• Loss of bone mineral density is associated with low polyunsaturated n-3 levels in adults of all ages. The issue is exacerbated when coupled with low calcium intake.
• Increasing ratio of total dietary n-6 to n-3 fatty acids is significantly and independently associated with lower BMD at the hip in female subjects.
• To help safeguard your patients’ BMD, ensure they’re getting the RDA for both calcium (1,200 mg) and EPA/DHA (at least 1.1 grams for women and 1.6 grams for men).
• Identify a quality omega 3 fish oil supplement using the “3 Ps”: Potency, Purity, and Palatability
• Patient Education Tool: 10 Health Benefits Of Fish Oil

Medical literature is rife with data on omega 3s ameliorating myriad biological functions. Among the most common are cardiovascular, orthopedic, and cognitive.

But a recent study from the Public Library of Science sheds new light on polyunsaturated fatty acid’s effect on the skeletal system.

The long-chain omega-3 polyunsaturated fatty acids (n-3) EPA and DHA are known to have numerous anti-inflammatory effects, including decreasing the production and activity of pro-inflammatory cytokines (like IL-1, IL-6 and TNF-alpha).

These cytokines activate osteoclasts. Plus, EPA and DHA boost the production and activity of osteoblasts, thus increasing the rate of new bone formation.

A study in the American Journal of Clinical Nutrition of healthy young men showed concentrations of EPA and DHA were positively associated with total bone mineral density (BMD) and spine BMD. And DHA especially was associated with bone mineral accrual.1

The same journal also published data on the effect of omega 6 (n-6) vis-a-vis n-3 concentrations and its effect on bone health for patients 45 and over.

An increasing ratio of total dietary n-6 to n-3 fatty acids was also significantly and independently associated with lower BMD at the hip in all women and at the spine in women not using hormone therapy.2

The researchers concluded: “These findings suggest that the relative amounts of dietary polyunsaturated fatty acids may play a vital role in preserving skeletal integrity in older age.”

Eating fatty fish, which are rich in n-3, has been shown to slow bone resorption and help prevent the loss of BMD in the femoral neck in older patients.

So, researchers decided to see if Spanish women who regularly consumed n-3s would have better BMD compared to those whose intake of n-3 was low. Spain has the highest amount of fish and seafood consumption in all of Europe.

Researchers tracked the women’s intake of not just EPA/DHA, but also ALA (the precursor n-3 for EPA/DHA found in nuts, seeds and some vegetable oils). 1,865 women ranging in age from 20-79 participated.

None were taking any medications that could interfere with calcium metabolism (e.g., corticoids, oral anticoagulants, antipsychotics, etc.).

None had any diseases that might interfere with calcium metabolism (e.g., diabetes mellitus, liver disease, chronic kidney disease, or parathyroid, thyroid, adrenal or ovarian disease).

None were using anti-osteoporotic drugs (bisphosphonates, denosumab, teriparatide). All led active lives, did not consume more than 3 ounces of alcohol daily, and 79.5% were non-smokers.

A significant positive correlation was seen between regular consumption of EPA/DHA and BMD.3 Regular ALA intake also showed a smaller but still positive correlation with BMD at the femoral neck. Women with osteoporosis had a far lower intake of EPA and DHA than women with normal bone density or those with osteopenia.

In some prior studies, regular intake of the omega-3s has not resulted in such a strong association with greater BMD. The researchers who conducted the current study believe this is because calcium intake was too low in the other studies.

Further research has shown that the increased loss of BMD in the femoral neck when n-3 intake is low is even worse when calcium intake is also low.

In this study, the women’s intake of calcium averaged 1,048 mg per day, so many did not meet the 1,200 mg/day RDI in the U.S. However, their intake was not so low that a lack of calcium would interfere with n-3’s beneficial effects on BMD.

Looking at the results of this study combined with those of prior studies, the researchers noted that n-3’s positive effects on BMD depend upon adequate calcium intake.

These findings suggest to help safeguard your patients’ BMD, ensure they’re getting the RDA for both calcium (1,200 mg) and EPA/DHA (at least 1.1 grams for women and 1.6 grams for men).

In light of all the evidence so far, you may want to recommend n-3s in your practice for older patients and particularly those with existing bone health issues. N-3 supplementation can be a complementary modality for treating bone loss.

How can you help your patients identify the best fish oil supplements to complement an n-3-rich diet? Here’s a handy guide to put any uncertainty to rest.

This mnemonic device can come in handy for practitioner and patient alike.
The “3 Ps” are:

Potency

Purity

Palatability

Here’s how to determine each:

There are two considerations:

1. The dosage of EPA and DHA (mg)

2. The serving size

This can prove challenging for some patients to reconcile, since many supplements are inconsistently labeled, brand-to-brand.

For example, some supplements will claim that a serving contains a high number of milligrams of fish oil (“1,200 mg of fish oil!”). But that’s not always the amount of EPA and DHA they’ll get. You’ll need to look at the Supplement Facts panel on the package to find out the exact EPA and DHA content per serving.

In order to reap the full benefits of omega 3s, you should aim to consume 2.6 to 3 grams combined of EPA and DHA each day. But every patient’s requirements are different, due to metabolism, nutrient absorption, and genetics.

One of the best ways to find out your daily needs is to take an omega 3 blood test. Here at AlgaeCal we recommend the OmegaQuant Analytics test for the easiest and fastest way to test n-3 levels. Consumers enjoy being able to do the test in a matter of seconds in the comfort of their own homes.

Once a daily omega 3 need is determined, the next question is: What does your omega 3 supplement serving size need to be? Once again, you’ll need to check the label. Depending on the product, it could be anywhere from one spoonful or tablet daily, to several spoonfuls or tablets.

Ideally the servings are low in order to maximize patient compliance.

But there’s one more factor to consider when it comes to Potency. And it’s a significant consideration for practitioner and patient alike, since it directly affects health outcomes. And that is, the form that the omega 3s take in the supplement. The body uses each of them differently.

The three different forms of omega 3s are:

• Natural triglycerides

• Ethyl esters

• Synthetic (reverse) triglycerides

There are currently no laws requiring supplement manufacturers to list what form their omega 3s take. That’s why we must be vigilant in determining which of the 3 forms they may take:

1. Natural triglycerides

This is omega 3s in their natural form. Natural triglycerides are highly bioavailable, and are the closest thing to eating the original food source.

Triglycerides consumed in the form of a high-quality omega 3s supplement may help to reduce harmful triglyceride levels in the body, leading to improved overall health.

2. Ethyl esters

When natural triglycerides go through a chemical process called “transesterification,” the result is ethyl esters (EEs). Supplement-makers convert natural triglycerides into EEs because it allows them to double or triple the levels of EPA/DHA, compared to what natural triglycerides provide.

That might sound like a great thing, but the process has major drawbacks.

Ethyl esters are much harder to digest, so they’re far less bioavailable than natural triglycerides. A 1988 study showed that EPA and DHA were, on average, more than 300% better absorbed in their natural triglyceride form than as EEs. A more recent study, in 2010, found that EPA/DHA bioavailability from EEs was 73% lower than from natural triglycerides.

So, even though a supplement made from EE-type omega 3s offers more EPA/DHA, the body will absorb far less.

Maybe even more importantly, the safety of the EE form has not been confirmed in humans. EEs are also known to accumulate in major organs such as the heart, liver and pancreas. And they can potentially accumulate in the placenta, which makes them an even bigger concern for pregnant women.

There’s another reason for pregnant women to avoid the EEs. When your body absorbs EEs, it has to convert them back into their natural triglyceride form. When it does this, alcohol is released. It’s a small amount of alcohol, but it still has the potential to harm a developing fetus. Pregnant women are advised not to use omega 3 supplements containing EEs.

3. Synthetic (reverse) triglycerides

Synthetic triglycerides are EEs taken one step further. After the manufacturer converts natural triglycerides to EEs, they then re-convert them back to triglycerides – except in a synthetic form. The triglycerides’ overall structure is altered, and the bioavailability of the omega 3s suffers compared to their natural form.

All in all, natural triglycerides are the optimal choice. It’s the form of omega 3s that’s best absorbed by the body, free of chemical intervention. It’s even better if those triglycerides are delivered as an emulsion. The bioavailability of omega 3s has been shown to be even better when they’re part of an emulsion.

Compared to encapsulated triglyceride oils, multiple studies show enhanced absorption of n-3 through dietary and emulsion-based delivery as measured by phospholipid fatty acid composition. ^4,5

What’s more, DHA and EPA particles delivered in nanoemulsions (particle radii below 100 nm) proved nearly 3 times more bioavailable in the intestinal tract of rats than conventional emulsions!⁶

If a patient is interested in a supplement and the label doesn’t list the form of omega 3s, suggest they contact the manufacturer. It’s worth the time and effort to find out whether they’re getting the best for their health – and their money.

A paper published in Nature reviewed the state of fish oil supplements in New Zealand. The results were grim. While only 32 supplements were involved in the study, the results are well worth noting.

Among the 32 different omega 3 supplements tested…

• Only 3 contained the levels of EPA and DHA listed on the label

• Over two-thirds contained less than 67% of the EPA and DHA listed on the label

• Only 8% met international recommendations for safe levels of toxic contaminants

The immediate implication is widespread rancidity of most omega 3 supplements. And the consumption of oxidized oils may actually increase inflammation. In effect, unsuspecting patients could be taking a supplement that’s doing the opposite of what they’re expecting of it.

Another study found that more than 80% of analyzed fish oil supplements contained unacceptably high levels of peroxide. Peroxide is the first toxic compound produced when oxidation occurs.

And here’s an additional cause for concern. The more unsaturated a fat is, the more vulnerable it is to becoming oxidized. Meanwhile, EPA and DHA are the most unsaturated of all fats.

If your omega 3 supplement is old, has been improperly stored, or was manufactured using fish oil that had already oxidized, it may be rancid.

Fortunately, it’s easy to detect any rancidity. Simply smell the contents. (If it’s in capsule form, break one open.) If it smells “fishy”, don’t use it!

Always refrigerate your supplement, ideally even before opening. And before you buy, make sure the supplement contains antioxidants that preserve the oil’s freshness. But remember, vitamin E — a popular choice in omega 3 supplements — doesn’t effectively prevent oxidation. You’ll want a supplement with antioxidants that are shown to be more effective. (More on the top antioxidants later.)

Among the common culprits causing toxicity are persistent organic pollutants (POPs). These toxic compounds persist in the water and soil. Therefore they’re present in the diet and accumulate in our bodies.

One type of POP is polychlorinated biphenyls (PCBs) — man-made industrial chemicals that U.S. Congress banned in 1979. PCBs are endocrine disruptors, and cause cancer and reproductive toxicity.

Sadly, PCBs don’t break down. So, even though they were banned over 40 years ago, they’re still with us.

Now, while it’s impossible to completely avoid trace amounts of toxins, patients should be encouraged to ensure they’re still consuming safe levels of them.

When it comes to fish oil supplements, one of the best ways to ensure this is to choose a supplement derived from fish species that are low on the food chain. Smaller, short-lived fish like sardine, anchovy and mackerel contain the smallest amounts of POP, mercury, and other potentially harmful substances.

As the name suggests, “Palatability” refers to the supplement’s flavor.

One of the most common complaints about omega 3 supplements is their unpleasant taste! This is inherent in the nature of the product, given the best sources of EPA and DHA come from seafood… particularly oily fish like trout, mackerel, anchovies and salmon. Vegetarian supplements source their omega 3s from algae, but they may not provide the recommended amounts of EPA and DHA.

Even if a supplement has no flavor when you swallow it, it might still produce the trademark “fish burps” soon after. And that’s not all. There is still the threat of other all-too-common side effects, like flatulence, bloating, and even diarrhea.

These digestive downfalls stem from the second ‘P’, Potency.

Recall we digest supplements made from natural triglycerides significantly better than the EE and synthetic triglyceride forms. If you experience fishy burps or other digestive disturbances after taking a supplement, it likely means it’s made with either the EE or synthetic triglyceride form of omega 3s.

Supplement manufacturers try to address this problem with the enteric coating of their pills. This prevents the capsule from dissolving until it gets to the intestinal tract. But while that might help reduce or eliminate side effects, the patient could still be consuming rancid oil that’s not only failing to improve their health… it could actually cause harm by increasing, rather than fighting, inflammation.

The insidious truth could be hidden all along in the capsule!

Two steps are required to ensure a fish oil supplement is palatable:

1. The EPA and DHA should be in the form of natural triglycerides

2. Those triglycerides should be paired with antioxidants that prevent rancidity

To solve the second step, many omega 3 supplements contain vitamin E. Unfortunately, studies show it isn’t up to the task of fully protecting EPA and DHA from oxidation. Vitamin E may reduce oxidation somewhat, but it won’t prevent it.

In order to preserve the delicate fish oils and ensure you don’t experience an unpleasant taste — now or later — a more effective antioxidant is needed. Two antioxidants in particular have been singled out for their potency: astaxanthin and curcumin.

These two nutrients prevent fish oil from going rancid. Plus, they provide powerful anti-inflammatory properties of their own, helping to support heart and brain health, improve joint function, and much more.

Here’s a helpful visual aid to give your patients who are interested in supplementing with omega 3 fish oil.

Harvard researchers have revealed that omega 3 deficiency is the 6th biggest killer of Americans! (It’s even more deadly than excess trans fat intake.)

What a shame, because maintaining healthy levels of omega 3s is much simpler now due to the ubiquitousness of fish oil supplements.

We need omega 3’s. And the best way to get adequate amounts is through fresh-water, fatty fish or fish oil supplements.

1. Am J Clin Nutr. 2007 Mar;85(3):803-7. doi: 10.1093/ajcn/85.3.803.
2. Am J Clin Nutr. 2005 Apr;81(4):934-8. doi: 10.1093/ajcn/81.4.934.
3. PLoS One. 2018 Jan 5;13(1):e0190539. doi: 10.1371/journal.pone.0190539.
4. Visioli F, et al. Lipids. 2003 Apr;38(4): 415-8
5. Raatz SK, et al. J Am Diet Assoc. 2009 Jun;109(6): 1076-81
6. Food Funct. 2015 Jan;6(1):42-55. doi: 10.1039/c4fo00723a. Epub 2014 Nov 11.