Omega 3s Question and Answer

Responses by Dr. Joseph Maroon, a board certified neurosurgeon at the University of Pittsburgh and team physician to the Pittsburgh Steelers, has become one of the nation's leading advocates of fish oil and has recently authored the book, "Fish Oil: The Natural Anti-inflammatory".

I have heard long term use of ibuprofen may be bad for my stomach?

You have heard correctly. Ibuprofen is a class of medication commonly called non-steroidal anti-inflammatories (NSAID). These medications were developed in response to the side effects often seen with steroidal medications, such as cortisone and prednisone, which were some of the first types of drugs used to treat joint inflammation and pain. Steroids have side effects of causing stomach bleeding and ulcers and also bone loss and elevation of blood sugar. Those who developed NSAID believed that they would have fewer side effects but similar effectiveness. The fact is despite there success they have retained many of the side effects seen with steroids.

NSAID work well to reduce inflammatory pain and swelling of joints and other tissue but they also can result in users developing ulcers and stomach bleeding if taken for extended periods. Even more disturbing is that NSAIDs has been shown to delay and hamper healing in all the soft tissues, including muscles ligaments, tendons, and cartilage and perhaps leading to additional injury. The NSAIDs also have been shown to have adverse effects on kidney function. Situations resulting in dehydration, common in athletics or preexisting chronic renal failure or disease, may predispose people to acute renal failure through inhibition of when taking NSAIDs. This became big news recently with some high profile professional basketball players who required kidney transplants which were linked to their use of NSAIDs.

Can natural supplements help occasional backache?

The "natural" products, I presume you are referring to are herbal or dietary supplements that may be effective for back or joint pain due to inflammatory causes. Plant-derived natural preparations have been used for hundreds and even thousands of years to obtain effective pain relief. Dietary supplements and herbals are becoming increasingly popular because of their relatively few side effects.

Many natural products have a similar capacity as the synthetic medications to treat inflammation because they both can function to block the inflammatory pathways that eventually cause pain. The classical, swelling, redness, heat and pain associated with an overworked joint all can be block by natural products in order to promote healing and pain relief. Since ancient times our ancestors have used many different plants preparations to curtail the inflammatory process. The most commonly know is the bark of the willow tree from which aspirin was derived.

One of the best natural products used for pain is the omega-3 fatty acids found in fish oils. As a practicing physician and triathlete I both personally like my patients experience the effects of joint pain and inflammation. I too was hooked on NSAIDs to relieve pain complaints. But I began to experience stomach upset which I directly linked to their use. I turned to a colleague who recommended fish oil and have since found a dramatic relief in my own joint pain and also in that of my patients whom I suggested also use fish oil. Forced by my own skepticism and the pressures of conventional medicine I surveyed over 250 of my patients who were using fish oil and found about 60% where able to stop using their traditional prescription NSAID and only required the fish oil. (1) Since this time I have tried, when ever possible, to recommend omega-3 fish oil as the treatment of choice to relieve joint and spine related pain and discomfort.

Can Omega-3 Fish Oil benefit inflammation in other parts of the body, such as the heart and blood vessels?

The fact is fish oil has properties that can also reduce inflammation not only in joints but also in blood vessels, including the blood vessels in the heart, similar to aspirin, and has been found to in many scientific studies to reduce the incidence of heart disease. If fact if you are traveling in Europe and you are unfortunate enough to suffer a heart attack be glad that in Europe at least when you are discharged from the hospital they will prescribe you to take fish oil supplements for the rest of your life.

In a recent NY Times article, appearing Oct 3, 2006, an interview with an Italian cardiologist related that "it would be considered tantamount to malpractice in Italy to omit fish oil" to a patient after a heart attack". (2) What a difference 2,000 miles makes and also the power of drug companies to push prescription drugs as the best and only way to treat medical conditions.

A study published in 2006 in The Journal of the American Board of Family Medicine found that only 17 percent of family doctors were likely to recommend fish oil to their patients, including patients who had suffered a heart attack. (3) There was a great need, the Italian doctors concluded, to "improve awareness of this important advice."

What is your general recommendation for the daily amount of Omega-3 Fish oil supplement?

I would recommend using about 1-2 gms of high quality, purified, and concentrated omega-3 fish oil per day for joint pain relief. Make sure you read the bottle to the get the 1-2 gms of EPA/DHA which are the "active" ingredients in fish oil. Currently the American Heart Association recommends taking 1 gm per day of omega-3 supplements as EPA/DHA for those people with heart disease. (4) However, many of the scientific studies evaluating heart disease, elevated blood lipids and hypertension have generally used larger amounts.

What are Essential Fatty Acids (EFAs) and why are they important?

Omega-3 and Omega-6 fatty acids constitute the two families of EFAs. EFAs are considered "essential" because they are needed throughout the human life cycle, cannot be manufactured in the human body, therefore they must be obtained through our diet on a daily basis for optimal health and wellness. The body must receive a constant and balanced supply of EFAs to ensure proper prostaglandin production. Prostaglandins are beneficial hormone-like compounds that affect virtually every system in the body. They regulate pain and swelling, help maintain proper blood pressure and cholesterol levels, and promote fluidity in nerve transmission.

If allergic to fish or on blood thinners you should avoid taking fish oil until you consult with your health care provider.

What are early signs of EFA deficiency?

Joint Pain, Poor Memory, Immune Weakness, Dry Skin, Eczema, Hair Loss, Heart Problems, Reproductive Problems (men and women), Mood Swings, Depression, Poor Circulation and Fatigue.

Where can I get a direct source of EFAs?

Omega-3 fatty acids, EPA and DHA, are found in cold water fish such as sardines, mackerel, anchovies and cod liver. GLA, an Omega-6 fatty acid, is abundant in borage and evening primrose oil.

What's the difference between fish oil and flax seed oil?

Omega-3 fatty acids fall into two major categories: Plant derived (flax seed oil, yielding alpha linolenic acid or ALA) or marine derived (fish oil, yielding both EPA and DHA). The human conversion of ALA to EPA and DHA is somewhat slow and can be inhibited by various conditions such as a diet high in linoleic acid (Omega-6), trans-fatty acids such as fast foods and baked goods, alcohol intake, certain health conditions, and vitamin and mineral deficiencies (B3, B6, C, zinc, magnesium). Fish, on the other hand, is a direct source of EPA and DHA. The general consensus is that only about 15% of ALA converts to EPA, and it may not convert to DHA at all.

How soon will I see results?

It will vary depending on the concentration of the fish oil, your current nutritional state, dosage, and current health. We often will hear that our customers "feel better" and experience "clearer thinking" and "an enhanced well being" within 2 weeks. For better results, we recommend you take EFAs daily for at least two months to evaluate their benefits and reduce your intake of hydrogenated and trans-fats.

Are there any side effects?

Generally, no. Consumers typically report having more energy and a greater mental clarity while taking EFAs. If you experience repeat (burping), your supplements are either rancid or your body may not be manufacturing the fat digestive enzyme, lipase, used to metabolize the oil. If you haven't ingested fish oils for a long period of time it should take about a week for your body to develop this enzyme.

Is it safe to take EFAs derived from fish? I've heard that fish oil contains mercury and other environmental toxins.

Fish oils may contain environmental toxins that accumulates in fish during its life span. Potential toxins can be virtually eliminated given the use of high quality raw materials and a technologically advanced refining process utilizing the very latest distillation technologies. Third party testing document the complete absence of heavy metals and dioxins (where heavy metals are tested down to 25 particles per billion and dioxins down to 0.5 particles per trillion).

Do pregnant women need EFAs?

It is especially important for a pregnant or lactating woman to get adequate amounts of DHA in her diet because the baby is drawing upon her supply. DHA is critical for healthy development of the brain, eyes, and nervous system. There is evidence linking a deficiency in Omega-3 fatty acids to an increased risk of premature birth. Some experts recommend that women take 500-600 mg per day during pregnancy and lactation. As with any supplement, it is best to check with your health care professional.

Can we get enough EFAs from the food we eat?

Fish is one of the most abundant sources of EFAs, but Americans simply don't eat enough fish on a regular basis. Even those who eat fish several times a week aren't getting enough EFAs because much of the fish consumed today are farm raised (fed a diet of grains instead of fish meal) and lack a significant amounts of EPA and DHA. In addition, there are several factors that can lead to a reduced absorption of EFAs: Age, poor diet, alcohol consumption, low levels of certain vitamins and minerals, some prescription drugs, compromised immune status, and a diet high in trans-fatty acids (fast food, baked goods).

What's the difference between Good fats and Bad fats?

The "bad" fats are trans-fatty acids and saturated fats from animal products. Trans-fatty acids should be avoided completely, this includes margarine, shortening, and processed foods. Meat and dairy products contain high levels of saturated fat and should be eaten in moderation.

The "good" fats include polyunsaturated Essential Fatty Acids (EFAs). EFAs are considered "essential" because they are needed throughout the human life cycle, cannot be produced in the human body, and therefore must be provided through the diet. Omega-3 and Omega-6 fatty acids constitute the two families of essential fatty acids. Omega-6 fatty acids include corn, soybean, safflower, and sunflower oil. While it is important that your diet include both of these essential fatty acids, it is becoming clear that balance is the key to good health.

What should I look for when purchasing fish oil?

1. Investigate the manufacturing process. How is the fish oil manufactured and what are the manufacturing standards?

2. Smell. Does the fish oil smell fishy? If it smells fishy, the fish oil has most likely been exposed to oxygen and is becoming rancid.

3. Taste. Does the fish oil taste fishy? The freshest fish oils should not taste fishy. Avoid fish oils that have really strong fruit flavor added to them because they are most likely trying to hide the fishy flavor of rancid oil.

Will EFAs interfere with my medical condition or medications I'm taking?

Check with your health care professional since EFAs can reduce blood viscosity and are not recommended if you are using blood thinners, taking high doses of aspirin, or anticipating surgery.

Can EFAs be taken with other supplements?

Yes, EFAs can be taken with a wide variety of supplements. EFAs are extremely well tolerated, natural, health-promoting, and safe to use every day.

(1) Maroon JC, Bost JW. Omega-3 Fatty acids (fish oil) as an anti-inflammatory: an alternative to nonsteroidal anti-inflammatory drugs for discogenic pain. Surgical Neurology 2006;65:326-331.

(2) Rosenthal, Elisabeth, In Europe It's Fish Oil After Heart Attacks, but Not in U.S. Website accessed 1/29/2008,

(3) Robert C. Oh, MD, MPH, Shirley A. A. Beresford, PhD and William E. Lafferty, MD

The Fish in Secondary Prevention of Heart Disease (FISH) Survey-Primary Care Physicians and Omega-3 Fatty Acid Prescribing Behaviors, The Journal of the American Board of Family Medicine 19:459-467 (2006)

(4) Fish and Omega-3 Fatty Acids, AHA Recommendation, AHA, website accessed 1/29/2008

These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnosis, treat, care, or prevent disease.

Omega-3 EFAs

A better choice for pain relief!

Written by Joseph C. Maroon, MD, FACS

For the first 15 years of my neurosurgical practice, most of my patients with spine complaints routinely left the office either scheduled for surgery or with a prescription for conservative treatments. These treatments included physiotherapy, traction, injections, and a host of other treatments too numerous to list. But in addition to active therapies, all patients received prescriptions for both a pain medication and a non-steroidal anti-inflammatory (NSAID) capsule. Conservatively, I wrote more than 5,000 of these prescriptions without any thought other than providing relief for my patient's pain complaints.

However, two events occurred in 2004 that forever changed the way I treat my patients' non-surgical pain, and what I prescribe for them to take. The first event was very personal. As a triathlete, having participated in more than 70 triathlons, including seven Ironman triathlons, I was accustomed to enduring pain. But I began to have severe left knee pain and took COX-1 NSAIDs, like ibuprofen, for this pain. Over approximately a two-month period, I felt much better but began to have stomach pains, which I found out later was gastritis and early gastric erosion. I became concerned about experiencing this common side effect myself, but also worried about the tens of thousands of patients I had placed on these medications. (I had recently begun to switch many of my patients to the newest COX-2 NSAIDs, but still heard occasional reports about stomach upset.) I considered switching to a different drug, myself, but the next event that sealed how I was going to change my practice, was about to break. On September 30, 2004, the FDA acknowledged the voluntary withdrawal of Vioxx® (rofecoxib), a COX-2 selective NSAID manufactured by Merck & Co.

omega 3

Graph 1 - Left - Demonstrates the pathway to EPA and DHA concentrated in Fish Oil can produce anti-inflammatory prostaglandins and leukotrienes. Right - Demonstrates the pathway of linoleic acid found in most vegetable oils to arachidonic acid, which produces inflammatory prostaglandins and leukotrienes. Whether inflammatory or anti-inflammatory, it is the balance of these localized cellular hormones that determine the body's overall level of inflammation.

Vioxx and its other COX-2 inhibitor cousins were actually believed to be safer than the COX-1. Because these drugs had gleaned fewer reports of gastrointestinal (GI) side effects, and since there had been no hint of the serious heart and coagulation complications that were now being reported, Vioxx had reached more than nine billion dollars in annual sales in the United States alone! The Vioxx storm started when an increased occurrence of serious cardiovascular events, including myocardial infarction (MI) and strokes, were reported during a clinical trial to determine whether the drug could reduce the risk of colon cancer. It became apparent that besides inhibiting COX-2, these agents selectively interfered with prostacyclin synthesis, a prostaglandin essential in reducing intravascular coagulation, and thus the increased incidence of MI and stroke. Because of persistent significant gastric, and now cardiovascular, side effects, the safety of these pharmaceutical choices was now being called into question.

With the removal of Vioxx from the market, many practitioners now treat NSAIDs with increased caution when prescribing. In 2006, The American Medical Association recommended the following considerations with their use:

  • Limit the duration and dosage of the prescribed NSAID and ask about and advise patients on combination NSAID therapy.
  • Treat patients with H pylori infection prior to beginning NSAID therapy so as not to increase the risk of complicated ulcers.
  • Institute "gastroprotection" for patients at high risk of gastrointestinal complications.


Following my own negative experience with NSAIDs and my heightened concern resulting from the Vioxx scare, I was determined to seek out a better choice for providing a reduction in inflammation-induced pain, and also reducing the side effects from medications consumed for months at a time. I began seeking out alternative treatments, and quickly found several hundred peer-reviewed journal articles in mainstream medical journals reporting on the use of omega- 3 essential fatty acids (EFAs) found in fish oil to block the inflammatory response in a similar but safer way as compared to NSAIDs. The majority of these articles had referenced omega-3's benefits with heart, vascular disease and improving lipid profiles. But several articles referenced the genesis of the omega-3 benefits and how they had a similar function to many NSAIDs of reducing inflammatory prostaglandin production (see Graph 1). EFAs, whether O3 or O6, are required for the production of hormone-like substances called eicosanoids which include thromboxanes, leukotrienes and prostaglandins. Additionally, omega-3s and the types of eicosanoids they produce help to balance the omega-6 eicosanoids associated with the inflammatory response.

The omega-6 EFA, linoleic acid (LA), is a polyunsaturated fatty acid found in many vegetable oils, especially corn oil, poppy seed, safflower and sunflower oils, and is used in the biosynthesis of arachidonic acid (AA), which can form inflammatory prostaglandins. Both omega-3s and omega-6s are incorporated into the bi-lipid membranes of animal cells and act as substrate repository for these localized hormones (eicosanoids). Both are polyunsaturated fatty acids that have two or more double bonds and, in addition to producing the eicosanoids, these EFAs are part of the phospholipids that are necessary for the formation and maintaining integrity of healthy cell membranes, neuronal development, and functioning of the brain and nervous system.

Omega-6s, when consumed in large amounts, such as is common in the Western diet, lead to excessive linolenic acid and increased formation of arachidonic acid, which then forms the pro-inflammatory eicosanoids. Animal proteins, especially red meat, also contain an abundant amount of arachidonic acid.

The anti-inflammatory eicosanoids derived from omega-3s, are found primarily in fish and, to a lesser extent, flax seed, walnuts, and certain algae. A deficiency in omega-3s, especially DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid), which are the most bioactive, will result in reduced levels of anti-inflammatory eicosanoids. An increase of omega-6 in the diet, versus omega-3, results in an imbalance and, in general, an inflammatory state. The reverse is also true. Increasing your diet with omega-3s or using dietary supplements will help to reduce inflammation. Having researched this supplement, my goal was to use omega-3s as a safer NSAID and treat my own pain as well as my patient's pain associated with arthritic joints of the spine.


I personally began to take two grams of mixed DHA and EPA fish oil supplements for a two-month period. I had no further knee pain, began to train again, and, importantly, had no further stomach problems. In 2005, I surveyed 125 of my non-surgical spine pain patients to whom I had also recommended taking omega-3 fish oil supplements. The survey showed a surprising result; 60 per cent had obtained significant spine pain relief and almost the same amount - 59 per cent - were able to stop taking pain medications and NSAIDs and just use omega-3 supplements for pain relief! I reported these results in Surgical Neurology, which prompted an editorial from the senior editor to encourage more neurosurgeons to learn about alternative treatments (see Graph 2).

omega 3

Graph 2 - Results of a survey of 125 respondents on omega-3 EFAs for a minimum of two months who had been seen with non-surgical spine pain.


For the last five years, I have continued to use omega-3 supplements as the first line of treatment for my patients with non-surgical spine pain, and I continue to receive tremendously positive feedback. As with any supplement, I urge patients to take a high-quality, pharmaceutical grade product, and caution them when taking blood thinners and fish oil, as there is a possibility of an accentuated effect on international normalized ratio (INR) values. In general, however, there are few complaints and most patients are very compliant with these supplements.

Because of continuing problems with pharmaceuticals with respect to withdrawal and black boxes on labels, many patients seek out natural alternatives to drug treatments. It is important to learn about those products that, like omega-3 fish oils, have been researched and have now crossed over to become standard treatments for patients and how they can be integrated with chiropractic to provide optimal pain treatment. You, as the practitioner, can be a better source of information than any commercial advertisement, and you are better equipped to alert them to any potentially harmful interactions.

Dr. Joseph Maroon, a board certified neurosurgeon at the University of Pittsburgh and team physician to the Pittsburgh Steelers, has become one of the leading advocates of fish oil in the United States.

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