Webinar Forum: UCONN Enduring CE Program: Scientific Evidence on the Health Benefits of Docosahexaenoic Acid (DHA) Through Every Stage of Life

In this knowledge-based continuing pharmacy education activity, Catherine Ulbricht, PharmD, discusses the available evidence of effectiveness for DHA, an omega-3 fatty acid.

Pharmacists, pharmacy technicians and nurses interested in learning about the clinical evidence for the use of DHA for various disease states throughout life are invited to participate in the webinar.

There is no fee for this activity; funding was generously provided by an educational grant from Martek Biosciences Corporation.

Dr. Ulbricht is Attending Pharmacist Massachusetts General Hospital and Chief Editor of Natural Standard Research Collaboration.

In accordance with the Accreditation Council for Pharmacy Education (ACPE) Criteria for Quality and Interpretive Guidelines, The University of Connecticut School of Pharmacy requires that faculty disclose any relationship that the faculty may have with commercial entities whose products or services may be mentioned in the activity. Dr. Catherine Ulbricht does not have any actual or potential conflicts of interest associated with this CPE activity.

To obtain CE credit: pharmacists, technicians, nurses:

• Go to: www.pharmacyce.uconn.edu
• Click on the DHA Tab in the top banner
• Click on the link “post test learning assessment and evaluation”
• Register as a new user if you have never used our system at UConn
• Enter your license number and APPROPRIATE session code for your profession.  Failure to use the correct code will result in the incorrect statement for your profession. 
• Take the quiz and evaluation
• Print your statement of credit

After July 28, 2009, individuals may view the recorded webinar, successfully complete the online post-test learning assessment and evaluate the program to receive 1 hour (0.1CEU) of pharmacist, pharmacy technician or nursing credit.

Comments

[Anonymous]

In the Natural Standard monograph, how rare are the "rare" side effects of DHA? Where was this information gathered from?

[Anonymous]

How common is vitamin A+D toxicity with fish oil supplementation?

[Aisha]

Is DHA an effective treatment for Alzheimer's disease? Is it safe? What types of studies have been done?

[Ryan]

What other herbs/supplements increase the risk of bleeding?

[Lizzy]

I've heard that fish oil can cause vitamin E deficiency. Is that true? If so, what dose/duration has it been associated with? How do you prevent it? Do doctors recommend taking concomitant vitamin E supplements?

[ER]

According to the NS Monograph on fish oils, fish liver oil (e.g., cod liver oil) may contain vitamins A and D, which can be toxic in excess (vitamin A >50,000 IU and vitamin D >2000 IU), and fish oil doses greater than 3g/day should be used cautiously. Vitamin A is fat soluble and can be stored in the liver for a long time, so it's important to check to see how much Vitamin A and D are in your fish oil product, which I will have to start doing.

While doing some research I also found a case report describing hypervitaminosis A after a patient consumed a large amount of fish oil capsules [30-50caps/day] (http://www.chestjournal.org/content/97/5/1260.abstract). The commentary following the discussion of this patient case explained that at the recommended levels, fish oil supplementation would likely be safe in terms of vitamin A toxicity, but it becomes a problem with excess consumption. This article also describes the signs and symptoms of vitamin A toxicity: fatigue, dry itchy skin, loss of body hair, irritability, headache, fever, vomiting, anorexia and myalgia.

[asr]

According to the NS monograph, fish oil taken for many months may cause a deficiency of vitamin E, and therefore, vitamin E is added to many commercial fish oil products. One of the studies cited in the monograph demonstrated a significant reduction in serum vitamin E levels in young women after 3 months of fish oil supplementation compared to after 1 month (PMID: 1826131). Based on this, vitamin E deficiency may be possible with prolonged use, but if the fish oil product contains vitamin E, then it may not be as common. I guess the level can always be checked, and supplementation can be started if needed.

[Angela]

To answer Ryan's question, there are a lot of herbal medications that can increase the risk of bleeding. Based on the omega-3 monograph on Natural Standard's Web site, the consumption of omega-3 with other herbs that may increase the risk of bleeding can potentiate the bleeding risk. Ginkgo biloba, garlic and saw palmetto may increase this risk. Other common herbs include: ginseng, bilberry, black cohosh, devil's claw, celery, vitamin E, etc.

[Novita]

The "rare" side effects were reported in the studies that were evaluated. The side effects that were rare are either that not a lot of people report the side effects to the study investigators or very small side effects were observed. The reported side effects could also be affected by other factors, such as other medications/herbs that the patient is taking or the formulation of the fish oils. Fish oils that are not regulated may contain pesticides and may harm patients.

[JK]

What evidence is there that omega-6 and omega-3 fatty acids compete?

[Robert]

Since fish oil increases the risk of bleeding, what would an appropriate dose be for someone who has a history or risk of hemorrhagic stroke?

[Heidi]

To answer Robert's question about patients with hemorrhagic stroke (documented Coronary Heard Disease), the American Heart Association recommends that these patients consume at about 1 gram of EPA + DHA daily, preferably from the oily fish, such as salmon, mackerel, sardines, etc. They should not exceed 3 grams per day because excessive consumption, or what's called "Eskimo" intakes, will increase the chance of bleeding, and hence, may increase the risk of stroke.

[Andrie]

There is little evidence to support the use of fish oil in Alzheimer's disease prevention or treatment, but there are data for dementia, which is one of the clinical symptoms of Alzheimer's disease. One of the studies is PMID: 12399342: shows there was a decrease in inflammation and a delayed onset of Alzheimer's disease. In terms of safety in Alzheimer's disease patients, there are no data to state the adverse effects of fish oil in these patients besides the hypervitaminosis or the vitamin E deficiency that have been shown in some trials.

[Laura]

In the Natural Standard monograph, why does hypertriglyceridemia get a grade A, while hypercholesterolemia get a grade D? How are these conditions different? I always thought they were pretty similar, so it's surprising to me that they would get such different grades. Can anyone help me out?

[MC]

Is there any evidence to support storing fish oil capsules in the freezer to decrease gastrointestinal side effects?

[Kelly]

Laura, that's a very good question. Hypertriglyceridemia is actually an elevated increase in triglyceride, which is part of total cholesterol. Triglyceride is particularly increased after we eat.

In contrast, hypercholesterolemia is an elevated increase of total cholesterol in the blood. Total cholesterol is a combination of VLDL, LDL, HDL and also TG.

Hypertriglyceridemia received grade A because it has a lot of data to support it. Based on the Natural Standard grading criteria, there has to be a "statistically significant evidence of benefit from >2 properly RCTs..." So this is why it received grade A.

On the other hand, hypercholesterolemia, doesn't have a lot of data to support it. This is why it received grade D.

[Raymond]

For MC, I was not able to find any evidence/RCTs that compare fish oil consumption before or after refrigeration on GI side effects. But you can take a look at this article, PMID: 16542466. The sentence towards the end of the article mentions that to eliminate the odor of the fish oil (is this what you refer to for the GI side effects? the fishy odor?), you can put it in the refrigerator.

[katie]

I think it is interesting how DHA can affect bleeding. I have heard that Eskimo populations have prolonged bleeding times due to their high-fish diets. I have also read cardiovascular disease is very low in this population.

[Zoey F.]

This is an interesting webinar by Dr. Ulbricht. Omega-3 fatty acids have been getting a lot of positive attention in the media recently. I am curious what clinical research has been done so far. One example is the study of the effect of omega-3 fatty acids on mood in pregnant women, recently published in Epidemiology. A quick PubMed search revealed a large number of results, so there should be a ton of interesting information presented at the webinar.

[ro]

On the topic of fish oil capsules- http://www.consumermedsafety.org/alerts.asp?p=2009_4_AL68 -- Just an FYI that I read an article the other day stating how it interacts with Styrofoam cups. If you try to dissolve the oil in some kind of fluid in a styrofoam cup, the fish oil interacts with, and essentially melts the cup. So be careful, and your best bet may just be to swallow the capsule whole!