• Overview
• Uses
• Dietary Sources
• Available Forms
• How to Take It
• Precautions
• Possible Interactions
• Supporting Research

Overview

Omega-3 fatty acids are considered essential fatty acids, which means that they are essential to human health but cannot be manufactured by the body. For this reason, omega-3 fatty acids must be obtained from food. Omega-3 fatty acids can be found in fish and certain plant oils. It is important to maintain an appropriate balance of omega-3 and omega-6 (another essential fatty acid) in the diet as these two substances work together to promote health. Also known as polyunsaturated fatty acids (PUFAs), omega-3 and omega-6 fatty acids play a crucial role in brain function as well as normal growth and development.

There are three major types of omega 3 fatty acids that are ingested in foods and used by the body: alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). Once eaten, the body converts ALA to EPA and DHA, the two types of omega-3 fatty acids more readily used by the body. Extensive research indicates that omega-3 fatty acids reduce inflammation and help prevent certain chronic diseases such as heart disease and arthritis. These essential fatty acids are highly concentrated in the brain and appear to be particularly important for cognitive and behavioral function. In fact, infants who do not get enough omega-3 fatty acids from their mothers during pregnancy are at risk for developing vision and nerve problems.

As mentioned previously, it is very important to maintain a balance between omega-3 and omega-6 fatty acids in the diet. Omega-3 fatty acids help reduce inflammation and most omega-6 fatty acids tend to promote inflammation. An inappropriate balance of these essential fatty acids contributes to the development of disease while a proper balance helps maintain and even improve health. A healthy diet should consist of roughly one omega-3 fatty acid to four omega-6 fatty acids. The typical American diet tends to contain 11 to 30 times more omega-6 fatty acids than omega-3 fatty acids, and many researchers believe this imbalance is a significant factor in the rising rate of inflammatory disorders in the United States.

In contrast, however, the Mediterranean diet consists of a healthier balance between omega-3 and omega-6 fatty acids and many studies have shown that people who follow this diet are less likely to develop heart disease. The Mediterranean diet does not include much meat (which is high in omega-6 fatty acids) and emphasizes foods rich in omega-3 fatty acids including whole grains, fresh fruits and vegetables, fish, olive oil, garlic, as well as moderate wine consumption.

Uses

Studies suggest that omega-3 fatty acids may be helpful in treating a variety of conditions. The evidence is strongest for heart disease and problems that contribute to heart disease, but the range of possible uses for omega-3 fatty acids include:

High Cholesterol
Those who follow a Mediterranean-style diet tend to have higher HDL ("good") cholesterol levels. Similar to those who follow a Mediterranean diet, Inuit Eskimos, who consume high amounts of omega-3 fatty acids from fatty fish, also tend to have increased HDL cholesterol and decreased triglycerides (fatty material that circulates in the blood). In addition, fish oil supplements containing EPA and DHA have been shown to reduce LDL ("bad") cholesterol and triglycerides. Finally, walnuts (which are rich in ALA) have been shown to lower total cholesterol and triglycerides in people with high cholesterol.

High Blood Pressure
Several studies suggest that diets and/or supplements rich in omega-3 fatty acids lower blood pressure significantly in people with hypertension. Fish high in mercury (such as tuna) should be avoided, however, because they may increase blood pressure.

Heart Disease
One of the best ways to help prevent and treat heart disease is to eat a low-fat diet and to replace foods rich in saturated and trans-fat with those that are rich in monounsaturated and polyunsaturated fats (including omega-3 fatty acids). Evidence suggests that EPA and DHA found in fish oil help reduce risk factors for heart disease including high cholesterol and high blood pressure. There is also strong evidence that these substances can help prevent and treat atherosclerosis by inhibiting the development of plaque and blood clots, each of which tends to clog arteries. Studies of heart attack survivors have found that daily omega-3 fatty acid supplements dramatically reduce the risk of death, subsequent heart attacks, and stroke. Similarly, people who eat an ALA-rich diet are less likely to suffer a fatal heart attack.

Stroke
Strong evidence from population-based studies suggests that omega-3 fatty acid intake (primarily from fish), helps protect against stroke caused by plaque buildup and blood clots in the arteries that lead to the brain. In fact, eating at least two servings of fish per week can reduce the risk of stroke by as much as 50%. However, people who eat more than three grams of omega-3 fatty acids per day (equivalent to 3 servings of fish per day) may be at an increased risk for hemorrhagic stroke, a potentially fatal type of stroke in which an artery in the brain leaks or ruptures.

Diabetes
People with diabetes tend to have high triglyceride and low HDL levels. Omega-3 fatty acids from fish oil can help lower triglycerides and raise HDL, so people with diabetes may benefit from eating foods or taking supplements that contain DHA and EPA. ALA (from flaxseed, for example) may not have the same benefit as DHA and EPA because some people with diabetes lack the ability to efficiently convert ALA to a form of omega-3 fatty acids that the body can use readily.

Weight Loss
Many people who are overweight suffer from poor blood sugar control, diabetes, and high cholesterol. Studies suggest that overweight people who follow a weight loss program including exercise tend to achieve better control over their blood sugar and cholesterol levels when fish rich in omega-3 fatty acids (such as salmon, mackerel, and herring) is a staple in their low fat diet.

Arthritis
Most clinical studies investigating the use of omega-3 fatty acid supplements for inflammatory joint conditions have focused almost entirely on rheumatoid arthritis. Several articles reviewing the research in this area conclude that omega-3 fatty acid supplements reduce tenderness in joints, decrease morning stiffness, and allow for a reduction in the amount of medication needed for people with rheumatoid arthritis.

In addition, laboratory studies suggest that diets rich in omega-3 fatty acids (and low in omega-6 fatty acids) may benefit people with other inflammatory disorders, such as osteoarthritis. In fact, several test tube studies of cartilage-containing cells have found that omega-3 fatty acids decrease inflammation and reduce the activity of enzymes that destroy cartilage. Similarly, New Zealand green lipped mussel ( Perna canaliculus ), another potential source of omega-3 fatty acids, has been shown to reduce joint stiffness and pain, increase grip strength, and enhance walking pace in a small group of people with osteoarthritis. In some participants, symptoms worsened before they improved.

Osteoporosis
Studies suggest that omega-3 fatty acids such as EPA help increase levels of calcium in the body, deposit calcium in the bones, and improve bone strength. In addition, studies also suggest that people who are deficient in certain essential fatty acids (particularly EPA and gamma-linolenic acid [GLA], an omega-6 fatty acid) are more likely to suffer from bone loss than those with normal levels of these fatty acids. In a study of women over 65 with osteoporosis, those given EPA and GLA supplements experienced significantly less bone loss over three years than those who were given a placebo. Many of these women also experienced an increase in bone density.

Depression
People who do not get enough omega-3 fatty acids or do not maintain a healthy balance of omega-3 to omega-6 fatty acids in their diet may be at an increased risk for depression. The omega-3 fatty acids are important components of nerve cell membranes. They help nerve cells communicate with each other, which is an essential step in maintaining good mental health.

Levels of omega-3 fatty acids were found to be measurably low and the ratio of omega-6 to omega-3 fatty acids were particularly high in a study of patients hospitalized for depression. In a study of people with depression, those who ate a healthy diet consisting of fatty fish two to three times per week for 5 years experienced a significant reduction in feelings of depression and hostility.

Manic/Depression (Bipolar Disorder)
In a study of 30 people with bipolar disorder, those who were treated with EPA and DHA (in combination with their usual mood stabilizing medications) for four months experienced fewer mood swings and recurrence of either depression or mania than those who received placebo. A similar but larger study is currently underway at the University of California- Los Angeles School of Medicine.

Schizophrenia

Preliminary evidence suggests that people with schizophrenia experience an improvement in symptoms when given omega-3 fatty acids. However, a recent well-designed study concluded that EPA supplements are no better than placebo in improving symptoms of this condition. The conflicting results suggest that more research is needed before conclusions can be drawn about the benefit of omega-3 fatty acids for schizophrenia. Similar to diabetes, people with schizophrenia may not be able to convert ALA to EPA or DHA efficiently.

Attention Deficit/Hyperactivity Disorder (ADHD)
Children with ADHD may have low levels of certain essential fatty acids (including EPA and DHA) in their bodies. In a study of nearly 100 boys, those with lower levels of omega-3 fatty acids demonstrated more learning and behavioral problems (such as temper tantrums and sleep disturbances) than boys with normal omega-3 fatty acid levels. In animal studies, low levels of omega-3 fatty acids have been shown to lower the concentration of certain brain chemicals (such as dopamine and serotonin) related to attention and motivation. Studies that examine the ability of omega-3 supplements to improve symptoms of ADHD are still needed. At this point in time, eating foods high in omega-3 fatty acids is a reasonable approach for someone with ADHD.

Eating Disorders
Studies suggest that men and women with anorexia nervosa have lower than optimal levels of polyunsaturated fatty acids (including ALA and GLA). To prevent the complications associated with essential fatty acid deficiencies, some experts recommend that treatment programs for anorexia nervosa include PUFA-rich foods such as fish and organ meats (which include omega-6 fatty acids).

Burns
Essential fatty acids have been used to reduce inflammation and promote wound healing in burn victims. Animal research indicates that omega-3 fatty acids help promote a healthy balance of proteins in the body -- protein balance is important for recovery after sustaining a burn. Further research is necessary to determine whether omega 3s benefit people in the same way.

Skin Disorders
In one study, 13 people with a particular sensitivity to the sun known as photodermatitis showed significantly less sensitivity to UV rays after taking fish oil supplements. Still, research indicates that topical sunscreens are much better at protecting the skin from damaging effects of the sun than omega-3 fatty acids. In another study of 40 people with psoriasis, those who were treated with medications and EPA supplements did better than those treated with the medications alone. In addition, many clinicians believe that flaxseed (which contains omega-3 fatty acids) is helpful for treating acne.

Inflammatory Bowel Disease (IBD)
When added to medication, such as sulfasalazine (a standard medication for IBD), omega-3 fatty acids may reduce symptoms of Crohn's disease and ulcerative colitis -- the two types of IBD. More studies to investigate this preliminary finding are under way. In animals, it appears that ALA works better at decreasing bowel inflammation than EPA and DHA. Plus, fish oil supplements can cause side effects that are similar to symptoms of IBD (such as flatulence and diarrhea). Time-release preparations may help reduce these unwanted effects.

Asthma
Preliminary research suggests that omega-3 fatty acid supplements (in the form of perilla seed oil, which is rich in ALA) may decrease inflammation and improve lung function in adults with asthma. Omega-6 fatty acids have the opposite effect: they tend to increase inflammation and worsen respiratory function. In a small, well-designed study of 29 children with asthma, those who took fish oil supplements rich in EPA and DHA for 10 months had improvement in their symptoms compared to children who took a placebo pill.

Macular Degeneration
A questionnaire administered to more than 3,000 people over the age of 49 found that those who consumed more fish in their diet were less likely to have macular degeneration (a serious age-related eye condition that can progress to blindness) than those who consumed less fish. Similarly, a study comparing 350 people with macular degeneration to 500 without found that those with a healthy dietary balance of omega-3 and omega-6 fatty acids and higher intake of fish in their diets were less likely to have this particular eye disorder. Another larger study confirms that EPA and DHA from fish, four or more times per week, may reduce the risk of developing macular degeneration. Notably, however, this same study suggests that ALA may actually increase the risk of this eye condition.

Menstrual Pain
In a study of nearly 200 Danish women, those with the highest dietary intake of omega-3 fatty acids had the mildest symptoms during menstruation.

Colon Cancer
Consuming significant amounts of foods rich in omega-3 fatty acids appears to reduce the risk of colorectal cancer. For example, Eskimos, who tend to follow a high fat diet but eat significant amounts of fish rich in omega-3 fatty acids, have a low rate of colorectal cancer. Animal studies and laboratory studies have found that omega-3 fatty acids prevent worsening of colon cancer while omega-6 fatty acids promote the growth of colon tumors. Daily consumption of EPA and DHA also appeared to slow or even reverse the progression of colon cancer in people with early stages of the disease.

However, in an animal study of rats with metastatic colon cancer (in other words, cancer that has spread to other parts of the body such as the liver), omega-3 fatty acids actually promoted the growth of cancer cells in the liver. Until more information is available, it is best for people with advanced stages of colorectal cancer to avoid omega-3 fatty acid supplements and diets rich in this substance.

Breast Cancer
Although not all experts agree, women who regularly consume foods rich in omega-3 fatty acids over many years may be less likely to develop breast cancer. In addition, the risk of dying from breast cancer may be significantly less for those who eat large quantities of omega-3 from fish and brown kelp seaweed (common in Japan). This is particularly true among women who substitute fish for meat. The balance between omega-3 and omega-6 fatty acids appears to play an important role in the development and growth of breast cancer. Further research is still needed to understand the effect that omega-3 fatty acids may have on the prevention or treatment of breast cancer. For example, several researchers speculate that omega-3 fatty acids in combination with other nutrients (namely, vitamin C, vitamin E, beta-carotene, selenium, and coenzyme Q10) may prove to be of particular value for preventing and treating breast cancer.

Prostate Cancer
Laboratory and animal studies indicate that omega-3 fatty acids (specifically, DHA and EPA) may inhibit the growth of prostate cancer. Similarly, population based studies of groups of men suggest that a low-fat diet with the addition of omega-3 fatty acids from fish or fish oil help prevent the development of prostate cancer. Like breast cancer, the balance of omega-3 to omega-6 fatty acids appears to be particularly important for reducing the risk of this condition. ALA, however, may not offer the same benefits as EPA and DHA. In fact, one recent study evaluating 67 men with prostate cancer found that they had higher levels of ALA compared to men without prostate cancer. More research in this area is needed.

Other
Although further research is needed, preliminary evidence suggests that omega-3 fatty acids may also prove helpful in protecting against certain infections and treating a variety of conditions including ulcers, migraine headaches, preterm labor, emphysema, psoriasis, glaucoma, Lyme disease, lupus, and panic attacks.

Dietary Sources

Fish oils and plant oils are the primary dietary source of omega-3 fatty acids. Another potential source of omega-3 fatty acids is New Zealand green lipped mussels ( Perna canaliculus ),used for centuries by the Maories to promote good health. EPA and DHA are found in cold-water fish such as salmon, mackerel, halibut, sardines, and herring. ALA is found in flaxseeds, flaxseed oil, canola (rapeseed) oil, soybeans, soybean oil, pumpkin seeds, pumpkin seed oil, purslane, perilla seed oil, walnuts, and walnut oil.

Available Forms

In addition to the dietary sources described, EPA and DHA can be taken in the form of fish oil capsules. Flaxseed, flaxseed oil, and fish oil should be kept refrigerated. Whole flaxseeds must be ground within 24 hours of use, otherwise the ingredients lose their activity. Flaxseeds are also available in ground form in a special mylar package so that the components in the flaxseeds stay active.

Be sure to buy omega-3 fatty acid supplements made by established companies who certify that their products are free of heavy metals such as mercury.

How to Take It

Pediatric

The precise safe and effective doses of all types of omega-3 fatty acid supplements in children have not been established.

EPA and DHA

• EPA and DHA are naturally found in breast milk; therefore, infants that are breastfed should receive sufficient amounts of these substances.
• Formula for infants should contain less than 0.1% EPA.
• Formula for infants should contain 0.35% DHA.

ALA

• Infants that are breastfed should receive sufficient amounts of ALA if the mother has an adequate intake of this fatty acid.
• Infant formula should contain 1.5% ALA. 

Flaxseed Oil

• Flaxseed oil may be added to a child's diet to help balance fatty acids. If an infant is breastfed, the mother may ingest oil or fresh ground seed to increase fat content in breast milk. See adult dosage below. 

Flaxseed

• Children (2 to 12 years): 1 tsp daily of ground flaxseeds or 1 tsp of fresh flaxseed oil for constipation  

Adult

EPA and DHA

• The adequate daily intake of EPA and DHA for adults should be at least 220 mg of each per day.
• Two to three servings of fatty fish per week (roughly 1,250 mg EPA and DHA per day) are generally recommended to treat certain health conditions.

Fish oil supplements

• 3,000 to 4,000 mg standardized fish oils per day. (This amount corresponds to roughly 2 to 3 servings of fatty fish per week.)
• Typically, a 1,000 mg fish oil capsule has 180 mg EPA and 120 mg DHA

ALA

• The adequate daily intake of ALA for adults should be roughly 2,220 mg per day.

Flaxseed oil

• One or two Tbsp of flaxseed oil per day is recommended for general health.
• Doses up to 3,000 mg per day are recommended to prevent certain conditions and doses up to 6,000 mg per day may be recommend to treat these conditions.

Flaxseed

• 1 Tbsp two to three times per day or 2 to 4 tbsp one time per day. Grind before eating and take with lots of water.
• Decoction (liquid prepared by boiling down the flaxseed in water): A rounded Tbsp of whole seed simmered in 1 cup water for 10 to 15 minutes, strain and drink.
• 100 grams of raw flaxseed provides 22,800 mg of ALA

Precautions

Because of the potential for side effects and interactions with medications, dietary supplements should be taken only under the supervision of a knowledgeable healthcare provider.

Omega-3 fatty acids should be used cautiously by people who bruise easily, have a bleeding disorder, or take blood-thinning medications because excessive amounts of omega-3 fatty acids may lead to bleeding. In fact, people who eat more than three grams of omega-3 fatty acids per day (equivalent to 3 servings of fish per day) may be at an increased risk for hemorrhagic stroke, a potentially fatal condition in which an artery in the brain leaks or ruptures.

Fish oil can cause flatulence and diarrhea. Time-release preparations may reduce these side effects, however.

People with either diabetes or schizophrenia may lack the ability to convert ALA to EPA and DHA, the forms more readily used in the body. Therefore, people with these conditions should obtain their omega-3 fatty acids from dietary sources rich in EPA and DHA.

Although studies have found that regular consumption of fish (which includes the omega-3 fatty acids EPA and DHA) may reduce the risk of macular degeneration, a recent study including two large groups of men and women found that diets rich in ALA may substantially increase the risk of this disease. More research is needed in this area. Until this information becomes available, it is best for people with macular degeneration to obtain omega-3 fatty acids from sources of EPA and DHA, rather than ALA.

Similar to macular degeneration, fish and fish oil may protect against prostate cancer, but ALA may be associated with increased risk of prostate cancer in men. More research in this area is needed.

It is best to use lipid extracts rather than the powder form of New Zealand green lipped mussels because there is less chance of an allergic reaction. People who are allergic to seafood should avoid New Zealand green lipped mussels. In some individuals who take New Zealand green lipped mussels, arthritis symptoms may worsen before they improve.

Possible Interactions

If you are currently being treated with any of the following medications, you should not use omega-3 fatty acid supplements without first talking to your healthcare provider.

Blood-thinning Medications
Omega-3 fatty acids may increase the blood-thinning effects of aspirin or warfarin. While the combination of aspirin and omega-3 fatty acids may actually be helpful under certain circumstances (such as heart disease), they should only be taken together under the guidance and supervision of your healthcare provider.

Cyclosporine

Taking omega-3 fatty acids during cyclosporine therapy may reduce toxic side effects (such as high blood pressure and kidney damage) associated with this medication in transplant patients.

Etretinate and Topical Steroids
The addition of omega-3 fatty acids (specifically EPA) to a drug regimen of etretinate and topical corticosteroids may improve symptoms of psoriasis.

Cholesterol-lowering Medications
Following certain nutritional guidelines, including increasing the amount of omega-3 fatty acids in your diet and reducing the omega-6 to omega-3 ratio, may allow a group of cholesterol lowering medications known as "statins" (such as atorvastatin, lovastatin, and simvastatin) to work more effectively.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
In an animal study, treatment with omega-3 fatty acids reduced the risk of ulcers from nonsteroidal anti-inflammatory drugs (NSAIDs). More research is needed to evaluate whether omega-3 fatty acids would have the same effects in people.

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• Review Date: 4/1/2002
• Reviewed By: Participants in the review process include: Ruth DeBusk, RD, PhD, Editor, Nutrition in Complementary Care, Tallahassee, FL; Jacqueline A. Hart, MD, Department of Internal Medicine, Newton-Wellesley Hospital, Harvard University and Senior Medical Editor Integrative Medicine, Boston, MA; Gary Kracoff, RPh (Pediatric Dosing section February 2001), Johnson Drugs, Natick, Ma; Steven Ottariono, RPh (Pediatric Dosing section February 2001), Veteran's Administrative Hospital, Londonderry, NH. All interaction sections have also been reviewed by a team of experts including Joseph Lamb, MD (July 2000), The Integrative Medicine Works, Alexandria, VA;Enrico Liva, ND, RPh (August 2000), Vital Nutrients, Middletown, CT; Brian T Sanderoff, PD, BS in Pharmacy (March 2000), Clinical Assistant Professor, University of Mayland School of Pharmacy; President, Your Prescription for Health, Owings Mills, MD; Ira Zunin, MD, MPH, MBA (July 2000), President and Chairman, Hawaii State Consortium for Integrative Medicine, Honolulu, HI.

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