Taking fish oil was one of the first dietary changes I made when I started to make some real progress towards health. After that seemed to help, I started to eat grass-fed beef for additional dietary Omega-3’s.
So this headline caught my attention:
Omega-3 fatty acids don’t help Crohn’s symptoms
I haven’t found that to be true for me, and I only started taking fish oil because of the studies I read about its beneficial effects on Crohn’s patients coupled with it’s articles about its beneficial effects on reducing inflammation problems in bodybuilders.
So I’m going to give you my interpretation of all this.
Looking at the key bullet points of the new study which was led by Dr. Brian Feagan:
In both trials, the relapse rate after one year was similar for those taking Omega-3 and those taking a placebo.
In the first trial, the one-year relapse rate was:
* 32 per cent for those who took Omega-3
* 36 per cent for those who took a placebo
In the second trial, the one-year relapse rate was:
* 48 per cent among those who took Omega-3
* 49 per cent for those who took a placebo
The first thing they’re saying is that the placebo (a pill that does nothing except fool the patient into thinking they are getting the medicine) had nearly the same success rate as the actual medicine.
This is something I’ve found to be true with nearly ever Crohn’s study I’ve read about.
As I’ve said since I first started reading about Crohn’s — “Just give me a really good sugar pill!”
Why do placebos work so well? I think it is because a lot of dealing with Crohn’s is a mindset issue. That’s why one of the fundamentals of this site is the writings of Napoleon Hill (author of Think and Grow Rich). I believe that the human body wants to live and be healthy. That’s a survival attribute. One of the things that can break that down is an unhealthy mental attitude, which can lead to a breakdown of the other systems. As the controller of the process, the mind leads the way. So just thinking that something can help you get the Crohn’s under control might be enough to help you make progress.
The doctor who authored the study states:
“A significant amount of time and money is spent annually on alternative therapies such as Omega-3 fatty acids, without strong evidence that they are beneficial to patients with inflammatory bowel disease,” gastroenterologist Dr. Brian Feagan, lead author on the study, said in a statement.
“I encourage Crohn’s patients to focus on prescription medications that we know are effective for preventing relapse of disease, such as azathioprine, methotrexate and TNF blockers.”
I don’t want to discount medicine, but I’ve found a lot of doctors discount everything other than medicine and I don’t think that’s the right thing to do either. As I’ll discuss elsewhere on this site, I’ve found discussions about nutrition with my gastroenterologist to be useless. My gastroenterologist has suggested to not eat anything that I find bothers me — but other than that he has no nutritional recommendations. Personally, I don’t see how the food a person eats could NOT affect their health. If I put ketchup into my car’s gas tank, I’d expect the car to not run. But for some reason, doctors act as if humans will work just as well no matter what is put into them as fuel. That doesn’t make sense to me. Especially not when dealing with problems with the actual digestive system.
Many of the effective prescription medications for Crohn’s have some scary side-effects or potential side-effects. Just read some of the warnings that come with them. For example, one of the recommended drugs is Azathioprine, which is converted in the body into 6-mercaptopurine.
I was on 6-mercaptopurine back in 2000. 6-mercaptopurine kept me vomiting constantly for several weeks until the combination of worsening Crohn’s symptoms plus starvation and dehydration forced me to be hospitalized for the first time in my life.
Just read some of the scary potential complications from 6-mercaptopurine from the above wikipedia link:
Mercaptopurine causes myelosuppression, suppressing the production of white blood cells and red blood cells. It may be toxic to bone marrow.
Mercaptopurine can lower the body’s ability to fight off infection. Those taking mercaptopurine should get permission from a doctor in order to receive immunizations and vaccinations. It is also recommended that while on the drug one should avoid those who have recently received oral polio vaccine.
Mercaptopurine causes changes to chromosomes in animals and humans. In mice these changes have given rise to lethal mutations. Therefore the drug has the potential to be cancer causing in humans.
Or as described here
Observed side effects in patients include pancreatitis, bone marrow depression, allergic reactions, drug hepatitis, neoplasms and lymphoma of the brain. Increased susceptibility to serious infection is an inherent risk in the use of 6-MP.
From the patient side, seeking out something that doesn’t carry such a laundry list of potential pitfalls means a LOT. You can’t be healthy when you’re dead.
Currently, the only medication I’m on for Crohn’s is Remicade. The whole Remicade infusion process is scary, the potential for severe reactions to it is scary, and the other problems Remicade can potentially cause are so scary that their medication warnings don’t even go into them in detail. That’s a whole ‘nother topic for another day.
Dr. Brian Feagan says that a significant amount of money is spent on alternative therapies as opposed to the proven medical treatments. Right now I take about $80 in fish oil per month and the cost of grass-fed beef may add another $40 per month over the cost of butcher bought meat. This is to compare against the medical treatment for Remicade which costs something over $8,000 every 8 weeks and keeps me in a desperate state to maintain health insurance.
From the patient side, seeking something that costs less than payments on a new Ferrari might also mean a LOT.
The article goes on to say:
However, study subjects who took Omega-3 were found to have very low triglyceride levels — a high reading is known to be a risk factor for heart disease.
Omega-3 fatty acids, found in fatty fish such as salmon, mackerel, herring and sardines, offer anti-inflammatory benefits for a variety of inflammatory illnesses, such rheumatoid arthritis.
So they didn’t find any harm from Omega-3 supplementation. They even point out that the Omega-3 fatty acids do help OTHER inflammatory diseases. Not doing harm and improving triglyceride levels is actually a pretty good deal compared to the unwanted side-effects of some of the alternative drugs suggested.
OK — now I’ll skip up to the final points where I disagree with the study.
More than 10 years ago, a small Italian study had suggested that Omega-3 alleviates the symptoms of Crohn’s disease. But Feagan and his team conducted a larger study to test this theory.
“Small, single-centre clinical trials often overestimate the true effects of treatment,” Feagan said. “That’s why it is important to conduct large-scale, randomized, multi-centre studies in order to confirm preliminary results.”
Interventions Patients with a Crohn’s Disease Activity Index (CDAI) score of less than 150 were randomly assigned to receive either 4 g/d of Omega-3 free fatty acids or placebo for up to 58 weeks. No other treatments for Crohn disease were permitted.
Conclusion In these trials, treatment with Omega-3 free fatty acids was not effective for the prevention of relapse in Crohn disease.
Here is a link to the abstract of the actual published article (If you have JAMA access you can read the entire article):
Here are some other links to articles about the study in case you don’t have JAMA access:
The following two links show that the name of the drug being tested is Epanova.
This is the company that manufactures Epanova. The page does not give much information about what Epanova is other than it contains Omega-3.
This page discusses Epanova, but only in the context of cardiovascular diseases. It again doesn’t say much about what Epanova contains.
Its two main active components, the free fatty acids DHA and EPA, are present in a highly concentrated pure formulation.
EPANOVA capsules contain a gastroresistant coating providing an easy intake devoid of the unpleasant gastrointestinal side effects observed with other products.
These are the best descriptions I’ve been able to find of the ingredients of Epanova:
Since the Phase II study, the product has been reformulated from a 500mg hard gel to a 1g soft gel capsule, thus reducing the daily dose to four capsules. The capsules are specially coated to delay the release of the active agents after ingestion, with the aim of improving tolerability.
The omega-3 supplement (Epanova; Tillotts Pharma AG, Ziefen, Switzerland) provided a dose of four grams of omega-3 per day, consisting of 50 to 60 per cent eicosapentanonic acid (EPA) and 15 to 25 per cent docosahexanoic acid (DHA). The free fatty acids were encapsulated in a delayed-release soft gelatin capsule.
I have not been able to find any exact reference on what these pills contain. I think it matters. How much EPA and DHA were actually delivered and what were the properties of the delayed-release coating?
Here is a link to the referenced Italian study which showed positive effects from Omega-3 supplementation:
The patients received either nine fish-oil capsules containing a total of 2.7 g of n-3 fatty acids or nine placebo capsules daily. A special coating protected the capsules against gastric acidity for at least 30 minutes.
Here is another study which claims that enteric coated fish oil was effective.
No significant adverse events were recorded in any of the studies and not enough data were available to analyze the other secondary outcomes.
AUTHORS’ CONCLUSIONS: Omega 3 fatty acids are safe and may be effective for maintenance of remission in CD when used in enteric coated capsules. However, there are not sufficient data to recommend the routine use of n-3 for maintenance of remission in CD. The small number of patients in the included studies warrants further larger RCTs.
However, the above study didn’t say the amount of enteric coated fish oil used. It only said:
The intervention must have been fish oil or n-3 given in pre-defined dosage.
From what I understand, the enteric coating helps increase absorption of the fish oil and gets more of it to wind up where it is needed. It also helps prevent you from tasting any of the fish oil since the fish oil isn’t released until after it leaves your stomach.
So there are some things I question:
1. How much does enteric coating help?
I currently take Fisol brand enteric coated fish oil. The box says that the enteric coating gives you proper release in the intestines, not in the stomach, and provides 3x better absorption than non-enteric coated fish oil meaning more EPA/DHA gets into your system (I’ll get to that in a moment).
2. How much fish oil is an effective dose to even be testing?
And this is where my doubts of Dr. Feagan’s study really come into play. Did they dose anywhere near high enough to cause any effect on the Crohn’s?
Quick point of reference:
As I understand it, the “good stuff” of the fish oil is the Eicosapentaenoic Acid (EPA) and Docosahexaenoic Acid (DHA). They are the Omega-3 fatty acids that you are trying to get from it. Different types of fish oil have differing amounts of Omega-3 content.
This is something I haven’t been able to figure out regarding exactly what amounts the study is representing. At least by the bottle labels of my fish oil, they break out the amount of Omega-3 content as a portion of the fish oil content. This means that you’d either need highly concentrated Omega-3 pills or very large pills in order to get 1g of Omega-3 in a single pill.
Fisol enteric coated fish oil capsules
500 mg capsule contains 250 mg Omega-3 fatty acids: 150mg EPA, 100mg DHA
Carlson’s cod liver oil
1000 mg capsule contains 240mg Omega-3 fatty acids: 90mg EPA, 120mg DHA, 20mg ALA, 10mg DPA
Something I think is important to look at is: What are some recommendations for healthy people?
Dr. Mercola recommends:
For Carlson’s Cod Liver Oil Softgels with Low Vitamin A, I recommend taking one softgel for every ten pounds of body weight, preferably in divided servings. Do not exceed 15 pills per day unless you have had your fatty acid levels tested.
The Carlson’s Cod Liver Oil Softgels with Low Vitamin A he recommends has a profile of:
1000mg capsule contains 270mg Omega-3 fatty acids: 110mg EPA, 110mg DHA, 50mg other Omega-3’s
So for someone of my weight, I’d be at his maximum recommendation for someone who is not getting their fatty acid levels tested. This would be 15 pills per day for a total of a little over 4 grams of Omega-3.
That’s the same amount used in the study for people with Crohns — and it’s the amount he recommends for every HEALTHY person.
T-nation is the fitness site that I trust most for information. In this article about taking fish oil to aid in losing fat:
The recommendation is to:
Take 2-3 grams of EPA/DHA per day. This is the lowest dosage I’d use to elicit a fat loss benefit. You may need to crank it up to 5 grams of EPA/DHA as the response can vary between individuals.
So this is another instance of a similar amount of Omega-3’s as used in the Crohn’s study being recommended for any healthy person who wants to be leaner and healthier.
This article about the study:
Pearls for Practice
* In patients with Crohn’s disease, 52 to 58 weeks of treatment with omega-3 free fatty acid at 4 g daily is not associated with reduction in the relapse rate of Crohn’s disease.
* Use of omega-3 free fatty acid in patients with Crohn’s disease is associated with lowering of triglyceride levels and no serious adverse effects.
So what do I think from all of this?
I wonder why the medscape article states that 4g daily is not associated with reduction in the relapse rate of Crohn’s disease while the actual JAMA article abstract states the more general:
Conclusion In these trials, treatment with omega-3 free fatty acids was not effective for the prevention of relapse in Crohn disease.
Because those two statements are not the same. One is written to suggest that Omega-3 fatty acids in any amount (since the amount was not mentioned) were not effective, while the other is written to say that 4g daily was not effective.
Without a accurate description of what the pills tested contained, it is difficult to compare the study to what I am currently taking. Since the EPA/DHA content of fish oil is a percentage of the amount of fish oil in the pill — were they actually giving 4g of EPA/DHA or 4g of fish oil with some percentage of that being EPA/DHA?
I don’t think that this study is sufficient to discourage the use of Omega-3 in treating Crohn’s. As I see it, the study used the amount of Omega-3 needed by a healthy person to deal with inflammation, etc. — but people with Crohn’s disease are known to have a lot more inflammation than a normal, healthy person (that’s what the disease is all about). So perhaps the amount used was not sufficient to help Crohn’s disease? However, that is very different from saying that Omega-3’s don’t help.
Here’s a bunch of other thoughts that I’ll expand upon at another time:
- Maybe one of the triggers for Crohn’s disease is the lack of Omega-3 fatty acids in the diet. This is a whole topic in itself — how the American diet (and more and more the world diet) has developed an unnatural lack of Omega-3 fatty acids.
- It doesn’t hurt the healthy people to take Omega-3’s — and even this new study showed it doesn’t hurt people with Crohn’s to take them either. Not causing harm is a good thing.
- Enteric coating (coating the fish oil so that it isn’t released until after it has left your stomache) may have an advantage — especially for people with Crohn’s disease — due to the way it delivers the Omega-3’s directly to the intestines. At least that’s what the previous studies showed.
- Considering that Crohn’s is a disease state, it might be worth examining the effect of more Omega-3’s than a healthy person might need.
- The new study (and the previous studies) didn’t specify what other things the participants did in addition to the Omega-3 supplementation. Although the intent of the studies seemed to be that the patients wouldn’t do anything else that would have an effect. While that may work for a study, in real life I want to do everything I can to keep myself healthy. That’s what Rise Above Crohns is all about.
Looking at the other positives of Omega-3:
Even if the Omega-3 doesn’t help the Crohn’s it might help prevent other medical problems. That’s still a lot better than side effects that are lethal. For instance:
So what do I do?
Based on this new study, those taking Omega-3 or the placebo experienced roughly a 30% or 50% relapse rate. Which means that a good number of people (50% to 70%) were helped by either.
I don’t think it is possible to self administer a placebo (just like you can’t tickle yourself). So the easiest thing for me to do on my own is to treat Omega-3 fatty acids as another tool in my toolbox.
The worst results — in the second trial of the new study, over 50% of the people did not have a relapse and ALL they were doing is taking the Omega-3 pills.
It’s very different looking at this from the patient side vs. from the doctor side.
On the personal side, I have a lot to gain from the extra Omega-3’s helping me and nothing to lose — even if in the worst case they are only helping my triglycerides and providing a placebo effect. I don’t know if it matters how it works as long as it works.
If you’ve ever experienced any of the worst Crohn’s symptoms, you know that achieving these kind of results is fantastic. Especially when the downside risk doesn’t include losing your hair, getting cancer, pancreatitis, or having an immune system so broken that you are susceptable to all sorts of other illnesses, etc.
Whereas on the doctor side, I’ve seen doctors happy for me to be doing better — but I’ve never seen them in physical pain or losing sleep over my condition being worse. The doctors are looking for something that they can prove works. As a quick example, Remicade (the drug I am currently taking) had an 82% response rate in this clinical trial.
My health is what’s important to me, and I’m going to do everything I can to maintain and improve it.
Over the years, I’ve taken all sorts of medications for the Crohn’s that have had varying effectiveness and varying side effects. None of the medication side effects were as harmless as the ones given for fish oil.
Right now I take a daily combination of cod liver oil pills, fish oil pills, and enteric-coated fish oil pills. I get about a total of a little over 3 grams of Omega-3 fatty acids from the supplementation (and 2 grams of what I take is enteric-coated). This comes from a total of 8.8 g of various fish oil pills. Plus I usually eat at least one meal per day made with grass fed beef which adds additional Omega-3 fatty acids to my diet.
I think the extra Omega-3’s are helping me and there’s no evidence they are harmful, so that’s what I’m sticking with. So far it has been working for me for several years.
However, taking extra Omega-3’s is not the only thing I do. Maybe each thing I do only has a certain percentage chance of helping, but the more things I do means that there is more of a chance that I will keep my Crohn’s under control.
That’s why this website is about mindset, nutrition, exercise, lifestyle, medication, and more. It all works together. Maybe each thing only does a small part and only has a percentage chance of helping — but when added all together it improves the odds a lot.