Quality analysis of commercial fish oil preparations

Omega-3 Fatty Acids and Arrhythmias

The pro- and antiarrhythmic effects of omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been extensively studied in preclinical and human trials. Despite early evidence of an antiarrhythmic role of n-3 PUFA in the prevention of sudden cardiac death and postoperative and persistent atrial fibrillation (AF), subsequent well-designed randomized trials have largely not shown an antiarrhythmic benefit. Two trials that tested moderate and high-dose n-3 PUFA demonstrated a reduction in sudden cardiac death, but these findings have not been widely replicated, and the potential of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) to reduce arrhythmic death in combination, or as monotherapy, remains uncertain. The accumulated clinical evidence does not support supplementation of n-3 PUFA for postoperative AF or secondary prevention of AF. Several large, contemporary, randomized controlled trials of high-dose n-3 PUFA for primary or secondary cardiovascular prevention have demonstrated a small, significant, dose-dependent increased risk of incident AF compared with mineral oil or corn oil comparator. These findings were reproduced with both icosapent ethyl monotherapy and a mixed EPA+DHA formulation. The proarrhythmic mechanism of increased AF in contemporary cohorts exposed to high-dose n-3 PUFA is unknown. EPA and DHA and their metabolites have pleiotropic cardiometabolic and pro- and antiarrhythmic effects, including modification of the lipid raft microenvironment; alteration of cell membrane structure and fluidity; modulation of sodium, potassium, and calcium currents; and regulation of gene transcription, cell proliferation, and inflammation. Further characterization of the complex association between EPA, EPA+DHA, and DHA and AF is needed. Which formulations, dose ranges, and patient subgroups are at highest risk, remain unclear.

Do patients benefit from omega-3 fatty acids?

Omega-3 fatty acids (O3FAs) possess beneficial properties for cardiovascular (CV) health and elevated O3FA levels are associated with lower incident risk for CV disease (CVD.) Yet, treatment of at-risk patients with various O3FA formulations has produced disparate results in large, well-controlled and well-conducted clinical trials. Prescription formulations and fish oil supplements containing low-dose mixtures of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have routinely failed to prevent CV events in primary and secondary prevention settings when added to contemporary care, as shown most recently in the STRENGTH and OMEMI trials. However, as observed in JELIS, REDUCE-IT, and RESPECT-EPA, EPA-only formulations significantly reduce CVD events in high-risk patients. The CV mechanism of action of EPA, while certainly multifaceted, does not depend solely on reductions of circulating lipids, including triglycerides (TG) and LDL, and event reduction appears related to achieved EPA levels suggesting that the particular chemical and biological properties of EPA, as compared to DHA and other O3FAs, may contribute to its distinct clinical efficacy. In vitro and in vivo studies have shown different effects of EPA compared with DHA alone or EPA/DHA combination treatments, on atherosclerotic plaque morphology, LDL and membrane oxidation, cholesterol distribution, membrane lipid dynamics, glucose homeostasis, endothelial function, and downstream lipid metabolite function. These findings indicate that prescription-grade, EPA-only formulations provide greater benefit than other O3FAs formulations tested. This review summarizes the clinical findings associated with various O3FA formulations, their efficacy in treating CV disease, and their underlying mechanisms of action.

An evaluation of the quality of Annona muricata leaf products

OBJECTIVES

Annona muricata, also known as graviola, is traditionally used for the treatment of a range of disorders including cancer. Interest in A. muricata use has increased in recent years. This study investigated the quality and safety of a selection of commercially available A. muricata leaf products.

METHODS

Seven commercially available products were purchased via online shopping sites. Each product was assessed for quality indicators including weight variation, quantification of the bioactive constituent annonacin, presence of annonaceous acetogenins and contaminants. The samples were evaluated by thin-layer chromatography, high-performance liquid chromatography, liquid chromatography-mass spectroscopy, low-resolution mass spectrometry and nuclear magnetic resonance spectroscopy. Microbial analysis was carried out in accordance with the British Pharmacopoeia. Heavy metals were analysed by inductive coupled plasma mass spectrometry.

KEY FINDINGS

Of the seven products analysed, one product contained less than half of the content stated on the label. The labelled dosage recommendation varied between products. There was a high variation in annonacin concentration (1.05-3.09 mg/g) and the presence of annonaceous acetogenins. One of the products was found to have a total aerobic microbial count above the United States Pharmacopoeia limit.

CONCLUSIONS

The variation in the indicators of quality and safety of commercially available A. muricata leaf products tested have implications for clinicians and people living with cancer who use these herbal products.

Influence of light conditions on the production of chrysolaminarin using Phaeodactylum tricornutum in artificially illuminated photobioreactors

The light conditions are of utmost importance in any microalgae production process especially involving artificial illumination. This also applies to a chrysolaminarin (soluble 1,3-β-glucan) production process using the diatom Phaeodactylum tricornutum. Here we examine the influence of the amount of light per gram biomass (specific light availability) and the influence of two different biomass densities (at the same amount of light per gram biomass) on the accumulation of the storage product chrysolaminarin during nitrogen depletion in artificially illuminated flat-panel airlift photobioreactors. Besides chrysolaminarin, other compounds (fucoxanthin, fatty acids used for energy storage [C16 fatty acids], and eicosapentaenoic acid) are regarded as well. Our results show that the time course of C-allocation between chrysolaminarin and fatty acids, serving as storage compounds, is influenced by specific light availability and cell concentration. Furthermore, our findings demonstrate that with increasing specific light availability, the maximal chrysolaminarin content increases. However, this effect is limited. Beyond a certain specific light availability (here: 5 µmolphotons  gDW -1  s-1 ) the maximal chrysolaminarin content no longer increases, but the rate of increase becomes faster. Furthermore, the conversion of light to chrysolaminarin is best at the beginning of nitrogen depletion. Additionally, our results show that a high biomass concentration has a negative effect on the maximal chrysolaminarin content, most likely due to the occurring self-shading effects.

Impact of cafeteria diet and n3 supplementation on the intestinal microbiota, fatty acids levels, neuroinflammatory markers and social memory in male rats

OBJECTIVE

To assess the effects of omega-3 (n3) supplementation on intestinal microbiota, fatty acids profile, neuroinflammation, and social memory of cafeteria diet (CAF)-fed rats.

METHODS

Male Wistar rats were fed with CAF for 20 weeks. Omega-3 (500 mg/kg/day) was supplemented between the 16th and 20th week. Colon morphology, intestinal microbiota composition, short-chain fatty acids (SCFA) and lipopolysaccharide (LPS) in the plasma, fatty acids profile, TLR-4 and claudin-5 expressions in the brain, and social memory were investigated.

RESULTS

CAF reduced colon length, crypts' depth, and microbiota diversity, while n3 increased the Firmicutes/Bacteroidetes ratio. CAF increased SCFA plasma levels, but n3 reduced butyrate and isobutyrate in obese rats. LPS was increased in CAF-fed rats, and n3 decreased its levels. In the cerebral cortex, n3 increased caprylic, palmitic, stearic, tricosanoic, lignoceric, myristoleic, and linoleic acids. CAF increased palmitic acid and TLR-4 expression in the cerebral cortex while decreasing claudin-5 in the hippocampus. In the social memory test, CAF-fed animals showed greater social interaction with no effect of n3.

CONCLUSIONS

The lack of n3 effect in some of the evaluated parameters may be due to the severity of the obesity caused by CAF. However, n3 reduced LPS levels, suggesting its ability to reverse endotoxemia.

Quantitative analysis of fatty acids and vitamin E and total lipid profiling of dietary supplements from the German market

Certain polyunsaturated fatty acids with n-3 double bonds are essential nutrients for the human body and are part of the bilayer of cell membranes or precursors of tissue hormones. The most abundant dietary n-3 fatty acids in human nutrition are α-linolenic, eicosapentaenoic, and docosahexaenoic acid and can be taken up through dietary sources such as vegetable oils or fish or, alternatively, dietary supplements with high levels of n-3 fatty acids. In previous studies, considerable variation of lipid patterns and quantities of n-3 fatty acids were observed. In this study, 33 dietary supplements from the German market, based on fish-, krill-, microalgae, and plant oil, have been analyzed. Lipid profiling (LC–MS) revealed triacylglycerols as the dominant lipid species in most samples. However, krill oil was rich in phospholipids and samples containing fatty acid concentrates featured abundant fatty acid ethyl esters and diacylglycerols. Furthermore, total lipid profiles showed considerable variance depending on the lipid sources (e.g., fish or plant oil), which was also apparent in fatty acid analysis. The contents of n-3 fatty acids ranged between 150 and 570 mg/g capsule content (GC–MS) and vitamin E (α-tocopherol and tocopheryl acetate) were found in quantities ranging from 1.2 to 86.1 mg/g capsule content (HPLC–UV/Vis). While our analyses indicated a good agreement between labeled and present quantities of total n-3 fatty acids and vitamin E for the majority of samples, significant differences in agreement between individual fatty acids were observed, as well as frequent mismatches between declared and present vitamin E derivatives.

Comparative membrane incorporation of omega-3 fish oil triglyceride preparations differing by degree of re-esterification: A sixteen-week randomized intervention trial

BACKGROUND

Fish oil is routinely concentrated into unmodified triglycerides, or trans-esterified into an ethyl ester form. Re-esterification of the ethyl ester form yields re-esterified triglycerides (rTG), which are reportedly more bioavailable than ethyl ester forms. However, the fidelity of the re-esterification process may yield variable triglyceride forms, with only 55-60% being rTG.

OBJECTIVE

To determine whether the blood lipidomic response to supplementation with two rTG supplements, varying by degree of re-esterification, would differ between treatments.

DESIGN

This was a double-blind, parallel-design, single-center, 128-day study with sixty young, healthy subjects randomized into two groups. One group received a >95% rTG (Ultimate Omega®), as 1,000 mg capsules containing 325 mg eicosapentaenoic acid (EPA) and 225 mg docosahexaenoic acid (DHA), and the other received a <70% rTG (MEG-3) as 1,000 mg capsules containing 300 mg EPA and 200 mg DHA. Total intake was 2,750 and 2,500 mg EPA+DHA for the Ultimate Omega® and MEG-3 groups, respectively, with blood drawn at 4, 16 and 24 weeks and analyzed for serum and erythrocyte phospholipid fatty acid (PLFA) content.

RESULTS

For erythrocyte PLFA profiles, EPA, docosapentaenoic acid (DPA) and DHA percentage of total erythrocyte PLFA were significantly greater for the Ultimate Omega® group than for the MEG-3 group, at week 16 (P < 0.05), as were the EPA:arachidonic acid (AA) ratio, DHA:AA ratio and EPA+DHA:AA ratio. For serum PLFA profiles, increases in EPA:AA ratio and EPA+DHA:AA ratio were significantly greater at week 4 in the Ultimate Omega® group compared to the MEG-3 group (P < 0.05).

CONCLUSIONS

These data suggest that the percentage of rTG in rTG fish oil preparations may evolve as a new chemoprofile/quality control marker that can influence its lipidomic pharmacodynamics. Additional investigations to assess the physiologic/vascular and metabolic/inflammasome responses to concentrated fish oil preparations differing in the percentage of rTG are warranted.

Role of Omega-3 Fatty Acids in Cardiovascular Disease: the Debate Continues

PURPOSE OF REVIEW

The omega-3 fatty acids (n3-FAs), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have recently undergone testing for their ability to reduce residual cardiovascular (CV) risk among statin-treated subjects. The outcome trials have yielded highly inconsistent results, perhaps attributable to variations in dosage, formulation, and composition. In particular, CV trials using icosapent ethyl (IPE), a highly purified ethyl ester of EPA, reproducibly reduced CV events and progression of atherosclerosis compared with mixed EPA/DHA treatments. This review summarizes the mechanistic evidence for differences among n3-FAs on the development and manifestations of atherothrombotic disease.

RECENT FINDINGS

Large randomized clinical trials with n3-FAs have produced discordant outcomes despite similar patient profiles, doses, and triglyceride (TG)-lowering effects. A large, randomized trial with IPE, a prescription EPA only formulation, showed robust reduction in CV events in statin treated patients in a manner proportional to achieved blood EPA concentrations. Multiple trials using mixed EPA/DHA formulations have not shown such benefits, despite similar TG lowering. These inconsistencies have inspired investigations into mechanistic differences among n3-FAs, as EPA and DHA have distinct membrane interactions, metabolic products, effects on cholesterol efflux, antioxidant properties, and tissue distribution. EPA maintains normal membrane cholesterol distribution, enhances endothelial function, and in combination with statins improves features implicated in plaque stability and reduces lipid content of plaques. Insights into reductions in residual CV risk have emerged from clinical trials using different formulations of n3-FAs. Among high-risk patients on contemporary care, mixed n3-FA formulations showed no reduction in CV events. The distinct benefits of IPE in multiple trials may arise from pleiotropic actions that correlate with on-treatment EPA levels beyond TG-lowering. These effects include altered platelet function, inflammation, cholesterol distribution, and endothelial dysfunction. Elucidating such mechanisms of vascular protection for EPA may lead to new interventions for atherosclerosis, a disease that continues to expand worldwide.

Taurine Attenuates Oxidized Fish Oil-Induced Oxidative Stress and Lipid Metabolism Disorder in Mice

The objective of this study was to determine the effect of dietary taurine on lipid metabolism and liver injury in mice fed a diet high in oxidized fish oil. The ICR mice (six weeks old) were randomly assigned to six groups and fed different diets for 10 weeks: control (CON), normal plus 15% fresh fish oil diet (FFO), normal plus 15% oxidized fish oil diet (OFO), or OFO plus 0.6% (TAU1), 0.9% (TAU2) or 1.2% (TAU3) taurine. Compared to the CON group, OFO mice showed increased liver index, aspartate aminotransferase (AST) and malondialdehyde (MDA) levels in serum (p < 0.05). In addition, OFO mice had increased cholesterol (CHOL)/high-density lipoprotein cholesterol (HDL-C) and decreased HDL-C/low-density lipoprotein cholesterol (LDL-C) and n-6/n-3 polyunsaturated fatty acid (PUFA) ratio in serum (p < 0.05) compared with CON mice. Notably, dietary taurine ameliorated the liver index and AST and MDA levels in serum and liver in a more dose-dependent manner than OFO mice. In addition, compared to OFO mice, decreased levels of CHOL and ratio of CHOL/HDL-C and n-6 PUFA/n-3 PUFA in serum were found in TAU3-fed mice. Supplementation with TAU2 and TAU3 increased the relative mRNA expression levels of peroxisome proliferator-activated receptor α, adipose triglyceride lipase, lipoprotein lipase, hormone-sensitive lipase and carnitine palmitoyl transferase 1 in liver compared with the OFO group (p < 0.05). Moreover, impaired autophagy flux was detected in mice fed with the OFO diet, and this was prevented by taurine. These findings suggested that dietary taurine might provide a potential therapeutic choice against oxidative stress and lipid metabolism disorder.

Omega-3-fatty acids: Do they prevent cardiovascular disease?

Despite cardiovascular disease (CVD) reductions with high-intensity statins, there remains residual risk among patients with metabolic disorders. Alongside low-density lipoproteins (LDL-C), elevated triglycerides (TG) are associated with incident CVD events. Omega-3 fatty acids (n3-FAs), specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), lower TG levels, but their ability to reduce CV risk has been highly inconsistent. Trials using icosapent ethyl (IPE), a purified EPA ethyl ester, produced reductions in CVD events and atherosclerotic plaque regression compared with mixed EPA/DHA formulations despite similar TG-reductions. The separate effects of EPA and DHA on tissue distribution, oxidative stress, inflammation, membrane structure and endothelial function may contribute to these discordant outcomes. Additional mechanistic trials will provide further insights into the role of n3-FAs in reducing CVD risk beyond TG lowering.

Oxidized PUFAs Increase Susceptibility of Mice to Salmonella Infection by Diminishing Host's Innate Immune Responses

Dietary ω-3 PUFAs are highly prone to oxidation, and this may potentially limit their application in the health-promoting field. Here, we sought to investigate whether and how oxidized PUFAs modulate the susceptibility of mice to Salmonella typhimurium (S. Tm) infection. Algae oil (AO) and oxidized algae oil (ox-AO) were administered to the C57BL/6 mice prior to S. Tm infection. Compared to the S. Tm group, ox-AO increased bacterial burden in systemic and intestinal tissues, downregulated host anti-infection responses, and developed worse colitis. In macrophages, ox-AO decreased both phagocytosis of S. Tm and clearance of intracellular bacteria and dampened the activation of mitogen-activated protein kinase (MAPK), NF-κB, and autophagy pathways. Furthermore, ox-AO diminished LPS-induced inflammatory cytokine production and S. Tm induced NLRC4 inflammasome activation. This study reveals that oxidized PUFAs may contribute to the development of enteric infections and regular monitoring of the oxidation status in commercial PUFA supplements to prevent their potential adverse impact on human health.

Controversies in the Use of Omega-3 Fatty Acids to Prevent Atherosclerosis

PURPOSE OF REVIEW

We discuss current controversies in the clinical use of omega-3 fatty acids (FA), primarily eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), and examine discrepancies between recent trials. Furthermore, we discuss potential side effects reported in these studies and the role of mixed omega-3 FA dietary supplements and concerns about their use.

RECENT FINDINGS

REDUCE-IT showed that addition of icosapent ethyl, a highly purified form of EPA, can reduce risk of cardiovascular events among statin-treated individuals with high triglycerides. Additional supportive evidence for EPA has come from other trials and meta-analyses of omega-3 FA therapy. In contrast, trials of mixed EPA/DHA products have consistently failed to improve cardiovascular outcomes. Discrepancies in results reported in RCTs could be explained by differences in omega-3 FA products, dosing, study populations, and study designs including the placebo control formulation. Evidence obtained from highly purified forms should not be extrapolated to other mixed formulations, including "over-the-counter" omega-3 supplements. Targeting TG-rich lipoproteins represents a new frontier for mitigating ASCVD risk. Clinical and basic research evidence suggests that the use of omega-3 FA, specifically EPA, appears to slow atherosclerosis by reducing triglyceride-rich lipoproteins and/or inflammation, therefore addressing residual risk of clinical ASCVD.

Assessment of the safety of dietary fish oil supplements in terms of content and quality

The fatty acid composition of top-selling fish oil dietary supplements in the markets was compared with the content stated on product label, and their oxidative qualities and heavy metal contents were evaluated in this study. While all the capsule groups (C) confirmed the label information, it was observed that one-third of the syrup groups (S) had less than the specified content. Capsule groups generally had richer EPA and DHA contents than syrup groups in the samples examined. The peroxide values (PV) of all fish oil capsules and syrups were found in the range of 1.97-2.89 mEq/kg and 2.22-18.30 mEq/kg, respectively. As for free fatty acids (FFA) values, the C4, S6, S9, and S10 groups were above the 3% oleic acid limit recommended for high-quality oils. However, thiobarbituric acid reactive substances (TBARs) values were found below 1 mg MA/kg in all groups. All fish oil supplements were within the limits specified in terms of As (0.50-4.19 µg/g), Cd (0.14 µg/g detected for one group, C5), Cu (not detected), Fe (0.32-15.7 µg/g), and Hg (≤ 0.1 µg/g). On the other hand, two fish oil supplements from the capsule group (0.17 for C6 and 1.01 µg/g for C8) and one group from the syrup group (0.29 µg/g for S10) exceeded the recommended limit in terms of Pb (0.1 mg/kg). As a result of the research, it can be concluded that the chemical quality of fish oils in syrup form needs to be improved and their reliability in terms of fatty acid content should be increased. Considering the heavy metals, it seems significant to follow up the fish oil products more strictly.

Co-cultivation of Phaeodactylum tricornutum and Aurantiochytrium limacinum for polyunsaturated omega-3 fatty acids production

Marine protist Aurantiochytrium limacinum produces docosahexaenoic acid (DHA) as main polyunsaturated fatty acid (PUFA) and lacks any monounsaturated fatty acids (MUFA), while eicosapentaenoic acid (EPA) and MUFA's are produced by Phaeodactylum tricornutum. The marine diatom P. tricornutum was co-cultured with A.limacinum to match the EPA:DHA ratio of fish oil. Modulation in initial cell density ratio overcame the dominance of A.limacinum during co-cultivation and led to regulated proliferation of both species. Media engineering with nitrate and glycerol concentration yielded 2:1 (56.44: 30.11) mg g^-1 and 1:1 (47.43: 49.61) mg g^-1 EPA: DHA ratio. The oil and biomass obtained from co-cultivation comprised of MUFA's such as palmitoleic acid (2.65 mg g^-1) and oleic acid (1.25 mg g^-1) along with pigments like fucoxanthin (367.18 µg g^-1), β-carotene (8.98 µg g^-1) and astaxanthin (0.77 µg g^-1). Thus, co-cultivation of P. tricornutum with A. limacinum represented a unique strategy towards achieving desired fatty acid composition.

Omega-3 mechanism of action in inflammation and endoplasmic reticulum stress in mononuclear cells from overweight non-alcoholic fatty liver disease participants: study protocol for the "Brazilian Omega Study" (BROS)-a randomized controlled trial

Abstract

The low-grade inflammation is pivotal in obesity and its comorbidities; however, the inflammatory proteins are out of target for traditional drug therapy. Omega-3 (ω3) fatty acids can modulate the downstream signaling of Toll-like receptor (TLR) and tumor necrosis factor-α receptor (TNFα) through GPR120, a G-protein-coupled receptor, a mechanism not yet elucidated in humans. This work aims to investigate if the ω3 supplementation, at a feasible level below the previously recommended level in the literature, is enough to disrupt the inflammation and endoplasmic reticulum stress (ER-stress), and also if in acute treatment (3 h) ω3 can activate the GPR120 in peripheral blood mononuclear cells (PBMC) and leukocytes from overweight non-alcoholic fatty liver disease (NAFLD) participants. The R270H variant of the Ffar4 (GPR120 gene) will also be explored about molecular responses and blood lipid profiles. A triple-blind, prospective clinical trial will be conducted in overweight men and women, aged 19–75 years, randomized into placebo or supplemented (2.2 g of ω3 [EPA+DHA]) groups for 28 days. For sample calculation, it was considered the variation of TNFα protein and a 40% dropout rate, obtaining 22 individuals in each group. Volunteers will be recruited among patients with NAFLD diagnosis. Anthropometric parameters, food intake, physical activity, total serum lipids, complete fatty acid blood profile, and glycemia will be evaluated pre- and post-supplementation. In the PBMC and neutrophils, the protein content and gene expression of markers related to inflammation (TNFα, MCP1, IL1β, IL6, IL10, JNK, and TAK1), ER-stress (ATF1, ATF6, IRE1, XBP1, CHOP, eIF2α, eIF4, HSP), and ω3 pathway (GPR120, β-arrestin2, Tab1/2, and TAK1) will be evaluated using Western blot and RT-qPCR. Participants will be genotyped for the R270H (rs116454156) variant using the TaqMan assay. It is hypothesized that attenuation of inflammation and ER-stress signaling pathways in overweight and NAFLD participants will be achieved through ω3 supplementation through binding to the GPR120 receptor.

Trial registration

ClinicalTrials.gov #RBR-7x8tbx. Registered on May 10, 2018, with the Brazilian Registry of Clinical Trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05702-x.

Fish Oil for Healthy Aging: Potential Application to Master Athletes

Master athletes perform high volumes of exercise training yet display lower levels of physical functioning and exercise performance when compared with younger athletes. Several reports in the clinical literature show that long chain n-3 polyunsaturated fatty acid (LC n-3 PUFA) ingestion promotes skeletal muscle anabolism and strength in untrained older persons. There is also evidence that LC n-3 PUFA ingestion improves indices of muscle recovery following damaging exercise in younger persons. These findings suggest that LC n-3 PUFA intake could have an ergogenic effect in master athletes. However, the beneficial effect of LC n-3 PUFA intake on skeletal muscle in response to exercise training in both older and younger persons is inconsistent and, in some cases, generated from low-quality studies or those with a high risk of bias. Other factors such as the choice of placebo and health status of participants also confound interpretation of existing reports. As such, when considered on balance, the available evidence does not indicate that ingestion of LC n-3 PUFAs above current population recommendations (250–500 mg/day; 2 portions of oily fish per week) enhances exercise performance or recovery from exercise training in master athletes. Further work is now needed related to how the dose, duration, and co-ingestion of LC n-3 PUFAs with other nutrients such as amino acids impact the adaptive response to exercise training. This work should also consider how LC n-3 PUFA supplementation may differentially alter the lipid profile of cellular membranes of key regulatory sites such as the sarcolemma, mitochondria, and sarcoplasmic reticulum.

Icosapent ethyl: safely reducing cardiovascular risk in adults with elevated triglycerides

INTRODUCTION

In patients at high cardiovascular risk, the rate of events remains elevated despite traditional, evidence-based lipid-lowering therapy. Residual hypertriglyceridemia is an important contributor to this risk. However, prior medications with triglyceride-lowering effects have not reduced adverse clinical outcomes in the statin era.

AREAS COVERED

The present review summarizes evidence and recommendations related to triglyceride-lowering therapy in the primary and secondary preventive settings. We provide an overview of findings from recent meta-analyses, important observational studies, and a detailed description of landmark trials, including the Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT). We further review recommendations from current guidelines.

EXPERT OPINION

Icosapent ethyl is a stable, highly purified ethyl ester of eicosapentaenoic acid that safely and effectively reduces cardiovascular events in the contemporary setting. It is prescribed at a dose of 2 grams twice daily and is indicated in patients at high cardiovascular risk who have fasting or non-fasting triglyceride levels ≥150 mg/dl despite maximally tolerated statin treatment, or in individuals with triglyceride levels ≥500 mg/dl. Conversely, omega-3 fatty acid preparations containing a combination of eicosapentaenoic acid and docosahexaenoic acid are not indicated for reduction of cardiovascular risk and should be actively deprescribed.

Quality of Fish-Oil-Based Dietary Supplements Available on the Italian Market: A Preliminary Study

The global market of food supplements is growing rapidly with a large turnover. Fish oil supplements represent a significant part of this turnover as they are believed to have important health benefits. Conversely, there are few papers in the literature about the quality control of fish oil capsules. As prior studies illustrate, a perfect agreement with the label is rarely found, and in some isolated cases, large amounts of soybean oil are also detected, indicating a true adulteration rather than a non-compliance with the label. None of the available studies refer to the Italian market, which ranks first in Europe in the consumption of food supplements. In this present communication, a quality control of fish-oil-based supplements from the Italian market was carried out for the first time. With minor deviations, all results showed substantial agreement with the label. However, the most important conclusion from this research is that compliance with the label is not enough to judge a product of good quality. The analysis of the overall fatty acid composition showed that some supplements have a high level of saturated fatty acids, and therefore they did not undergo a proper purification process. This may represent a safety issue since the purification process also allows the removal of toxic contaminants.

Response to Bannenburg and Rice

This manuscript is a response to concerns expressed in a letter by industry-based scientists Bannenburg and Rice in response to our recent narrative review. In the review, we largely discussed why supplementation with n-3 PUFA rich oils might have benefits to the body composition and metabolism of the offspring of overweight or obese pregnant women. Bannenburg and Rice raised concerns about a number of points that may be perceived as negative about the quality and functionality of commercial fish oils. We provide a refutation to their comments and a brief review of recent evidence regarding the n-3 PUFA content, and oxidative state of supplements available to consumers. From a clinical research perspective, there remains a need to exercise caution. An oil containing less n-3 PUFAs than expected may be ineffective, and lead to incorrect conclusions that n-3 PUFAs lack efficacy. Oxidized fish oil may be ineffective or even cause unwanted harm. Although we must not overinterpret limited evidence from animal models, we have a responsibility to minimize risk to study participants, especially those most vulnerable, such as pregnant women. Prior to selecting a fish oil to be used in a clinical trial, it is essential to independently verify the n-3 PUFA content of the oil, and that the oil is unoxidized.

Oxidized fish oils increased lipid deposition via oxidative stress-mediated mitochondrial dysfunction and the CREB1-Bcl2-Beclin1 pathway in the liver tissues and hepatocytes of yellow catfish

At present, the harmful effects and relevant mechanism of oxidized fish oils on fish and fish cells remain unknown. Our study found that oxidized fish oils increased lipogenesis, and reduced lipolysis, activated oxidative stress by decreasing glutathione peroxidase (GPX) activity, increasing malondialdhyde (MDA) content and damaging mitochondrial structure, and activated autophagy in the liver of yellow catfish; oxidized eicosapentaenoic acid (oxEPA) induced oxidative stress in yellow catfish hepatocytes. Oxidative stress, mitochondrial dysfunction and lipophagy mediated oxEPA induced-variations in lipid metabolism. Our further investigation indicated that oxEPA-activated lipophagy was via inhibiting the DNA binding capacity of the cAMP-response element binding protein (CREB)-1 to the region of Bcl-2 promoter, which in turn suppressed the binding activity of Bcl-2 to Beclin1 and promoted autophagosome formation. For the first time, our study elucidated the mechanisms of oxidized fish oils-induced lipid deposition by the oxidative stress, mitochondrial dysfunction and CREB1-Bcl-2-Beclin1 pathway in fish.

Fish oil supplements, oxidative status, and compliance behaviour: Regulatory challenges and opportunities

BACKGROUND

Fish oil supplements that are rich in omega-3 long-chain polyunsaturated fatty acids (n-3 PUFAs). PUFAs are among the most widely-used dietary supplements globally, and millions of people consume them regularly. There have always been public concerns that these products should be guaranteed to be safe and of good quality, especially as these types of fish oil supplements are extremely susceptible to oxidative degradation.

OBJECTIVES

The aim of the current study is to investigate and examine the oxidation status of dietary supplements containing fish oils and to identify important factors related to the oxidation status of such supplements available in the United Arab Emirates (UAE).

METHODS

A total of 44 fish oil supplements were analysed in this study. For each product, the oxidative parameters peroxide value (PV), anisidine value (AV), and total oxidation (TOTOX) were calculated, and comparisons were made with the guidelines supplied by the Global Organization for EPA and DHA Omega-3s (GOED). Median values for each of the above oxidative parameters were tested using the Kruskal-Wallis and Mann-Whitney U tests. P values < 0.05 were chosen as the statistically significant boundary.

RESULTS

The estimate for the average PV value was 6.4 with a 95% confidence interval (CI) [4.2-8.7] compared to the maximum allowable limit of 5 meq/kg. The estimate for the average P-AV was 11 with a 95% CI [7.8-14.2] compared to the maximum allowable limit of 20. The estimate for the average TOTOX value was 23.8 meq/kg with a 95% CI [17.4-30.3] compared to the maximum allowable limit of 26 according to the GOED standards.

CONCLUSION

This research shows that most, although not all, of the fish oil supplements tested are compliant with the GOED oxidative quality standards. Nevertheless, it is clear that there should be a high level of inspection and control regarding authenticity, purity, quality, and safety in the processes of production and supply of dietary supplements containing fish oils.

How To Stabilize ω-3 Polyunsaturated Fatty Acids (PUFAs) in an Animal Feeding Study?-Effects of the Temperature, Oxygen Level, and Antioxidant on Oxidative Stability of ω-3 PUFAs in a Mouse Diet

Substantial studies have shown that ω-3 polyunsaturated fatty acids (PUFAs) have various health-promoting effects; however, there are inconsistent results from animal studies that showed that ω-3 PUFAs have no effects or even detrimental effects. Emerging research suggests that oxidized ω-3 PUFAs have different effects compared to unoxidized ω-3 PUFAs; therefore, lipid oxidation of dietary ω-3 PUFAs could contribute to the mixed results of ω-3 PUFAs in animal studies. Here, we prepared an AIN-93G-based, semi-purified, powder diet, which is one of the most commonly used rodent diets in animal studies, to study the oxidative stability of fortified ω-3 PUFAs in animal feed. We found that lowering the storage temperature or the addition of a certain antioxidant, notably tert-butylhydroquinone (TBHQ), helps to stabilize ω-3 PUFAs and suppress ω-3 oxidation in the animal diet, while reducing the level of oxygen in the storage atmosphere is not very effective. The addition of 50 ppm of TBHQ in the diet inhibited 99.5 ± 0.1% formation of primary oxidation products and inhibited 96.1 ± 0.7% formation of secondary oxidation products, after 10 days of storage of the prepared diet at a typical animal-feeding experiment condition. Overall, our results highlight that ω-3 PUFAs are highly prone to lipid oxidation in a typical animal-feeding experiment, emphasizing the critical importance to stabilize ω-3 PUFAs in animal studies.

Feasibility of a portable, low-cost near-infrared spectrophotometer for the quality screening of omega-3 dietary supplements

The quality of omega-3 supplements, commercialized at substantial high prices and supplied by several manufacturers, must be assessed. The existing reference methods to attest the quality of omega-3 supplements are based on chromatography, which requires expensive equipment, a cumbersome analytical protocol to determine the contents of the active components, and operates ex-situ. This work evaluates, comprehensively, the feasibility of a low-cost near-infrared spectrophotometer and simple chemometrics to achieve fast and robust characterization of omega-3 supplements. The necessary attention, very often neglected, to the performance of the low-cost portable equipment is highlighted, and an appropriate sample measurement protocol is established. A non-conventional way to construct multivariate regression models based on partial least square regression to evaluated the omega-3 content in the supplements was proposed using few references values and completing the data set with the label values selected using the X-Y relation outliers plots. The results showed that the simple, fast and inexpensive approach proposed could deliver in situ relevant information related to the quality of the supplements such as identification several raw materials employed in its fabrication, screening for the content of the active components, identify frauds/non-conformities, and report on unscrupulous marketing practices.

Are dietary fish oil supplements appropriate for dyslipidemia management? A review of the evidence

PURPOSE OF REVIEW

The purpose of this review is to assess whether dietary fish oil supplements can be appropriate for patients with elevated triglycerides and cardiovascular risk based on a comprehensive analysis of their composition, and level of regulatory oversight.

RECENT FINDINGS

Approximately 19 million people in the United States take fish oil supplements, many for the purpose of treating or preventing heart disease. Unlike prescription products, fish oil supplements are classified as food by the Food and Drug Administration (FDA) and are not required to undergo manufacturing oversight or clinical testing. Analysis of widely used dietary fish oil supplements show that they may have lower amounts of ω-3 than advertised as well as significant levels of saturated fat and oxidized oils which actually may contribute to dyslipidemia. Clinical outcome trials have failed to show a consistent cardiovascular benefit with fish oil supplements and other low-dose mixed ω-3 fatty acids.

SUMMARY

In light of limited regulatory oversight and evidence of quality concerns, dietary fish oil supplements are not an appropriate substitute for FDA approved prescription ω-3 fatty acids for their indicated use in treatment of elevated triglycerides or the prevention of cardiovascular events.

Critical Differences Between Dietary Supplement and Prescription Omega-3 Fatty Acids: A Narrative Review

INTRODUCTION

Currently available omega-3 (OM-3) fatty acid products in the US are either nonprescription dietary supplements (e.g., fish oils) or prescription (Rx) medications. As such, we aimed to describe critical therapeutic differences among the OM-3 fatty acids, focusing on differences between fish oil supplements and Rx OM-3s.

METHODS

A narrative review of known papers salient to this topic was conducted.

RESULTS

Despite the multiple purported clinical benefits, the published evidence for OM-3 dietary supplements is generally insufficient, inconsistent, or negative. Rx OM-3 products are indicated as an adjunct to diet to reduce triglycerides (TG) in adults with severe hypertriglyceridemia (TG ≥ 500 mg/dl). Recently, the Rx eicosapentaenoic acid (EPA)-only OM-3, icosapent ethyl, demonstrated cardiovascular (CV) risk reduction among statin-treated patients at high risk of CV disease in a large CV outcomes trial (CVOT), and is now also indicated as an adjunct to maximally tolerated statin therapy to reduce the risk of myocardial infarction, stroke, coronary revascularization, and unstable angina requiring hospitalization in adult patients with elevated TG (≥ 150 mg/dL) and established CVD or diabetes mellitus and ≥ 2 additional risk factors for CVD. In contrast to the rigorous regulatory standards for safety, efficacy, and manufacturing of medications (whether Rx or over the counter), the Food and Drug Administration manages dietary supplements as food. Issues specific to OM-3 dietary supplements include variable content, labeling inconsistencies, and poor product quality/impurity. Given these issues, OM-3 dietary supplements should not be substituted for Rx OM-3 products. The efficacy of the EPA-only Rx OM-3 product in a large CVOT cannot be extrapolated to other OM-3 products.

CONCLUSION

Consumers and health care providers need to recognize critical differences between Rx and OM-3 dietary supplements to ensure appropriate use of each OM-3 product.

Omega-3 Fatty Acids for the Management of Hypertriglyceridemia: A Science Advisory From the American Heart Association

Hypertriglyceridemia (triglycerides 200-499 mg/dL) is relatively common in the United States, whereas more severe triglyceride elevations (very high triglycerides, ≥500 mg/dL) are far less frequently observed. Both are becoming increasingly prevalent in the United States and elsewhere, likely driven in large part by growing rates of obesity and diabetes mellitus. In a 2002 American Heart Association scientific statement, the omega-3 fatty acids (n-3 FAs) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were recommended (at a dose of 2-4 g/d) for reducing triglycerides in patients with elevated triglycerides. Since 2002, prescription agents containing EPA+DHA or EPA alone have been approved by the US Food and Drug Administration for treating very high triglycerides; these agents are also widely used for hypertriglyceridemia. The purpose of this advisory is to summarize the lipid and lipoprotein effects resulting from pharmacological doses of n-3 FAs (>3 g/d total EPA+DHA) on the basis of new scientific data and availability of n-3 FA agents. In treatment of very high triglycerides with 4 g/d, EPA+DHA agents reduce triglycerides by ≥30% with concurrent increases in low-density lipoprotein cholesterol, whereas EPA-only did not raise low-density lipoprotein cholesterol in very high triglycerides. When used to treat hypertriglyceridemia, n-3 FAs with EPA+DHA or with EPA-only appear roughly comparable for triglyceride lowering and do not increase low-density lipoprotein cholesterol when used as monotherapy or in combination with a statin. In the largest trials of 4 g/d prescription n-3 FA, non-high-density lipoprotein cholesterol and apolipoprotein B were modestly decreased, indicating reductions in total atherogenic lipoproteins. The use of n-3 FA (4 g/d) for improving atherosclerotic cardiovascular disease risk in patients with hypertriglyceridemia is supported by a 25% reduction in major adverse cardiovascular events in REDUCE-IT (Reduction of Cardiovascular Events With EPA Intervention Trial), a randomized placebo-controlled trial of EPA-only in high-risk patients treated with a statin. The results of a trial of 4 g/d prescription EPA+DHA in hypertriglyceridemia are anticipated in 2020. We conclude that prescription n-3 FAs (EPA+DHA or EPA-only) at a dose of 4 g/d (>3 g/d total EPA+DHA) are an effective and safe option for reducing triglycerides as monotherapy or as an adjunct to other lipid-lowering agents.

New Insights into Mechanisms of Action for Omega-3 Fatty Acids in Atherothrombotic Cardiovascular Disease

PURPOSE OF REVIEW

Treatment of hypercholesterolemia with statins results in significant reductions in cardiovascular risk; however, individuals with well-controlled low-density lipoprotein cholesterol (LDL-C) levels, but persistent high triglycerides (TG), remain at increased risk. Genetic and epidemiologic studies have shown that elevated fasting TG levels are associated with incident cardiovascular events. At effective doses, omega-3 fatty acids, such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), lower TG levels but may have additional atheroprotective properties compared to other TG-lowering therapies such as niacin and fibrates. The purpose of this review is to evaluate mechanisms related to the potential benefits of omega-3 fatty acids in atherothrombotic disease.

RECENT FINDINGS

Large randomized clinical trials are currently under way to test the cardiovascular benefits of omega-3 fatty acids at a pharmacologic dosage (4 g/day). A large randomized trial with a prescription EPA-only formulation was shown to reduce a composite of cardiovascular events by 25% in statin-treated patients with established cardiovascular disease or diabetes and other CV risk factors. EPA and DHA have distinct tissue distributions as well as disparate effects on membrane structure and lipid dynamics, rates of lipid oxidation, and signal transduction pathways. Compared to other TG-lowering therapies, EPA has been found to inhibit cholesterol crystal formation, inflammation, and oxidative modification of atherogenic lipoprotein particles. The anti-inflammatory and endothelial benefits of EPA are enhanced in combination with a statin. Omega-3 fatty acids like EPA only at a pharmacologic dose reduce fasting TG and interfere with mechanisms of atherosclerosis that results in reduced cardiovascular events. Additional mechanistic trials will provide further insights into their role in reducing cardiovascular risk in subjects with well-managed LDL-C but elevated TG levels.

Examination of marine and vegetable oil oxidation data from a multi-year, third-party database

Fish oil (FO) products constitute good sources of omega-3 fats. Oxidation data from a large third-party database of 1900 + globally-sourced FO samples were assessed. In FO products, for peroxide value (PV), 13.9% exceeded 5 mEq O₂/kg (2.2% >10); for acid value (AcV) 2.1% exceeded 3 mg KOH/g, while for p-anisidine value (pAV) in unflavoured oils, 6.1% exceeded 20, (3.8% >30), and 8.8% exceeded TOTOX limits (26). Additionally, we compared FO with other dietary oils. The FO median PV was similar to those of algal and sunflower oils, 4.8-fold greater than krill oil, and 5.2-fold less than extra-virgin olive oil. The median pAV differed non-significantly among oils. The FO median AcV was similar to those of algal and extra-virgin olive oils, 3.4-fold greater than sunflower oil, and 11.9-fold less than krill oil. This study has provided new insight that retail FO products predominantly meet regulatory guidelines and are comparable in oxidative status to other dietary oils.

Cardiovascular disease and omega-3s: Prescription products and fish oil dietary supplements are not the same

BACKGROUND AND PURPOSE

Despite achievement of optimal low-density lipoprotein cholesterol (LDL-C) control with statin therapy, patients with elevated triglycerides (TGs) and residual cardiovascular risk are commonly encountered in clinical practice.

METHODS

We present information from completed and ongoing clinical trials examining Rx omega-3s for TG-lowering and omega-3 dietary supplements to highlight important differences affecting patient management for nurse practitioners.

CONCLUSIONS

Rx omega-3s demonstrate robust reductions in TGs and may have a role in reducing residual cardiovascular risk. Products containing docosahexaenoic acid (DHA) may raise LDL-C and should not be substituted for Rx eicosapentaenoic acid (EPA)-only icosapent ethyl, which does not raise LDL-C. Omega-3 dietary supplements (e.g., fish oils containing EPA and DHA) may be used for general health promotion; however, they are not regulated as medications and concerns regarding quality, purity, safety, and variability of content exist. It is important to advise patients that omega-3 dietary supplements are not medications and should not be substituted for Rx omega-3s. Large-scale cardiovascular outcomes studies are underway for Rx omega-3s in statin-treated patients.

IMPLICATIONS FOR PRACTICE

Nurse practitioners can take an active role in reducing residual cardiovascular risk and educating patients about important differences between Rx omega-3s and fish oil supplements.

Omega-3 Long-Chain Polyunsaturated Fatty Acid Content and Oxidation State of Fish Oil Supplements in New Zealand

Forty-seven fish oil products available on the New Zealand market were analyzed for eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) content, as well as for oxidative status in a collaborative effort by several analytical laboratories. Of the tested products, 72%, 86% and 77% complied with voluntary industry-set maximum limits on Peroxide Value (PV), para-Anisidine Value (p-AV), and TOTOX, respectively. 91% of the products complied with EPA/DHA content claims. All fish oils complied with a p-AV limit of 30, 98% with a PV limit of 10 meq O2/kg, and 96% with a calculated TOTOX value of 50, which are less stringent limits used by the European and British Pharmacopeia and the Australian authorities. The results are in stark contrast to the very low percentage of fish oil products reported to be in compliance with primary oxidation limits and EPA/DHA content by a recently published assessment of fish oil supplements in New Zealand. Possible reasons for this discrepancy are evaluated and discussed.

Concerns with the Study on Australian and New Zealand Fish Oil Products by Nichols et al. (Nutrients 2016, 8, 703)

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Prescription omega-3 fatty acid products containing highly purified eicosapentaenoic acid (EPA)

The omega-3 fatty acid eicosapentaenoic acid (EPA) has multiple actions potentially conferring cardiovascular benefit, including lowering serum triglyceride (TG) and non-high-density lipoprotein cholesterol (non-HDL-C) levels and potentially reducing key steps in atherogenesis. Dietary supplements are a common source of omega-3 fatty acids in the US, but virtually all contain docosahexaenoic acid (DHA) in addition to EPA, and lipid effects differ between DHA and EPA. Contrary to popular belief, no over-the-counter omega-3 products are available in the US, only prescription products and dietary supplements. Among the US prescription omega-3 products, only one contains EPA exclusively (Vascepa); another closely related prescription omega-3 product also contains highly purified EPA, but is approved only in Japan and is provided in different capsule sizes. These high-purity EPA products do not raise low-density lipoprotein cholesterol (LDL-C) levels, even in patients with TG levels >500 mg/dL, in contrast to the increase in LDL-C levels with prescription omega-3 products that also contain DHA. The Japanese prescription EPA product was shown to significantly reduce major coronary events in hypercholesterolemic patients when added to statin therapy in the Japan EPA Lipid Intervention Study (JELIS). The effects of Vascepa on cardiovascular outcomes are being investigated in statin-treated patients with high TG levels in the Reduction of Cardiovascular Events With EPA-Intervention Trial (REDUCE-IT).

Lipid effects of switching from prescription EPA+DHA (omega-3-acid ethyl esters) to prescription EPA only (icosapent ethyl) in dyslipidemic patients

OBJECTIVES

Residual cardiovascular risk and persistently elevated triglycerides (TGs) may remain despite statin therapy in patients with dyslipidemia. Prescription omega-3 fatty acid formulations containing docosahexaenoic acid (DHA) and/or eicosapentaenoic acid (EPA) have been shown to reduce TGs and may potentially lower residual cardiovascular risk. However, DHA may raise low-density lipoprotein cholesterol (LDL-C) and compromise treatment goals. Icosapent ethyl (Vascepa®), a high-purity prescription EPA formulation, has been shown to lower TGs and other lipid parameters without raising LDL-C. There are no prospective, randomized, controlled trials of the effects of switching patients from omega-3-acid ethyl esters (Lovaza®), a prescription formulation containing EPA+DHA, to icosapent ethyl.

METHODS

This retrospective chart review included records of high-risk patients aged ≥18 years receiving stable statin therapy for dyslipidemia who had been switched from prescription omega-3-acid ethyl esters 4 g/day to prescription icosapent ethyl 4 g/day and had available laboratory lipid profiles after receiving each for ≥2 months. Lipid assessments were conducted by local laboratories. Patient records were excluded if there were changes in medication or health condition that could affect lipid parameters.

RESULTS

The records of 8 patients (6 women and 2 men; 54-83 years) met eligibility criteria. Following the switch to icosapent ethyl, LDL-C changes ranged from +3.2% to -69.1% (reduced in 7 patients), total cholesterol was reduced in all patients (-3.5% to -44.3%), and TG changes ranged from +32.4% to -59.0% (reduced in 6 patients). Decreases or no changes in non-high-density lipoprotein cholesterol were observed; changes in high-density lipoprotein cholesterol varied. No adverse events related to either product were reported.

CONCLUSION

In this real-world retrospective analysis, switching high-risk statin-treated patients from omega-3-acid ethyl esters to icosapent ethyl resulted in favorable lipid changes. The analysis was limited by the small patient numbers, but lipid results were consistent with randomized controlled trials and previous case series.

Oxidized fish oil in rat pregnancy causes high newborn mortality and increases maternal insulin resistance

Fish oil is commonly taken by pregnant women, and supplements sold at retail are often oxidized. Using a rat model, we aimed to assess the effects of supplementation with oxidized fish oil during pregnancy in mothers and offspring, focusing on newborn viability and maternal insulin sensitivity. Female rats were allocated to a control or high-fat diet and then mated. These rats were subsequently randomized to receive a daily gavage treatment of 1 ml of unoxidized fish oil, a highly oxidized fish oil, or control (water) throughout pregnancy. At birth, the gavage treatment was stopped, but the same maternal diets were fed ad libitum throughout lactation. Supplementation with oxidized fish oil during pregnancy had a marked adverse effect on newborn survival at day 2, leading to much greater odds of mortality than in the control (odds ratio 8.26) and unoxidized fish oil (odds ratio 13.70) groups. In addition, maternal intake of oxidized fish oil during pregnancy led to increased insulin resistance at the time of weaning (3 wks after exposure) compared with control dams (HOMA-IR 2.64 vs. 1.42; P = 0.044). These data show that the consumption of oxidized fish oil is harmful in rat pregnancy, with deleterious effects in both mothers and offspring.

Omega-3 Fatty Acid Formulations in Cardiovascular Disease: Dietary Supplements are Not Substitutes for Prescription Products

Omega-3 fatty acid products are available as prescription formulations (icosapent ethyl, omega-3-acid ethyl esters, omega-3-acid ethyl esters A, omega-3-carboxylic acids) and dietary supplements (predominantly fish oils). Most dietary supplements and all but one prescription formulation contain mixtures of the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Products containing both EPA and DHA may raise low-density lipoprotein cholesterol (LDL-C). In clinical trials, the EPA-only prescription product, icosapent ethyl, did not raise LDL-C compared with placebo. To correct a common misconception, it is important to note that omega-3 fatty acid dietary supplements are not US FDA-approved over-the-counter drugs and are not required to demonstrate safety and efficacy prior to marketing. Conversely, prescription products are supported by extensive clinical safety and efficacy investigations required for FDA approval and have active and ongoing safety monitoring programs. While omega-3 fatty acid dietary supplements may have a place in the supplementation of diet, they generally contain lower levels of EPA and DHA than prescription products and are not approved or intended to treat disease. Perhaps due to the lack of regulation of dietary supplements, EPA and DHA levels may vary widely within and between brands, and products may also contain unwanted cholesterol or fats or potentially harmful components, including toxins and oxidized fatty acids. Accordingly, omega-3 fatty acid dietary supplements should not be substituted for prescription products. Similarly, prescription products containing DHA and EPA should not be substituted for the EPA-only prescription product, as DHA may raise LDL-C and thereby complicate the management of patients with dyslipidemia.

Improving lipids with prescription icosapent ethyl after previous use of fish oil dietary supplements

Managing dyslipidemia can be challenging in patients with statin intolerance. We describe the lipid effects of icosapent ethyl 4 g/day (high-purity prescription omega-3 eicosapentaenoic acid) in two coronary artery disease patients with statin intolerance who were self-treating with fish oil dietary supplements. After initiating icosapent ethyl, improvements were noted in the first and second patients, respectively, in total cholesterol (-12%; -21%), LDL cholesterol (-3%; -24%), triglycerides (-34%; -16%), non-HDL cholesterol (-12%; -22%), the omega-3 index (+42%; +8%) and eicosapentaenoic acid levels (+275%; +138%). Icosapent ethyl was well tolerated with no adverse events reported. These cases demonstrated favorable lipid effects with prescription icosapent ethyl treatment that may help optimize the care of high-risk coronary artery disease patients with statin intolerance.

Prescription omega-3 fatty acid products: considerations for patients with diabetes mellitus

Type 2 diabetes mellitus (T2DM) and metabolic syndrome contribute to hypertriglyceridemia, which may increase residual risk of cardiovascular disease in patients with elevated triglyceride (TG) levels despite optimal low-density lipoprotein cholesterol (LDL-C) levels with statin therapy. Prescription products containing the long-chain omega-3 fatty acids (OM3FAs) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are an effective strategy for reducing TG levels. This article provides an overview of prescription OM3FAs, including relevant clinical data in patients with T2DM and/or metabolic syndrome. Prescription OM3FAs contain either combinations of DHA and EPA (omega-3-acid ethyl esters, omega-3-carboxylic acids, omega-3-acid ethyl esters A) or EPA alone (icosapent ethyl). These products are well tolerated and can be used safely with statins. Randomized controlled trials have demonstrated that all prescription OM3FAs produce statistically significant reductions in TG levels compared with placebo; however, differential effects on LDL-C levels have been reported. Products containing DHA may increase LDL-C levels, whereas the EPA-only product did not increase LDL-C levels compared with placebo. Because increases in LDL-C levels may be unwanted in patients with T2DM and/or dyslipidemia, the EPA-only product should not be replaced with products containing DHA. Available data on the effects of OM3FAs in patients with diabetes and/or metabolic syndrome support that these products can be used safely in patients with T2DM and have beneficial effects on atherogenic parameters; in particular, the EPA-only prescription product significantly reduced TG, non-high-density lipoprotein cholesterol, Apo B, remnant lipoprotein cholesterol, and high-sensitivity CRP levels without increasing LDL-C levels compared with placebo. Ongoing studies of the effects of prescription OM3FAs on cardiovascular outcomes will help determine whether these products will emerge as effective add-on options to statin therapy for reduction of residual cardiovascular disease risk.

Switching statin-treated patients from fenofibrate to the prescription omega-3 therapy icosapent ethyl: a retrospective case series

Introduction

Patients receiving statin therapy for dyslipidaemia often require treatment with an additional agent to control triglyceride levels. Options for add-on therapy include fibrates and omega-3 fatty acids. This case series describes the effects of switching add-on therapy from fenofibrate to icosapent ethyl (the ethyl ester of the omega-3 fatty acid, eicosapentaenoic acid) on patient lipid profiles.

Methods

This was a retrospective analysis of patient records from a private medical practice in western New York. Statin-treated patients with dyslipidaemia who had been treated with fenofibrate and later switched to icosapent ethyl were selected for analysis. Lipid profiles before and after the switch to icosapent ethyl were compared.

Results

The records of five patients were analysed. All patients had hypertension and were overweight, male, and at high cardiovascular risk. After the switch to icosapent ethyl (treatment duration 3.9–5.8 months), triglyceride levels decreased in four patients, and low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, and total cholesterol levels decreased in all patients. High-density lipoprotein levels increased in four patients. Icosapent ethyl was well tolerated.

Conclusions

Switching from fenofibrate to icosapent ethyl as add-on to a statin therapy due to clinical need may provide an option for patients to maintain or improve lipid parameters.

Development of new reference material neohesperidin for quality control of dietary supplements

BACKGROUND

Neohesperidin is an important natural flavanone glycoside distributed in several citrus species. This compound is widely used as a raw material for food additives in the food industry. The request for certified reference materials (CRMs) in dietary supplements was stipulated by the National Administrative Committee for CRMs and was underpinned by the need to improve the accuracy and comparability of measurement data and to establish metrological traceability of analytical results.

RESULTS

This paper reports the sample preparation methodology, homogeneity and stability studies, value assignment and uncertainty estimation of a new certified reference material of neohesperidin (GBW09522). Differential scanning calorimetry, coulometric titration and mass balance methods proved to be sufficiently reliable and accurate for certification purposes. The certified value of neohesperidin CRM is 994 g kg(-1) with an expanded uncertainty of 4 g kg(-1) (k = 2). The reference material described above was homogeneous and stable for 12 months at a storage temperature of 25 °C.

CONCLUSION

The new CRM of neohesperidin can be used to validate analytical methods and improve the accuracy of measurement data as well as quality control of neohesperidin-related dietary supplements, foods, traditional herbs and pharmaceutical formulations.