No, fish oil isn't as multipurpose as Windex...it's still about overall lifestyle

I am devoting this blog post to my friends who think I've gone fish oil overboard! I write and talk about fish oil so much, it seems, they've gotten the impression that maybe I've forgotten about all of the other things that determine health. One of my neighbors constantly teases me about the fact that I believe in and promote fish oil like the guy who uses Windex for everything in the movie My Big Fat Greek Wedding. Colleague Karen Siegel (Houston registered dietitian and licensed acupuncturist) sent me the following article.

Note that the recommendations at the end of this quote are the same recommendations commonly made for diabetes prevention--and you HAVE seen in this blog, that I have written on the connection between diabetes and Alzheimer's disease.

It's not that I think fish oil can replace a healthy lifestyle, it's that I see so many people who pretty much have the right idea, and not balancing omega-3's is the piece that keeps them from being completely on the right train.

Though I do believe fish oil is important, this article perfectly sums up how I do feel: by no means is fish oil a "bad habit eraser"! You've got to live a healthful life, and when you do that, fish oil may help decrease your health risk.

Oh, BTW, that neighbor who teases me? She told me the other day she secretly went to Costco and got the pills...and her hair and nails have started to become longer and stronger.

Dangour AD, Allen E, Elbourne D, Fletcher A, Richards M, Uauy R. Fish Consumption and Cognitive Function among Older People in the UK: Baseline Data from the Opal Study. J Nutr Health Aging. 2009;13(3):198-202.


A UK study has cast doubt on claims that eating oily fish can protect against dementia in old age.

Data from a trial of more than 800 older people initially showed that those who eat plenty of oily fish seem to have better cognitive function.

But factors such as education and mood explained most of the link.

Researchers need to clarify what, if any, benefits fish oil has on the ageing brain, they wrote in the Journal of Nutrition, Health and Ageing.

In recent years, there has been increasing interest in diet as a way of preventing dementia.


It's not at all clear that healthy older people get any benefit from eating fish oil

Dr Alan Dangour, study leader
Much focus has been on omega 3 fatty acids found in oily fish, such as salmon and mackerel.

And there are biological reasons, backed by tests in the laboratory, why in theory, these fatty acids would be neuroprotective.

The latest study found a significant association between eating a couple of portions of fish a week and better scores on tests of cognitive function.

But when the researchers, from the London School of Hygiene and Tropical Medicine, took into account education and psychological health the association almost disappeared.

Healthy

Experts advise eating a couple of portions of fish a week, with at least one being an oily fish, because there are proven benefits on the heart.

Study leader Dr Alan Dangour said claims about the benefits of oily fish in warding of dementia in older people seemed to have been oversold.

"The evidence on this has always been sporadic.

"What this shows is there is a link between people who eat oily fish and better cognitive function, but if you adjust for education and mood this relationship goes, so it's not at all clear that healthy older people get any benefit from eating fish oil."

The evidence collected by Dr Dangour was for a study due to report later this year comparing fish oil supplements with placebo.

He added that this randomised, controlled study should provide clarification.

Neil Hunt, chief executive of the Alzheimer's Society, said: "One of the best ways to reduce your risk of dementia is by eating a Mediterranean diet rich in fruit, vegetables, grains, fish and poultry.

"However, we still do not know which components of this sort of diet help the most.

"Unfortunately this study does not add to our understanding.

"Once age, sex and education are accounted for the research does not show any significant benefit of regularly eating oily fish."

The American Heart Association Needs to Check Its Omega-3 Math

I have heard the following recommendations made by the American Heart Association repeatedly for years now. And I hear them parroted everywhere by well-intended medical experts who, it seems, did not stop to check the math on which the recommendations are based:

Population Recommendation
Patients without documented coronary heart disease (CHD)
Eat a variety of (preferably fatty) fish at least twice a week.
Include oils and foods rich in alpha-linolenic acid (flaxseed, canola
and soybean oils; flaxseed and walnuts).

Patients with documented CHD Consume about 1 g of EPA+DHA per day,
preferably from fatty fish. EPA+DHA in capsule form could be
considered in consultation with the physician.

Patients who need to lower triglycerides 2 to 4 grams of EPA+DHA per
day provided as capsules under a physician's care.

Patients taking more than 3 grams of omega-3 fatty acids from
capsules should do so only under a physician's care. High intakes
could cause excessive bleeding in some people.

Evidence from prospective secondary prevention studies suggests that
taking EPA+DHA ranging from 0.5 to 1.8 grams per day (either as fatty
fish or supplements) significantly reduces deaths from heart disease
and all causes. For alpha-linolenic acid, a total intake of 1.5–3
grams per day seems beneficial.

I couldn't sit back anymore. Ellen Reiss Goldfarb, RD, a member of my inCYST Network for Women With PCOS collaborated with me on hopefully setting the record straight. We hope it helps, especially to get a mathematically-correct set of recommendations out to the public so they can go grocery shopping with a better sense of empowerment.

Regarding the omega-3 recommendations recently discussed, you all may want to consider that there are several contradictions within that make it very difficult (maybe even impossible) for the average American to follow them. As dietitians, it is important that we understand this math so that we help, not confuse or hurt, people who look to us for advice.

First of all, we are telling people that they are not to eat more than 3 grams of omega-3's per day unless they are under a physician's care. However, if you try to get 1.8 mg of combined EPA + DHA combined, in the form of food first, 3 ounces of Alaskan salmon, which contains 384 mg of EPA plus DHA, would have to be eaten in a DAILY QUANTITY OF 14 ounces in order to get there. Are you really saying that if you're eating enough fish to get the amount of omega-3's we recommend, that the MD has to manage it??? You are unnecessarily putting yourself out of business if you are!!!

Secondly, given those numbers for salmon, the densest seafood source of omega-3's, there is no way eating fish just a few times a week is going to get you to the level of omega-3 intake these recommendations are making. It is so frustrating watching colleagues parrot these recommendations and wondering if we're the only ones who've actually sat down and done this math..

We also went to three popular fish oil brands and calculated out how many pills you would need to get the upper level of DHA + EPA recommended. Two of those, Nordic Naturals and Carlson's, if taken at the level needed to get there, would also place your client at levels you say a physician needs to manage.

Realistically and honestly, how many of you are really doing that?

With regards to bleeding, in all of our collective years actively recommending fish oil, only one client encountered a bleeding problem. The people at greatest risk for that are people who are on medications such as coumadin...and if you work closely with a physician who "gets it"--the dose of that medication can be dropped as EPA levels rise and help normalize blood clotting function. Always start low, titrate up, look closely for symptoms in people not on contraindicated medicatoins and let the MD check blood levels in people who are...and work very hard to minimize omega-6 intake. You'll get a lot more bang out of your omega-3 buck if you focus on the omega 6 to omega 3 ratio than if you only think about one.

If you don't know how to use omega-3's to promote health, you may actually CREATE health risks for your clients, which I don't think any of you want to do.

Here are the numbers from our calculations for your reference.

EPA + DHA, total mg
3 ounces salmon 384 mg
Nordic Naturals 550 mg
Carlson's 500 mg
Barlean's 600 mg

Total omega-3 content
3 ounces salmon 3250 mg
Nordic Naturals 690 mg
Carlson's 600 mg
Barlean's 780 mg

Amount needed to meet n-3's needed to meet upper DHA + EPA recommendation/total omega-3 content of that amount
3 ounces salmon 14 oz DAILY/15.2 total gms n-3
Nordic Naturals 3.27 capsules/3.6 gm total n-3
Carlson's 3.6 capsules/6.0 gm total n-3
Barlean's 3.0 capsules/2.3 gm total n-3

Monika M. Woolsey, MS, RD
Ellen Reiss Goldfarb, RD

Are "vegetarians" at risk for depression?

One of my biggest jobs in this specialty is clarifying what vegetarian eating IS...and what it is NOT. Unfortunately, the vast majority of people I know who are vegetarian define that by describing what they DON'T eat, rather than what they DO eat. That is why the word "vegetarians" is in quotes in my title, because it refers to what many vegetarians consider the definition, and that is absolutely not what I define it as.

My definition of vegetarian is a person who replaces the essential nutrients found in animal based foods with non-animal sources.

People who don't eat fish have an incredibly difficult time getting omega-3 fatty acids, because they are primarily found in seafood. In addition, if they're eating more salads, thinking they are "healthy", they may be getting excessive amounts of the proinflammatory omega-6 fatty acids, which are often the base for commercial salad dressings.

"Vegetarians" with a more disordered bent to their habits, who are filling up on baked goods and processed foods, are also prone to excessive omega-6 fatty acids.

Which may explain the findings of this most recent study. Women experiencing psychological distress and symptoms of depression were divided into two groups. (It is my experience that of the two genders, women are the guiltiest when it comes to not eating meat and subsisting on salads and carbs.) The first group received 1.05 grams of EPA (a pretty hefty dose, given that most fish oil capsules have only 20-30% of that amount) plus .15 grams DHA. The second group received a placebo. They received this dose for 8 weeks.

The women on the fish oil supplement showed a degree of decrease in symptoms that the women on placebo did not.

Of the two omega-3 fatty acids found in fish oil, EPA is the one that is primarily found in fish. So if you're not eating fish, and you are having trouble with depression, chances are your food choices have something to do with that!

If you can't, off the top of your head, list five significant sources of DHA, your only other source of EPA (it can be converted when DHA stores are sufficient and there is excess in your diet), you're not getting enough. For a list of food products containing marine-algae based DHA...click here.

And, if your diet is heavy on processed foods and salads, and you are using salad dressings based on soybean or corn oil...you're likely breaking down whatever omega-3's are in your system before you can even benefit from them.

Maybe now you can see why I'm so fussy about where the line should officially be drawn between vegetarian and omnivore. It's not at all about what you don't eat...it's about what you DO eat.

Lucas M, Asselin G, Mérette C, Poulin MJ, Dodin S. Ethyl-eicosapentaenoic acid for the treatment of psychological distress and depressive symptoms in middle-aged women: a double-blind, placebo-controlled, randomized clinical trial. Am J Clin Nutr. 2009 Feb;89(2):641-51. Epub 2008 Dec 30.

Safely using eicosapentaenoic acid (fish oil) for schizophrenia

Fish oil, primarily eicosapentaenoic acid (EPA) is gaining popularity as a natural treatment for schizophrenia. (Before I continue, just want to say I have to be very careful with this post because I don't want to encourage anyone who needs to be on antipsychotics to read that I'm saying to discontinue them--I AM NOT!)

Because of this popularity, a prominent group of schizophrenia researchers in the UK decided to evaluate whether or not therapeutic doses of EPA produced any safety issues for its users. They divided 84 individuals with schizophrenia into two groups; one group received 2 grams EPA per day along with their antipsychotic, the other received a placebo along with their medication.

Those individuals receiving EPA experienced a trend toward decreased total cholesterol and HDL. Weight tended to increase. And their bleeding time increased, meaning it took longer for their blood to clot when they cut themselves.

Here are some thoughts to take away from this study.

1. 2 grams daily of EPA is a very high dose. Most over the counter capsules have about 10% of that amount. This was a very specific protocol unlikely to be randomly adopted by the average person.

2. If you have ever had any issues with blood clotting, or are on any type of medication that affects clotting time, such as Coumadin, it is very important to work with your prescribing physician in order to coordinate appropriate dosages of medications and supplements.

3. I'm not working with critically ill schizophrenics on an outpatient basis, so I have the liberty of starting low and upping doses to evaluate for tolerance. I tend to work with a mixture of dietary fats and fish oils and not use such a specific, directed protocol. I feel much safer with that. But I am always on the lookout for the kinds of reactions that this study produced.

4. What is not known is whether or not all the subjects were on the same antipsychotic, or for how long before starting this study. Each antipsychotic has a slightly different effect on lipids, weight, and hormones, and that information would likely affect the results that were reported.

Overall, I'd say the most important finding in this study was the effect of super-high doses of EPA on clotting time. Because EPA has been getting more attention for its potential in treating bipolar disorder and schizophrenia, it is showing up more and more as a single supplement rather than as a component of fish oil. There is a tendency to use the "more is better" approach and to assume that if it's natural, and it's over the counter, it's safe. That may or may not be true with EPA, and it should be used judiciously.

Emsley R, Niehaus DJ, Oosthuizen PP, Koen L, Ascott-Evans B, Chiliza B, van Rensburg SJ, Smit RM. Safety of the omega-3 fatty acid, eicosapentaenoic acid (EPA) in psychiatric patients: Results from a randomized, placebo-controlled trial. Psychiatry Res. 2008 Dec 15;161(3):284-91. Epub 2008 Oct 29.

Fatty aspirin: a new perspective in the prevention of dementia of Alzheimer's type?

One of the reasons many nutritional therapies don't get much research attention is that research studies need to be funded. And the biggest bank accounts to be accessed for those funds are those held by companies who can get a return on their investment for supporting that research. In other words, if a company can invest research in a project that results in a chemical that can be patented and sold at a profit, there's a motivation to spend money in that way.

You can't patent a salmon.

And if you saw the way my pecan farming friends managed their businesses here in Arizona...a few pecans here, a bed and breakfast there...not really multi-million dollar enterprises.

So it makes sense that some of the best answers to medical problems are likely not going to show up in medical journals. For all their good intent and peer reviews, these journals are often promotional venues for the companies funding the studies they report on. Those promotions just aren't formatted as advertisements.

But I always wonder when reading all these studies, why the Reese's Peanut Butter Cup Effect hasn't happened. What I mean by that is, if there is a little bit of (very strong) evidence to support natural remedies such as fish oil and herbs, why these drug companies don't come up with combinations of supplements and medications that (1) increase the effectiveness of the treatment, (2) reduce the side effects that minimize drug compliance, like weight gain, and (3) engage the interest of people who don't necessarily want to take medications but might consider them if the natural remedies they DO trust were somehow incorporated into the treatment? Just like the old, "You got chocolate in my peanut butter" ads.

Here is a reference for such a combo, a "fatty aspirin", or fish oil-aspirin combination, that could be used to delay the development of Alzheimer's disease.

OK, in that case I can't say you heard it here first, but when you guys start coming up with fatty antipsychotics, fatty antidepressants, yadayada...and you know it's eventually going to happen...you know where to send the royalty check!

Pomponi M, Di Gioia A, Bria P, Pomponi MF. Fatty aspirin: a new perspective in the prevention of dementia of Alzheimer's type? Curr Alzheimer Res. 2008 Oct;5(5):422-31.

Biochemical and brain differences in bipolar disorder--that nutrition might be able to help

These guys think like me. Instead of coming up with a pill that fixes what appears to be wrong on the outside...why not start on the inside and figure out what's really causing the problem?

This group of researchers started out looking at tissue samples of people who had had depression. What they discovered was that these individuals had low levels of docosahexaenoic acid (DHA, if you read this blog you know that's fish oil and marine algae) in their red blood cells and their cortices. The cortex is the part of the brain that does logical, rational problem solving.

They decided to poke around some brains that had been under the influence of bipolar disorder in their time and discovered that there were several abnormalities. As with depressin, DHA levels were low. Arachidonic acid and stearic acid levels were also low. Brains of individuals who had been on mood stabilizing or antipsychotic medications were not as deficient. The deficiencies appeared to be more severe if alcohol abuse had been an issue.

It's not clear whether or not the issue is totally dietary, or if there is some kind of abnormal metabolic process that alters fatty acid ratios, but it does seem that researchers in this area are leaning toward the possibility that nutrition is extremely important to brain function--as well as to the management of psychiatric disorders.

It causes me to wonder why dietary controls are not a standard protocol in psychotropic drug studies, but that's a topic for another blog post. I'm sure you'll see that soon!

McNamara RK, Jandacek R, Rider T, Tso P, Stanford KE, Hahn CG, Richtand NM. Deficits in docosahexaenoic acid and associated elevations in the metabolism of arachidonic acid and saturated fatty acids in the postmortem orbitofrontal cortex of patients with bipolar disorder. Psychiatry Res. 2008 Sep 30;160(3):285-99. Epub 2008 Aug 20.

Oh! Why the graphic? Just some random thinking...all this writing about fish, and brains, and fish for brain health kind of has me wondering...if fish might not be more intelligent than we give them credit for, if fish ever get depressed...and if there is such a thing as a manic salmon?

Your brain loves lipoic acid!

I'm primarily a food first, supplements second kind of person. However, lipoic acid is a supplement I love to recommend. It's not something that you can readily find in food, but it does a whole lot of good, especially in the brain.

It can delay and prevent Alzheimer's disease, and dementia, in a variety of ways. It helps to increase acetylcholine levels. Acetylcholine is the neurotransmitter in charge of memory function. It helps to bind free radicals, preventing them from doing damage. It prevents the formation of proteins associated with inflammation.

Not a bad friend, is it?

The amount given in the two studies evaluating lipoic acid's effect on the brain was 600 mg per day.

Lipoic acid is also unique in that it has the ability to make other antioxidants more powerful. The authors of the article reviewed here suggested that in combination with curcumin, EGCG (active ingredient in green tea), and DHA (in fish oil and marine algae), lipoic acid could be a very powerful warrior in the fight against degenerative brain disease.

Hmmmm...anyone for some fish curry, with a green tea chaser?

Maczurek A, Hager K, Kenklies M, Sharman M, Martins R, Engel J, Carlson DA, Münch G. Lipoic acid as an anti-inflammatory and neuroprotective treatment for Alzheimer's disease. Adv Drug Deliv Rev. 2008 Oct-Nov;60(13-14):1463-70. Epub 2008 Jul 4.

Want to get someone's attention? Mess with their head

In all the years I've been doing this work, I've noticed people gradually tune out messages about fitness, weight management, and exercise...at least the ones with meaningful, important information. Except when it comes to their brains.

This past weekend, for example, I ran a demo booth at a local Whole Foods store for one of my company's sponsors, Organic Bistro. A gentleman and his son stopped by, and I offered them some samples of salmon cakes. The man pretty much went off on me.

"I'm vegan. I'm 51 years old. I'm a professional athlete. Just look at this body. Look at my legs. Do I look like I need your food? If I didn't know what I was doing would I be in this condition?"

I let him rant, and accommodated, interestingly, his wish that his son get a sample of the food that in his mind was not good enough for him.

After he finished, I said to him, "You clearly take very good care of yourself. I'm curious, though, because I'm a sports nutritionist and even athletes seem to not be getting some really important information about nutrition. Did you know that omega-3 fatty acids have been found to delay and possibly prevent the progression of Alzheimer's disease? And that it is possible but not easy to get those omega-3's in a completely vegan diet?"

The man's posture slumped, his voice got quiet, and he said, "My wife has permission, if I ever go there...to shoot me."

Since he'd dug a hole for himself and everyone in the frozen food aisle had been drawn into this interchange because of its decibel level, he couldn't really ask for more information.

So I pulled him aside and suggested that on his own, in the privacy of his own cable connection, that he Google "omega-3" and "Alzheimer's" and draw his own conclusions.

I'm not sure why it is that we're ok with a few extra pounds, we can justify eating that piece of cake even if we've been diagnosed with diabetes and there is a possibility that poor dietary choices might even lead to amputation...or eating those potato chips even though we want a baby and the evidence suggests that trans fats interfere with fertility...

...but you mention the brain and you've got a whole new, motivated audience.

My guess is, that by the time I'd broken down my demo this athlete had already been online learning about Alzheimer's. And hopefully, by now, has been back to Whole Foods for some of those really tasty wild salmon cakes.

Just one gram, that's all it takes!

A couple of years ago I prescribed fish oil to a client with depression. Her psychologist told her my recommendation was not proven in the research. These days, I'd be able to counter with a lot more hard data.

For example, in one study, 35 depressed adults (about half women, half men) were divided into 3 groups and given 3 different doses of DHA, one of the omega-3 fatty acids found in fish oil. 83% of the group with the lowest dose responded to the DHA with decreased symptoms of depression! Higher doses did not seem to be as effective.

My guess is, there may be a threshold over which adding more therapy into the system exceeds the body's ability to use it. So even with fish oil, more is not better may not be the appropriate approach.

However, I do like knowing that even a little bit of this very available, very inexpensive, nonpharmacological treatment can have profound effects on a common and debilitating issue. It's worth a try!

Mischoulon D, Best-Popescu C, Laposata M, Merens W, Murakami JL, Wu SL, Papakostas GI, Dording CM, Sonawalla SB, Nierenberg AA, Alpert JE, Fava M. A double-blind dose-finding pilot study of docosahexaenoic acid (DHA) for major depressive disorder. Eur Neuropsychopharmacol. 2008 Sep;18(9):639-45. Epub 2008 Jun 6.

It's the marijuana, stupid

Much of my work is with polycystic ovary syndrome, PCOS, an inflammatory syndrome that is the leading cause of infertility in the United States. Women who have this syndrome are plagued with intense carbohydrate cravings that can make it nearly impossible to follow any kind of healthy diet.

A dietitian with the syndrome, who had a master's degree in nutrition, once told me, "If it's carbohydrate, and it's not nailed down...I eat it."

It happens more often than not, when I work with clients who have PCOS, that they cannot conceive of being in a physiological state where the majority of their thoughts revolve around sugar and where to find more. They might politely listen to what I have to say about how to eat to quell these cravings, but the inevitable question at the end of my pitch for my nutrition plan is, "OK, but what am I going to do when I crave sugar?" They have absolutely no knowledge of a time when cravings did not rule their food choices, and their experience causes them to assume that my program is going to fail their expectations just as every other diet has done.

That's why I work so hard for those clients who are willing to trust me and try my program. It's incredibly rewarding to talk to them a couple of weeks later and hear the surprised delight over not spending hours of time and energy trying to suppress the urge to binge on a chocolate cake.

It seems that one of the reasons women with PCOS have so much trouble with their carbohydrate cravings, is that their endocannabinoid systems are out of balance.

You may know of cannabinoids as the substance in marijuana that causes the munchies. These compounds have been found to be important appetite regulators.

Of course, in Western medicine, when receptor trouble is identified, that means dozens of scientists in drug companies around the world race to find the right chemical to fix the troubled receptor.

Currently, a drug has been developed designed to "improve" the function of cannabinoid receptors. For a lot of obesity scientists, this drug, rimonabant, (Acomplia), was supposed to be the obesity miracle drug. However, Acomplia was tripped up during the FDA approval process, because there were concerns about an increased risk of severe depression being a major side effect. That is what has been tested and observed with Acomplia use.

What is also apparently a concern is that since this drug is somewhat like "anti-marijuana," it has potential for antagonizing many of the neuroprotective properties that marijuana may actually have. In other words, users of Acomplia may find themselves at increased risk of neurodegenerative diseases such as Multiple sclerosis, Alzheimer's disease, Amyotrophic lateral sclerosis (ALS), Parkinson's disease, and Huntington's disease.

So what are women with PCOS--and men whose obesity is also fueled by carbohydrate cravings supposed to do?

If you're a regular reader of this blog, you should know by now that the first answer to any question should always be fish oil. :) Yup, fish oil can help to silence the marijuana munchies.

I included a reference for your perusal, but I have to say, it was a client who taught me about this. We'd spent a couple of hours in our initial assessment, and I gave her my standard omega-3 and diet protocol. She had been embarrassed to tell me in that initial meeting, that every Sunday evening she baked a chocolate cake, which she used to satisfy her voracious carbohydrate appetite. Two weeks into using fish oil, she had thrown out two chocolate cakes, because her appetite for sweets had so radically diminished, she didn't even think about bingeing.

The relationship between carbohydrates and omega-3 balance is so strong, that I know I've titrated the right dose of fish oil with the right amount of other fats when the cravings are gone.

If you've taken fish oil and you have not experienced a drop in carb cravings, chances are you either aren't taking enough of the stuff...or you haven't eliminated enough of the other fats that get in the way of fish oil doing its amazing job.

So don't despair because the FDA kept rimonabant out of the drug supply and out of YOU. Give thanks, and look to the ocean for an even better way of getting the same results.

Pasquali R, Gambineri A, Pagotto U. The impact of obesity on reproduction in women with polycystic ovary syndrome. BJOG. 2006 Oct;113(10):1148-59. Epub 2006 Jul 7.

http://www.springerlink.com/content/41v7536525023722/

Kim AH, Kerchner GA, and Choi DW. Blocking Excitotoxicity. Chapter 1 in CNS Neuroprotection. Marcoux FW and Choi DW, editors. Springer, New York. 2002. Pages 3-36.

Engeli S, Heusser K, Janke J, Gorzelniak K, Bátkai S, Pacher P, Harvey-White J, Luft FC, Jordan J. Peripheral endocannabinoid system activity in patients treated with sibutramine. Obesity (Silver Spring). 2008 May;16(5):1135-7.

Watanabe S, Doshi M, Hamazaki T. n-3 Polyunsaturated fatty acid (PUFA) deficiency elevates and n-3 PUFA enrichment reduces brain 2-arachidonoylglycerol level in mice. Prostaglandins Leukot Essent Fatty Acids. 2003 Jul;69(1):51-9.

Eye see some potential problems with Ritalin

Ritalin has its purpose. But Ritalin is also given to an awful lot of children. In fact, one source I found estimates that as many as 10 to 15% of all children have been placed on Ritalin at some point. Some researchers believe that children who are sleep deprived can act as if they have ADHD. And sometimes they get the diagnosis simply because they aren't behaving. Often, Ritalin is given before any behavioral, nutritional, or otherwise alternative options are considered. What that all means, potentially, is that there are many, many children out there who are at risk for what the researchers in this study discovered.

Twenty-seven female rats were divided into 3 groups; each was given a different oral dose of methylphenidate (Ritalin). Changes in eye tissue observed (at all doses, the degree of change correlated with the dose) included:
(1) degenerative changes of the corneal epithelium, the protective layer of cells on the outside of the cornea. (these changes included the appearance of apoptotic bodies, which are vesicles produced by dying cells.)
(2) increased collagen (fibrous material) production
(3) edema (fluid accumulation) around corneal cells
(4) vacuolization in cell cytoplasm (appearance of vacuoles, which help to
remove unwanted material from cells)

Interestingly, a group of Australian researchers is reporting that children diagnosed with ADHD actually respond better to fish oil than they do to Ritalin. And...hmmm...fish oil can help to preserve eyesight.

I italicized the word "diagnosed" in that last paragraph, because while fish oil can help to improve the biochemical imbalance that is the foundation of ADHD, a child who is misbehaving because of poor parental boundaries including appropriate bedtimes...is not going to change with a single pill or supplement available on the planet. It's called taking the time to be a good parent.

Kids can be snotty, they can be weird, and they can challenge your patience to the max. But when they misbehave, they're not asking for medicine. They're asking you to show them you know they are there, that they are important, and that you have the ability to set the boundaries that help them to feel safe and to be healthy. Not an easy job in this day and age, but the children in our lives owe it to us adults to have a vision for their healthy futures, and to protect their vision in the process.

Gozil R, Take G, Bahcelioglu M, Tunc E, Oktem H, Caglar G, Calguner E, Erdogan D.Dose-dependent ultrastructural changes in rat cornea after oral methylphenidate administration. Saudi Med J. 2008 Apr;29(4):498-502.

http://www.add-adhd.org/ritalin.html

http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=391503&in_page_id=1774

Windex, epilepsy, and bones

In an earlier post I discussed an emerging relationship between antidepressant use and decreased bone density. The problem is not limited to antidepressants. In fact, there is a large body of research devoted to the same issue in people with epilepsy.

The data is a little bit challenging to read through, as one study reports a finding that only one medication causes changes in bone health, while another finds problems in several. In digging through the available discussions on the topic, I discovered one article suggesting that the research discrepancies may be more related to our lack of knowledge about bone health, and therefore our ability to design a study that really tells us what is going on, than it does poor research methodology.

In this study, researchers looked at the effects of three antiepileptic medications on bone health. What they found that even though levetiracetam (Keppra) did not decrease bone mass, it did reduce bone strength and bone formation. What that means is that studies that define bone health only in terms of bone density/mass will not find changes in bone health even though they exist.

The more accurate thing to say is that antiepileptic medications change bone integrity, a more all-encompassing way to define the event, than to narrow the definition down to one method of measuring bone health and strength.

My statistics professor in graduate school used to always tell us, "If you torture the statistics long enough, they'll always confess," so if you really want a study to say what you want it to say, you can refine it and define it to do just that.

This blog is intended to help those people who use the medications, and the most important message seems to be here, is that if you take any kind of psychiatric medication, be sure you are diligent about following recommendations to maximize bone health: minimize your caffeine intake, and be sure you get calcium in your diet.

And here I go with my fish oil again. Fish oil can be a wonderful ally for two reasons: (1) if used properly, in many cases, it can minimize the necessary dose of a medication, therefore limiting the chances of encountering negative side effects, and (2) it in itself helps to strengthen bone.

My neighbor says I'm like the guy in My Big Fat Greek Wedding, only I'm waving fish oil at everything instead of Windex! I'm beginning to think she's right.

Ha! Made you read all the way through the post to see what in the heck Windex had to do with epilepsy and bones. That was my intent! :)

Pack AM, Morrell MJ, Randall A, McMahon DJ, Shane E. Bone health in young women with epilepsy after one year of antiepileptic drug monotherapy. Neurology. 2008 Apr 29;70(18):1586-93.

Chou IJ, Lin KL, Wang HS, Wang CJ. Evaluation of bone mineral density in children receiving carbamazepine or valproate monotherapy. Acta Paediatr Taiwan. 2007 Nov-Dec;48(6):317-22.

Nissen-Meyer LS, Svalheim S, Taubøll E, Gjerstad L, Reinholt FP, Jemtland R. How can antiepileptic drugs affect bone mass, structure and metabolism? Lessons from animal studies. Seizure. 2008 Mar;17(2):187-91. Epub 2008 Jan 3.

There's something fishy about depression treatment...

Here's the study I've been looking for. There are plenty of studies showing the effectiveness of antidepressant medications. And there are plenty of studies showing the effectiveness of fish oil in treating depression. But no one had compared the two. Until now.

In Iran, researchers compared the separate relative effectiveness of eicosapentaenoic acid (EPA), one of the chemicals commonly referred to as fish oil, and fluoxetine (Prozac). What they found was that EPA was equally as effective as fluoxetine, in an 8 week trial, in reducing symptoms of depression. The most superior outcome was found in subjects who received both EPA and fluoxetine.

If you're wanting to try this at home, as always, discuss this with your physician. The risk of using fish oil in conjunction with antidepressants is almost always outweighed by the potential benefits--however, it is not advised that you discontinue any prescription medications you are on without consulting with the prescribing party.

A word about EPA. There is a lot of confusion about what it means to use fish oil. Most products available in the grocery store that are labeled as containing "omega-3 fatty acids" actually contain ALA, a great omega-3 but not the one that has been associated with improved mental health. If you're using omega-3 eggs, or vegan (marine algae-based) omega-3's, you're getting DHA, not EPA. That primarily comes from fish. Even though you will read that there are conversions to EPA from both ALA and DHA, the efficiency of these conversions is great and likely not enough to achieve results such as were seen in this study.

If your diet is high in pro-inflammatory oils (those "S" and "C" oils you see me routinely discuss in this blog), it will be harder to get effects described in this study. You're going to need to tweak your diet in order to get the most bang for your buck. And, realistically, that means you're going to have to get rid of most processed foods and salad dressings.

But, for those individuals motivated to make these changes, the results can be profound. I see it routinely in my private counseling. It is certainly my first recommended item of action when someone is trying to reduce the number of medications they are on.

Finally, for physicians who prescribe antidepressants, this study suggests that if you do so without strong nutritional guidance as well, you're not as helpful to your patients as you have the potential to be. It's not just about pills. Your patients did not become depressed because they were antidepressant-deficient!

Jazayeri S, Tehrani-Doost M, Keshavarz SA, Hosseini M, Djazayery A, Amini H, Jalali M, Peet M. Comparison of therapeutic effects of omega-3 fatty acid eicosapentaenoic acid and fluoxetine, separately and in combination, in major depressive disorder. Aust N Z J Psychiatry. 2008 Mar;42(3):192-8.

Omega 3's and epilepsy

When I was a nutrition intern, waaaay back when, one of the special diets we had to learn about was the ketogenic diet. Epilepsy researchers were looking for a way to control seizures without medication, since so many medications have side effects worse than the problem they are designed to treat. The ketogenic diet, developed at Johns Hopkins University, is a high fat diet designed to do just that. The reason it never took off, and that you never see "The Epilepsy Diet Miracle" on the shelf at Borders, is because this diet is extremely unpalatable and impossible to follow. (Think butterballs!) It is also not nutritionally complete.

However, despite the downside, scientists were encouraged by the early success of this diet and have persisted at improving on the original model.

What seems to be coming out of this persistent research, is that it's not so much the AMOUNT of fat, but the TYPE of fat, that matters. And if your diet is high in omega-3 fatty acids (especially those that come from fish), you can better control seizures.

These omega-3's seem to raise the seizure threshold in neurons, meaning they "chill out" neurons and make it harder for them to become excited or overstimulated. Mice with a genetic ability to synthesize high levels of DHA, (which we typically get when we eat fish), have significantly less seizure activity than mice who don't have this ability.

The Atkins Diet is a moderate version of the ketogenic diet. I have often wondered if people who say they feel better on this diet are not describing the weight loss, but rather are trying to describe how it feels to finally have their brains finally relax!

There are important benefits to reducing seizure activity. (1) When neurons are relaxed, they are less metabolically active, which means they are using less energy. Since the brain prefers glucose for energy, this often means that relaxing the brain reduces carbohydrate cravings. I've seen this over and over again in clients who start to incorporate more omega-3 fatty acids into their diet. (2) Metabolic activity is oxidative activity, and oxidation is a degenerative process. I'm not saying the goal here is to be brain dead so you can live longer...but it certainly is worth considering ways to use your brain cells judiciously and not waste them on unfocused, unproductive activity.


Taha AY, Huot PS, Reza-López S, Prayitno NR, Kang JX, Burnham WM, Ma DW. Seizure resistance in fat-1 transgenic mice endogenously synthesizing high levels of omega-3 polyunsaturated fatty acids. J Neurochem. 2008 Apr;105(2):380-8. Epub 2007 Nov 25.

Voskuyl RA, Vreugdenhil M, Kang JX, Leaf A. Anticonvulsant effect of polyunsaturated fatty acids in rats, using the cortical stimulation model. Eur J Pharmacol. 1998 Jan 12;341(2-3):145-52.

What's the deal with wheatgrass?

Many of my work connections (as well as personal friends) are people working in the addictions recovery field. Part of the challenge of being in recovery is developing comfort with emotions-all of them--comfortable and uncomfortable. Even if you're off the hard stuff, it can still be tempting to want to manage moods with external tools. So it's very common for people in recovery to look to nutritional supplements as mood regulators, rather than to learn to ride through the natural ups and downs of daily life.

It can be a slippery slope, because some supplements actually CAN help you to feel better. That's why I talk about fish oil so much--it has been proven in many research studies to actually help regenerate neurons and to improve aspects of all Axis I (psychiatric) diagnoses in measurable ways. I do make other recommendations as well, but only when I've been able to find peer-reviewed literature in the National Library of Medicine (PubMed) database that supports those claims.

Which brings me to the supplement in the title, wheatgrass. Most people who know about wheatgrass either own cats, or shop at health food stores. Wheatgrass got its comical five minutes of fame recently on The Apprentice, when one of the Backstreet Boys requested it in his dressing room, and Trace Adkins, the country singer who was managing this performance, had absolutely no idea where, in all of Manhattan, to find it. (I was throwing things at my TV, yelling..."DUDE! WHOLE FOODS!!!).

Back to my point.

This Backstreet Boy wanted a shot of wheatgrass juice before going on stage, because he felt it gave him an energy boost and helped him perform better. And that's what most people will tell you about it. In all of my training and all of my hours in PubMed, I've never, ever seen any research to back up or support wheatgrass as an evidence-based energy booster.

This morning on a professional listserve, a colleague posted a position statement on wheatgrass, published by the National Council on Health Fraud. You can follow this link for the entire report (http://www.ncahf.org/articles/s-z/wheatgrass.html), but in general, the author suggests that while feeling better on wheatgrass is a common report, this enhanced feeling is not evidence-based and is more likely due to one of the following:
--natural changes in the symptoms people experience
--the placebo effect mentioned above
--wishful thinking on the part of the desperate
--lying by people who have a financial interest
--something else that the patient is doing--especially if they are using
psychoactive drugs, such as herbal uppers or downers.

My cats love wheatgrass, but my observation is that not long after they eat it...they throw up hair balls. I don't know about you...but that's not anything I hope to achieve personally in my quest for better health.

Photo courtesy of www.healthyjuicer.com

Fish oil, anxiety, and anger

I am noticing in my most recent medication reviews, that more and more psychotropic medications are being tested as treatments for aggressive behavior. I've worked in treatment centers and I know that the kind of aggression seen in substance users is more than just being "a little pushy"...and that this behavior, if it can be intervened on, can help a person with this problem to have more productive relationships and overall life successes.

A recent study found that substance abusers have dietary habits that promote poor omega-3 balance. (Anyone reading this who has attended a 12 Step meeting will attest to the donuts and sugared coffee these meetings are known for!)

In this study, 3 months of using 3 grams per day of fish oil (containing both EPA and DHA), anger and anxiety on test scores decreased significantly.

Interestingly, EPA and anxiety were most closely associated, and DHA and anger were most closely associated. For anyone using fish oil as a supplement, this distinction is likely moot. However, for anyone who is vegetarian and using marine algae or marine algae-supplemented foods as their omega-3 source, they may not see the reduction in anger that a fish-eating person may eat.

I just love it when nature shows us ways to feel better that don't always have to involve medication!

Buydens-Branchey L, Branchey M, Hibbeln JR. Associations between increases in plasma n-3 polyunsaturated fatty acids following supplementation and decreases in anger and anxiety in substance abusers. Prog Neuropsychopharmacol Biol Psychiatry. 2007 Nov 1 [Epub ahead of print]