In this article, we will explore fish oil and Vitamin B-12 dietary supplements. We include a great deal of well-researched up-to-date medical information about the fish oil you may take, so that you can use it to get the most out of it, while using them safely.
‘Buyer Beware’ Information about Supplementation
Most supplements are not tested adequately for efficacy, purity, or safety.
Be careful of misleading product information.
‘Natural’ does not mean safe!
‘More’ is seldom better!
Nothing replaces a well-balanced diet that includes a variety of high-quality foods with plenty of nutrients.
Athletes, and others, use supplements at their own risk!
Fish Oil – EPA/DHA:
Claims: Fish oil can be obtained from eating fish or by taking supplements. Fish that are especially rich in the beneficial oils known as omega-3 fatty acids include mackerel, tuna, salmon, sturgeon, mullet, bluefish, anchovy, sardines, herring, trout, and menhaden. They provide about 1 gram of omega-3 fatty acids in about 3.5 ounces of fish. I am, by the way, a strong proponent of getting plenty of DHA into the body. See below for the explanation and for dosages.
Fish oil supplements are usually made from mackerel, herring, tuna, halibut, salmon, cod liver, whale blubber, or seal blubber. Fish oil supplements often contain small amounts of vitamin E to prevent spoilage. They might also be combined with calcium, iron, or vitamins A, B1, B2, B3, C, or D.
Fish oil is used for a wide range of conditions. It is most often used for conditions related to the heart and blood system. Some people use fish oil to lower blood pressure or triglyceride levels (fats related to cholesterol). Fish oil has also been tried for preventing heart disease or stroke. The scientific evidence suggests that fish oil really does lower high triglycerides, and it also seems to help prevent heart disease and stroke when taken in the recommended amounts. Ironically, taking too much fish oil can actually increase the risk of stroke.
Fish may have earned its reputation as “brain food” because some people eat fish to help with depression, psychosis, attention deficit-hyperactivity disorder (ADHD), Alzheimer’s disease, and other thinking disorders.
Some people use fish oil for dry eyes, glaucoma, and age-related macular degeneration (AMD), a very common condition in older people that can lead to serious sight problems.
Women sometimes take fish oil to prevent painful periods; breast pain; and complications associated with pregnancy such as miscarriage, high blood pressure late in pregnancy, and early delivery.
Fish oil is also used for diabetes, asthma, developmental coordination disorders, movement disorders, dyslexia, obesity, kidney disease, weak bones (osteoporosis), certain diseases related to pain and swelling such as psoriasis, and preventing weight loss caused by some cancer drugs.
Fish oil is sometimes used after heart transplant surgery to prevent high blood pressure and kidney damage that can be caused by the surgery itself or by drugs used to reduce the chances that the body will reject the new heart. Fish oil is sometimes used after coronary artery bypass surgery. It seems to help keep the blood vessel that has been rerouted from closing up.
When fish oil is obtained by eating fish, the way the fish is prepared seems to make a difference. Eating broiled or baked fish appears to reduce the risk of heart disease, but eating fried fish or fish sandwiches not only cancels out the benefits of fish oil, but may actually increase heart disease risk.
Over the last several years, there has been considerable publicity about the benefits of Omega 3’s, most of which is true and some of which is not.
There is no doubt that Omega 3’s can not only help your heart and joints but it will also help your brain; most people are aware of this. However, do the benefits of Omega 3’s apply across the board for all types of Omega 3’s? There are now many companies in the world market today trying to capitalize on the Omega 3 ‘boom’ with such a wide range of products and so many claims that it is hard for the consumer to sift out fact from fiction.
We will try to give you the basics here so that you can choose the proper fish oil supplement and dosage that you need, or you can decide to skip fish oil altogether.
DHA (docosahexaenoic acid) is essential for the growth and functional development of the brain in infants. DHA is also required for maintenance of normal brain function in adults. The inclusion of plentiful DHA in the diet improves learning ability, whereas deficiencies of DHA are associated with deficits in learning. DHA is taken up by the brain in preference to other fatty acids. The turnover of DHA in the brain is very fast, more so than is generally realized.
DHA deficiencies are associated with fetal alcohol syndrome, attention deficit hyperactivity disorder, cystic fibrosis, phenylketonuria, unipolar depression, aggressive hostility, and adrenoleukodystrophy. Decreases in DHA in the brain are associated with cognitive decline during aging and with onset of sporadic Alzheimer disease.
The leading cause of death in western nations is cardiovascular disease. Epidemiological studies have shown a strong correlation between fish consumption and reduction in sudden death from myocardial infarction. The reduction is approximately 50% with 200 mg/day1 of DHA from fish. DHA is the active component in fish oil. Not only does fish oil reduce triglycerides in the blood and decrease thrombosis, but it also prevents cardiac arrhythmias.
The association of DHA deficiency with depression is the reason for the robust positive correlation between depression and myocardial infarction. Patients with cardiovascular disease or Type II diabetes are often advised to adopt a low-fat diet (remember, fish oil is a fat) with a high proportion of carbohydrate.
For Athletes: Reduces Inflammation; omega-3 fatty acids decrease inflammation by diminishing the production of prostaglandins, hormone-like substances associated with inflammation in the body, according to the Science Daily website.
Increases Lung Function: Omega-3 fatty acids might boost lung function of athletes during and after exercise.
Improves body composition: In a study researchers found that participants taking fish oil for six weeks improved their body composition by increasing lean muscle mass and decreasing fat mass.
Fish oil decreases the proliferation of tumor cells, whereas arachidonic acid, a longchain n-6 fatty acid, increases their proliferation. These opposite effects are also seen with inflammation, particularly with rheumatoid arthritis, and with asthma. DHA has a positive effect on diseases such as chronic pain, hypertension, arthritis, atherosclerosis, depression, adult-onset diabetes mellitus, myocardial infarction, thrombosis, and some cancers.
Mechanism: The prime objective for consuming Omega 3 should be to get DHA (Docosahexaenoic Acid) into your body. The scientific evidence supporting the benefits of DHA is now overwhelming. It is much more important than EPA (Eicosapentaenoic Acid) which is the major Omega 3 component of most fish oils. A lot of the benefit of fish oil seems to come from the omega-3 fatty acids that it contains. Interestingly, the body does not produce its own omega-3 fatty acids, nor can the body make omega-3 fatty acids from omega-6 fatty acids, which are common in the Western diet. A lot of research has been done on EPA and DHA, two types of omega-3 acids that are often included in fish oil supplements.
DHA plays a key role in the development of eye and nerve tissues. DHA may also reduce the risk of heart and circulatory disease by decreasing the thickness of the blood and lowering blood levels of triglycerides. DHA plays a key role in the development of eye and nerve tissues. DHA may also reduce the risk of heart and circulatory disease by decreasing the thickness of the blood and lowering blood levels of triglycerides.
Not all Omega 3’s will provide you with DHA and EPA. This is because these essential fatty acids are not present in a lot of Omega 3 products. For example, ground flax seed is an excellent oil for certain uses and contains Omega 3’s but does not actually contain any DHA or EPA at all. Instead it contains alpha linolenic acid which your body has to convert to DHA and EPA.
In many people, particularly the elderly this conversion process is very inefficient. To give you an idea, it is estimated that most adults would have to consume 10 – 40 grams of flaxseed oil to produce just 0.2 grams of DHA.
So, if you want to get the proven benefits of DHA do not rely on getting your Omega 3’s from vegetable oils such as flaxseed. Note: There are now some products being produced from algae which contain good levels of DHA that do not require the body to convert the ALA to the DHA, but they are still not readily available and are very expensive.
The best source of DHA is from fish oil. However, there are some drawbacks with many fish oils: The amount of DHA is low in most fish oils. A typical level is 12% DHA and 18% EPA. The popular ‘salmon’ oils (which are not really salmon) are usually of the 12/18 type. Many oils on the market today are from questionable sources and some have high levels of heavy metals or other contaminants such as PCB’s. To ensure that you don’t ingest these contaminants, either use oils which have been molecularly distilled, or are from impeccable sources with a reliable certificate of analysis. This basically rules out many oils which are processed from fish caught in the Northern Hemisphere.
Effective for: High triglycerides (Triglycerides are a type of fat (lipid) found in your blood. When you eat, your body converts any calories it doesn’t need right away into triglycerides. Triglycerides are stored in your fat cells. Later, hormones release triglycerides for energy between meals. If you regularly eat more calories than you burn, particularly “easy” calories like carbohydrates and fats, you may have high triglycerides (hypertriglyceridemia). Triglycerides are associated with heart disease and untreated diabetes. To reduce the risk of heart disease, doctors believe it is important to keep triglycerides below a certain level. Doctors usually recommend increasing physical activity and restricting dietary fat to lower triglycerides. Sometimes they also prescribe drugs such as gemfibrozil (Lopid) for use in addition to these lifestyle changes. Now researchers believe that fish oil, though not as effective as gemfibrozil, can reduce triglyceride levels by 20% to 50%. Likely effective for…
Heart disease: Research suggests that consuming fish oil by eating fish can be effective for keeping people with healthy hearts free of heart disease. People who already have heart disease might also be able to lower their risk of dying from heart disease by eating fish or taking a fish oil supplement. However, for people who already take heart medications such as a “statin,” adding on fish oil might not offer any additional benefit.
Possibly effective for:
High blood pressure: Fish oil seems to produce modest reductions in blood pressure in people with high blood pressure. The omega-3 fatty acids in fish oil seem to be able to expand blood vessels, and this brings blood pressure down.
Rheumatoid arthritis: Fish oil alone, or in combination with the drug naproxen (Naprosyn), seems to help people with rheumatoid arthritis get over morning stiffness faster. People who take fish oil can sometimes reduce their use of pain medications such as nonsteroidal anti-inflammatory drugs (NSAIDs).
Menstrual pain (dysmenorrhea): Taking fish oil alone or in combination with vitamin B12 seems to improve painful periods and reduce the need for pain medications such as nonsteroidal anti-inflammatory drugs (NSAIDs).
Attention deficit-hyperactivity disorder (ADHD) in children: Taking fish oil seems to improve thinking skills and behavior in 8 to 12 year-old children with ADHD.
Raynaud’s syndrome: There’s some evidence that taking fish oil can improve cold tolerance in some people with the usual form of Raynaud’s syndrome. Nevertheless, people with Raynaud’s syndrome caused by a condition called progressive systemic sclerosis do not seem to benefit from fish oil supplements.
Stroke: Moderate fish consumption (once or twice a week) seems to lower the risk of having a stroke by as much as 27%. However, eating fish doesn’t lower stroke risk in people who are already taking aspirin for prevention. On the other hand, very high fish consumption (more than 46 grams of fish per day) seems to increase stroke risk, perhaps even double it.
Weak bones (osteoporosis): Taking fish oil alone or in combination with calcium and evening primrose oil seems to slow bone loss rate and increase bone density at the thigh bone (femur) and spine in elderly people with osteoporosis.
Hardening of the arteries (atherosclerosis): Fish oil seems to slow or slightly reverse the progress of atherosclerosis in the arteries serving the heart (coronary arteries), but not in the arteries that bring blood up the neck to the head (carotid arteries).
Kidney problems: Long-term use (two years) of fish oil 4-8 grams daily can slow the loss of kidney function in high-risk patients with a kidney disease called IgA nephropathy. Fish oil also seems to reduce the amount of protein in the urine of people who have kidney disease as a result of diabetes.
Bipolar disorder: Taking fish oil with the usual treatments for bipolar disorder seems to improve symptoms of depression and increase the length of time between episodes of depression. But fish oil doesn’t seem to improve manic symptoms in people with bipolar disorder.
Psychosis: Taking a fish oil supplement might help prevent full psychotic illness from developing in people with mild symptoms. This has only been tested in teenagers and adults up to age 25.
Weight loss: Some evidence shows that eating fish improves weight loss and decreases blood sugar in overweight people and people with high blood pressure. A preliminary study also shows that taking a specific fish oil supplement 6 grams daily (Hi-DHA Nu-Mega – Nu-Mega uses a patented microencapsulation technology that converts the HiDHA® tuna oil into a stable dry powder form (Driphorm®). This protects the fish oil against oxidation and provides a form of taste barrier, such that manufacturers can increase the levels of Omega-3 DHA in a broad range of everyday foods, with minimal flavor impact and often without any alterations to product formulations, providing 260 mg DHA/gram and 60 mg EPA/gram, significantly decreases body fat when combined with exercise. Any other high-DHA, high quality fish oil supplement should do the job as well. It can also cost rather less/dose. Check online or ask your doctor or pharmacist for advice.
Endometrial cancer: There is some evidence that women who regularly eat about two servings of fatty fish per week have a reduced risk of developing endometrial cancer.
Age-related eye disease (age-related macular degeneration, AMD): There is some evidence that people who eat fish more than once per week have a lower risk of developing age-related macular degeneration.
Reducing the risk of blood vessel re-blockage after heart bypass surgery or “balloon” catheterization (balloon angioplasty): Fish oil appears to decrease the rate of re-blockage up to 26% when given for one month before the procedure and continued for one month thereafter. Apparently, taking fish oil before surgery is important. When taken for less than one month before angioplasty, fish oil doesn’t help protect the blood vessel against closing down.
Recurrent miscarriage in pregnant women with antiphospholipid syndrome: Taking fish oil seems to prevent miscarriage and increase live birth rate in pregnant women with a condition called antiphospholipid syndrome.
High blood pressure and kidney problems after heart transplant: Taking fish oil seems to preserve kidney function and reduce the long-term continuous rise in blood pressure after heart transplantation.
Damage to the kidneys and high blood pressure caused by taking a drug called cyclosporine: Cyclosporine is a medication that reduces the chance of organ rejection after an organ transplant. Fish oil might help reduce some of the unwanted side effects of treatment with this drug.
Movement disorder in children (dyspraxia – a disorder in which motor difficulties are caused by perceptual problems). Taking fish oil orally, in combination with evening primrose oil, thyme oil, and vitamin E (Efalex, Efamol Ltd), seems to improve movement disorders in children with dyspraxia.
Developmental coordination disorder: A combination of fish oil (80%) and evening primrose oil (20%) seems to improve reading, spelling, and behavior when given to children age 5-12 years with developmental coordination disorder. However, it does not seem to improve motor skills.
Preventing blockage of grafts used in kidney dialysis: Taking fish oil orally seems to help prevent clot formation in hemodialysis grafts.
Psoriasis: There is some evidence that administering fish oil intravenously (by IV) can decrease severe psoriasis symptoms. But taking fish oil by mouth doesn’t seem to have any effect on psoriasis.
High cholesterol: There is interest in using fish oil in combination with “statin” drugs for some people with high cholesterol. Doctors were worried at first that taking fish oil might interfere with statin treatment, but early studies show this is not a problem, at least with the statin called simvastatin. Scientists think fish oil may lower cholesterol by keeping it from being absorbed in the intestine. There is some evidence that using vitamin B12 along with fish oil might boost their ability to lower cholesterol.
Coronary artery bypass surgery: Taking fish oil seems to prevent coronary artery bypass grafts from re-closing following coronary artery bypass surgery.
Cancer-related weight loss: Taking a high dose (7.5 grams per day) of fish oil seems to slow weight loss in some cancer patients. Some researchers believe these patients eat more because the fish oil is fighting depression and improving their mood.
Asthma: Some research suggests fish oil may lower the occurrence of asthma in infants and children when taken by women late in pregnancy. Furthermore, fish oil seems to improve airflow, reduce cough, and lower the need for medications in some children with asthma. However, fish oil treatment doesn’t seem to provide the same benefit for adults.
Chronic pain. In some chronic pain patients, fish oil seems to have an ameliorating effect. Chronic pain and depression are often interactive.
Possibly ineffective for:
|Chest pain (angina)||Preventing migraine headaches|
|Gum infection (gingivitis)||Preventing muscle soreness caused by physical exercise|
|Liver disease||Breast pain|
|Leg pain due to blood flow problems (claudication)||Skin rashes caused by allergic reactions.|
Likely ineffective for:
Type 2 diabetes. Taking fish oil does not seem to lower blood sugar in people with type 2 diabetes. However, fish oil can provide some other benefits for people with diabetes, such as lowering blood fats called triglycerides.
Insufficient evidence to rate effectiveness for:
Allergies. Some research suggests that mothers who take fish oil supplements during the late stages of pregnancy may lower the occurrence of allergies in their children.
Alzheimer’s disease and Dementia: There is some preliminary evidence that fish oil may help prevent Alzheimer’s disease. Fish oil does not seem to prevent a decline in cognitive skills for most patients who already have mild-to-moderate Alzheimer’s disease.
People with Alzheimer’s disease have dramatically lower levels of DHA in the neurons of their hippocampus, an area of the brain severely affected in the disease. This area is vital to creating recent memories (so-called working memory or declarative memory). Researchers from the University of Kentucky found that phospholipids such as phosphatidyl-ethanolamine (PE), which normally contain the highest levels of DHA, are severely depleted in those regions of the brain most affected by Alzheimer’s disease.
DHA and Brain Development: While DHA is essential for the proper development of the infant brain, it also plays a vital role in the ongoing structure and function of the adult brain. It is a component of several important phospholipids in the brain, with the highest levels of DHA being found in phosphatidylethanolamine (PE) and phosphatidyl-serine (PS). Lower levels exist in phosphatidylcholines (PC). Structurally, DHA comprises 22 carbons and six double bonds, making it the most unsaturated fatty acid in cell membranes and an important ingredient in increasing the fluidity of cell membranes.
Changing the fluidity of cell membranes alters their physical properties, such as permeability and protein activity. This change can drastically alter cell signaling and plays a major role in increasing membrane permeability of cancer cells, making them more susceptible to immunologic and chemotherapeutic killing. EPA, however, has much less effect on membrane fluidity than DHA.
It has also been shown that a greater incorporation of DHA into cell membranes results in dramatically less susceptibility to lipid peroxidation and oxidative stress in cells, especially neurons.
Although many view the brain as a stable structure that changes little after adolescence, it is in fact always in a state of flux, not only by forming millions of new nerve connections, but also by replacing and altering its biochemical makeup, especially membrane lipids. Connected with this constant turnover of brain lipids are the phospholipase enzymes, which can release arachidonic acid and DHA from the cell membrane. Dietary changes can therefore drastically alter brain lipids, which can significantly alter brain function, even worsening neuropsychiatric disorders.
Furthermore, there is evidence that as we age, the distribution of DHA in the brain changes. For example, during infancy the highest levels are found in the striatum (associated with motor control) and are lower in the hypothalamus (linking the nervous and endocrine systems) and hippocampus (associated with memory). In adults, the highest levels are in the cortex (essential to cognition) and lowest in the medulla (crucial for autonomic function). With aging, the highest levels are in the cortex and cerebellum (involved in motor control). An example of this regional specificity was seen in a recent study when scientists restored dietary DHA to rats that had been deprived of the nutrient. They found that all areas of brain DHA were restored after 12 weeks, except for the medulla, which recovered only 62% of its DHA. These findings therefore provide plentiful evidence that consuming enough DHA may be essential for upkeep of the adult brain.
DHA supplementation not only improves memory in cases of Alzheimer’s disease but has also been shown to improve age-related memory loss as well.6 Animal studies have shown that DHA-supplemented diets can counteract learning difficulties when soluble amyloid-beta (the most injurious form of Alzheimer’s-associated amyloid) is infused into the animals’ brains.
Atopic dermatitis: Mothers who take fish oil supplements during pregnancy might reduce the occurrence and severity of atopic dermatitis in babies and children who are at risk for this condition. However, fish oil does not seem to be effective for treating atopic dermatitis.
Atrial fibrillation: Research studies into the effects of fish oil on atrial fibrillation have produced conflicting results.
Depression: There is inconsistent information about the effect of taking fish oil on depression. Some research shows that taking fish oil along with an antidepressant might help improve symptoms. Nevertheless, other research shows that taking fish oil does not improve symptoms.
Dry eye syndrome: Some research links eating more fish with a lower risk of getting dry eye syndrome in women. Some preliminary clinical research also suggests that taking a specific product containing fish oil plus flaxseed oil (TheraTears Nutrition) might reduce symptoms of dry eye and increase tear production.
Cancer: Research studies into the effects of fish oil on cancer prevention have produced conflicting results.
Cataracts: There is some evidence that eating fish three times a week can modestly lower the risk of developing cataracts.
Chronic fatigue syndrome (CFS): There is some conflicting evidence about the use of a product (Efamol Marine) that combines fish oil and evening primrose oil to reduce the symptoms of CFS.
Chronic kidney disease: Preliminary evidence shows that fish oil might have benefit for some people with chronic kidney disease who are receiving dialysis treatments.
Thinking skills (cognitive function): Research studies into the effects of fish oil on cognitive function have produced conflicting results.
Crohn’s disease: Research studies into the effects of fish oil on Crohn’s disease have produced conflicting results.
Prediabetes: Early studies suggest that fish oil may help prevent prediabetes from advancing to type 2 diabetes.
Infant development: There is some evidence that mothers who take 4 grams of fish oil daily during the last half of pregnancy may improve their baby’s cognitive development by some measures, but not others. At age 2.5 years, these children seem to have better hand and eye coordination, but reasoning, social, motor, and speech skills are not significantly improved.
Ulcerative colitis: Research studies into the effects of fish oil on ulcerative colitis have produced conflicting results.
Pregnancy complications: There is some evidence that taking fish oil during the last ten weeks of pregnancy can help prevent premature delivery. However, fish oil doesn’t seem to help prevent high blood pressure during pregnancy.
Prematurity: Baby formula that has been fortified with fatty acids from fish oil and borage seems to improve growth and the development of the nervous system in premature infants, especially boys.
Salicylate intolerance: Some limited research suggests that taking fish oil might improve symptoms of salicylate intolerance such as asthma attacks and itching.
Schizophrenia: There is one report of fish oil improving schizophrenia in a pregnant woman.
Systemic lupus erythematosus (SLE): Research shows conflicting results. Some studies suggest that fish oil helps the symptoms of SLE, while others show no effect.
Irregular heartbeat affecting the ventricles (ventricular arrhythmia’s): Research studies into the effect of fish oil on ventricular arrhythmias have produced conflicting results.
Improving night vision in children with a disorder called dyslexia: Children with dyslexia who take fish oil seem to be significantly better able to adapt to the dark.
More evidence is needed to rate fish oil for these uses.
Side Effects: Fish oil is LIKELY SAFE for most people, including pregnant and breast-feeding women, when taken in low doses (3 grams or less per day). There are some safety concerns when fish oil is taken in high doses. Taking more than 3 grams per day might keep blood from clotting and can increase the chance of bleeding. If one is taking a blood-thinner or has a bleeding disorder, then his /her physician must supervise the patient.
High doses of fish oil might also reduce the immune system’s activity, reducing the body’s ability to fight infection. This is a special concern for people taking medications to reduce their immune system’s activity (organ transplant patients, for example) and the elderly.
Only take high doses of fish oil while under medical supervision.
Fish oil can cause side effects including belching, bad breath, heartburn, nausea, loose stools, rash, and nosebleeds. Taking fish oil supplements with meals or freezing them can often decrease these side effects.
Consuming large amounts of fish oil from some DIETARY sources is POSSIBLY UNSAFE. Some fish meats (especially shark, king mackerel, and farm-raised salmon) can be contaminated with mercury and other industrial and environmental chemicals, but fish oil supplements typically do not contain these contaminants.
|Liver disease: Fish oil might increase the risk of bleeding||High blood pressure: Fish oil can lower blood pressure and might cause blood pressure to drop too low in people who are being treated with blood pressure-lowering medications|
|Fish or seafood allergy: Some people who are allergic to seafood such as fish might also be allergic to fish oil supplements. There is no reliable information showing how likely people with seafood allergy are to have an allergic reaction to fish oil; however, until more is known advise patients allergic to seafood to avoid or use fish oil supplements cautiously||HIV/AIDS and other conditions in which the immune system response is lowered: Higher doses of fish oil can lower the body’s immune system response. This could be a problem for people whose immune system is already weak|
|Bipolar disorder: Taking fish oil might increase some of the symptoms of this condition||An implanted defibrillator (a surgically placed device to prevent irregular heartbeat): Some, but not all, research suggests that fish oil might increase the risk of irregular heartbeat in patients with an implanted defibrillator. Stay on the safe side by avoiding fish oil supplements|
|Depression: Taking fish oil might increase some of the symptoms of this condition||Familial adenomatous polyposis: There is some concern that fish oil might further increase the risk of getting cancer in people with this condition.|
|Diabetes: There is some concern that taking high doses of fish oil might make the control of blood sugar more difficult|
Interactions with medications:
Be cautious with these combinations:
|Birth control pills (Contraceptive drugs). There is some evidence that birth control pills might interfere with the triglyceride-lowering effects of fish oil.|
Some of these drugs include ethinyl estradiol and levonorgestrel (Triphasil), ethinyl estradiol and norethindrone (Ortho-Novum 1/35, Ortho-Novum 7/7/7), and others.
Medications for high blood pressure (Antihypertensive drugs). Using fish oil with drugs that lower blood pressure can increase the effects of these drugs and may lower blood pressure too much. Some medications for high blood pressure include captopril (Capoten), enalapril (Vasotec), losartan (Cozaar), valsartan (Diovan), diltiazem (Cardizem), amlodipine (Norvasc), hydrochlorothiazide (HydroDIURIL), furosemide (Lasix), and many others.
Orlistat (Xenical, Alli). Orlistat (Xenical, Alli) might keep the beneficial fatty acids in fish oil from being absorbed by the body. Taking fish oil and orlistat (Xenical, Alli) at least 2 hours apart may keep this from happening.
Be watchful with these combinations: medications that slow blood clotting (anticoagulant/antiplatelet drugs). Using fish oil with medications that slow clotting may cause bleeding. Some of these drugs include aspirin, clopidogrel (Plavix), dalteparin (Fragmin), dipyridamole (Persantine), enoxaparin (Lovenox), heparin, ticlopidine (Ticlid), warfarin (Coumadin), and others.
Interactions with herbs and supplements:
Herbs and supplements that might slow blood clotting: High doses of fish oil seem to slow blood clotting. Taking fish oil with other herbs that slow clotting might cause bleeding in some people. These herbs include angelica, clove, danshen, garlic, ginger, ginkgo, Panax ginseng, red clover, turmeric, willow, and others.
Vitamin E: Fish oil can reduce vitamin E levels. Researchers aren’t sure whether fish oil keeps vitamin E from being absorbed from food or whether it causes the body to use up vitamin E faster than it should.
*Breaking News*: I received a study from a news wire late yesterday (7/10/2013), and have already received a number of emails from patients, friends and colleagues on the latest news suggesting that omega-3 fatty acids increase the risk of prostate cancer…including aggressive prostate cancer.
One must be very careful when making decisions based on the latest news bytes and headlines. We, as a society, have a tendency to make decisions based on the last study or news, rather than the combination of studies published on a specific topic.
That study is not the best study. In addition, studies should be read critically – there are inherent flaws in most of them. The findings appear to be a retrospective study (looking back in time) and does NOT show cause and effect. Studies that are prospective in design (prospective study watches for outcomes, such as the development of a disease, during the study period and relates this to other factors such as suspected risk or protection factor(s). The study usually involves taking a cohort of subjects and watching them over a long period. The outcome of interest should be common; otherwise, the number of outcomes observed will be too small to be statistically meaningful (indistinguishable from those that may have arisen by chance). All efforts should be made to avoid sources of bias such as the loss of individuals to follow up during the study. Prospective studies usually have fewer potential sources of bias and confounding factors than retrospective studies). They rank higher in importance of evidence and are more useful and suggestive in decision making on what to consume to improve our health. Are there prospective studies showing protective benefits of omega 3 fatty acids against prostate cancer? Yes.
Researchers investigated the effect of dietary fish intake amongst 6272 Swedish men who were followed-up for 30 years. That study reported that men who ate no fish had a two/three-fold increase in the risk of developing prostate cancer compared with those who consumed large amounts of fish in their diet (2001).
Another prospective cohort study based on the Physician’s Health Study found that fish consumption (≥5 times per week) was not related to prostate cancer risk but was protective of prostate cancer-specific death (2008).
Other studies have suggested lower prostate cancer risk with Omega 3 fatty acids from fish in Swedish men (Norrish AE, et al.) and in Japanese and Brazilian men (1999).
A large prospective cohort established in 1986 looked at 51,529 American men, 40 – 75 years of age, completed mailed questionnaires about demographic and medical information found that a high intake of fish was associated with a lower risk of metastatic prostate cancer. A similar association was also found for dietary marine fatty acids from food.
An important clinical study published by a group at the Harvard School of Public Health examined the link between dietary fish consumption and the risk of metastatic prostate cancer. This paper reported results from the Health Professionals Follow-up Study that involved 47,882 men over twelve years. During the twelve years, 2,483 cases of prostate cancer were identified. Of these, 617 were advanced and 278 were metastatic. Eating fish more than three times a week reduced the risk of prostate cancer but had an even greater impact on the risk of metastatic prostate cancer. For each additional 500 mg of marine fat consumed, the risk of metastatic disease decreased by 24%!
A meta-analysis (a study of studies) found that a significant 63% reduction in prostate cancer-specific mortality in those that consumed fish but no link between eating lots of fish and men’s risk of developing prostate cancer (2010).
I know the content is scientifically weighty, but I just wanted to make the point that there are reasons why most practitioners recommend fish and fish oils to patients.
Most men will develop prostate cancer within time regardless of what they eat or don’t eat. If you live long enough, you’ll probably get it (but for some men, living long enough may be much greater than today’s elderly many of whom did not each much fish in their lives. The deadly kind is what we are trying to avoid. My father (76) died of aggressive disease and did not eat a lot of fish. He came from a long-lived family, too (into their 90s). Many of you may know someone like this who died of prostate cancer, especially the aggressive form. I wish we knew this stuff a long time ago!
The 71% aggressive prostate cancer associated with Omega 3 fatty acid consumption sounds dubious.
The fish oils from fish or supplements in the study did not control for the quality of fish or fish oil. Some fish (and fish oil supplements) can contain environmental chemicals that can contribute to prostate cancer such as PCB. Also, fish oils can oxidize easily if not careful which may make them more damaging. This was not accounted for in this study.
Personally and professionally, I am not ready to ignore the plethora of research suggesting its beneficial effects.
I take enough fish oil every day to provide 1440 mg of DHA, and I eat fish 2-3 times/week. I am not making any personal changes on my fish oil consumption based on a blood test of Omega 3 fatty acids from a retrospective study as poorly done as this one. In my opinion, this study is informative, mildly suggestive, but weak.
I do recommend that readers be properly monitored by a physician when making dietary choices. There are individual nuances where, indeed, a nutrient can potentially make health matters worse.
Lastly, another shortcoming of both studies is that we do not know the diet of the studied subjects.
The consumption of fish or fish oil supplements with unhealthy food does not make that food any the less inferior. In other words, a poor diet with fish or fish oils will not protect men from prostate cancer.
Dosage: The following doses have been studied in scientific research:
A simple blood test can reveal whether your triglycerides fall into a healthy range.
|Normal — Less than 150 milligrams per deciliter (mg/dL), or less than 1.7 millimoles per liter (mmol/L)|
Borderline high — 150 to 199 mg/dL (1.8 to 2.2 mmol/L)
High — 200 to 499 mg/dL (2.3 to 5.6 mmol/L)
Very high — 500 mg/dL or above (5.7 mmol/L or above)
The American Heart Association (AHA) recommends that a triglyceride level of 100 mg/dL (1.1 mmol/L) or lower is considered “optimal.” The AHA says this optimal level would improve your heart health. However, the AHA doesn’t recommend drug treatment to reach this level. Instead, for those trying to lower their triglycerides to this level, lifestyle changes such as diet, weight loss and physical activity are encouraged. That’s because triglycerides usually respond well to dietary and lifestyle changes.
For high triglycerides: 1-4 grams/day of fish oil (1,000-4,000mg).
For high blood pressure: Either 4 grams of fish oil or fish oil providing 2.04 grams of EPA and 1.4 grams of DHA per day.
In atrial fibrillation, one of the chambers of the heart does not empty properly. This increases the risk of blood clot formation leading to stroke; eating tuna or baked or broiled fish providing omega-3 fatty acids (fish oil) one or more times per week seems to reduce the risk of atrial fibrillation in patients aged 65 or older, compared to consuming fish once per month or less. However, there is no benefit from eating fried fish or a fish sandwich.
For kidney problems related to using cyclosporine to prevent organ transplant rejection: 12 grams/day containing 2.2 grams EPA and 1.4 grams DHA.
For reducing the overall risk of death and risk of sudden death in patients with coronary heart disease: Fish oil providing 0.3-6 grams of EPA with 0.6 to 3.7 grams of DHA.
For asthma in children: Fish oil providing 17-26.8 mg/kg EPA and 7.3-11.5 mg/kg DHA for reducing symptoms. Maternal ingestion of fish oil 4 grams daily, providing 32% EPA and 23% DHA with tocopherol, during late-phase pregnancy has been used for preventing the development of asthma in children.
For preventing childhood allergies: Maternal ingestion of fish oil 4 grams daily, providing 32% EPA and 23% DHA with tocopherol, during late-phase pregnancy.
For preventing childhood atopic dermatitis: Maternal ingestion of fish oil 4 grams daily, providing 32% EPA and 23% DHA with tocopherol, during late-phase pregnancy.
For treating asthma: 17-26.8 mg/kg EPA and 7.3-11.5 mg/kg DHA.
For preventing and reversing the progression of hardening of the arteries: 6 grams/day of fish oil for the first three months, followed by 3 grams/day thereafter.
For rheumatoid arthritis: Fish oil providing 3.8 grams/day of EPA and 2 grams/day DHA.
For attention deficit-hyperactivity disorder (ADHD): A specific supplement containing fish oil 400 mg and evening primrose oil 100 mg (Eye Q, Novasel) six capsules daily.
For preventing miscarriage in women with antiphospholipid antibody syndrome and a history of past miscarriage: 5.1 grams fish oil with a 1.5 EPA: DHA ratio.
For painful menstrual periods: A daily dose of EPA 1080 mg and DHA 720 mg.
For weight loss: A daily serving of 2-7 ounces of fish containing approximately 3.65 grams omega-3 fatty acids (0.66 gram from EPA and 0.60 gram from DHA).
For slowing weight loss in patients with cancer: 7.5 grams/day of fish oil providing EPA 4.7 grams and DHA 2.8 grams.
For improving movement disorders in children with poor coordination (dyspraxia): Fish oil providing DHA 480 mg combined with 35 mg arachidonic acid and 96 mg gamma-alpha linoleic acid from evening primrose oil, 24 mg thyme oil, and 80 mg vitamin E.
For developmental coordination disorder in children: fish oil providing EPA 558 mg and DHA 174 in 3 divided doses.
For depression along with conventional antidepressants: Fish oil 9.6 grams/day.
To prevent full psychosis from developing in people with mild symptoms: Fish oil 1.2 grams/day.
For keeping veins open after coronary bypass surgery: 4 grams/day of fish oil containing EPA 2.04 grams and DHA 1.4 grams.
For preventing the collapse of arteries opened by “balloon” therapy (PTCA): 6 grams/day of fish oil (6,000 mg) starting one month before PTCA and continuing one month after PTCA, followed by 3 grams of fish oil daily thereafter for six months.
For reducing and preventing the long-term continuous rise in blood pressure and to preserve kidney function after heart transplantation: 4 grams/day of fish oil (46.5% EPA and 37.8% DHA).
For preventing clotting after placement of a tube for dialysis: 6 grams/day of fish oil.
Used for preserving kidney function in patients with severe IgA nephropathy (nephropathy (neh-FROP-uh-thee). This is also known as Berger’s disease, a kidney disease that occurs when an antibody called immunoglobulin A (IgA) lodges in the kidneys; this results in local inflammation that, over time, may hamper the kidneys’ ability to filter waste, excess water and electrolytes from the blood.): 4-8 grams/day of fish oil has been used.
For combined high triglycerides and high cholesterol: Fish oil providing EPA 1800-2160 mg and DHA 1200-1440 mg combined with garlic powder 900-1200 mg/day has been used to lower total cholesterol, LDL, triglycerides, and the ratios of total cholesterol to HDL, and LDL to HDL.
For salicylate intolerance: Fish oil 10 grams daily.
For best results, purchase high DHA fish oil that will reach 1440 mg (1.4 g) with fewer capsules, or take as many regular capsules to reach 1440mg of DHA daily. Look first at DHA. If you are getting enough DHA, you will also get enough EPA.
This concludes our discussion of fish oil, DHA, and EPA. This should help you when looking at advertising or news about fish oil.
Vitamin B12: The 50th anniversary of the discovery of vitamin B12 came and went and nobody noticed. There were no conferences to mark the occasion, no fanfares, no speeches, not a mention in the press, not even in the nutritional media. “Vitamin B12 isn’t sexy,” a sports nutrition consultant, put it. “It is just for old people, to keep them from getting anemic.”
Welcome to the new story of vitamin B12. Vitamin B12 occurs naturally in animal products. Some cereals and other foods are fortified with B12. Seafood, beef, poultry pork, milk, cheese, yogurt and eggs are natural sources of the vitamin. Vegetarians may choose to take a supplement or seek products fortified with vitamin B12. Vitamin deficiency can cause low energy levels. It is most likely to affect older adults, particularly those with health problems. Vegans and vegetarians may also suffer from vitamin B12 deficiency due to the lack of animal products in their diet. Other symptoms of B12 deficiency are anemia, weakness, loss of appetite, fatigue, confusion, loss of balance and poor memory. To avoid long-term damage, seek medical attention if you suspect you have a deficiency.
Claims: Vitamin B12 is an essential vitamin. It helps form healthy blood cells and is a building block for DNA. Still, several myths about the vitamin persist. For instance, B12 injections are no more potent than any other form of the vitamin, including supplements. The only reason to get vitamin B12 injections is if you have a deficiency and absorption problems.
Mechanism: Vitamin B12 has the largest, most complex structure of any vitamin, according to the Linus Pauling Institute at Oregon State University.
Essential to many aspects of overall health, vitamin B12 has a unique mechanism of action within the human body.
As soon as your stomach begins digesting food you have eaten that contains vitamin B-12 — such as eggs, meat and poultry — the first step of B12‘s mechanism of action begins. Hydrochloric acid and an enzyme in your stomach called gastric protease initiate the separation of B12 from the proteins to which it is bound so that your body can use the vitamin. If the B12 comes from a food fortified with the vitamin, then it is free — or already separated when it reaches your stomach — and skips this step, reports the Office of Dietary Supplements.
After separation, free vitamin B12 combines with a glycoprotein secreted by the stomach called intrinsic factor. This allows B12 to absorb through the stomach and into the small intestine, which uses calcium supplied by the pancreas to pull the B12, mixed with intrinsic factor, into specialized receptors within the lining of the small intestine. After this is complete, B12 can begin to play its crucial role within the body.
When vitamin B12 enters the bloodstream in its new, bio-available form, it immediately begins to work for your body’s health. The effects of vitamin B12‘s mechanism of action within the human body include production of new red blood cells, maintenance of healthy neurological cells, and synthesis of DNA. According to the National Institutes of Health, B12 is also pivotal in regulating your metabolism — the process through which your body converts food into energy, maintains healthy tissues, regulates your body temperature and allows for healthy organ function.
As with other water-soluble vitamins, excess vitamin B12 is excreted through urine. However, B12 is unique in that, unlike its water-soluble counterparts, it can be stored in the liver for years, according to the NIH. However, your body needs a steady supply of vitamin B12 through diet or supplementation in order to avoid a deficiency of the vitamin, which can lead to feelings of weakness, numbness and potentially cause anemia. Ensuring that you’re getting enough B12 is especially important if you are a vegetarian or vegan, in which case you must talk to your physician about supplementing with B12 to make sure you stay healthy.
Vitamin B12 helps maintain healthy metabolism, but it will not provide an energy boost to a healthy person with normal levels.
In 2008, the deputy director of the National Heart, Lung and Blood Institute, made a statement before Congress regarding the efficacy of vitamin B12. She stated, “Claims are made that vitamin B12 administration will improve energy levels, memory, concentration and mood. All of these are true when persons deficient in vitamin B12 are treated; however, there is no evidence at all of those clinical benefits when the vitamin is given to persons who are not deficient.”
There’s a buzz over B12 these days for two reasons, one scientific and the other economic. First, the science: Over the last decade or so, researchers have strongly implicated the toxic amino acid homocysteine in a variety of disease states. Homocysteine tends to accumulate in the body whenever B12 becomes deficient, and this accumulation has been linked with increased risk of Alzheimer’s disease, cardiovascular disease, chronic fatigue syndrome/fibromyalgia and multiple sclerosis among other conditions.
Folic acid deficiency can also lead to increased homocysteine levels – that’s because folate and B12, in their active ‘coenzyme’ forms, are both necessary cofactors for the enzymatic conversion of homocysteine to methionine. Until recently it’s been thought that the availability of folate was the most important determinant of the body’s ability to remethylate homocysteine. New research has revealed that vitamin B12 is more important for homocysteine disposal than previously believed. In particular, a study conducted among dialysis patients with kidney failure showed that a monthly shot of B12 plus conventional oral folate was more effective than high-dose folate without B12 in lowering elevated homocysteine.
The coenzyme form of vitamin B12 is known as methylcobalamin or methyl B12. It’s the only form of vitamin B12 which can directly participate in homocysteine metabolism. In addition, converting homocysteine to methionine via methyl B12 generates an increased supply of SAMe (S-adenosyl methionine), the body’s most important methyl donor. Indeed, some of the benefits of methyl B12, such as protection from neurotoxicity, appear to derive from increased production of SAMe. Methyl B12 has also been reported to be neurotrophic or growth-promoting for nerve cells, a property which may help regenerate central and peripheral nervous tissues damaged in disorders such as amyotrophic lateral sclerosis and diabetic peripheral neuropathy.
All of this scientific news is biological hot stuff, but it’s still only half the story. The other half is that, starting around 1998, methylcobalamin first became widely available in this country at an affordable price, thus offering new options for treating B12 deficiencies and lowering elevated homocysteine. Before then, methyl B12 had been enormously expensive and widely available only in Japan, where it still remains a prescription medication. Today any health-conscious American consumer can easily access the most powerful known form of vitamin B12.
When most of us think of vitamin B12, the molecule we really have in mind is cyanocobalamin or cyano B12. As its name suggests, cyano B12 has a cyanide group (CN) attached, whereas methyl B12 carries a methyl group (CH3) instead. Very little of the body’s natural B12 is in the cyano form under normal circumstances; exceptions are in cases of cyanide poisoning or chronic smoking, both of which can raise cyanocobalamin levels. The fact that most of our vitamin pills contain cyano rather than methyl B12 is largely an accident of history, the result of using charcoal to filter extracts during the isolation of B12. Unknown to the early researchers who first isolated B12, the traces of cyanide present in such charcoal rapidly convert all natural forms of B12, including methyl B12 into the more stable cyano form. As a result, the discovery of the B12 coenzymes and their metabolic role was delayed for years.
Cobalamin deficiency may manifest as megaloblastic anemia, peripheral neuropathy, irritability, dementia, depression, psychosis, and increased risk of myocardial infarction and stroke.
Whenever we swallow a conventional vitamin pill, any cyano B12 present gets carried along and absorbed by B12-binding proteins. Operating in the stomach and small intestine, this transport system provides a very efficient mechanism for absorbing a just a few micrograms of B12, yet is quickly swamped by anything larger. As a result, only about 1% of a large oral dose of any form of B12 usually makes it into the bloodstream. Fortunately, we can bypass intestinal absorption entirely by taking B12 sublingually (under the tongue). Sublingual administration is a simple and effective way of substantially raising blood levels by absorbing B12 through the oral mucosa. It’s also unquestionably the most convenient way to take B12, especially for people taking supplements on a daily basis.
So, let us say we’ve taken a sublingual tablet and a significant amount of B12 shows up in the bloodstream. End of story? Not if it’s cyano B12. Most of the B12 naturally circulating in the blood plasma is in the methyl form. Before cyano B12 can join this metabolic pool and be properly utilized by the body, it has to be stripped of its cyano group and ‘reduced’ (i.e., made to gain electrons) in a time-consuming, multi-step process. The result of all this processing is a B12 molecule with its cobalt ion reduced from the +3 to the +1 oxidation state, ready to take on a methyl group and be distributed throughout the body as methyl B12.
It should be obvious that there are certain advantages inherent in taking methyl B12 as a supplement, versus cyano B12. For one thing, methyl B12 doesn’t have to engage the body’s resources to convert it into coenzyme form, it’s already there. Even more important is the fact that methylcobalamin is the most highly reduced form of vitamin B12 possible; this makes methyl B12 a very potent reducing agent (antioxidant) indeed. In a body undergoing oxidative stress — for example from a disease process, stress in any form (exercise is a stressor), and from a diet deficient in antioxidants — it’s possible that methyl B12 production can become impaired. A similar derangement in the cellular synthesis of adenosyl B12 (another reduced coenzyme form of B12 into which methyl B12 can be converted) is already known to occur in association with vitamin E deficiency. So it makes sense to consume B12 in a form in which it’s already metabolically active and maximally reduced, and thereby put less of a strain on our bodies’ antioxidative capacity.
Side Effects: Vitamin B12 is generally considered safe when taken in amounts that are not higher than the recommended dietary allowance (RDA). There are not enough scientific data available about the safety of larger amounts of vitamin B12 during pregnancy or breastfeeding.
The chance of toxicity from vitamin B12 is low, according to the Institute of Medicine. Excess vitamin B12 is normally excreted in your urine. There is a greater chance of vitamin B12 deficiency if you are taking certain medications, such as metformin, a diabetes drug; chloramphenicol, an antibiotic; omeprazole and lansoprazole, used to treat acid reflux disease; or famotidine, ranitidine and cimetidine, drugs used to treat peptic ulcers.
Use cautiously in patients with cardiovascular concerns. After coronary stenting, an intravenous loading dose of folic acid, vitamin B6, and vitamin B12 followed by oral administration daily has been shown to increase rates of restenosis (reoccurrence of narrowing of a blood vessel). Due to the potential for harm, this combination of vitamins should not be recommended for patients receiving coronary stents.
Use cautiously in patients with elevated blood pressure, as high blood pressure following intravenous administration of hydrocobalamin has been reported.
Use cautiously in patients with dermatologic concerns, as pustular or papular rash, pruritus, and erythema have been reported. Vitamin B12 and pyridoxine have been associated with cases of rosacea fulminans (rosacea is a chronic skin condition that makes your face turn red and may cause swelling and skin sores that look like acne, characterized by intense erythema with nodules, papules, and pustules). Symptoms may persist for up to four months after the supplement is stopped and may require treatment with systemic corticosteroids and topical therapy. Pink or red skin discoloration has also been reported.
Use cautiously in patients with genitourinary concerns, as urine discoloration has been reported.
Use cautiously in patients with gastrointestinal concerns, as nausea, difficulty swallowing, and diarrhea have been reported.
Use cautiously in patients with hematological concerns, as, according to case report data, treatment of vitamin B12 deficiency may lead to polycythemia vera, which is characterized by an increase in blood volume and the number of red blood cells.
Use cautiously in patients with subnormal serum levels of potassium, as the correction of megaloblastic anemia with vitamin B12 may result in fatal hypokalemia in susceptible individuals.
Use cautiously in patients with a history of gout, or elevated uric acid levels, as the correction of megaloblastic anemia with vitamin B B12 may precipitate gout in susceptible individuals.
Use cautiously in patients taking the following agents, as they have been associated with reduced absorption or reduced serum levels of vitamin B12: ACE inhibitors, acetylsalicylic acid (aspirin), antibiotics, anticonvulsants, bile acid sequestrants, colchicine, H2 blockers, metformin, neomycin, nicotine, nitrous oxide, oral contraceptives, para-aminosalicylic acid, potassium chloride, proton pump inhibitors (PPIs), and zidovudine (AZT, Combivir®, Retrovir®). Additionally, vitamin C may cause the degradation of vitamin B12 in multivitamin supplements, and chloramphenicol may inhibit the biosynthesis of vitamin B12.
Avoid in patients sensitive or allergic to cobalamin, cobalt, or any other vitamin B12 product ingredients.
Pregnancy and Breastfeeding: Vitamin B12 is likely safe when used orally in amounts that do not exceed the recommended dietary allowance (RDA). There is insufficient reliable information available about the safety of larger amounts of vitamin B12 during pregnancy.
There is a paucity of reliable information available about the safety of larger amounts of vitamin B12 in humans (larger amounts as described in the Dosage section below).
Ask your doctor about the appropriateness of taking B12, for your particular health status, medications and supplements, age, and other factors.
Dosage: The recommended daily requirement for vitamin B12 varies by age, according to the NIH. At age 14 and older, the recommended daily intake of vitamin B12 is 2.4 mcg. For pregnant women, the recommendation is 2.6 mcg per day, and for lactating women, it is 2.8 mcg per day. In the United States, most children and adults absorb more than the recommended daily intake from their daily diets, according to the NIH, unless they are on various diets to lose weight. Then their nutrition should be fortified with enough B12 to make up for smaller and/or fewer instances of food intake.
How much methyl B12 should be taken for optimal health? In some studies on animals and humans, large doses (equivalent to 25-40 milligrams per day for an adult human were found to halt or improve neural degeneration. The problem is, nobody knows the long-term effects of such huge doses. A more prudent approach would be to take about a tenth as much, say, 3-5 milligrams per day (3,000-5000 micrograms) as a maintenance dose, with the dose increased as needed in cases of increased stress, oxidative or otherwise.
Next up is a discussion of more supplements that many people use to better their health.