Omega 3 and Heart Disease

Feb 10, 2021

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

"I don't see a problem with it." During the cold snap in January, it was difficult to get Eric to put on appropriate outdoor attire. I'd ask him to walk Sheldon, the dog, and catch Eric at the front door dressed in a hoodie and slides. Apparently plastic sandals without a heel strap are called "slides". No, I didn't know that either. I assume they are called slides because you can slide your foot in. They are also appropriately named for what your feet do when you go outside with them at -30 C in the snow. As Sheldon was bouncing around on his leash, excited to go outside, I had to tell my 15 year old that -30 C was cold and he should put on a coat, hat, mitts and boots. However, when it warmed up to -4 C at beginning of February, I asked Eric to walk Sheldon again. This time he put on a coat, winter boots, mitts and a full balaclava all without me asking. At -4 C, Eric could easily have gotten around the block with the dog wearing just a hoodie, but he chose to excessively bundle up. When I asked him why, all he said was, "I don't see a problem with it."

We have been told for quite a while that omega 3 fatty acid supplements reduce the chance of heart problems. It is now starting to look like maybe they don't. This is despite what looked like good news from a study called REDUCE-IT looking at a prescription omega 3 supplement called Vascepa.

Let's back up and talk about cholesterol and the heart. Cholesterol is a naturally occurring substance in the body that is essential for life. If you had no cholesterol in you, you would die. Cholesterol helps form bile acids in your digestive system, hormones in your endocrine system and important components of every cell membrane in your body. Your liver can make all the cholesterol your body needs. The cholesterol in the food you eat doesn't go directly into your blood stream. Your liver makes cholesterol for you. We care about blood cholesterol levels because if they are too high for too long you have higher chance of getting a heart attack or a stroke. Every 7 minutes in Canada, someone dies of cardiovascular disease. That is why we care about blood cholesterol levels. And that is why cholesterol medications are so common.

Before we get back to omega 3's, fish oils and heart disease, we must quickly mention statins. Statins are the most popular cholesterol medications because they have by far the most and best evidence for reducing heart attacks, strokes and death. Even the REDUCE-IT trial was done with people who were already on a statin. The omega 3 fatty acid was an add on to the statin. Now why are we so interested in fish oils and omega 3's? In the late 1960's, some Danish researchers looked at the diets of American, Danish and Inuit peoples in Greenland. They all eat about the same amount of fat, but the Inuit had way fewer heart attacks. It was attributed to the Inuit consuming more omega 3 fatty acids. Those omega 3 fatty acids came from their diet which contained the meat of a lot of cold water marine fish, birds and mammals. There were further studies that showed adding omega 3 supplements decreased heart attacks and strokes in the participants in recent years. However, the pendulum might be swinging the other way on omega 3's.

Back to REDUCE-IT. Vascepa contains a very specific component of omega 3 fatty acids called EPA or eicosapentaenoic acid. Half the participants in REDUCE-IT were given the EPA (Vascepa) and half were given mineral oil. They were all already on a statin. Even though they were on a statin, one of their blood lipid numbers, their triglycerides, were still high. After about 5 years, 4.9 % fewer of the people getting the EPA group had a heart event than those on mineral oil. Heart events were cardiovascular death, nonfatal heart attack, nonfatal stroke, getting a by-pass operation or unstable angina. That means you'd need to treat about 21 people with EPA for 5 years to prevent one heart event. That sounded very promising for EPA and omega 3's in general.

REDUCE-IT wasn't perfect. It showed a higher incidence of a less serious heart condition called atrial fibrillation in the EPA group. There is some possibility that the mineral oil used in the placebo group might have interfered with the absorption of the statin in the placebo arm. It is possible the people in the placebo arm just got less statin drug.

Studies of EPA and DHA (another specific omega 3 with the name docosahexaenoic acid) together show no benefit when it comes to heart problems. Researchers aren't sure why. One possibility is the DHA counteracts the benefits of the EPA. Another is the mineral oil. It is possible the mineral oil placebo in the REDUCE-IT trial actually made the placebo group absorb less of their statin and so got less statin benefit. The mineral oil might also have increased the LDL and the C-reative protein in the placebo group. And the last reason not to get Vascepa is it is expensive. It is about $340 per month.

So, do omega 3 supplements help the heart? Maybe, maybe not. The Canadian Cardiovascular Society does not recommend taking an omega-3 supplement just to protect your heart. A large study called ASCEND with 15,480 people found no difference in heart problems between people who took an omega-3 supplement versus a placebo over about 8 years. Another large trial called VITAL with 25,871 people also found no real difference in total heart problems between omega-3 and placebo over about 5 years. VITAL did seem to indicate that people on omega-3 fatty acid supplements might get fewer heart attacks.

If you want to get the benefits of omega 3's but now think that supplements might not help, what should you do? Eat fish. The American Heart Association still recommends adults eat a 3.5 ounces of cooked or ¾ cup flaked fatty fish like tuna or salmon twice a week.

We ordered a couple pizzas from one of our local shops on Saturday. I served pizza to Doris and Eric. Serving Eric is really just opening his bedroom door and putting food next to his Xbox. Whether doing school work, watching Netflix or gaming, that is where he seems to be all day. Then I put the remaining pizza back in a box and hid it in the garage. I left an empty box on the stove. I knew Eric would come out of his room scavenging for food at 2 am while Doris and I were sleeping. I hoped he would find the empty pizza box and stop looking. It worked. We got to enjoy left over pizza the next day. Eric was annoyed. "Hey! I thought we finished off all the pizza yesterday. You tricked me!" My answer was, "I don't see a problem with it."

As always if you have any questions or concerns about these products, ask your pharmacist.

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

NEJM - REDUCE-IT trial - www.nejm.org/doi/full/10.1056/NEJMoa1812792

American Heart Association- Omega-3 fatty acids - www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/fish-and-omega-3-fatty-acids

Historical overview of n-3 fatty acids and coronary heart disease - https://academic.oup.com/ajcn/article/87/6/1978S/4633486

 


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