The heart is a functioning muscle and needs oxygen and fuel in order to do its work. It is the job of the coronary arteries to supply the necessary oxygen and nutrients to the muscle. When one of the three major coronary arteries become narrowed or blocked, blood flow to the muscle is reduced, resulting in angina pectoris—a feeling of tightness or pressure in the chest often associated with shortness of breath. At first, angina may only be obvious during periods of exercise or emotional stress, and may go away when the activity ceases. Later, it may occur even while resting. If the blood flow to an area of the heart completely stops, heart muscle cells die, causing a heart attack, or myocardial infarction. While healing, the infarcted or damaged area forms a scar, but is no longer a functioning part of heart muscle.

Conventional medical treatments for angina include blood vessel dilators such as nitroglycerine and other nitrites and calcium channel blockers. If arteriograms show clogged coronary arteries, bypass surgery is usually recommended.

Dietary Supplements: Primary Recommendations

Vitamin C
Those pesky little free radicals really get around. They seem to be involved in almost every cardiovascular condition, and angina is no exception.^1,2 Consequently, it's not surprising that vitamin C and other antioxidants, which neutralize free radicals, are beneficial in the prevention and treatment of angina. In fact, studies have shown that men and women with lower blood levels of vitamin C have a higher risk for angina.^3,4,5,6 Furthermore, research has also shown that vitamin C supplementation, with or without other antioxidants, has been able to reduce the incidence of angina.^7,8,9 About 2,000 mg of vitamin C daily is recommended.

Co-enzyme Q10
Co-enzyme Q10 is a vitamin-like substance involved in cellular energy metabolism. It is also an antioxidant, like vitamin C, that is beneficial in the prevention and treatment of angina. In a study, which reviewed the scientific literature, Co-enzyme Q10 was revealed to be used in oral form to treat various cardiovascular disorders including angina.¹⁰ In one study, patients with acute myocardial infarction experienced a significant reduction in angina, arrhythmias (abnormal heartbeat), and poor heart function when supplemented with 120 mg of Co-enzyme Q10 daily.¹¹ Of course everyone knows that exercise is good to prevent cardiovascular disease. But in one study, patients with ischemic heart disease/effort angina were found to experience a faster loss of Co-enzyme Q10 during exercise.¹² Does this mean that you shouldn't exercise if you have angina? No, it just means you should supplement with Co-enzyme Q10. In another study, 150 mg of Co-enzyme Q10 given to angina patients not only increased their blood levels of Co-enzyme Q10, but also increased their ability to exercise longer. These results lead the researchers to conclude, "This study suggests that Co-enzyme Q10 is a safe and promising treatment for angina pectoris."¹³ (Note: If you have acute angina, you should only exercise in accordance to a program approved by your physician.)

Vitamin E
Vitamin E is considered by many to be the granddaddy of all antioxidant and cardiovascular support vitamins—and this reputation certainly holds true in the case of angina. As with vitamin C and Co-enzyme Q10 previously discussed, vitamin E protects against the free radical damage associated with angina. But what happens when there are inadequate levels of vitamin E? Not surprisingly, research shows that blood levels of vitamin E are significantly lower in patients with angina, and that these lower levels render them more susceptible to further cardiovascular damage.^14,15,16 And what happens if vitamin E is supplemented? Various studies show that vitamin E supplementation, with or without other antioxidants, is able to successfully decrease the incidence of angina in affected patients.^17,18,19 In fact, in a study, which examined vitamin use in 2313 men, vitamin E supplementation was found to have the strongest association with a reduced risk of ischemic heart disease, including angina.²⁰ Finally, vitamin E supplementation together with conventional anti-anginal drug therapy has been found to bring a higher response and exercise improvement, as well as other positive changes, than drug therapy alone.²¹ About 100 –400 IU of vitamin E daily is recommended.

L-Carnitine
L-carnitine is an amino acid involved in energy metabolism. Extensive research has also shown that l-carnitine has a valuable role to play in cardiovascular disease, especially where angina is concerned. Several studies have demonstrated that supplementation with l-carnitine (2000 to 4000 mg daily) is able to reduce the incidence of anginal attacks in cardiovascular disease patients.^22,23,24,25 Furthermore, in studies involving patients with angina pectoris and effort angina (i.e., angina induced by physical effort, such as exercise), supplementation with l-carnitine (2000 or 3000 mg daily) was able to improve exercise performance.^{26,27,28,29,30} Furthermore, in a study where l-carnitine was given to patients with effort angina along with anti-arrhythmic drugs, the l-carnitine was found to improve the action of those drugs.³¹

Hawthorne
Germany's Commission E has validated the use of Hawthorn in cases of cardiac insufficiency, resulted in an improvement of subjective findings as well as an increase in heart work tolerance, and a decrease in pressure/heart rate product.³² (Although Hawthorne Berry products are often marketed, it is the Hawthorne leaves and flowers which have been so carefully researched and validated.). In one study, a 60 mg hawthorn extract taken three times per day improved heart function and exercise tolerance in angina patients.³³

L-Arginine
Typically physicians will give their angina patients a prescription for nitroglycerin tablets, which are used in case of an angina attack. Nitroglycerine works through dilation of arteries, which in turn, works through an interaction with nitric oxide, which stimulates dilation. It is interesting to note that nitric oxide is made from the amino acid arginine. Furthermore, blood cells in people with angina have been shown to make insufficient nitric oxide,³⁴ (possibly due to abnormalities of arginine metabolism). Of greatest significance is research showing that 2 grams (2,000 mg) of arginine, three times per day for as little as three days improved the ability of angina sufferers to exercise.³⁵ Additional research has shown that the mechanism by which arginine operates is through stimulating blood vessel dilation.₃₆ (Note: If you have an active herpes virus, you should avoid arginine supplements since they can "feed" the virus.)

Dietary Supplements: Secondary Recommendations

Magnesium
The heartbeat normalizing effects of magnesium has been described repeatedly since 1935, both as a factor in human disease and in animal experiments. Nevertheless, this therapeutic effectiveness is rarely mentioned in textbooks. Both the therapeutic effect of magnesium and the correction of magnesium deficiency have been used in treatment of digitalis toxicity (a drug used to treat angina), angina, as well as in arrhythmia (abnormal heartbeat) of unknown origin. Magnesium deficiency can be caused by a number of situations. Of possible concern to the angina sufferer are the uses of drugs such as digitalis, diuretics, gentamicin, as well as cisplatinum, which appreciably enhance urinary magnesium loss. Correction of magnesium deficiency should lead to recovery.₃₇ About 300 – 500 mg daily is recommended. Please note, however, that it may take weeks or even months of magnesium supplementation, to achieve an angina-relieving result.

Omega-3 fatty acids
The omega-3 fatty acids EPA and DHA have been studied in the treatment of angina. Some research indicates that 3 grams or more of omega-3 oils (e.g., fish oils) three times per day (providing a total of about 3 grams of EPA and 2 grams of DHA) have reduced chest pain as well as the need for nitroglycerin, a common medication used to treat angina.₃₈ However, other research did not confirm these benefits.₃₉ In any case, if omega-3's are used, vitamin E should be supplemented with it, since the vitamin E may protect the oils against free radical oxidation.₄₀ Also, if you are using any type of blood-thinning medication, consult with your doctor before using omega-3 fatty acids.

Bromelain
Bromelain acts naturally as a blood thinner agent since it prevents excessive blood platelet from clumping together,₄₁ which would otherwise cause "sludgy" blood. Furthermore, there have been positive reports in a few clinical trials of bromelain to decrease thrombophlebitis (inflammation of veins) and pain from angina and thrombophlebitis.^42,43 About 1200–1500 mg daily (derived from at least 900 GDU/Gram material) is recommended.

References:

1. Ito K, et al, Am J Cardiol(1998) 82 (6):762-7.
2. Kugiyama K , et al, J Am Coll Cardiol (1998) 32(1):103–9.
3. Ibid.
4. Riemersma RA, et al, Ann NY Acad Sci (1989) 570:29–5.
5. Riemersma RA, et al, Lancet (1991) 337(8732):1–5.
6. Ness AR, et al, J Cardiovasc Risk (1996) 3(4):373–7.
7. Ito K, et al, Am J Cardiol (1998) 82 (6):762–7.
8. Kugiyama K, et al, J Am Coll Cardiol (1998) 32(1):103–9.
9. Singh RB, et al, Am J Cardiol (1996) 77(4):232–6.
10. Greenberg S, Frishman WH, J Clin Pharmacol (1990)30(7):596–608.
11. Singh RB, et al, Cardiovasc Drugs Ther (1998) 12(4):347–53.
12. Karlsson J, et al, Ann Med (1991) 23(3):339–44.
13. Kamikawa T, Am J Cardiol (1985) 56 (4):247–51.
14. Miwa K, et al, Cardiovasc Res (1999) 41(1):291–8.
15. Miwa K, et al, Circulation (1996) 94(1):14–8.
16. Pucheu S, et al, Free Radic Biol Med (1995) 19(6):873–81.
17. Rapola JM, et al, JAMA(1996) 275(9):693–8.
18. Singh RB, et al, Am J Cardiol (1996) 77(4):232–6.
19. Motoyama T, et al, J Am Coll Cardiol (1998) 32(6):1672–9.
20. Meyer F, Bairati I, Dagenais GR, Can J Cardiol (1996)12(10):930–4.
21. Pimenov LT, Churshin AD, Ezhov AV, Klin Med (1997) 75(1):32–5.
22. Singh RB, et al, Postgrad Med J (1996) 72(843):45–50.
23. Davini P, et al, Drugs Exp Clin Res (1992) 18(8):355–65.
24. Fernandez C, Proto C, Clin Ter (1992) 140(4):353–77.
25. Ferrari R, Cucchini F, Visioli O, Int J Cardiol (1984) 5(2):213–6.
26. Kobayashi A, Masumura Y, Yamazaki N, Jpn Circ J (1992) 56(1):86–94.
27. Cacciatore L, et al, Drugs Exp Clin Res (1991) 17(4):225–35.
28. Canale C, et al, Int J Clin Pharmacol Ther Toxicol(1988) 26(4):221–4.
29. Cherchi A, et al, Int J Clin Pharmacol Ther Toxicol (1985) 23(10):569–72.
30. Kamikawa T, et al, Jpn Heart J (1984) 25(4):587–97.
31. Mondillo S, et al, Clin Ter (1995) 146(12):769–74.
32. Blumenthal, M., et al, The Complete German Commission E Monogrpahs: Therapeutic Guide to Herbal Medicines/CD version (1998) American Botanical Council, Austin, Texas.
33. Hanack T, Bruckel MH, Therapiewoche (983) 33:4331–33 [in German].
34. Mollace V, et al, Am J Cardiol (1994) 74:65–68.
35. Ceremuzynski L, Chamiec T, Herbaczynska-Cedro K, Am J Cardiol (1997) 80:331–33.
36. Egashira K, et al, Circulation (1996) 94:130–34.
37. Laban E, Charbon GA, J Am Coll Nutr (1986) 5(6):521–32.
38. Saynor R, Verel D, Gillott T, Atheroscl (1984) 50:3–10.
39. Mehta JL, et al, Am J Med (1988) 84:45–52.
40. Wander RC, et al, J Nutr (1996) 126:643–52.
41. Heinicke R, van der Wal L, Yokoyama M, Experientia (1972) 28:844–45.
42. Nieper HA, Acta Med Empirica (1978) 5:274–78.
43. Seligman B, Angiology (1969) 20:22–26.

The body’s ability to detect foreign substances varies from person to person. Thus, some people react to certain substances while others do not. What may be recognized by one person’s body as foreign is not recognized as such by another person’s body.

While allergies are part of the normal function of the immune system, it does not follow that they cannot be managed or minimized. Certain nutrients, when taken in the right amounts, can go a long way in minimizing—if not totally eliminating—the unpleasant symptoms of allergies. Following are my top nutrients for beating allergies:

1. Vitamin C
Vitamin C is an antioxidant that helps reduce allergy symptoms like inflammation. It has been shown in past medical studies that a high intake of vitamin C prevents or at least minimizes the release of histamine, and consequently decreases the unpleasant sensations endured by allergy sufferers.⁴

Vitamin C can be readily added into the diet, because of the many fruits and vegetables that contain it. Citrus fruits like oranges and lemons contain very high amounts of vitamin C in its most natural form. Excellent non-citrus sources include papaya, pineapple, and strawberries. Aside from fruits, vitamin C can also be obtained from over-the-counter supplement tablets or capsules and one of the best forms to consume it in is camu camu berry.

2. Selenium
Selenium is a trace element that is a component of some proteins with powerful antioxidant properties. These proteins help reduce allergy symptoms by minimizing tissue damage and inflammation.⁵ The U.S. National Institute of Health recommends that all adults take 100 mcg of selenium daily. Fruits, vegetables, dairy products, and whole grains are rich sources of selenium. Meat sources include poultry (turkey and chicken), lean pork, beef, and eggs.

3. Omega-3 fats
Also known as healthy fats, omega-3 fatty acids have long been proven by science to have anti-inflammatory properties. As such, they help relieve some allergy symptoms. On the other hand, the structurally-related omega-6 fatty acids have the opposite effect: they stimulate the production of inflammatory substances. In fact, one study appearing in the British Journal of Nutrition, indicated that pregnant women who had a lower intake of omega-6 and a higher intake of omega-3’s, gave birth to children with lower risks of certain allergies.⁶ Allergy sufferers are therefore advised to decrease intake of foods that are rich in omega-6 fatty acids (i.e. poultry, eggs, nuts, cereals, durum wheat, whole-grain breads and most vegetable oils). Dietary sources of omega-3 fatty acids include cold-water fish, soybeans, flaxseeds, spinach, parsley, walnut oil, soybean oil, and flaxseed oil.

4. Vitamin E
Vitamin E, when taken in proper amounts, can help reduce allergies. A study investigating the connection between vitamin E and allergies suggested that sufficient vitamin E intake decreased the production of IgE, the antibody responsible for allergic reactions, anywhere from 34–62 percent.^7,8

Dietary sources of vitamin E are sunflower seeds, almonds, cooked spinach, safflower oil, and beet greens. And even though the RDA for vitamin E is fifteen milligrams (which is equivalent to 22 IUs or International Units), studies indicate a lot more than the RDA is needed to ensure optimal health. Also, I highly advise the most natural forms of vitamin E, as mixed tocopherols, as opposed to only one isolate form like alpha tocopherol.

5. Quercetin
Quercetin belongs to a class of organic molecules called bioflavonoids. Scientific research has proven it to have anti-inflammatory, antioxidant, and anti-histamine properties. Quercetin has been shown to exert properties that prevent the production of substances involved in allergic reactions.⁹ Sources of quercetin include apples, black tea, red wine, onions, beans, grapefruit, berries, peppers and green leafy vegetables. There are also commercial quercetin supplements that are sold online and in health food stores, should the allergic person choose to take it in tablet or capsule form.

6. Probiotics
Probiotics is the collective term for the live microorganisms (bacteria and yeast) that are essential for optimal health. These microorganisms are present in the body, as well as in various supplements, drinks, and food (i.e. yogurt made fron grassfed cows). Their main role is to prevent the growth of “bad” bacteria, and in doing so, also prevent diseases brought about by these “bad” bacteria. There are two very common probiotic bacteria—Lactobacillus acidophilus and Bifidobacterium bifidum. One of the most research proven shelf-stable forms of the latter is found in my Ultimate Probiotic,^10,11 product.

While probiotics are usually involved in digestive health, studies have suggested that they can also help prevent or minimize allergies¹², since digestive health is very closely connected to overall body health.

Foods with probiotics include miso, fermented milk, kefir, sourdough bread, tempeh, and fermented vegetables like sauerkraut.

7. Rosmarinic acid
Rosmarinic acid is a plant substance that is found in large amounts in herbs like rosemary, marjoram, sage, and oregano. Studies have shown that it has anti-inflammatory properties that are more potent than those of vitamin E. In 2004, Japanese researchers published a paper that demonstrated the ability of rosmarinic acid as a therapeutic substance for those who suffer from asthma.¹³ Rosmarinic acid seems to prevent allergic reactions by blocking the activation of biochemicals produced by the immune system in response to a foreign substance.¹⁴

1. Pawankar R, et al. World Health Organization. White Book on Allergy 2011–2012 Executive Summary.
2. Why is Allergy Increasing? Allergy UK. www.allergyuk.org.
3. Li L. Biologist studies possible link between chronic low-grade inflammation, major diseases. Virginia Polytechnic Institute and State University. Jun 12, 2011.
4. Johnston CS, Solomon RE, Corte C. Vitamin C depletion is associated with alterations in blood histamine and plasma free carnitine in adults. J Am Coll Nutr. 1996 Dec;15(6):586–91.
5. Kamer B, et al. Role of selenium and zinc in the pathogenesis of food allergy in infants and young children. Arch Med Sci. See comment in PubMed Commons below 2012 Dec 20;8(6):1083–8. doi: 10.5114/aoms.2012.32420. Epub 2012 Dec 19.
6. Nwaru BI, et al. Maternal intake of fatty acids during pregnancy and allergies in offspring. Br J Nutr. 2012 Aug;108(4):720–32. doi: 10.1017/S0007114511005940. Epub 2011 Nov 9.
7. Yamada K, Tachibana H. Recent topics in antioxidative factors. Biofactors. 2000;13(1-4):167–72.
8. Tsoureli-Nikita, et al. Evaluation of dietary intake of vitamin E in the treatment of atopic dermatitis: a study of the clinical course and evaluation of the immunoglobulin E serum levels. Int J Dermatol. 2002 Mar;41(3):146–50.
9. Salvatore Chirumbolo. Dietary Assumption of Plant Polyphenols and Prevention of Allergy. Current Pharmaceutical Design, 2014, 20, 000-000 1.
10. Ballongue J, et al. Effects of Bifidobacterium fermented milks on human intestinal Lait 73, 249–256 (1993).
11. Tomoda T, et al. Effect of yogurt and yogurt supplemented with Bifidobacterium and/or lactulose in healthy persons : A comparative study. Bifidobacteria Microfloa 10, 123–30 (1991).
12. Prakash S, et al. Probiotics for the prevention and treatment of allergies, with an emphasis on mode of delivery and mechanism of action. Curr Pharm Des. 2014;20(6):1025–37.
13. Osakabe N, et al. Anti-inflammatory and anti-allergic effect of rosmarinic acid (RA); inhibition of seasonal allergic rhinoconjunctivitis (SAR) and its mechanism. Biofactors. 2004;21(1-4):127–31.
14. Huang SS, Zheng RL. Rosmarinic acid inhibits angiogenesis and its mechanism of action in vitro. Cancer Letters. 2006 Aug 8;239(2):271–80. Epub 2005 Oct 18.

Omega-3 fatty acids (O3FA) are well-known for their role in human health and wellness—and there are various sources of O3FA, including fish oils (i.e. fish body oils), krill oil and algal oils. But there is another "old school" source of O3FA that has been overlooked in recent times: cod liver oil. Now if you're wondering why I'm taking the time to talk about a product that your grandmother or great-grandmother probably used, the reason (primarily) has to do with inflammation.

About Inflammation

Let's start with a brief review about inflammation, a useful natural reaction that the body has in response to injury and certain other conditions. Chronic inflammation, however, can be more destructive than beneficial and is a major component in many human diseases. Furthermore, it must be understood that chronic inflammation isn't just associated with disease states. In fact, higher intakes of red and processed meats, sweets, desserts, French fries, and refined grains are associated with experiencing more inflammation,¹ as is exposure to colder temperatures (i.e. colder climates).²

Since prolonged inflammation is detrimental to the host, higher organisms have evolved protective mechanisms to ensure resolution of the inflammatory response in a limited and specific time-and space-manner. Once thought as a mere passive process of dilution of inflammation, resolution is today envisioned as a highly orchestrated process coordinated by a complex regulatory network of cells and mediators.³

Pro-resolving Mediators
Among the molecules that facilitate resolution of inflammation, resolvins, protectins, and maresins produced from O3FA are the lipid mediators which are particularly important. These internally produced anti-inflammatory and pro-resolving mediators counteract the effects of proinflammatory signaling systems and act as "braking signals" of the persistent vicious cycle leading to unremitting inflammation.

In fact, the same pro-inflammatory factors that initially trigger the inflammatory response also signal the termination of inflammation by stimulating the biosynthesis of pro-resolving mediators. Resolvins, protectins and maresins and have been shown to reduce airway inflammation, dermal inflammation colitis, arthritis, and postoperative pain. Studies have shown that these mediators increase with time during the inflammatory process.^4,5,6

DHA The most well-known O3FA are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). While these two O3FA can be used to generate resolvins, there is another O3FA called docosapentaenoic acid (DPA), which is a particularly effective precursor to different resolvins.⁷ DPA is an intermediate in the biosynthesis of DHA from EPA. In any case, DPA is not always seen in omega-3 fatty acid products. It can, however, be found in some cod liver oil products.

Cod Liver Oil And Inflammation

It should be noted that cod liver oil is a natural source of vitamins A and D, in addition to O3FA. This is significant since maintaining healthy vitamin D levels is necessary for supporting cardiovascular health,^8,9,10,11 and vitamin D plays an important role in healthy skin and in regulating a healthy immune system.¹² Furthermore, some cod liver oil products are a direct source of pro-resolving mediators. Not surprisingly, cod liver oil has shown value for its anti-inflammatory effects.

A study¹³ was conducted to compare the effects of supplementation with either sunflower oil (source of omega-6) or cod liver oil (source of omega-3) oil, in rates with inflammatory colitis. Inflammatory markers increased in rats fed sunflower oil but was blunted in rats fed cod liver oil. In fed cod liver oil group, the damage score was markedly reduced by day 30, and inflammation and ulceration were almost absent by day 50.

A 9-month, double-blind, placebo-controlled, randomized human study¹⁴ was conducted in 58 patients with rheumatoid arthritis (RA) to determine whether cod liver oil supplementation would help reduce daily NSAID (pain medication) requirement. Patients took either 10 g of cod liver oil containing or identical placebo capsules. Documentation of NSAID daily requirement, clinical and laboratory parameters of RA disease activity, and safety checks were done at 0, 4, 12, 24 and 36 weeks. At 12 weeks, patients were instructed to gradually reduce, and if possible, stop their NSAID intake. Results were that 39 percent of patients in the cod liver oil group and 10 percent of patients in the placebo group were able to reduce their daily NSAID requirement by more than 30 percent. Researchers concluded that cod liver oil supplements containing n-3 fatty acids can be used as NSAID-sparing agents in RA.

Conclusion
Due to its naturally occurring EPA, DHA, DPA, and pro-resolving mediators, cod liver oil is an ideal supplement for helping to reduce inflammation. Furthermore, it is a natural source of vitamins A and D; and may also have "beauty from within" applications. That being said, if you're going to use a cod liver oil supplement, it is important to use a clean product. I suggest looking for supplements from cod from Alaskan waters (a more pristine area) that are line-caught and flash-frozen to preserve freshness.

References:

1. Lopez-Garcia E, Schulze MB, Fung TT, Meigs JB, Rifai N, Manson JE, Hu FB. Major dietary patterns are related to plasma concentrations of markers of inflammation and endothelial dysfunction. Am J Clin Nutr. 2004 Oct;80(4):1029–35.
2. Halonen JI, Zanobetti A, Sparrow D, Vokonas PS, Schwartz J. Associations between outdoor temperature and markers of inflammation: a cohort study. Environ Health. 2010 Jul 23;9:42.
3. Clària J. Resolution of Acute Inflammation and the Role of Lipid Mediators. Scientific World Journal. 2010; 10:1553–5.
4. Recchiuti A, Serhan CN. Pro-resolving lipid mediators (SPMs) and their actions in regulating miRNA in novel resolution circuits in inflammation. Front Immunol. 2012 Oct 22;3:298.
5. Serhan CN. Novel Pro-Resolving Lipid Mediators in Inflammation Are Leads for Resolution Physiology. Nature. 2014 Jun 5; 510(7503): 92–101.
6. Spite M, Serhan CN. Novel lipid mediators promote resolution of acute inflammation: impact of aspirin and statins. Circ Res.2010 November 12; 107(10): 1170–84.
7. Primdahl KG, Aursnes M, Walker ME, Colas RA, Serhan CN, Dalli J, Hansen TV, Vik A. Synthesis of 13(R)-Hydroxy- 7Z,10Z,13R,14E,16Z,19Z Docosapentaenoic Acid (13R-HDPA) and Its Biosynthetic Conversion to the 13-Series Resolvins. J Nat Prod. 2016 Oct 28;79(10):2693–2702.
8. Wang TJ, Pencina MJ, Booth SL, et al. Vitamin D deficiency and risk of cardiovascular disease. Circulation 2008;117;503–11.
9. Dobnig H, Pilz S, Scharnagl H, et al. Independent association of low serum 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D levels with all-cause and cardiovascular mortality. Arch Intern Med 2008;168:1340–49.
10. Giovannucci E, Liu Y, Hollis BW, Rimm EB. 25-hydroxyvitamin D and risk of myocardial infarction in men. Arch Intern Med 2008;168:1174–80.
11. Martins D, Wolf M, Pan D, et al. Prevalence of cardiovascular risk factors and the serum levels of 25-hydroxyvitamin D in the United States. Arch Intern Med 2007;167:1159–65.
12. Institute of Medicine. Food and Nutrition Board. Vitamin A. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. National Academy Press, Washington, DC; 2001:82–161.
13. Vilaseca J, Salas A, Guarner F, Rodríguez R, Martínez M, Malagelada JR. Dietary fish oil reduces progression of chronic inflammatory lesions in a rat model of granulomatous colitis. Gut. 1990 May;31(5):539–44.
14. Galarraga B, Ho M, Youssef HM, Hill A, McMahon H, Hall C, Ogston S, Nuki G, Belch JJ. Cod liver oil (n-3 fatty acids) as an nonsteroidal anti-inflammatory drug-sparing agent in rheumatoid arthritis. Rheumatology (Oxford). 2008 May;47(5):665–9.
15. Latreille J, Kesse-Guyot E, Malvy D, Andreeva V, Galan P, Tschachler E, Hercberg S, Guinot C, Ezzedine K. Association between dietary intake of n-3 polyunsaturated fatty acids and severity of skin photoaging in a middle-aged Caucasian population. J Dermatol Sci. 2013 Dec;72(3):233–9.
16. Daroach M1, Narang T, Saikia UN, Sachdeva N, Sendhil Kumaran M. Correlation of vitamin D and vitamin D receptor expression in patients with alopecia areata: a clinical paradigm. Int J Dermatol. 2018 Feb;57(2):217–222.
17. Gerkowicz A, Chyl-Surdacka K, Krasowska D, Chodorowska G. The Role of Vitamin D in Non- Scarring Alopecia. Int J Mol Sci. 2017 Dec 7;18(12).
18. Cheung EJ, Sink JR, English Iii JC. Vitamin and Mineral Deficiencies in Patients With Telogen Effluvium: A Retrospective Cross-Sectional Study. J Drugs Dermatol. 2016 Oct 1;15(10):1235–37.

Which supplements should people take to help promote good health, and at what doses? Vitamins? Minerals? Herbs? Nutraceuticals? Perhaps the best answer is before experimenting with exotic dietary supplement ingredients, it first makes sense to start out with the three dietary supplements that everyone should be taking. This includes a multivitamin, vitamin D and omega- fatty acids.

MULTIVITAMINS

There is a good case for the daily use of a multivitamin, as a nutrition insurance policy that helps to fill in the gaps for those nutrients people may not be getting in their diet. Furthermore, in a study¹ of 90,771 men and women, the regular use of a multivitamin was found to significantly improve adequate intake of nutrients compared to non-users. Also, research² found that multivitamin supplements are generally well tolerated, do not increase the risk of mortality, cerebrovascular disease, or heart failure, and their use likely outweighs any risk in the general population (and may be particularly beneficial for older people). So, the bottom line is that multivitamins really do work as a nutrition insurance policy.

Other multivitamin benefits
In addition to functioning as a nutrition insurance policy, the daily use of a multivitamin may offer other benefits as well.

Cardiovascular Disease
A 12-week, randomized, placebo-controlled study³ of 182 men and women (24 to 79 years) found that a multivitamin was able to lower homocysteine levels and the oxidation of LDLcholesterol—both of which are highly beneficial in reducing the risk for cardiovascular disease. Other multivitamin research⁴ has also demonstrated effectiveness in lowering homocysteine levels.

A 6-month, randomized, double-blind, placebo-controlled study⁵ of 87 men and women (30 to 70 years) found that multivitamin use was associated with lower levels of C-reactive protein, a measurement of inflammation associated with cardiovascular disease and other degenerative diseases. Other multivitamin research⁶ in women has shown similar results.

A Swedish, population-based, case-control study⁷ of 1296 men and women (45 to 70 years) who previously had a heart attack and 1685 healthy men and women as controls, found those using a multivitamin were less likely to have a heart attack. Other multivitamin research⁸ in Swedish women has shown similar results.

Cancer:
A large-scale, randomized, double-blind, placebo-controlled study⁹ was conducted with 14,641 male U.S. physicians initially 50 years or older, including 1312 men with a history of cancer, to determine the long-term effects of multivitamin supplementation on the incidence of various types of cancers. Results showed that during a median follow-up of 11.2 years, men with a history of cancer who took a daily multivitamin had a statistically significant reduction in the incidence of total cancer compared to those taking a placebo.

Stress/Energy:
A human clinical study¹⁰ with 96 healthy men (18 to 46 years) examined the effect of multivitamin supplementation in relation to plasma interleukin-6 (IL-6, a pro-inflammatory chemical produced by the body) and anger, hostility, and severity of depressive symptoms. The results showed that plasma IL-6 was associated with anger, hostility, and severity of depressive symptoms, and that multivitamin use was associated with lower plasma IL-6 levels.

A review¹¹ of the scientific literature indicated that patients complaining of fatigue, tiredness, and low energy levels may have low levels of vitamins and minerals. Certain risk groups like the elderly and pregnant women were identified, as was the role of B-vitamins in energy metabolism. Results found that supplementation with nutrients including B-vitamins (e.g., a multivitamin) can alleviate deficiencies, but supplements must be taken for an adequate period of time.

A meta-analysis¹² of eight randomized and placebo-controlled studies evaluated the influence of diet supplementation on stress and mood. Results showed that supplementation reduced the levels of perceived stress, mild psychiatric symptoms, anxiety, fatigue, and confusion. Supplements containing high doses of B-vitamins (e.g., multivitamins) may be more effective in improving mood states.

Aging:
At the ends of our chromosomes are stretches of DNA called telomeres. These telomeres protect our genetic data, making it possible for cells to divide. Each time a cell divides, telomeres get shorter. When they get too short, the cell can no longer divide and becomes inactive or "senescent" or dies. This process is associated with aging. In a cross-sectional analysis of data from 586 women (35 to 74 years), multivitamin use was assessed, and relative telomere length was measured. The results were that multivitamin use was significantly associated with longer telomeres. Compared with nonusers, the relative telomere length was on average 5.1 percent longer among daily multivitamin users. It is possible, therefore, that multivitamins may help us live longer.

VITAMIN D

Vitamin D is the "sunshine vitamin," so coined because exposure to the sun's ultraviolet light will convert a form of cholesterol under the skin into vitamin D. This nutrient is best known for its role in helping to facilitate the absorption of calcium and phosphorus (as well as magnesium), and so helping to promote bone health.¹³ Over the past decade, however, research on vitamin D has identified numerous other roles it plays in human health and wellness, which includes:

• Inhibiting the uncontrolled proliferation of cells (as in the case of cancer) and stimulating the differentiation of cells (specialization of cells for specific functions).¹⁴
• Helping prevent cancers of the prostate and colon.^15,16
• Functioning as a potent immune system modulator.^17,18
• Helping prevent autoimmune reactions.^19,20,21
• Helping improve insulin secretion.^22,23,24
• Decreasing the risk of high blood pressure via the reninangiotensin system's regulation of blood pressure.²⁵
• Reducing osteoporotic fractures.^26,27,28
• Reducing the incidence of falls in older adults.^29,30
• Reducing the risk of developing premenstrual syndrome (PMS).³¹
• Reducing the prevalence of depression, especially in the elderly.³²
• Reducing the prevalence of urinary infections and lower urinary tract symptoms (e.g., benign prostatic hyperplasia or BPH).³³

Vitamin D deficiency and insufficiency
Outright vitamin D deficiency is present in 41.6 percent of the U.S. population,³⁴ while vitamin D insufficiency (i.e., lacking sufficient vitamin D) is present in 77 percent of the world's population.³⁵ If you are deficient in vitamin D you will not be able to absorb enough calcium to satisfy your body's calcium needs.³⁶ It has long been known that severe vitamin D deficiency has serious consequences for bone health, but other research indicates that lesser degrees of vitamin D deficiency are common and increase the risk of osteoporosis and other health problems.^37,38

Vitamin D sufficiency is measured by serum 25-hydroxyvitamin D levels in the body.³⁹ Laboratory reference ranges for serum 25-hydroxyvitamin D levels are based upon average values from healthy populations. However, recent research examining the prevention of secondary hyperparathyroidism and bone loss suggest that the range for healthy 25-hydroxyvitamin D levels should be considerably higher. Based upon the most current research, here are the ranges for serum 25-hydroxyvitamin D values:

• Less than 20–25 nmol/L: Indicates severe deficiency associated with rickets and osteomalacia.^40,41
• 50–80 nmol/L: Previously suggested as normal range.⁴²
• 75–125 nmol/L: More recent research suggests that parathyroid hormone^43,44 and calcium absorption⁴⁵ are optimized at this level; this is a healthy range.⁴⁶

Based upon the 75–125 nmol/L range, it is estimated that one billion people in the world are currently vitamin D deficient.⁴⁷ Furthermore, research indicates that supplementation with at least 800–1,000 IU daily are required to achieve serum 25-hydroxyvitamin D levels of at least 80 nmol/L.^48,49 Furthermore, there are many groups of individuals who currently are at risk for vitamin D deficiency. These include:

• Exclusively breast-fed infants: Especially if they do not receive vitamin D supplementation and if they have dark skin and/or receive little sun exposure.⁵⁰
• Dark skin: People with dark-colored skin synthesize less vitamin D from sunlight than those with light-colored skin.⁵¹ In a U.S. study, 42 percent of African American women were vitamin D deficient compared to four percent of white women.⁵²
• The Elderly: When exposed to sunlight have reduced capacity to synthesize vitamin D.⁵³
• Those using sunscreen: Applying sunscreen with an SPF factor of eight reduces production of vitamin D by 95 percent.⁵⁴
• Those with fat malabsorption syndromes: The absorption of dietary vitamin D is reduced in Cystic fibrosis and cholestatic liver disease.⁵⁵
• Those with inflammatory bowel disease: An increased risk of vitamin D deficiency occurs in those with inflammatory bowel disease like Crohn's disease.⁵⁶
• Obese individuals: Obesity increases the risk of vitamin D deficiency.⁵⁷

Vitamin D2 and D3
There are two forms of vitamin D available as a dietary supplement: cholecalciferol (vitamin D3) and ergocalciferol (vitamin D2). Cholecalciferol is the form made in the human body, and it is more active than ergocalciferol. In fact, Vitamin D2 potency is less than one third that of vitamin D3.⁵⁸

Commercially, ergocalciferol is derived from yeast, and so is considered vegetarian, while cholecalciferol is commonly derived from lanolin (from sheep) or fish oil—although a vegetarian D3 derived from lichen is available.

Ideal dosing for vitamin D
The Linus Pauling Institute recommends that generally healthy adults take 2,000 IU of supplemental vitamin D daily.⁵⁹ The Vitamin D Council states that if well adults and adolescents regularly avoid sunlight exposure, then it is necessary to supplement with at least 5,000 IU of vitamin D daily.⁶⁰ The Council for Responsible Nutrition recommends 2,000 IU daily for adults.⁶¹ Taking a conservative position, at least 2,000 IU of vitamin makes sense for adults.

OMEGA-3 FATTY ACIDS
Chemically, a fatty acid is an organic acid that has an acid group at one end of its molecule, and a methyl group at the other end.⁶² Fatty acids are typically categorized in the omega groups 3, 6 and 9 according to the location of their first double bond (there's also an omega 7 group, but these are less important to human health).⁶³ The body uses fatty acids for the formation of healthy cell membranes, the proper development and functioning of the brain and nervous system, and for the production of hormone-like substances called eicosanoids (thromboxanes, leukotrienes, and prostaglandins). These chemicals regulate numerous body functions including blood pressure, blood viscosity, vasoconstriction, immune and inflammatory responses.⁶⁴

Deficiency of omega-3 fatty acids
While omega-3, 6 and 9 fatty acids are all important for different reasons, it is the omega-3 fatty acids (O3FA) that are currently particularly critical—and specifically the O3FA known as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The reason for this current importance is that Western diets are deficient in O3FA, and have excessive amounts of omega-6 fatty acids. While human beings evolved on a diet with approximately a 1:1 ratio of omega-6 to omega-3 fatty acids (EFA), the current Western diet provides about a 16:1 ratio.⁶⁵ As a matter of fact, a recent Harvard School of Public Health study indicates that Omega-3 deficiency causes 96,000 U.S. deaths per year.⁶⁶ Other research has clearly shown that excessive amounts of omega-6 fatty acids and a very high omega-6 to omega-3 ratio, as is found in today's Western diets, promote many diseases, including cardiovascular disease, cancer, and inflammatory and autoimmune diseases, whereas increased levels of omega-3 (a low omega-6 to omega-3 ratio) exert protective effects.⁶⁷

Benefits of omega-3 fatty acids

O3FA offer a broad range of benefits in human health. These benefits are listed below categorically:

Cardiovascular Health
In several studies O3FA have been shown to help lower triglyceride levels.⁶⁸ In fact, the FDA has even approved an O3FA product for this purpose.⁶⁹ Individually, EPA and DHA also have triglyceride-lowering properties. Consuming 1 gram/day of fish oils from fish (about 3 ounces of fatty fish such as salmon) or fish oil supplements has a cardioprotective effect.⁷⁰

Evidence suggests increased consumption of O3FA from fish or fish-oil supplements, but not of alpha-linolenic acid, reduces the rates of all-cause mortality, cardiac and sudden death, and possibly stroke.⁷¹ Higher consumption of fish and O3FA has been associated with a lower risk of coronary heart disease.^72,73 Clinical research shows that DHA supplementation helps increase HDL cholesterol levels (the "good cholesterol").^74,75 Supplementation with fish oil produces modest, but significant reductions in systolic and diastolic blood pressure in patients with mild hypertension.^76,77,78

Inflammation
O3FA have been shown to help relieve inflammation caused by a variety of factors.^79,80

Research⁸¹ has demonstrated that fish oil supplementation is effective in the treatment of rheumatoid arthritis.

Menopause
Clinical research shows that taking supplements with 500 mg EPA, three times daily, modestly but significantly reduces the frequency of hot flashes compared to placebo in menopausal women.⁸²

ADHD
Research has shown children with attention deficit/hyperactive disorder (ADHD) may have low plasma levels of EPA and DHA.^83,84 Clinical research suggests that supplementation with DHA might improve aggression and social relationships in ADHD children.⁸⁵

Macular degeneration
Increased dietary consumption of DHA is associated with reducing the risk of macular degeneration.⁸⁶

Alzheimer's Disease
Participants who consumed fish once per week or more had 60 percent less risk of Alzheimer's disease compared with those who rarely or never ate fish, and this was attributed to the DHA content of the fish.⁸⁷

The sources of omega-3 fatty acids

To begin with, the overwhelming majority of research on the health benefits of supplementation with O3FA has been conducted using fish oil products. Consequently, a strong argument can be made that fish oil supplements are the preferred source of O3FA. Amongst these, the primary fish used commercially as the source from which O3FA are derived include mackerel, herring, tuna, halibut, salmon and cod liver.⁸⁸ Although some fish are touted as superior over others as sources for supplemental fish oil, it is the opinion of this author that they all provide acceptable sources of omega-3s. Still, there are other sources of O3FA besides fish oil. This includes squid, krill, flax seed oil and algae oil.

Squid
Squid-derived O3FA are derived from by-products of squid that are usually discarded when squid are commercially fished, and provides a much higher concentration of DHA (up to 50 percent) than do fish oil. However, there is a lack of human clinical data on squid-source O3FA, although they likely will have similar effects as fish oil.

Krill
Krill oil derived from the shrimp-like crustacean know as krill contain significant amounts of the EPA and DHA omega-3 fatty acids, as well as phospholipids (e.g., phosphatidylcholine),⁸⁹ vitamin A, vitamin E and astaxanthin, a powerful carotenoid antioxidant.^90,91 Human clinical research⁹² has shown that krill oil has greater absorption than fish oil—although krill provides significantly less EPA/DHA per gram than fish oil.

Flaxseed
Flaxseed oil contains about 52–55 percent omega-3s, but as alpha-linolenic acid (ALA), not EPA/DHA.⁹³ This is significant since ALA has to be converted to EPA and DHA before it will provide the much-touted health benefits attributed to O3FA. This is problematic since studies indicate that in men approximately eight percent of ALA is converted to EPA and 0–4 percent is converted to DHA.⁹⁴ In women, approximately 21 percent of dietary ALA is converted to EPA and nine percent is converted to DHA.⁹⁵ This is not to say that flaxseed oil has no value. It does, but just not as significant a value as fish oil.

Algae oil
Certain algae extracts provide a vegetarian source of O3FA—but in this case the O3FA are EPA and DHA, not ALA. Consequently, for vegetarians, algae oil is a viable substitute for fish oil. That being said, human clinical research on algae oil sources of O3FA is limited, and the cost is far more than fish oil.

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94. Burdge GC, Wootton SA. Conversion of alpha-linolenic acid to eicosapentaenoic, docosapentaenoic and docosahexaenoic acids in young women. Br J Nutr. 2002;88(4):411–20.

Today, most people know that the omega-3 fatty acids, such as are found in cold-water fish, are good for us. In fact, these are among the “stars players” of health supplements. The omega-3 fatty acids eicosapentanoic acid (EPA) and docosahexaenoic acid (DHA) have been widely studied in connection with cardiovascular, joint, immune and brain health. Numerous scientific findings have demonstrated that omega-3 fatty acids are important for a healthy inflammatory response. In fact, research on omega-3s is so compelling that the FDA has granted a qualified health claim to the effect that consuming omega-3s reduces the risk of heart disease. For more than a decade, many of the benefits of omega-3 fatty acids have been largely beyond reasonable doubt. This year, that certainty has been called into question.

Publications from early 2015 challenge, or at least appear to challenge, two of the most important assertions often made for omega-3 fatty acid supplementation. These are the assertion that fish oils are valuable assets in reducing key components of cardiovascular disease and the assertion that these oils are useful supplements for preventing cognitive decline. The first shoe fell on March 31 with the publication in the New York Times of the essay, “Fading claims on fish oils.” This article was quite direct in judging that “no evidence that fish oil lowers risk for heart attack or stroke” has been found according to the majority of clinical trials that have been conducted on the topic.

The second shoe fell on August 26 in the form of a Newsweek article entitled “Omega-3 Supplements Are a Waste of Money.” The basis of this judgment was a medical study published in August 2015 in which the authors Chew et al. concluded, “oral supplementation with LCPUFAs (long-chain polyunsaturated fatty acids) … had no statistically significant effect on cognitive function.” 1 The same research group the previous year, based on the same trial design and data, had concluded that omega-3 supplementation “did not reduce the risk of CVD in elderly participants with age-related macular degeneration.” 2 This study, dubbed AREDS2, was a large double-blinded randomized study involving more than 4,000 subjects in its overall design and lasting approximately five years. On the surface, the results appear to be definitive. As often is the case, however, appearances can be deceiving.

The latest studies are not always the best or the most definitive studies despite the breathless hype so often found in the popular press. As usual, the devil is in the details with both of the negative judgments in the above paragraphs. The following sections provide a bit of guidance for the perplexed.

Omega-3s versus Cardiovascular Disease

In evaluating the findings of clinical trials, it is necessary to consider a range of questions regarding the basis and the aims of the trials in question. For instance, was a given trial performed in the right subject population to support its conclusions? The AREDS2 study mentioned above for its CVD conclusions used a population of participants who were “primarily white, married, and highly educated, with a median age at baseline of 74 years” that included “participants with stable, existing CVD (>12 months since initial event)” to determine a “composite outcome of myocardial infarction, stroke, and cardiovascular death…” “Approximately 19% had a history of CVD; 44% reported taking a statin medication; and 14% reported taking any type of medication for congestive heart failure, CVD, or cerebrovascular disease.” Several issues should be flagged immediately with this study population.

First, it was a group that might be expected to already have adopted dietary changes, such as eating fish two or more times per week and preferring olive oil for cooking and salads, that would have reduced the impact of supplementation with additional omega-3 oils. The average American may eat a diet highly unbalanced in the ratio of omega-3 to omega-6 fatty acids, high in saturated fats and low in magnesium, low in vegetables and fiber, etc., but the study population would have been much less likely to be following the standard American diet. Did the researchers check? Not as far as I could tell from reading the methods section. My suspicion is that a substantial percentage of the subjects already were consuming considerable omega-3 fatty acids in their diets and already had adopted a more healthful ratio of omega-3 to omega-6 fatty acids than is true of most Americans.

Second, 44 percent of the study group already was taking a statin medication and 14 percent (whether overlapping the statin takers is not indicated, but the implication is “not”) were taking other CVD medications. In other words, this was not a medically “naïve,” i.e., pharmaceutically untreated, starting population. The researchers in AREDS2 did try to control for some of these issues (see Figure 3 in the study), yet their data in this regard are a bit odd. Despite the non-significance of the statistics regarding the number of cardiac events between omega-3 and non-omega-3 arms with regard to, say, statin use, there were statistically significant differences between the arms involving hypertension history (a proven benefit of omega-3 supplementation, P = 0.02) and cardiovascular disease history (P = 0.04) implying a medical treatment effect not captured in the write-up. The authors, by the way, do admit the data that I mention imply potential benefit from omega-3 supplementation, but then try to explain this away without pursuing the implications regarding their collected data and its reliability regarding the impact of medications and lifestyle changes.

Another issue involves the endpoints selected for evaluating the outcome of a study. Surely, the meta-analyses have been conducted to evaluate the quite massive volume of clinical research, which has been performed with omega-3 fatty acids. This research consistently has found that fish oil consumption reduces cardiac death risk between approximately 10 and 30 percent with a low of nine percent and a high of 35 percent.³ These figures surely are not bad for a simple and safe dietary supplement!

With regard to other important CVD risk factors, omega- 3s have been found to consistently perform well. Omega-3 supplementation reduced blood pressure in studies in the general population approximately 4.5 mm Hg, which similar to lifestyle changes, including reduced intake of dietary sodium, increased physical activity and a reduction in excessive alcohol consumption. High fasting triglycerides were reduced by 30– 40 percent, yet another healthful change.⁴

Again, it must be remembered that study populations are important for outcomes. If one focuses on populations with advanced cardiovascular disease, this will be quite misleading with regard to the benefits of taking a nutrient, in this case, omega-3 fatty acids, over a significant period of time starting before the disease has manifested. This, of course, is precisely the role of supplements as opposed to drugs. The New York Times article applied the wrong model and created a controversy by doing so.

Omega-3s and Cognition

Let’s return to the citation above in which Chew et al. concluded, “oral supplementation with LCPUFAs (long-chain polyunsaturated fatty acids) … had no statistically significant effect on cognitive function.” The authors actually state in another spot, “Contrary to popular belief, we didn’t see any benefit of omega-3 supplements for stopping cognitive decline.”

The study by Chew et al. refers to its experimental supplementation as a “high dose,” yet the truth is that only 350 mg of the dose was DHA and the other 650 mg was EPA. This matters because these two omega-3 fatty acids do different things. To combat depression, which the AREDS2 study did not examine, EPA is the more significant nutrient. Trials using a mixture of the two mostly have been successful.⁵ Nevertheless, in a face-off of the two omega-3 fatty acids, EPA is the stronger anti-inflammatory in the brain and may deliver better results against depression.⁶

For cognition, the reverse is true: DHA outperforms EPA. This should not come as a surprise given that DHA plays a major structural role in brain cellular membranes and in the neurologic system more generally. In a study of 22 healthy adults, 12 weeks of daily dietary supplementation with either 1 g DHA-rich or 1 g EPA-rich fish oil (FO) or placebo (1 g olive oil) were assessed with the result being that DHA consumption leads to greater blood flow and activity in the prefrontal cortex during cognitive tests than does EPA.⁷ In older adults, episodic memory outcomes in adults with mild memory complaints are improved with the intake of greater than 1 gram DHA/EPA per day.⁸ In other words, the study by Chew et al., focused on the wrong omega-3 fatty acid to better influence cognition and was below an accepted threshold for the dosage for some aspects of cognition and memory.

To be fair to Chew et al., their trial was designed before papers became available that demonstrated that higher dosages of DHA and/or DHA/EPA improved cognition and memory, whereas lower dosages did not. A clarifying discussion of the issues involved has been published under the title “Omega-3s and Cognition: Dosage Matters.”⁹ For those interested in pursuing this issue further, a table of relevant papers can be downloaded from http://goedomega3.com/files/download/334/memory-and-cognitive-functionpapers-table.pdf.

Conclusion
The misleading conclusions of the New York Times article on fish oils and cardiovascular disease and the Newsweek article on DHA and cognition are cautionary tales regarding the interpretation of studies. In reality, adequate intakes of omega-3 fatty acids reduce CVD mortality by 10 to 30 percent, although supplementation may not deliver this same degree of benefit in populations already suffering from active CVD, already taking numerous medications or already having adopted appropriate diet and lifestyle modifications. Similarly, DHA supplementation significantly improves some aspects of cognition and memory, but only at intake levels above 1 gram per day in older individuals. Younger adults may benefit from 1 gram mixed DHA/EPA with the proviso still in place that for this purpose DHA is more active than is EPA whereas for depression, the opposite is true.

Endnotes:

1. 1. Chew EY, Clemons TE, Agron E, Launer LJ, Grodstein F, Bernstein PS; Age-Related Eye Disease Study 2 (AREDS2) Research Group. Effect of Omega-3 Fatty Acids, Lutein/Zeaxanthin, or Other Nutrient Supplementation on Cognitive Function: The AREDS2 Randomized Clinical Trial. JAMA. 2015 Aug 25;314(8):791.801.
2. 2. Writing Group for the AREDS2 Research Group, Bonds DE, Harrington M, Worrall BB, Bertoni AG, Eaton CB, Hsia J, Robinson J, Clemons TE, Fine LJ, Chew EY. Effect of long-chain ƒÖ-3 fatty acids and lutein + zeaxanthin supplements on cardiovascular outcomes: results of the Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial. JAMA Intern Med. 2014 May;174(5):763.71.
3. 3. Ismail A. The real story of omega-3s in heart health. April 3, 2015. http://goedomega3.com/index.php/blog/2015/04/the-realstory-of-omega-3s-in-heart-health
4. 4. Ibid.
5. 5. Yang JR, Han D, Qiao ZX, Tian X, Qi D, Qiu XH. Combined application of eicosapentaenoic acid and docosahexaenoic acid on depression in women: a meta-analysis of double-blind randomized controlled trials. Neuropsychiatr Dis Treat. 2015 Aug 10;11:2055.61.
6. 6. Martins JG. EPA but not DHA appears to be responsible for the efficacy of omega-3 long chain polyunsaturated fatty acid supplementation in depression: evidence from a meta-analysis of randomized controlled trials. J Am Coll Nutr. 2009 Oct;28(5):525.42.
7. 7. Jackson PA, Reay JL, Scholey AB, Kennedy DO. DHA-rich oil modulates the cerebral haemodynamic response to cognitive tasks in healthy young adults: a near IR spectroscopy pilot study. Br J Nutr. 2012 Apr;107(8):1093.8.
8. 8. Yurko-Mauro K, Alexander DD, Van Elswyk ME. Docosahexaenoic acid and adult memory: a systematic review and meta-analysis. PLoS One. 2015 Mar 18;10(3):e0120391.
9. 9. Ismail A. Omega-3s and Cognition: Dosage Matters. August 31, 2015. http://goedomega3.com/index.php/blog/2015/08/omega-3s-and-cognition-dosage-matter