased carotid artery blockage--a known risk factor for stroke and heart attack. Regular egg consumption had two thirds of the association of smoking. Interestingly, those who did not smoke or who rarely ate eggs showed increasing carotid wall thickness after age 40; blockage increased linearly. Thickness for smokers or egg eaters, on the other hand, increased exponentially; it became more and more rapid. The study found that those eating three or more yolks a week had significantly more plaque than those who ate two or fewer yolks per week.

"We believe our study makes it imperative to reassess the role of egg yolks, and dietary cholesterol in general, as a risk factor for coronary heart disease," the researchers wrote. While acknowledging that more research should be done with more detailed information about diet, and other possible confounders such as exercise and waist circumference, Dr. Spence and his colleagues suggested that regular consumption of egg yolks should be avoided by persons at risk for cardiovascular disease. (Some people appear to be particularly vulnerable to cholesterol consumption; diabetics are an example.)

Sounds bad; but is the connection between eggs and arterial blockage as clear as this study suggests? Should everyone curb their egg consumption?

Maybe not. First, the new study found an association between egg consumption and plaque build-up, which is quite different than finding a cause-and-effect relationship. We don't know what other factors may have been involved, as the researchers acknowledged in their conclusion.

For example, the study doesn't explore what the subjects were eating along with their eggs. How many people do you see ordering soft- or hard-boiled eggs? Fried eggs are far more prevalent--with hash browns and bacon or sausage, along with buttered toast. The problem may not be egg yolks, but how the eggs are cooked and what comes with them.

I have my hard-boiled eggs sliced with a little salt and fruit (usually orange slices) in the morning and in an egg salad made with Nayonaise and a dash of mustard in the afternoon.

Exercise and belly fat were two other possible confounders listed by the Canadian researchers. How many of the subjects were sedentary or overweight? We don't know.

If you are at risk for cardiovascular disease or have high cholesterol, limiting egg consumption is probably wise--especially if that's what your doctor recommends.   Even more important, however, may be whether you exercise regularly, your body composition, and your overall diet.

Eaten in moderation, eggs may still be a very good thing for most people.

(For more facts about the pros and cons of egg consumption, see my earlier article on the subject: http://www.cbass.com/Eggs.htm )

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Is Cancer a Lifestyle Disease?

Q: Your commentary on Next Medicine (# 301, Lifestyle) says that Dr. Bortz makes a strong case for lifestyle in the prevention of cancer, but you didn’t elaborate. What’s the story on lifestyle and cancer?

A: I focused on heart disease and touched on diabetes, because cancer is more complex. Cancer is an umbrella name for many different diseases—colon cancer, breast cancer, prostate cancer, kidney cancer, skin cancer, etc—with lifestyle playing a different role in each permutation. That said, Dr. Bortz argues forcefully that well over 50 percent—perhaps as high as 90%—of cancers are preventable. He believes the current emphasis on treatment over prevention is misguided. “Playing catch up with surgery, radiation, and toxic drugs once cancer has taken hold reflects an inappropriate obsession with the concept of cure,” he writes. “Some call the present war on cancer futile,” he adds.

The additional factor in cancer prevention is environmental. Citing Walter Willett, head of the Harvard School of Public Health, Bortz asserts that 60% to 80% of cancers have an environmental cause. “Among the many identified environmental factors are smoking, radiation, hormones, viruses, and organic solvent [and] surely others,” he explains.

As in the case of heart disease and type 2 diabetes, diet and physical activity are the other primary factors. “Dr. Michael Marmot, professor of public health at the University of London, suggests that physical exercise, low [saturated] fat and low-sugar diet, and limiting one’s consumption of meat, alcohol, and salt would prevent one third of all cancers,” Bortz writes.

Continuing, Bortz opines: “Individual and collective responsibility calls for avoiding as many of those factors as possible: not smoking, using organic products, eating a diet rich in leafy vegetables, being careful about sun exposure, building lean muscle mass, and taking precautions against toxins at home and at work.”

 Two Forms of Fitness

Separately, in another article, we explained how fitness and strength training fight cancer separately. A key finding was that muscular strength and cardiorespiratory fitness were only “moderately correlated.” This suggests that the associations between the two forms of fitness and cancer risk involve “different mechanisms.” Both strength and aerobic fitness appear to have profound and independent effects on cancer risk. A combination of the two forms of fitness, working together, would appear to be most protective—and that’s what one of the studies found. For full details, see Strength and Fitness Fight Cancer Independently http://www.cbass.com/Strengthtrainingandcancer.htm

Too Much Exercise

Finally, there has been some indication that ultra-endurance races, such as the Western States 100-mile, may weaken immunity and possibly heighten cancer risk. Writing in the July 2011 special issue of Runner’s World devoted to “Outrunning Cancer,” Amby Burfoot dismissed this concern. Burfoot quoted David Nieman, DrPH, who studied Western States competitors. “There’s no question that running Western States represents a real physiological insult,” Nieman said. Still, he concluded that “the immune resiliency displayed by [most runners] was the most impressive result.” (The special edition of Runner’s World is filled with runners who have overcome or succumbed to cancer.)

It is well-known that marathon runners often come down with colds or worst in the weeks and sometimes months after the race. This is especially true of ultra-marathoners. In a five year study of 350 athletes in the Western States Endurance Run, perhaps the same study cited by Amby Burfoot, Dr. Nieman found that one out of four runners reported sickness during the 2-week period after the race. (Medicina Sportiva, November 16, 2009)

In another study, Dr. Nieman found that runners who trained for a marathon, but ended up not running the race, had fewer colds than runners who trained for and ran the marathon.

Experts generally agree that moderate physical activity may enhance immune function. Most studies also agreed that high-intensity exercise temporarily impairs immune function. 

As you’ll recall, Dr. Bortz, now in his 80s and healthy as a horse, has run a marathon every year for the last 40 years. Clearly, he doesn’t consider long distance running harmful. I would agree, but only if you are well trained—and allow plenty of time for recovery between races. Dr. Bortz fills the bill in both cases.

That’s the story on lifestyle and cancer, as I understand it. As noted earlier, cancer is a many-sided and baffling disease. We can, however, defend against it. A healthy and active lifestyle can substantially reduce the risk of developing the disease. Through lifestyle and a little luck we can prevent cancer. Then we won't need a cure. Cure is good--wonderful if you need it--but prevention is far better.

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