A Primer in Fatty Acids: Why We Need to Understand Fish Oil

Here are my disclosures and I'll point out a couple of relevant ones. I formulated VitalOils1000™. My wife owns VitalRemedyMD®, and I believe in the biologic importance of EPA and DHA. So thus I am biased. So there you have it. Okay. The objectives today, you can see, are to define common fats and fatty acids. Understand EPA, DHA, and the derivatives of EPA and DHA, which is actually very complex. Examine the flaws in the omega-3 cardiovascular disease intervention trials and there are many flaws. Learn to read a label that would be a fish oil label, but this can be applied to any label. So label in the in the supermarket and understand omega-3 testing and why it makes sense to test our patients. But I'd like you to come away from this meeting with a couple of just key understanding and the key understandings would be number one, the omega-3 fatty acids and the omega-6 fatty acids and their derivatives are incredibly complicated. There are many of them. The lipidome is expanding. And so although I'm going to show you a bunch of stuff, it's going to change and it will change over the next couple of years. I guarantee it. Okay. So that's one thing. Another thing is that in the United States, we consume a paltry amount of omega-3 is relative to Japan. It's about 1/10 of the omega-3s that Japan consumes and we need to increase that. And finally, I think everybody should understand that we don't know where we want to go until we can see where we are. So testing for omega-3 is, in my view, is essential. And that's actually one of the major flaws of the clinical trials. Nobody tested. So if you come away with those three points, I'd be very, very happy. Here you see three different food types. You see a steak, you see some oils, you see a fish. And in our clinical trials, we say steak, saturated fat. Oils, mono-unsaturated or polyunsaturated fat. Fish, omega-3 fatty acids. And I'm sure every one of you is thinking that as you look at these foods. However, if you look at this graph, you'll see that it's not quite as simple as that. In fact, everything chicken, fish, beef, oils, everything has a combination of each of those components. So so meat is not saturated fat. In fact, oil is not mono-unsaturated fat. Oil is not polyunsaturated fat, and fish is not even the omega-3 fatty acids. They comprise a whole bunch of different fatty acids, an array of fatty acids. It's really the the the magnitude of a given fatty acid in a particular foodstuff that's that's important. But we can't neglect or we can't ignore the fact that there are other oils in these different foodstuffs. So thus food is complex and therefore our studies that are based upon food consumption are inherently flawed. Because if you take a study and you say, okay, we're going to look at meat eaters and this equates to saturated fat, you're really missing the point because meat has a lot of other stuff in it. Okay, so what is food natural food? Well, natural food taught to me by a woman named Sheila Innis, who unfortunately passed away this last year, who was a brilliant, brilliant researcher, told me something very simplistic, but it's really true, which is that in nature, food comes in two forms. It's either protein and fat or carbohydrate. And if you think about it, meat is protein and fat. Chicken is protein, and fat. Fish is protein, and fat. Nuts are protein and fat. Vegetables are carbohydrates. Fruit are carbohydrates. Now, there are various types of carbohydrates, various types, as you've seen, of saturated, rather, of fats and various types of proteins. But that's the general rule that we should go by when we look at foodstuffs. So that's a nice little tidbit to take home. Today, or at this point I'm going to go through these different topics and define them. I will start with the triglycerides. So triglycerides or triacylglycerol is a glycerol backbone, which then has three fatty acids on it. And this is the dominant form of any food we eat is in the triglyceride form and those three fatty acids can vary. So this is what the backbone looks like. You have the hydroxyl groups and then you have the carbon atoms that are where the fatty acids will join. And you see here the triglyceride with three different fatty acids. And if you notice, the one in the middle has a bend and it should be about a 60 degree angle because the double bond that occurs in these fatty acids when you have an unsaturated fatty acid is about a 60 degree bend. And the more of those bends you have, the larger in a sense that fatty acid is in space. It occupies more space and the fatty acid doesn't sit still, it moves around, it's constantly altering its shape and it's really very cool in that regard. And that's actually plays a major role in its efficacy as a cell signaler. Then we have to absorb these triglycerides. So what do we do? We start with our bile acids. The bile acids will emulsify the fats. And why does it do that? It takes me to these little teeny globules to increase the surface area of the fat so that lipases can get around it and cleave the fatty acids off the triglycerides. We're then left with monoglycerides and free fatty acids. The monoglycerides are absorbed in micelles and the free fatty acids are actually absorbed directly into the enterocyte. The inside of the enterocyte. We then rebuild a lipoprotein particle and that's the chylomicron which is then dumped into the lymphatics and then into the bloodstream. So that's how in the gut we absorb and bring fat into the body. This is a diglycerides or diacylglycerol, and there's a whole bunch of literature around this. It's a second messenger, actually, but we're not going to get into that. This is a phospholipid and phospholipids are incredibly important in our bodies and in cellular function. And you can see what this is. This has two different fatty acids. And then on the bottom in the third position, you see a nitrogen containing and phosphate containing fatty acid. So the phospholipid is a is a class of lipid that is truly essential for membrane function. I'm going to show you a picture of how complex it is and why it's so important. But I would say the major aspect or one of the major aspects of a phospholipid is it has a characteristic called amphipathic or amphiphilic, meaning that it can interact with both an aqueous and a lipid environment. So the head of the phospholipid can interact with an aqueous environment which is our blood or the inside of a cell and the tail is lipid and interacts with lipid. So if you see this, you see the cell membrane, which is a complex bi-layer, and in that two layer system you have the phospholipids oriented so the head is facing out into the blood and also in into the cell membrane, into the cell. Okay? So the cytoplasm is aqueous. In the middle you have the tails facing each other. And there there the the lipophilic regions. And then you have embedded in there cholesterol and you have different proteins. And some proteins go from inside the cell to outside the cell. And these they function as cell signalers. These proteins can move laterally within the cell membrane. It is really remarkable and complex and everything that we learn becomes more and more complex. I was speaking to Mark about this earlier. It seems that we learn one thing, whether it be in lipids or in fatty acids, and everything we learn shows us that we don't know two things. So it's really it's really a challenging subject, but also a very interesting subject. This is a general scheme of things. Again, this is very, very simplified. We have our fats and fatty acids are broken into the saturated or the unsaturated. Unsaturated are then broken into mono-unsaturated meaning there's one double bond or polyunsaturated meaning multiple double bonds. And then you see below that the omega-3 is you see the fish on top, but then you also see flaxseed and other things. And you know, that's a common misconception that's out there in the world that you can just eat flaxseed and you're going to have the same impact as you would if you eat fish. The reality is flaxseed has alpha linolenic acid in it, but not EPA and DHA. And you're going to see in a moment that EPA and DHA, which you get only from fish, can not be made from ALA cannot. So you need to eat the fish. This is showing the difference between the saturated unsaturated fats and a saturated fat means it's saturated with hydrogen atoms. There's no double bond. In an unsaturated fat you remove a couple of hydrogen atoms when you create a double bond, and then at that point you get about a 60 degree band. And a mono-unsaturated fat, obviously, one area of a double bond. Here we see the most common mono-unsaturated fat that we talk about, oleic acid, which is an omega-9 fatty acid. And then 9 refers to the position of the double bond counting from the end of the chain. So that's if you count carbon atoms from the end of the chain, that's the ninth one, that's where your double bond is. And there's only one in oleic acid. And that's very prevalent, remember, not the only thing though, but in olive oil or canola oil or avocado. And there are other foodstuffs that also have large quantities of oleic acid. But remember, olive oil is not only oleic acid. Here we have other polyunsaturated fats. This is a comparison of the omega-3s and the omega-6s. And you see that we also have we have ALA alpha, linolenic acid and EPA, and DHA. So alpha linolenic acid is 18 carbons, EPA, 20 carbons, DHA 22 carbons. And as you move along, you also increase the number of double bonds. And if you remember, as you increase the number of double bonds, you're also increasing the number of bends in the fatty acid. It becomes a much more complex structure. It's also much more biologically active. The omega-6s start with linoleic acid just to confuse us because the omega-3 alpha linolenic acid. So this is linoleic acid, that's an 18 carbon chain. And if this too is not sufficiently produced in the body, just like the ALA, EPA and DHA are not sufficiently produced in the body. So we call these essential fatty acids, meaning we have to consume them. We can't make them in an adequate supply in order to be able to survive. So from a survival standpoint, we really do need to consume these fats. And then you see what this moves down to. It moves down to Arachidonic acid, which is a 20 carbon long fatty acid that sits on the omega-6 side in a sense in competition with EPA, which sits on the omega-3 side. And you see the foodstuffs that will will deliver linoleic acid, well, basically everything in the Western diet gives us linoleic acid from good stuff like nuts and seeds and oils to bad stuff like processed foods. So linoleic acid is incredibly prevalent in our diet and it's very hard to limit that, although it has been shown that is possible with a very restrictive diet, it's still very, very difficult. The meat on this slide is showing us where we get arachidonic acid, so there's a lot of arachidonic acid in meat, in egg yolk, in chicken. So these foodstuffs have arachidonic acid. Now we're all built and we've been taught to think that arachidonic acid is evil and, uh, it's the evil omega-6. But I'm going to show you in a few slides that in fact it's not quite so simple. There is a relationship among these polyunsaturated fatty acids, and that's one of competition, at least in theory, because the competition really is is is stacked. It's stacked in the favor of the omega-6s. Because I told you that in the Western diet, linoleic acid and arachidonic acid are much, much, much more prevalent than the omega-3 side of things. So as a consequence, those tend to win. And that means that linoleic acid is converted much more easily to arachidonic acid. Then alpha Linolenic acid would be converted to EPA. Okay, so that's very important to know. Let's take a momentary break from the science part of things, and it's not the science part of the, I should say, the basic science part of things. And we'll move on to clinical science. And this is important because it's really confused the issue as to whether or not fish and fish oil, i.e. the omega-3 fatty acids, are of value in cardiovascular health and disease. First, we had the observational trials. We always start with those and uniformly across the observational trials we found benefit for fish eating societies and we found detriment for those societies that did not consume fish, and that was in the form of cardiovascular outcomes. Then we did interventional trials. So you give people fish or fish oil and then you give the controls something else. And the initial studies were very positive. GC was one of them and showed a tremendous benefit in risk reduction by giving post infarct patients omega-3 fatty acids. Subsequent trials didn't show that and I'll show you why that is. Then meta analysis are done by bringing all these different trials together and saying, okay, let's really try to use the the information we find in these different trials and then we'll come to a much more robust and significant conclusion. And unfortunately, what you put into the meta analysis is what you get out of the meta analysis of Thus the garbage in equals garbage out. So if you have a medley of different trials with different flaws, you know your meta analysis is going to produce a flawed result. And I'll give you one example of that in a second. So here there were eight major cardiovascular intervention trials. The comparisons among them is very, very difficult because they differ on so many levels. You can see the time of intervention differed. The dose of the product, whether it's fish or fish oil differed, the duration of intervention differed and the size of the trial differed. So there were so many differences that you really can't make a good meta analysis out of this. Dariush Mozaffarian did something to address one of these issues, and this issue deals with dose. So we have dose here and we have effect. And if you look at the at the graph, you'll see on the top sudden cardiac death or arrhythmia, Okay, which causes sudden cardiac death. And you'll see that at about 250 milligrams, you achieve 75% of your goal and then it levels off at about 750 milligrams. So if you go higher than 750 milligrams a day of of omega-3 intake, you are not going to move your risk of sudden cardiac death. Now, the average American consumes about 100 milligrams a day. So we're all at risk for sudden cardiac death. But the Japanese consume a thousand, so they're not at risk. And if you look at the jealous trial, which piled 1.8 grams of omega-3 on top of their diet, it had no impact on sudden cardiac death. It did on cardiovascular outcomes, but not on sudden cardiac death. And that's why. So that's why dose is important and that's why you have to know your background level of omega-3s before you conduct one of these clinical trials. Now, on the other hand, if you look at triglycerides and if you look at antithrombotic effect, you'll see that there are slopes to some of these and you'll see that that for instance, the antithrombotic one takes a long time to to start having an impact and then it starts sloping upward. So it's only at the very high doses where you'll have an impact on that. Our trials don't use doses like that, so we're not going to see any effect. The other thing is duration of the trial, and you could see that the duration, the effect can take weeks or it could take years. And some of our trials just don't go out long enough. In terms of fatal versus nonfatal cardiovascular disease events, this really just refers to Dari's slide that I just showed you and shows that you really can't talk about fatal events, which are all driven by arrhythmias in the setting of acute coronary syndromes. You can't talk about that if you're above that 750 mark and you can barely talk about it, frankly, if you're above the 250 mark. But even given all of this in 2012, Rizo's et al actually published a very damning paper in JAMA and got a lot of press for their damning paper. But if you look at their 20 trials that they included in their meta analysis, you'll see some shocking stuff. So the duration of this of the studies went from 1 to 6 years. Big variability endpoints included all cause mortality, sudden cardiac death, MI, stroke, it varied from study to study. Levels or doses of EPA rather, went from 0 to 2 and a half. So none no DHA to 2.5 grams of DHA. The controls varied as well: non fish, diet, margarine, different oils. So totally variable. Number of participants went from 59 to over 18,000. The inclusion criteria included primary prevention, secondary prevention, defibrillators, people on dialysis. I mean, it was just all over the place. And the source of the omega-3 even varied from fish to fish oil. Did they ask the most important question, though, which is what was the baseline level of EPA and DHA in these individuals and where did it go with supplementation? And the answer is no. So in none of these trials did they ask the most important question. Did the patients have low level of EPA and DHA or did they not? At the end of the study, did those move and where did they move to? So that was a major flaw. If you eyeball these next two slides from the meta analysis, you'll get a sense of whether or not this was actually a significant effect. And this does not look like there is no effect. But even still, how about this one? Okay, this is all of their trials and it certainly looks like if you do a meta analysis using these data points, you're going to find an effect. But this is what they said. And internally, I knew who unfortunately has also passed away. I'm going to tell you about all these people have passed away. I'm sorry. I knew who has passed away. Told me something very intelligent. He said, When you read a legal contract, if you can't understand the legal contract, it's poorly written because it should be written for everybody to understand. They should be able to put legalese into layman's terms. Well, the same holds true for clinical trials, and this is what they said. And if my vision is not that great either, Andrew. But so from a data, this is what they said, data extraction, descriptive and quantitative information was extracted, absolute and relative risk estimates were synthesized under a random effects model. Heterogeneity was assessed using the Q statistic and I2. Subgroup analyzes were performed for presence of blinding, the prevention settings, and patients with implantable cardioverter-defibrillators and meta-regression analyses were performed for the omega-3 dose. A statistical significance threshold of 0.0063 was assumed after adjustment for multiple comparisons. First of all, I mean, we barely understand what they said, but aside from that, the bottom line is they chose a p-value of 0.0063, so about ten times as difficult to achieve success in this trial. And why did they do that? They did it because there were so many variables that they had to account for. And this we look back at JAMA meta analysis for that year or actually two years. No other studies had they done that. The only time it's valuable to do that is if you have a a product or a drug you're testing that can be really dangerous and you really want to be sure that it's really having an effect. Fish oil is not one of those things. Okay. So after this was released, what happened? People got on the news. You see these very famous statements. There is no evidence for routine use of omega-3 fatty acids in for heart disease. That was said by a very famous person. Don Arnett, who's a former president of the American Heart Association, said it closes the book basically on omega-3s in heart disease. But nobody mentioned the p-value of 0.0063. And if you were to look at a p-value of 0.05 and use that instead, this actually showed a significant effect because the p-value for mortality, cardiac mortality was 0.01. So in essence, by using our normal criteria that we would have used, this study was actually positive, showing the benefit of fish and fish oil. Still was a terrible study. So now we'll go back to the basic stuff, EPA, DHA and why they're important. I'd like you to understand that there are some products out there that are pure EPA. There are other products out there that are pure DHA. I firmly believe and this is based upon my understanding of what each of these fatty acids does in our body, and they're derivatives of each of these fatty acids that we need combinations. Nobody knows what that combination should be. Okay? Nobody's 100% sure of that. But a pure substance in America where we don't take in enough DHA or EPA makes no sense. In Japan, where they have plenty of EPA and DHA makes a potential sense. But here products should be should be balanced. There should be both DHA and EPA. And these are the various effects they have. And you can read the slide. Diabetes, inflammatory conditions, yeah, heart disease, lipids. I mean, it really runs the gamut that these are all being studied now. These are five biological effects of EPA and DHA. There's triglyceride lowering, and for every gram of EPA, DHA, we administer, you get about about an 8% reduction in triglyceride. DHA is a little more powerful than EPA at triglyceride lowering. Also at HDL raising may have a little more effect on increasing LDL in these very high triglyceride patients. It increases lipoprotein lipase. Lipoprotein lipase is that key enzyme that takes both the LDL and chylomicrons, which are predominantly triglyceride and cleaves the triglycerides. That's a very important enzyme. It also lowers ApoC3. ApoC3 is basically a break for lipoprotein lipase. It stops Lipoprotein lipase from working well. So this will relieve that break or release that break. VLDL production itself is diminished with EPA and DHA and chylomicron clearance is increased with EPA and DHA. So that's why we get such a nice response with omega-3 fatty acids in triglyceride lowering. The antiarrhythmic stuff is very, very complicated and multiple channels are involved. But I think the coolest part about this is the resting membrane potential. If you remember this from our action potential, the resting membrane potential is lowered by DHA predominantly, so it's brought down. The refractory period is prolonged. So when a PVC comes along in the setting of an infarct, it's harder to achieve that all or none depolarization that we require because you have a lower resting membrane potential and a longer refractory period so that is the reason that it blunts ventricular fibrillation onset or ventricular tachycardia onset, and that's probably the reason why sudden cardiac death is diminished when patients are on omega-3 fatty acids. In terms of antioxidant effects, decreases production of F2 Isoprostanes. These are derived from arachidonic acid. They can lead to platelet aggregation. And so this in a sense, the antioxidant effect has a downstream effect of decreasing platelet aggregation. Anti-inflammatory effects, the IL6 thing is important. IL6 is really probably the only cytokine that's known that will induce all acute phase reactants, and this will blunt that effect. And antithrombotic effects, this is humorous actually. So it's never really been shown that under 5 grams a day of omega-3 fatty acid intake is going to do anything of substance or, you know, clinically relevant for causing people to bleed. Yet whenever you have a patient who is about to go to surgery, surgeons always say stop those omega-3 fatty acids. Right? Doesn't everybody get that? And I always sit there and kind of scratch my head and go, I just don't understand it. You know, there's no data to support that. And then to make matters worse, do they tell patients to stop eating salmon? And I've never seen a single surgeon tell a patient to stop eating salmon. Right? Each piece of salmon, if you have a big piece of salmon, you're getting more than a gram of EPA and DHA. So something's wrong with that. But, you know, they’re surgeons and I'm sure there are no surgeons in the house. All right, So now we'll talk about the eicosanoids. And it's these are derivatives. These are 20 carbon long chains, these derivatives of arachidonic acid and and EPA. And there are the classical and the non-classical eicosanoids. There was first speak briefly about the classical eicosanoids, prostaglandins being the most well known, and they're produced by the action of Cox cyclooxygenase and membrane derived arachidonic acid or EPA, and that's with cytosolic phospholipase A2 that comes in and does this and there are autocrine and paracrine functions. Autocrine meaning it affects that that cell itself. Paracrine meaning it affects the adjacent cell. And these, these prostaglandins are very short lived. So they come in, they have their action, they leave, they're done. They do, however, have a very substantial biological impact. Thromboxanes and also Cox derived same way arachidonic acid and EPA that are in the membrane. And you'll see that this increases vasoconstriction and platelet aggregation and thromboxane A3 which is different from A2 in it comes from EPA. It's actually less of a platelet aggregator and vasoconstrictor than thromboxane A2. So you see this complex relationship starting to occur between the prostaglandins and thromboxane, I just want to point out a couple of things on this slide. One is that F2 isoprostane relationship with platelet aggregation. So when we see on the Cleveland HeartLab panel elevated F2 isoprostanes and we see, oh, maybe that implies a bad diet or whatever, we should really understand there's a downstream effect. If you have a patient with coronary disease, you know, subclinical coronary disease and that patient ruptures, ruptures of plaque and has elevated F2 isoprostanes, that individual may be more likely to form a clot that's platelet derived and have a heart attack. So that's an important signal for us to recognize when we're looking at our lab work. The other thing to recognize here is that Cox 1's inhibition by aspirin, you see on the right side of the slide is effective at decreasing thromboxane A2 production in any in any platelet that sees aspirin. As a little side note, sorry about that, there's a little side note and it would be a lecture unto itself. Aspirin has a half life of 20 minutes. Most of us probably don't realize this has a half life of 20 minutes, so it's out of the body within 2 to 4 hours. The body makes 4 billion platelets an hour in the normal individual, far more than that in the diabetic patient or the patient with coronary disease or hyperlipidemia. Yeah, so that's 100 billion platelets a day that you're making and we have a trillion platelets in our body so about 10% of platelets in the normals are being made every day. Most of those are not seeing aspirin because it's not the body. So there are now new aspirin out there, new aspirin prescriptions for that are extended release. Just so you have that in the back of your mind. So here is the danger of non-steroidals. And this was a an experiment that went awry. And the thought was that selective COX -2 inhibition could kill two birds with one stone. You decrease PGE2, which is a bad actor, and you decrease therefore pain and cardiovascular disease. Also, no COX-1 inhibition so no GI side effects. COX So so the unanticipated outcome and I skipped this line, I apologize for that, but I'm running out of time anyway, the unanticipated outcome was that COX-2 inhibition dramatically decreased prostacyclin or PGI2 and thereby increased cardiovascular events. This is the whole Vioxx deal. Thromboxane A2 was rendered unopposed because you lost your prostacyclin. So when you start messing with this very intricate and complex system, you know, bad things can happen if you don't know what you're doing. And this was an experiment and it went awry. So I said that aspirin is the only nonsteroidal to decrease cardiovascular disease events. That's probably because it has an irreversible effect on Cox. It, by the way, blocks Cox-1. It also has an impact on Cox-2 as well. Here we'll going to look at the non-classical eicosanoids briefly. And we start with the EETs and you see what something different happens here. The non-classical eicosanoids is now start having a good effect. So they're coming from the same stuff that just gave us that bad effect, that proinflammatory effect, the prothrombotic effect. So now all of a sudden we have anti-inflammatory, antithrombotic, you know, vascular protective effects. So the same initiators are starting to bruise good effects, and this you'll see again. Here we have the lipoxins, also non-classical eicosanoids, anti-inflammatory. Decrease neutrophil chemotaxis. Attenuate tumor necrosis factor alpha. Good effects. So again complex system. When we turn on inflammation, we actually turn off the inflammation at the same time. So we put into place the mechanism to eradicate inflammation. Once we started an inflammatory cascade. Very interesting, very complex. Here we have non-classical eicosanoids in a single docosanoid. These are the resolvins. That's from EPA and DHA. Docosanoids are from 20 22 carbon chains or DHA, and these too have good effects. And you see there different enzymes that help make these fatty acids. Here we have the resolvins again, anti-inflammatory, vascular protective, utilizing receptors different from other receptors. And then I threw in this one quick docosanoid slide, there’s resolvin D, you just saw resins that are macrophage resolving inflammatory substances and finally protectin D1. These all come from DHA, by the way. So DHA is producing these three different things that are anti-inflammatory, but protectin D1 is the most powerful neuralprotective agent that's ever been discovered. It was discovered by Charles Serhan at Harvard and Nick Bazan in Louisiana, and they might win the Nobel Prize for this. So it's protectin D1. It's being studied right now in neurology to regenerate nerves after injury. So we'll see. You know, everybody's very optimistic. So now we'll move on to different forms of fish oils. Why it's important, the concentration of fish oils, why blood tests are important. I've already alluded to that fact. And here, how do you make fish oil? Well, people take fish and they crush the fish and it's really disgusting. And then they take all the guts in the solids and the waste and they throw it out and they're left with oil. Then they take the oil and they refine the oil, multiple steps of refining the oil. Ultimately, however, this oil is in a triglyceride form and in the triglyceride form I've told you that the long chain polyunsaturated fatty acids have a lot of double bonds. As a consequence, in a triglyceride form, you can only fit one EPA or DHA per glycerol backbone. There's just not enough space to fit two. So in nature, your maximum amount of EPA or DHA in a given oil is going to be about a third. That's maximum. So these are all cleaved off the triglycerides with ethanol and potassium hydroxide, and then they're turn into ethyl esters. The ethyl esters can be concentrated up to 99%. So that's easy to do, to concentrate them. Then they're turned into one of another forms of of fish oil, or they're left as ethyl esters. The different forms are the free fatty acid form, which is only in one prescription. It's a very stringent oil. So the capsule has to be produced very precisely otherwise it's going to burn through. But that, remember, doesn't require any help in being absorbed. The phospholipid form is low in the EPA and DHA, and that's one of the problems. And the triglyceride form is unnatural now, because to put it back in the triglyceride form into concentrated, you have to heat it for a long period of time. That could damage the oil. So when you see a triglyceride fish oil that has a very high concentration of EPA and DHA, that's not a natural form. So now let's let's look at reading a label. We want to get fish oil that's highly concentrated. We don't want to have excess fat because it's fattening. And it also contains sometimes impurities like PCBs, dioxins, and furans. And we we we want to know how to pick this this fish oil. There are a billion of them out there. So in terms of reading the label, what do you do? Ignore the front of the label because that's all marketing. Okay? And in the marketing world, they fool us and they'll say a thousand milligrams of fish oil and everything goes, Oh, that's a thousand milligrams of EPA and DHA, but it's not, okay? So you look at the serving size first, and here you have an example of a serving size with one soft gel. And what that refers to then is the ingredients below. Okay, How much of a given substance is in each serving, which in this case is one soft gel and you see DHA 750 milligrams, EPA 250 milligrams. So there's a thousand milligrams of combined DHA and EPA per single soft gel. Now, other fish oils might have two pills, three pills, four or five, whatever. Read it carefully. The same goes for when you go to the supermarket. If you want to keep somebody from eating sugar, you look at sugar and you look at the serving size. So the servings, if it looks like there's three grams of sugar, make sure that, you know, the serving size is proper. Or if it's if it's, you know, I don't know. I was trying to give you an example. It could be 100 cookies, let's say. You know, that that gives you a given amount of sugar or one cookie. So let's say the sugar is 20 grams and it's in one box it's 100 cookies in the other box it's a half a cookie. Obviously, you want to take the 20 cookie box. So that's the example that I want to give you. Okay. Finally will go on to the measurement of different omega-3 fatty acids. And we have different types of measurements of plasma, whole blood, RBC, tissue. Nobody tests tissue because, you know, it really represents years of accumulation of fatty acids. It is fat and that goes and gets stored there and can last for years. So the things we use are pretty much whole blood or RBC, which is in the weeks to months range. And here you see that in whole blood examples that when you supplement with an oil you achieve an effect within about eight weeks. I will tell you though, I usually wait about three months to four months before rechecking. That's what I personally do. But in eight weeks you are getting a very significant effect from supplementation. And here you see that the dose of supplementation will impact the success of your elevation of body stores, of EPA and DHA or whole blood stores of EPA and DHA. And so we are going to skip this slide because my time is running out. It's not that important. Okay. So the guidelines are are interesting. We have guidelines from different sources. We have guidelines from the American Heart Association. A gram a day for people with heart disease, guidelines from ISSFAL, The International Society for the study of fatty acids and Lipids, at least 500 milligrams, at least 200 milligrams in a pregnant or lactating mother. DHA is really, really important in pregnant and lactating mother. It is key for proper neural development. So all pregnant lactating women need at least 200 milligrams of DHA a day and that's actually not enough. So in conclusion, and only 3 seconds late, thank you very much. I can say that in America and in the Western world our our intake of DHA and EPA is woefully low and that we need to do something to increase it. Increasing fatty fish consumption is great. If people don't like fish, give them fish oil pills. You know how to read a fish oil label now. Give them something that's concentrated so they won't gain weight from the fat and they won't get the impurities. The fatty acids are incredibly complex. Understand that it's really very important. Always use a combination of EPA and DHA. That's what fish is. A salmon is six fold DHA or rather threefold DHA, EPA, the human is sixfold, DHA, EPA, and for for diet issues, we have to rely upon our understanding of physiology. We will never, ever have a very successful RCT for diet because of the things I showed you. That food is complex. It's comprised of a multitude of different substances. Meat is not just saturated fat. It's got a lot more in it than that. And then finally test our patients, know where they are before and know where they are after. And I know I'm running 2 minutes over, but I'm just going to say one case that's really interesting. Forgive me, next Speaker Mark Houston, I apologize. Here's the case. I just saw a new patient. New patient tells me, ooh, ten years ago, I had sudden death. So, okay, he survived the sudden death, obviously, because he was sitting in my office and actually had had a month of being in a coma. And he was perfect. So I did his labs and my labs, including Cleveland Heart Labs, and his omega-3 levels were pitiful. They were incredibly low and he was actually taking an omega-3 product. And I just wonder what his omega-3 levels were prior to that sudden cardiac death event. Clearly, on an omega-3 product, he was way, way low. He must have been I mean, essentially nil. He must have had like nothing. And I am convinced that that contributed to his sudden cardiac death. So pay attention. Do the test. I think it's valuable. Follow up. Make sure you get your patients in a good level. Thank you very much.