DHA Case Study

Just added this to Omega-3 Fatty Acid Recommendations for Vegetarians at VeganHealth.org:

A 60 year old, male, long time vegan forwarded his fatty acid lab reports to me. In August 2012 his EPA levels were .3% and DHA was 1.0% (of fatty acids in blood). He had been using “a lot of” canola oil but it apparently wasn’t increasing his EPA and DHA levels. After six months of daily supplementation of 320 mg DHA plus 130 mg of EPA (one capsule of Ovega-3 vegan supplement), his EPA levels went to 1.0% (about average for omnivores) and DHA to 4.8% (towards the higher average range for omnivores). It appears that this regimen was adequate.

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32 Responses to “DHA Case Study”

  1. Idan Says:

    Did he have any symptoms , How can we tell if his levels were not adequate?

  2. Jack Norris RD Says:

    Idan,

    I’m not aware of any symptoms.

  3. Dan N Says:

    Thanks for this,

    I have been recommended taking 3g (3.000mg) of DHA per day to reduce ADD symptoms. Do you know if that is safe and if there is indeed any reason to believe it has positive effects?

  4. Jack Norris RD Says:

    Dan N,

    I don’t follow the literature on DHA and ADD, but it sounds like more than I’d be willing to give someone on any sort of long term basis without careful monitoring for bleeding or bruising.

  5. Jordi (Barcelona, Spain) Says:

    Hi Jack!

    I would like to know if he was using “unrefined cold pressed canola oil” or we don’t know. Because if he was using refined canola oil as his source of omega 3 I think that could be one of the reasons why he had low blood levels of EPA or DHA.

    Thank you so much for your work!

  6. Jack Norris RD Says:

    Jordi,

    I don’t know. I’m skeptical that this would be an issue, but I’ll ask him to find out.

  7. Dan Hackam Says:

    As someone else pointed out in a previous thread, levels of many things derived from meat/fish/eggs will be low in vegans – this alone does not suggest any potential harm from this. For instance, HCA’s and PAH’s in barbequed or high-heat fried meats are extremely low to undetectable in vegans. Should we supplement with HCA/PAH, just because they are low? Cholesterol is also low in vegans – should we start supplementing with cholesterol?

    Drawing DHA and EPA blood levels are not standard of care practice and likely have to be paid for privately. There’s no good evidence that a clinical syndrome of DHA deficiency exists, unlike the case for B12, for example. I have never seen any report in the literature suggesting perturbed downstream biochemistry from very low DHA levels (such as the case with homocysteine/B12 deficiency or iron deficiency) .

    (I am no longer worried about my DHA levels and will be stopping my supplement at the end of this bottle – vegan DHA is extremely expensive.)

    The epidemiological studies linking low DHA with various bad outcomes are confounded by lifestyle, in that regular-consumers of omega-3-rich marine fish tend to have better health habits than non-fish-eaters (e.g. strict non-pesco-carnivores).

    By the way, I hope this gentleman is not frying with his “lots of canola oil”, or he is generated highly oxidized fatty acids from ALA, which tends to be abundant in canola oil.

  8. Andreas Says:

    Idan,

    I have tried an omega 3 vegan supplement before trying food sources of omega 3’s and my hand writing improved dramatically BUT I suffered nose/brain bleeds after a while of taking a low dose; 1 cupsule per day of Opti3 Omega-3 EPA & DHA.

    I would recommend trying walnuts if you have trouble with hand writing and see if your hand writing improves. Other food sources are hemp seeds, flax seeds and leafy greens.

    Dan N,

    ADD/ADHD didn’t exist before the advent of technology.

    ADD/ADHD is caused by the overuse of technology. Such as… video games, porn, television and internet addiction.

    Dan Hackam,

    Did you know that HCA’s and PAH’s are carcinogens?
    http://www.youtube.com/watch?v=oCFg_NLNQrU

  9. Dan Says:

    There have been controlled bleeding studies with up to 4000mg of omega-3 (DHA and EPA) showing no impact on bleeding time. In fact, LOVAZA, which is a prescription-grade DHA-only supplement in the US, and VASCEPA, which is a prescription-grade purified EPA-only supplement in the US, both contain very high doses of DHA and EPA, respectively, and are used for the treatment of high triglycerides.

    On the other hand, people on this website seem to have a lot of anecdotal reports of the association of DHA/EPA and bleeding. I have not noticed any increased bleeding or bruising since starting 900 mg of DHA/EPA 4 months ago, then substituting with DHA 250 mg two weeks ago, despite playing squash and in general being physically active (getting hit by a squash ball or raquet on the court will tell you quickly if you are an easy bruiser).

    I don’t see a true scientifically verifiable benefit to being on DHA long-term. In the observational studies, which compared DHA intake in the top quartile or quintile with the bottom quartile or quintile and found reduced incidence of various bad outcomes, DHA could simply be a marker for some other component of fish which is the beneficial actor (and which would then not be found in a vegan’s diet by taking a DHA supplement), or a set of healthy behaviors of fish-eaters in general, who may be more prevention-minded. Just as in the observational studies of saturated fat intake, those who had the greatest intake were also more likely to smoke, drink heavily, be overweight or obese, etc. While they adjust for a number of these measures, many hidden confounders likely remain (you can’t adjust for everything).

    As noted, the last 5 clinical trials of EPA/DHA omega-3 supplementation for the prevention of cardiovascular events and death were all neutral (and one showed an increased risk of malignancy in women).

  10. Tyler Says:

    What about his omega-6/omega-3 ratio? Vegan diets, especially when they contain processed foods, tend to be very high in omega-6 and even with the use of canola oil (which has a ~4:1 ratio) the ratio may still be high enough to impair the conversion of ALA into DHA.

    What I’ve always found strange about DHA supplementation is that the body can up/down regulate the conversion, so why would naturally occurring levels be problematic? This is, of course, assuming you’re not doing anything to prevent the conversion (e.g., consuming a poor omega-6/omega-3 ratio).

  11. Dan Says:

    Tyler, I have seen conflicting papers in the literature on the ability to convert ALA into DHA in vegetarians. I think Jack covered the EPIC data well in his post on DHA in vegans. Some studies seem to suggest that conversion of ALA to DHA does proceed but at quite a low rate. Others suggest that vegans are quite DHA-deficient (as this case report does); don’t think these papers commented much on the omega-6/omega-3 ratio though, and how much LA people were ingesting.

  12. Jack Norris RD Says:

    I am skeptical that reducing omega-6 will increase ALA to DHA conversion enough to justify the effort. Much easier to just take a supplement and don’t worry about the omega-6s.

  13. Dan Says:

    >Much easier to just take a supplement and don’t worry about the omega-6s.

    Jack, there may be other harms of omega-6’s.

    A trial conducted in Sydney in the 1970’s showed that an LA-rich, safflower oil margarine increased cardiovascular, coronary and non-cardiovascular deaths in men with a history of MI.

    A trial conducted in Los Angeles in veterans living in an institution (a captive population) using corn oil, showed that rates of death from cancer were doubled compared with the placebo group.

    There is alot of evidence that omega-6 fatty acids lead to lipid peroxidation, making LDL much stickier and promoting uptake of LDL cholesterol into scavenger macrophages in atheromatous plaques. In addition, omega-6 LA is a potent precursor for the arachidonic acid pathway of inflammatory eicosanoids.

    I try to minimize my intake of direct vegetable oils and have stopped cooking with them. For different reasons, ALA-rich vegetable oils like canola are far more likely to oxidize when heated – it’s bad to add heat to a double bond.

    Many blame industrial seed oils together with refined sugar and flour for the modern epidemics of degenerative diseases of western civilization (heart disease, cancer, diabetes, stroke, dementia).

  14. Jack Norris RD Says:

    > In addition, omega-6 LA is a potent precursor for the arachidonic acid pathway of inflammatory eicosanoids.

    http://jacknorrisrd.com/omega-6s-not-so-bad/

  15. Jack Norris RD Says:

    The person in question responded and said that the canola oil was refined and he didn’t know of any symptoms.

  16. Tyler Says:

    The omega-6/omega-3 ratio seems to be more important to the conversion rate than overall omega-3 intake, see this study:

    http://www.jlr.org/content/43/9/1537.long

    This study also shows that plasma DHA levels aren’t very good markers for tissue DHA levels. The ideal seems to be around 4:1 and that isn’t hard to achieve if you are, ahem, largely avoiding processed foods and use an omega-3 rich cooking oil if you use such things.

    How do we know that DHA supplementation isn’t equivalent to vegan cholesterol supplementation?

  17. Andreas Says:

    Dan,

    I take back what I said since it wasn’t from a scientific view point.

    From a scientific view point, DHA and AA get converted to their respective inflammatory eicosanoids in scenarios of inflammation and then to their respective anti-inflammatory eicosanoids in the resolution fase.

    I was taking the DHA supplement in the winter when pollution is at its worst. Naturally DHA was converted to inflammatory eicosanoids after I inhaled air pollution and caused my bleeding episodes.

    “There is alot of evidence that omega-6 fatty acids lead to lipid peroxidation, making LDL much stickier and promoting uptake of LDL cholesterol into scavenger macrophages in atheromatous plaques. In addition, omega-6 LA is a potent precursor for the arachidonic acid pathway of inflammatory eicosanoids.”

    Please differentiate the difference between oxidized linoleic acid found in refined vegetables oils and natural linoleic acid found in nuts and seeds. The omega 6 scare mongering needs to stop. It is very rare that linoleic acid will get converted to inflammatory eicosanoids unless someone is inhaling or ingesting toxins, smoke, air pollution and other toxins, on a daily basis.

    Omega 6’s eaten from whole foods, nuts and seeds, have the benefits of curing cancer, gum disease, neurological disorders and any other disease. From their conversion to inflammatory eicosanoids to alert the immune system of the disease and then to their conversion to anti-inflammatory eicosanoids in the resolution fase of the disease.

    Jack,

    What were his(60 year old, male) Vitamin D levels?

    What does he eat?
    Does he get any form of activity? Walking?
    Does he get sunshine or take Vitamin D supplements?

  18. Jack Norris RD Says:

    Andreas,

    No idea. In the absence of compelling evidence that those things make a difference for ALA to DHA conversion, I’m not going to bother finding out.

  19. Dan Says:

    Jack, the meta-analysis you quoted in http://jacknorrisrd.com/omega-6s-not-so-bad/ I have not read it but you state that EPA levels went down as LA intake went up. Isn’t that a bad thing, according to most nutritionists? Purified EPA 1400 g/d on top of an already marine fish rich diet in Japanese decreased cardiovascular events (JELIS trial in Lancet a few years ago). So if LA is reducing EPA in the blood of vegetarians, additional intake of EPA may be necessary (or additional intake of ALA to convert to EPA). There’s no guarantee that if LA levels are high in the diet, sufficient quantities of ALA will be converted to EPA.

    That’s assuming that EPA, ALA and DHA are relevant to human health, particularly in vegan adults and children.

    The last 5 supplementation trials for EPA/DHA were all negative for cardiovascular events, so I am losing my faith in omega-3 supplementation anyway. But those trials largely apply to sick omnivores. Still, if they cannot improve health in those populations, how can they improve health in relatively healthy vegans?

  20. Jack Norris RD Says:

    Dan,

    > you state that EPA levels went down as LA intake went up. Isn’t that a bad thing,

    Not sure, but it didn’t increase inflammation.

  21. Dan Says:

    Just out of curiousity, Andreas, would you consider tahina, which is roasted sesame seeds that are crushed into paste, a healthy or unhealthy source of linoleic acid? I supposed since it is roasted then crushed, it is not actually a whole food.

  22. Dan Says:

    Tyler, one could achieve a more optimal omega-6/omega-3 ratio simply by adding more omega-3-containing foods to one’s diet, such as walnuts, flax, chia, etc.

  23. Andreas Says:

    Dan,

    Have you tried raw sunflower seeds and pecans?

    Info regarding roasting/cooking:
    http://en.wikipedia.org/wiki/Acrylamide#Toxicity_and_carcinogenicity
    http://www.ncbi.nlm.nih.gov/pubmed/15168561
    http://www.flavorfood.com.br/artigos/perigos_quimicos/Contaminantes%20formados%20durante%20o%20processamento/Acrylamide%20in%20cereal%20products%20A%20review.pdf

    BREAKTHROUGH SCIENCE on why high-PUFA oils are toxic and why the Omega 3/6 ratio doesn’t exist:
    1997: http://aslo.org/lo/toc/vol_42/issue_6/1454.pdf (You’ll have to read the abstract to understand the 2013 paper)
    2013: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3652295/ (BREAKTHROUGH SCIENCE)
    2011: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3118035/ (ADDITIONAL)
    http://en.wikipedia.org/wiki/Phospholipase_A2
    http://en.wikipedia.org/wiki/Thromboxane_A2

    http://www.jlr.org/content/39/8/1529.full

    I highly recommend placing nuts and seeds into the fridge because lipid peroxidation is temperature/light dependent and occurs much faster during the warmer months.

    Educational articles:
    http://www.bluemountainorganics.com/BlogRetrieve.aspx?BlogID=10047
    http://bluemountainorganics.com/_blog/Health_and_Nutrition/post/Nutrient_Density_Its_Significance_in_Our_Everyday_Health/

    You might want to try nut/seed butters but I don’t know if there is any benefits or harmful effects with the intake of stone ground nut/seed butters since I’ve never tried them. Maybe Jack or someone else can chime in.

  24. Jack Norris RD Says:

    Andreas,

    > Maybe Jack or someone else can chime in.

    You have lost me on all of this — I’m working on a big article (that I hope to publish real soon) and I don’t have the brain cells left to follow all this omega-6 stuff. I haven’t seen anything to change my mind about what recommendations I generally give but I have not followed all your links.

  25. Dan Says:

    Andreas,

    In terms of your question, I eat basically only raw nuts and seeds, with the exception of 3-4 tablespoons of tahini (which is crushed, roasted sesame seed paste). I eat 7 types of nuts/seeds per day, and I don’t store them in the fridge but use a dark pantry. Perhaps I will start storing them in the refrigerator. I too am lost when it comes to omega-3/omega-6 balance issues – I just don’t know whether to consider this relevant or not. Besides the tahini, I eat very little industrial seed oil (basically only olive oil). I am phasing out my tofurkey sausages in favour of raw edamame. The tofurkey does have high-oleic safflower and/or canola as listed ingredients. I will fairly soon not be eating any tofu whatsoever and going back to boiled or steamed raw soybeans.

    I consider my diet healthy because it’s low in carbs, contains no or very little sugar or chemical additives, high in vegetables, low in processed oils and fats, practically zero cholesterol, no trans fats, limited saturated fats, no artificial sweeteners, limited high-glycemic fruits. Staples for me are beans, nuts, vegetables and a bit of dairy (which would be tough to let go of). I eat minimal grain. I supplement with vitamins in where the diet is deficient (e.g. D3, iodine, B-complex). Overall this is a much healthier diet than what the average North American eats.

  26. John Says:

    Jack,

    Have seen this? Comments?

    http://www.sciencedaily.com/releases/2013/07/130710183637.htm

    I had been taking DHA supplement, but this has made me reconsider.

  27. Steve Says:

    What are your thoughts regarding the prostate cancer risks that have recently been posted. http://www.medicalnewstoday.com/articles/263179.php

    As a vegan who has been taking algae derived dha/EPA supplements, it all gets very confusing.

  28. Dan Says:

    This is not at all surprising to me. We’ve known since at least 1994 that men with high blood levels of ALA, which is a precursor of EPA, are at 3-fold increased risk of prostate cancer compared with men with low blood levels of ALA. As a man with a strong family history of prostate cancer, I have decided to stop supplementing with omega-3’s (EPA, DHA, ALA).

  29. Andreas Says:

    Jack,

    Chime in on nut butters. I’ve personally never tried them.

    No worries about not following.

    Dan,

    If the tahini isn’t causing you problems, no worries. Worrying about it will cause more health problems. Here is some good advice: http://www.youtube.com/watch?v=2frjM-S8YXg

    Why limit carbs? I don’t believe macronutrients should be limited unless the food source is processed and if the carbs are grain based.

    ALA doesn’t cause prostate cancer but its oxidized form most likely does. Oxidized ALA found in seed oils and oxidized EPA/DHA found in fish oil. – From personal experience, I tried taking a teaspoon of flaxseed oil daily for a week and suffered some type of macular degeneration, like presbyopia. On the other hand, no health problems from daily snacking on walnuts.

    Steve,

    Long and truthful article: http://www.the-scientist.com/?articles.view/articleNo/32901/title/Omega-3s–Fishing-for-a-Mechanism/

    The comments by AlanB at the end of the article are also valid.

  30. Jack Norris RD Says:

    > Chime in on nut butters. I’ve personally never tried them.

    If you make a nut butter using only the nuts, then it shouldn’t be any different than just eating the nuts. If you add oil, sugar, and/or salt, then those ingredients should be considered in your overall diet.

  31. Steve Says:

    Andreas,
    Thanks for the link. Interesting read but I’m not sure I’m much the wiser. Possibly says more about my understanding… Perhaps my brain needs a bit more omega 3.

  32. Jack Norris RD Says:

    John,

    http://jacknorrisrd.com/dha-supplements-and-prostate-cancer/

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