MD, PhD, FMedSci, FSB, FRCP, FRCPEd

The fish oil (FO) story began when a young Danish doctor noticed that there were no heart attacks in Greenland. Large epidemiological studies were initiated, mechanistic investigations followed, and a huge amount of fascinating data emerged. Today, we know more about FO than most other dietary supplements.

Fish oil contains large amounts of omega-3 fatty acids which are thought to be beneficial in treating hypertriglyceridemia,  preventing heart disease.  In addition, FO is often recommended for a wide variety of other conditions, such as  cancer, depression, and macular degeneration. Perhaps the most compelling evidence exists in the realm of inflammatory diseases; the mechanism of action of FO is well-studied and includes powerful anti-inflammatory properties.

Australian rheumatologists just published a study of FO supplements for patients suffering from rheumatoid arthritis (RA). Specifically, they examined  the effects of high versus low dose FO in early RA employing a ‘treat-to-target’ protocol of combination disease-modifying anti-rheumatic drugs (DMARDs).

Patients with chronic RA <12 months’ who were DMARD-naïve were enrolled and randomised 2:1 to FO at a high dose or plaacebo (low dose FO for masking). These groups were given 5.5 or 0.4 g/day, respectively, of  eicosapentaenoic acid + docosahexaenoic acid. All patients received methotrexate (MTX), sulphasalazine and hydroxychloroquine, and DMARD doses were adjusted according to an algorithm taking disease activity and toxicity into account. DAS28-erythrocyte sedimentation rate, modified Health Assessment Questionnaire (mHAQ) and remission were assessed three monthly. The primary outcome measure was failure of triple DMARD therapy.

The results indicate that, the FO group, failure of triple DMARD therapy was lower (HR=0.28 (95% CI 0.12 to 0.63; p=0.002) unadjusted and 0.24 (95% CI 0.10 to 0.54; p=0.0006) following adjustment for smoking history, shared epitope and baseline anti–cyclic citrullinated peptide. The rate of first American College of Rheumatology (ACR) remission was significantly greater in the FO compared with the control group (HRs=2.17 (95% CI 1.07 to 4.42; p=0.03) unadjusted and 2.09 (95% CI 1.02 to 4.30; p=0.04) adjusted). There were no differences between groups in MTX dose, DAS28 or mHAQ scores, or adverse events.

The authors conclude that FO was associated with benefits additional to those achieved by combination ‘treat-to-target’ DMARDs with similar MTX use. These included reduced triple DMARD failure and a higher rate of ACR remission.

These findings are most encouraging, particularly as they collaborate those of systematic reviews which concluded that evidence is seen for a fairly consistent, but modest, benefit of marine n-3 PUFAs on joint swelling and pain, duration of morning stiffness, global assessments of pain and disease activity, and use of non-steroidal anti-inflammatory drugs and …there is evidence from 6 of 14 randomized controlled trials supporting a favourable effect of n-3 LCP supplementation in decreasing joint inflammation in RA. And you don’t need to buy the supplements either; regularly eating lots of fatty fish like mackerel, sardine or salmon has the same effects.

So, here we have an alternative, ‘natural’, dietary supplement or diet that is supported by reasonably sound evidence for efficacy, that has very few adverse effects (the main one being contamination of the supplement with toxins), that generates a host of potentially useful effects on other organ systems, that is affordable, that has a plausible mechanism of action…. Hold on, I hear some people interrupting me, FO is not an alternative medicine, it is mainstream! Exactly, an alternative medicine that works is called….MEDICINE.

52 Responses to Fish oil: what do we call an alternative medicine that works?

  • Out of interest, would you call acupuncture ‘medicine’, when used to treat the conditions for which it has demonstrable efficacy?

    • in the sense the sentence is meant, yes.

    • Out of interest, would you call acupuncture ‘medicine’, when used to treat the conditions for which it has demonstrable efficacy?

      A very powerful (invasive) placebo method alright but I wasn’t aware that it had a demonstrable efficacy. Did I miss something?

      • It seems you did miss something, yes – see EE’s post below for some of the more robust evidence that shows conclusively that acupuncture is more than placebo. Of course, I and many others would argue that this is just the tip of the iceberg, based on our own clinical experience. It is also quite clear to me why the scientific evidence isn’t better than it is (I’ll try to elaborate on this below when I get a chance).

  • I’m not sure what you mean by ‘in the sense the sentence is meant’, but glad to hear you see acupuncture as legitimate medicine, at least in a limited way. I’m sure range of ‘proven’ conditions will broaden, too.

  • …but it’s ok for you to say things like ‘It is therefore clear to me that the advice given is likely to be misleading’ (referring to acupuncturists and medical advice), despite this being pure assumption? Here’s my full post taken from another thread, for clarity:

    ‘Dr Ernst, it’s interesting that you choose to cherry pick one part of the acupuncture survey that fits your own perception of events. I suggest that anyone who hasn’t already made up their mind on the subject clicks on the link and reads the whole paper, which makes strong case for the safety of acupuncture as practised by non-NHS practitioners – in fact, ‘Patients not funded by the NHS were *less* [my emphasis] likely to report adverse events’:

    ‘Our secondary objective to establish whether patients are at risk because they are consulting acupuncturists was not supported by the evidence from this study. We received reports of adverse but non-serious consequences related to advice about conventional (prescribed) medication from only six patients and delayed conventional treatment from only two.’

    When you say ‘It is therefore clear to me that the advice given is likely to be misleading’, where is your evidence for this? You seem to be displaying just the sort of non-scientific, belief-based response that you criticize Peter Hain for. The evidence, as presented in the study to which you refer, suggests that the overwhelming majority of the advice given (to the 3% of patients who received it at all) produced absolutely no adverse effects, and not a single case of serious consequence. I’m speculating, but perhaps some/most of it was even useful?

    As an acupuncturist, I regularly give ‘advice’ to my patients about medication. For example, when their symptoms are improving, they sometimes ask whether they should discontinue or reduce their medication. I routinely advise them to discuss it with their GP – presumably this would result in those patients ticking the box saying they’d received advice on medication from me? It isn’t clear to me from the paper whether respondents were asked to differentiate between being told ‘Stop your medication’, and being told ‘You may be able to reduce your medication – talk to your GP’. The latter is certainly what is taught in accredited acupuncture schools in this country, during the solid grounding we are given as standard in Western medicine, and I suggest this may account for many of the 3% who received advice on medication. After all, 58% of this sub-group did also consult their GP – perhaps they were advised to?’

  • Regarding : The results indicate that, the FO group, failure of triple DMARD therapy was lower (HR=0.28 (95% CI 0.12 to 0.63; p=0.002) unadjusted and 0.24 (95% CI 0.10 to 0.54; p=0.0006) following adjustment for smoking history, shared epitope and baseline anti–cyclic citrullinated peptide.

    Are the groups here independent in this study Nobert? the way you meant in this post: http://edzardernst.com/2013/09/drowning-in-a-sea-of-misinformation-part-2-the-uk-society-of-homeopathy/

    I also invite Dr. Ernst to comment on this specific criterion.

  • Perhaps I should post this under “aetiology”, but it’s on the “root cause” of RA.
    In 1985, almost 3 decades ago, immunologist Prof. Alan Ebringer et al. published the results of an investigation on antibodies against some bacteria in RA patients, showing that a chronic infection with Proteus mirabilis likely is the cause of RA.
    As is well known women have about 3x the risk for RA than men: how that? Well: P.mirabilis is a common cause of a urinary tract infection / UTI, and women (with their short urethra) have more UTIs than men.

    Meanwhile Ebringer et al. have explored all aspects of this hypothesis (an example of “molecular mimicry”…) – and everything fits neatly. What’s missing are clinical studies with adequate antimicrobial substances, active against P.mirabilis in the urinary tract, to prove the hypothesis – which in my eyes should be honoured with the Noble Prize. But rheumatologists obivously prefer to ignore the findings of Ebringer et al., for more than a quarter of a century, as far as I am aware.

    O’Dell et al. in Nebraska have shown a remarkable effectiveness of mino- or doxycycline in early RA. Without going into details I am convinced that this is another piece in the puzzle proving the “Ebringer hypothesis” – but for some reason Ebringer does not seem to like the idea (at least he does not answer emails from me) – and O’Dell knows of the Ebringer research (because I told him), but argues those tetracyclines would act by inhibiting MMPs / matrix metallo proteases.
    So we have sound natural / medical science on the “root cause” of RA, but rheumatologists still do studies with all sorts of substances of questionable benefit. (RA patients under “modern therapy” are known to have a shortened life expectancy, as far as I know, not to mention severely compromized quality of life.)

  • In addition I want to point out that tetracycline is the product of bacteria living in the soil: natural products which in my opinion are misnomed as “antibiotics”. Nobody would call alcohol or lactic or acetic acid antibiotics, despite their high antimicrobial activity!

    In ancient Nubia, South Egypt, people obviously brewed beer with effective tetracycline concentrations. Since tetracyline is tightly bound to the bone matrix it can be shown to be there after some 1500 years, and even be extracted to be rigorously identified.
    Was this (preventive) therapy with a special beer? How about tetracycline in sorghum beer nowadays? Maybe such beer would be preferred, compared to some bitter tablets? (Nobody would talk about the risk of producing resistant “bugs” with such beer – which is of no great concern with tetracyclines anyways, as far as I know.)

    But modern pharmaceutical science has enormously improved “old” tetracycline by making it more lipophilic (mino- and doxycycline), quickly and quantitatively absorbed, bound to blood proteins, which increases the half life of elimination from the body (and greatly reduces the necessary doses), and even effective behind the blood brain barrier, in the CNS.
    If I had RA I certainly would prefer tetracycline beer or doxycycline preparations instead of fish oil! I even would expect that RA could be cured this way…

  • Apparently Tom is under the allusion (delusion?) that acupuncture is effective for ANYthing. No well-designed study has shown it thus. A few much poorer ones show vague effects, but no more than what could be lumped with placebo. Furthermore, what is the mechanism for plausibility, pray tell? Oh, yes..the “qi” gets “unclogged”, that’s it!

    • I’m not sure even Prof. Ernst would agree with your summary of acupuncture as ‘no more than what could be lumped with placebo’.

  • Irene, what makes you say I think acupuncture is effective for anything?

  • (Saturday, apologies again)

    • repeat the question you want answered; there were more than one in that post

      • Ok, let’s go with ‘When you say ‘It is therefore clear to me that the advice given is likely to be misleading’, where is your evidence for this?’

        This refers to another thread of course, but I bring it up here because of your accusation to me about being ‘sure of the resukt before the data are in’ – aren’t you doing the same here?

        • do I understand you correctly?
          you want evidence for the statement that alt med practitioners mislead through unsubstantiated claims?
          the post you refer to offers links to evidence, and this blog is full with further evidence.

          • No, if you read my full post I challenged your specific suggestion about acupuncturists, especially when based on the evidence you provided. When only 3% of the sample received advice on medication, and 58% of these went on to consult their GP as well (possibly also on the advise of the acupuncturists, as we are taught), and there were no serious consequences to any of this advice, I suggest this is flimsy evidence at best, and that you are making unjustified assumptions.

          • this is not the question you asked me; can you please make up your mind?

  • I come from “theoretical medicine”, but as a GP I would determine serum ferritin in every adult, and in case of values above 30…40 ng/ml (and after checking some more questions) would recommend to become a blood donor. In case there is a reason for rejection as donor I even would offer preventive phlebotomies, depending on a rough analysis of the iron metabolism of any person which wants to stay healthy. That is to say I would (re-)institute “blood-letting” for prevention, rather than therapy of a disease that already has developed. (This is not a new idea, but has been discussed hundreds of years ago, of course without knowledge of iron metabolism at that time.) In case of rejection of my recommendation by the healthy “client” I certainly would try again when he or she would show signs of the “metabolic” syndrome, or rather insulin resistance (IR) syndrome, e.g. raised blood pressure or blood glucose.

    Question to Dr. Ernst: would you qualify that as “alternative” medicine? If so: could it be that you are not aware of a “flood” of relatively new evidence on iron storage as the “root cause” of dozens of “diseases of affluence” (not just the IR syndrome), which typically develop earlier in men than in women, because the latter in younger years loose more or less iron by their menses, or by pregnancies, and more often are vegetarians than men, or eat less red meat?

  • I agree, Ernst about fish oil.

    However, if one could make up his/ her mind about fish oil effectiveness solely based on the available reviews about its efficacy it would be more difficult to draw definite conclusions. Maybe

    http://www.consumerreports.org/cro/news/2012/09/study-casts-doubt-on-fish-oil-pills-for-heart-disease/index.htm
    http://healthland.time.com/2010/11/02/study-fish-oil-pills-dont-stall-alzheimers/

    What do you think?

    • Dr. Ernst started this blog post with: “The fish oil (FO) story began when a young Danish doctor noticed that there were no heart attacks in Greenland. Large epidemiological studies were initiated, mechanistic investigations followed, and a huge amount of fascinating data emerged. Today, we know more about FO than most other dietary supplements. ”

      Question to Dr. Ernst: is this to imply that FO protects against heart attacks? (Where is the evidence?)

      I have to offer an alternative explanation for the absence of heart attackts, not from Greenland but from natives in Alaska. In health surveys (I’m not sure, but probably the large NHANEStudies) it was found that those natives were anemic – which is really surprising with their high meat consumption.
      It was found that whole communities were infected with Helicobacter pylori and continuously lost blood from their chronically inflamed GI mucosa – that made them anemic, despite their high consumption of readily reesorbable heme-bound iron.

      Now we have to assemble a large puzzle of (mostly) epidemiological evidence. As far as is known mankind was infected with H. pylori very early, “a million years ago”, and constantly lost blood from inflamed mucosa. So there was no need for evolution to provide for iron excretion from the body. And meat consumption was advantageous for mankind as a source of the the iron needed to replace the constant losses.
      Then came modern life with hygiene – and steeply decreasing H.pylori infection rates over decades in the 20th century (and with gastric cancer decreasing in parallel, since chronic H.pylori is the / a main cause, e.g. IARC report of the WHO of ?1994).

      Whoever does not loose blood will store iron over his lifetime, because we have no excretory mechanism for iron. Stored iron is TOXIC, promotes oxidative damage (sort of “rusting” of the body), all sorts of degenerative processes. Iron is a nutrient to many infective organisms (including that of Tbc) as well as tumours. Iron promotes all kinds of deadly diseases – and whoever has much of it stored has a high risk of early death.

      If you are not infected with H.pylori, what protects? Menstruation and pregnancies in women before menopause. Vegetarian diet, if you don’t carry one of many mutations which speed iron absorption. “Blood rituals”, like fighting with sharp weapons (a “sport” for many men over millenia). Regular blood donations. (Blood donors are protected from hypertension, heart attacks, type 2 diabtes, have a lower cancer risk…)
      Of course there are books with that collected knowledge, in first line by Randall B. Lauffer 1991, 1992 and 1993, Francesco S. Facchini 2002 / 2012, several by Eugene Weinberg, to name a few. But all that is IGNORED!

      Whoever is not eligible for blood donations (e.g. beyond the age limit) might be phlebotomized. BUT: there is Prof. E. Ernst with his warning that blood-letting is highly dangerous, absolutely outdated, quackery etc.! (He DID know better in the 1980s…)
      Cui bono? Well: the “disease industry”, which profits from millions with chronic diseases. Health prevents those profits.

      Your comments, Prof. Ernst?

  • There was no option to ‘reply’ above so I’ll do it here. It is absolutely related to the same question – I am questioning your use of evidence to assert that acupuncturists give misleading medical advice. I’ll rephrase – do you feel the evidence you provided really makes it ‘clear’ that ‘advice given is likely to be misleading’ as you suggest, despite the details of the paper I presented above?

    • I think you are wrong, but anyway, here is some evidence: Schmidt K, Ernst E: Internet advice by acupuncturists – a risk factor for cardiovascular patients? Perfusion 2002; 15: 44-50. I also consider the survey I cited as evidence. finally, you could go on the internet and see what acupuncturists claim.

      • I haven’t been able to find this on the Internet – can you provide a link please?

        But the implication I am taking issue with specifically is that acupuncturists give misleading advice about medication to their patients. Are you suggesting that the data in your cited survey is sufficient to be sure this is fair? If not, I suggest you retract it. But if this level of evidence IS acceptable to you then certainly I could claim a scientific basis for acupuncture and virtually any condition.

        • http://smokingcessationacupuncture.com/
          http://www.acupunctureclinicfortmyers.com/smoking-cessation/
          http://smokingacupuncture.net/
          above are the first 3 sites that pop up when I google ACUPUNCTURE SMOKING CESSATION. all are run by acupuncturists and all make misleading claims. there are millions of such sites. do you really want to pretend that acupuncturists do not mislead their patients??
          I think it is time you answer MY question now: for what conditions do you use acupuncture in your practice?

          • Some acupuncturists present misleading information, sure – find me a profession where this never hapepns. But I don’t see any good evidence that acupuncturists give misleading advice about medication, which is a specific accusation you make. I just find it ironic that you mock me for my belief that more evidence will emerge for acupuncture due to lack of data, when you’re happy to bandy this about with paper-thin evidence.

            I will answer your question shortly.

          • there is no profession where not a single member misleads, I guess. but that is not the point: find me one where nearly 100% fall into that trap!

  • Dr. Ernst started this blog post with: “The fish oil (FO) story began when a young Danish doctor noticed that there were no heart attacks in Greenland. Large epidemiological studies were initiated, mechanistic investigations followed, and a huge amount of fascinating data emerged. Today, we know more about FO than most other dietary supplements. ”

    Question to Dr. Ernst: is this to imply that FO protects against heart attacks? A large effect, large enough?

    I have to offer an alternative explanation for the absence of heart attackts, not from Greenland but from natives in Alaska. In health surveys (I’m not sure, but probably the large NHANEStudies) it was found that those natives were anemic – which is really surprising with their high meat consumption.
    It was found that whole communities were infected with Helicobacter pylori and continuously lost blood from their chronically inflamed GI mucosa – that made them anemic, despite their high consumption of readily reesorbable heme-bound iron.

    Now we have to assemble a large puzzle of (mostly) epidemiological evidence. As far as is known mankind was infected with H. pylori very early, “a million years ago”, and probably lost blood from inflamed mucosa. So there was no need for evolution to provide for iron excretion from the body. And meat consumption was advantageous for mankind as a source of the the iron needed to replace the constant losses.
    Then came modern life with hygiene – and steeply decreasing H.pylori infection rates over decades in the 20th century (and with gastric cancer decreasing in parallel, since chronic H.pylori is the / a main cause, e.g. IARC report of the WHO of ?1994).

    Whoever does not loose blood will store iron over his lifetime, because we have no excretory mechanism for iron. Stored iron is TOXIC, promotes oxidative damage (sort of “rusting” of the body), all sorts of degenerative processes. Iron is a nutrient to many infective organisms (including that of Tbc) as well as tumours. “Surplus” iron promotes all kinds of deadly diseases – and whoever has much of it stored has a high risk of early death, e.g. form heart attacks.

  • Hello Dr. Ernst, I found this statement from you: “My allegiance is firstly to the patient – I feel that very strongly as an ex-clinician – and secondly to science. If in the course of that I have to hurt the feelings of homeopaths I regret that, but I can’t help it.”
    I completely agree with you.

    But what’s your advice to “the patient”, besides not to trust homeopythy etc.? Would you propose to take lots of fish oil to avoid heart attacks? Could we PLEASE try to figure out what prevents heart attacks, myocardial infarction / MI? Is it fish oil?

    “Fish oil: what do we call an alternative medicine that works?” “Work” what for? To prevent heart attacks (in Greenland? elsewhere? In GB? Germany?…) Please explain.
    Last time I read articles on that matter was ?15…20 years ago. I for sure do NOT take fish oil: Would you advocate I – or anyone else – should?

  • For decades fish oil has been advocated as preventing heart attacks, with support from Prof. Ernst. Two days ago George posted a link to a Sept. 2012 Consumer Report article:
    “… Greek researchers looked at 18 randomized trials involving a total of 63,533 people between ages 49 and 70, about half of whom took supplements containing 1.5 grams of omega-3 fatty acids per day for two years, on average. Most of the studies were trying to prevent second heart attacks or strokes in people who had already had one. The study, in this week’s issue of the Journal of the American Medical Association, found no statistically significant association between fish-oil pills and all-cause mortality, cardiac death, sudden death, heart attack, or stroke. … ”
    (The question is open, Prof. Ernst: what prevents heart attacks in Greenland?)

    I suggest a rational basis for medical research (as was common 100…120 years ago): Try to clarify the “root causes” of diseases, then take a causal approach. In RA immunologists A. Ebringer et al. / London since at least 2 decades propose to treat an upper UTI from P. mirabilis infection, but rheumatologists obviously don’t do the necessary studies. However, O’Dell et al. already have shown remarkable effectiveness of mino- or doxycycline in early RA.

    Heart attacks: Jerome Sullivan suggested that age-related iron storage could be counteracted by blood donations = “blood-letting” for prevention, LANCET 1981. Tuomainen et al. presented evidence for this to be true, BMJ 1997 – but nobody seems to care, including Prof. Ernst.
    Forget snake and fish oil, ask for “root causes”, then decide what to do on a RATIONAL basis. This will hurt both “big pharma” and quackery, but serve our health.

    There’s more to come, e.g.: Alzheimer’s progression can be slowed by therapy with the iron chelator desfer(ri)oxamine, Crapper McLachlan et al. LANCET 1991. With years of hard work neuropathologist Judith Miklossy / Lausanne has proven a causal role of chronic CNS infections, e.g. neuroborreliosis (which in Sweden routinely is treated with cheap doxy). So do your own reserach, then draw your conclusions. From own experience I “know” that dementia can be prevented.
    Ebringer and Miklossy should be considered as Nobel Prize candidates.

  • Now that we’ve established that the weight of evidence you require of other people doesn’t seem to apply to your own statements (it is ‘clear’ that acupuncturists give misleading advice about medication, based on 84 people out of 6348 patients (1.3%) receiving unspecified advice not followed up with GPs, none of which led to serious consequences), I’ll answer your question. Of course, I don’t expect this to satisfy those who are entrenched in their opinions, and I apologise that this is necessarily a little long-winded, but here we go:

    As I am trained to do, I treat people and their specific set of signs and symptoms, rather than disease labels. For example (and I’m aware individual case studies count for little, but this is illustrative of the way things often work in the clinic), I recently had an elderly gentleman – let’s call him Bill – come to see me with a diagnosis of gout from his GP. He had crippling foot pain, as well as elbow pain and sleeping problems. He asked me if I could help, and rather than say ‘yes, I can cure your gout’, I said that I would take a fresh look at his condition from the perspective of Chinese medicine. I explained some basic principles to him about the metaphorical concepts of trapped Heat, and stagnant Qi and Blood, and he was happy to proceed. I examined him carefully, and found that as well as having pronounced toe extension, there were acutely sensitive areas around the acupuncture point Stomach 36 (in the tibialis anterior muscle). In other words, tightness in this muscle seemed to be causing constant extension of the tendons in his feet. Amongst other things, I needled ST-36 to cause visible muscle twitches, and sensations spreading into the foot.

    Before he had acupuncture his pain had been gradually increasing and his mobility reducing for some months, despite the medication he was on. After a few treatments in our low-cost clinic, he is now walking the whole way to his appointments with only mild discomfort in one foot, and no elbow pain. He is sleeping better, and the depressed and desperate man who first came to see me is now bright and cheerful.

    I believe strongly that this kind of individualised treatment is what makes some alternative medicines very valuable, and it is what is often missing from Western medicine. Western medicine sees the trees in great detail, but sometimes misses the forest. When properly administered, acupuncture can often offer great relief to people stuck in the rut of ineffective or harmful medication, or even better prevent them from requiring it in the first place. This is why I gave up a much better paid job to become an acupuncturist, and why I feel strongly enough to respond when I read what I consider to be unfair and severely restricted representations of what acupuncture is and what it is capable of.

    • the plural of anecdote is anecdotes, not evidence.

      • I expected more from you than that tired cliche, I have to say. As I said, I’m aware individual case studies count for little. I was using this case purely as an example of how I treat people holistically and with an open mind, rather than based on disease labels.

  • What about supplemenation with Fish Oil for average healthy people? Is there any evidence that recommends that?
    Thanks

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